Every finding on record at Edith Lane of Cincinnati

Based on observation and staff interviews, the facility failed to ensure the facility had properly operating phones system in place. This had the potential to affect all residents who resided in the facility. The facility census was 145.Observation of Secured Women's Behavioral Unit on 03/18/26 at 11:24 A.M. with Certified Nursing Assistant (CNA) #182, revealed the phone at the nurses station did not work. Observation of a second phone within the unit revealed it was unplugged and not operational. During an interview on 03/18/26 at 11:24 A.M., CNA #182 verified the Secured Women's Behavioral Unit did not have a working phone. CNA #182 stated if a resident's family member tried calling in, there was no way to reach the staff.Observation of Secured Men's Behavioral Unit on 03/18/26 at 11:31 A.M., with CNA # 319, revealed the phone was not plugged in. Interview at the same time with CNA #319, verified the phone was not operational CNA #319 stated the facility had a lot of issues with the phones working and the phones were often not working. During an interview on 03/18/26 at 11:38 A.M., Registered Nurse (RN) #221 assigned to the Secured Men's Behavioral Unit verified the phone was not operational. During an interview on 03/19/26 at 12:46 P.M., Receptionist #325 stated she works Monday through Friday from 9:00 A.M. to 5:00 P.M. Receptionist #325 stated during her off times, the incoming phone calls would roll to the nurse's station depending on what prompt is pushed. Receptionist #325 stated there were times when the phones were not working recently. During an interview on 03/19/26 at 12:55 P.M., the Administrator stated he did not think it was an issue when the families were not able to call into the facility. The Administrator stated the staff would often give families their personal phone numbers. The Administrator stated there was no specific policy regarding phones.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to provide a sanitary, clean, and safe environment, This had the potential to affect all 12 Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, and #12) who resided on the Secured Women's Behavioral Unit and 34 Residents (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76 and #77) who resided on the One [NAME] Unit and utilized the main entrance. The facility census was 145.1) Review of the medical record for Resident #12 revealed an admission date of 02/09/24. Diagnoses included schizophrenia, chronic obstructive pulmonary disease (COPD), essential primary hypertension, hypothyroidism, schizoaffective disorder, osteoarthritis, and osteoarthritis.Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 12/30/25, revealed she had impaired cognition, required supervision or moderate assistance from staff for activities of daily living (ADL). She was dependent on staff for medication administration.Observation on 03/18/26 at 11:18 A.M. with Certified Nurse Aide (CNA) #182, revealed Resident #12's bathroom was soiled with brown splatter up the corner of the wall behind the toilet. The toilet was heavily soiled, the floor was blackened with dirt and debris, brown splatter was observed on the opposite wall of the toilet. Resident #12's bedroom wall was soiled and scuffed up with exposed dry wall. Resident #12's wall around the receptacle and under the light was soiled with an unknown splatter and dried substance on the wall. Interview with CNA #182 at the same time verified the findings in Resident #12's room. 2) Review of the medical record for Resident #07 revealed an admission date of 03/07/23. Diagnoses included essential primary hypertension, anti-social personality disorder, inhalant abuse, diabetes mellitus (DM), schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder.Review of the MDS assessment for Resident #07 revealed she had severely impaired cognition, required set up assistance or supervision with ADL. She was dependent on staff for medication administration.Observation on 03/18/26 at 11:21 A.M. with CNA #182, revealed Resident #07 did not have sheets on her bed. Resident #07's bed had a wadded-up blanket heavily soiled with yellow and brown substance. A swarm of fruit flies were on the wadded up heavily stained blanket and all over the bed. The floor in front of Resident #07's bed was blackened with dirt and debris. Resident #07's bedroom had a soiled incontinent brief with drops of what appeared to be blood and stool all around the soiled brief. The floor was stained with reddish brown droplets. The wall had brown, dried splatter all over it by the toilet and the bathroom floor was missing tiles.During an interview on 03/18/26 at 11:21 A.M., CNA #182 stated the wadded-up blanket on Resident #07's bed was soiled with urine. CNA #182 verified the conditions of Resident #107's room. During an interview on 03/18/26 at 11:23 A.M., Housekeeper (HK) #168 walked into Resident #07's bathroom and confirmed the stool and blood on the floor in Resident #07's bathroom. HK #168 stated she does not clean up blood.Observation on 03/18/26 at 2:14 P.M., with CNA #182, revealed Resident #07's bathroom sink had brown water and cigarette butts floating in it. The cold and hot water did not work. The bathroom floor was spotted with a red and brown substance. Interview at the same time with CNA #182 verified the condition of Resident #07's room. CNA #182 verified the bathroom had dried blood on the floor. During an interview on 03/18/26 at 2:55 P.M., Maintenance Supervisor (MS) #155 stated he was aware Resident #07 did not have any running water in the bathroom sink and verified the resident's bathroom sink had standing brown water. MS #155 stated the facility had not provided any type of pest treatment to Resident #07's room. MS #155 verified the five ceiling lights were not working in the Women's behavioral dining/activity room. MS #155 stated he was aware of the hole in the wall below the half broke window between the nurse's station and the dining/activity room. MS #155 stated he was not aware of the broken window between the nurse's station and dining/activity room.3) Observation of the women's secured unit on 03/18/26 at 11:25 A.M. with CNA #182, revealed the shower room floor was blackened with dirt and heavily soiled. The shower room had an unknown brown spotted and splatter in the corners of the shower and up the walls. The toilet in the shower room was heavily soiled, and the shower room drain broke off on one side. The ceiling fan was hanging down out of the ceiling and the ceiling was spotted with an unknown black substance. During an interview on 03/18/26 at 11:26 A.M., CNA #182 stated the shower room was utilized by all twelve residents in the women's behavioral unit and verified the conditions of the shower room. CNA #182 stated the unknown substance appeared to be mold. CNA #182 confirmed the ceiling fan was hanging out of the ceiling and the drain was broken with half of the circle drain missing.Observation of the Women's Behavioral Unit on 03/18/26 at 2:10 P.M. with CNA #320, revealed the large dining/activity room had a half-broken window that opened into the nurses station from the dining room. The window was broken in half with a sharp edge on it and underneath the window was a large hole in the wall with exposed dry wall. The dining room/activity room had five large ceiling lights with no light bulbs.During an interview on 03/18/26 at 2:10 P.M., During an interview with CNA #320 at the same time, verified the findings inside the unit. 4) Review of the medical record for Resident #08 revealed an admission date of 09/23/25. Diagnoses included DM, essential primary hypertension, asthma, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and gastroesophageal reflux disease (GERD).Review of the MDS assessment for Resident #08 dated 01/23/26, revealed Resident #08 had impaired cognition. Resident #08 required supervision, moderate assistance and set-up assistance for ADL. Resident #08 was dependent on staff for medication administration.During an interview on 03/18/26 at 2:15 P.M., Resident #08 stated she was tired of her room being cold. Resident #08 pointed to her heating unit in her room which had a blanket on it, and a blanket at the base of the window over top of the unit. Resident #08 stated the unit was blowing out cold air and it was very cold in her room. Resident #08 stated the maintenance director told her he fixed the heat, but it continued to blow cold air. Observation of Resident #08's room at the same time, revealed a blanket was on top of the heating unit. The unit was running but cold air filled the room. Resident #08's bathroom was soiled, missing floor tiles, and the toilet was heavily soiled with a black ring around the toilet.During an interview on 03/18/26 at 2:17 P.M., CNA #182 stated Resident #08's room had been blowing cold air for some time; however, she could not say how long. CNA #182 confirmed the bathroom was soiled, missing floor tiles, and had a black ring around the base of the toilet. CNA #182 confirmed the room was very cold.During an interview on 03/18/26 at 2:55 P.M., MS #155 confirmed Resident #08's room heater was blowing cold air. MS #155 stated he was not aware of this because he thought he had repaired the heating unit. MS #155 confirmed Resident #08 had holes in the wall beside her bed and shredded pieces of her privacy curtain hanging from the ceiling.5) Review of the medical record for Resident #04 revealed an admission date of 05/02/23. Diagnoses included essential primary hypertension, DM, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and cystitis.Review of the MDS for Resident #04 dated 12/25/25, revealed she had impaired cognition. Resident #04 required set up assistant, supervision or moderate assistance for ADL.Observation on 03/18/26 at 2:16 P.M. revealed Resident #04 had a dish with water under her sink. A large pile of what appeared to be mouse droppings was identified under the sink. The sink did not drain correctly when water was running. During an interview on 03/18/26 at 2:16 P.M., Resident #04 stated the small dish of water was for the mice in her room. Resident #04 pointed at the large hole in the corner of her room under the sink and stated the mice lives in the hole and she made it her pet.During an interview on 03/18/26 at 2:55 P.M., MS #155 stated he was aware of the mice droppings under Resident #04's bathroom sink. MS #155 stated he was aware of the mice issue in Resident #04's room and had the facility treated for mice.Review of the most recent facility's Work Orders from the contracted pest control company revealed no specific treatments to Resident #07's room for fruit flies or Resident #04's room for mice.6) Observation of the main entrance to the facility on [DATE] at 2:35 P.M., with CNA #194, revealed a double set of doors with a small concreate pad and awning overhead where residents/visitors and staff entered the building. Resident #62 was observed smoking on the concrete pad and directly outside of the front doors which was a non-smoking area. There were numerous discarded cigarette butts scattered across the ground near the front door, throughout the landscaping rocks on both sides of the doors and all around the trash can with a plastic liner. There was no container for discarded cigarettes. Interview with CNA #194 at the same time verified Resident #62 was smoking directly outside the main entrance door which was a non-smoking area. CNA #194 identified an area across the parking lot which was the designated smoking area. CNA #194 also verified the numerous discarded cigarette butts were scattered on the ground near the front door.During an interview on 03/18/26 at 2:36 P.M., Resident #62 stated he smoked by the main entrance doors often. Subsequent observation of the main entrance to the facility on [DATE] at 11:48 P.M., revealed Residents #46 #56 were observed smoking directly outside the main entrance door in the non-smoking area. The area was still littered with numerous discarded cigarette butts throughout the ground and in the landscaping. During an interview on 03/19/26 at 11:48 P.M., Licensed Practical Nurse (LPN) #388, verified Residents #46 and #56 were smoking directly outside the main entrance in a non-smoking area. LPN #388 verified the large amount of discarded cigarette butts scattered on the ground, throughout the landscaping rocks against the building, and around the trash can with a plastic liner. LPN #388 indicated the designated smoking area was across the parking lot.Review of the facility policy titled, Maintenance Service, dated December 2009, revealed maintenance shall be provided to all areas of the building. The maintenance department was responsible for maintaining the buildings, the grounds, and equipment in a safe and operable manner at all times. The maintenance department would maintain heating/cooling system, plumbing fixtures, and ensure lights are in good working condition. The maintenance director is responsible for inspection of the building. This deficiency represents non-compliance investigated under Master Complaint Number 2797716.

Based on observation, staff interview, resident interview, staff interview, and policy review, the facility failed to maintain a safe smoking environment. This had the potential to affect all 12 Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, and #12) who resided on the Secured Women's Behavioral Unit and 34 Residents (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76 and #77) who resided on the One [NAME] Unit and utilized the main entrance. The facility census was 145. 1) Observation of the Secured Women's Behavioral Unit on 03/18/26 at 2:08 P.M. with Certified Nurse Aide (CNA) #182, revealed the door exiting to the smoking area contained numerous discarded cigarette butts lying all over the ground and near the door. The sidewalk leading away from the building contained numerous discarded cigarette butts. During an interview on 03/18/26 at 2:10 P.M., CNA #182 verified the door smoking area contained numerous discarded cigarette butts lying on the ground. 2) Review of the medical record for Resident #62 revealed an admission date of 04/04/14. Diagnoses included essential primary hypertension, antisocial personality, inhalant abuse, allergic rhinitis, schizoaffective disorder, bipolar disorder, anxiety disorder, and psychosis.Review of the most recent Smoking Evaluation for Resident #62 dated 04/11/25, revealed the resident was assessed to be an independent smoker with no history of safety concerns regarding smoking.Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 was cognitively intact. Review of the medical record for Resident #46 revealed an admission date of 12/09/23. Diagnoses included paranoid schizophrenia, bipolar disorder, essential primary hypertension, anxiety disorder, and psychotic disorder with delusions.Review of the most recent Smoking Evaluation for Resident #46 dated 06/10/24, revealed the resident was assessed to be an independent smoker.Review of the MDS assessment dated [DATE], revealed Resident #46 was cognitively intact. Review of the medical record for Resident #56 revealed an admission date of 12/17/25. Diagnoses included cerebrovascular disease, hemiplegia and hemiparesis, hyperlipidemia, depression, anxiety disorder, and epilepsy. Review of the most recent Smoking Evaluation for Resident #56 dated 05/30/24, revealed Resident #56 was assessed to be an unsafe smoker. Resident #56 had paralysis on the left side of his body and required supervision by staff while smoking.Review of the MDS assessment for Resident #56 dated 02/27/26, revealed the resident was cognitively intact. Observation of the main entrance to the facility on [DATE] at 2:35 P.M., with CNA #194, revealed a double set of doors with a small concreate pad and awning overhead where residents/visitors and staff entered the building. Resident #62 was observed smoking on the concrete pad and directly outside of the front doors which was a non-smoking area. There were numerous discarded cigarette butts scattered across the ground near the front door, throughout the landscaping rocks on both sides of the doors and all around the trash can with a plastic liner. There was no container for discarded cigarettes. Interview with CNA #194 at the same time verified Resident #62 was smoking directly outside the main entrance door which was a non-smoking area. CNA #194 identified an area across the parking lot which was the designated smoking area. CNA #194 also verified the numerous discarded cigarette butts were scattered on the ground near the front door.During an interview on 03/18/26 at 2:36 P.M., Resident #62 stated he smoked by the main entrance doors often. Subsequent observation of the main entrance to the facility on [DATE] at 11:48 P.M., revealed Residents #46 #56 were observed smoking directly outside the main entrance door in the non-smoking area. The area was still littered with numerous discarded cigarette butts throughout the ground and in the landscaping. During an interview on 03/19/26 at 11:48 P.M., Licensed Practical Nurse (LPN) #388, verified Residents #46 and #56 were smoking directly outside the main entrance in a non-smoking area. LPN #388 verified the large amount of discarded cigarette butts scattered on the ground, throughout the landscaping rocks against the building, and around the trash can with a plastic liner. LPN #388 indicated the designated smoking area was across the parking lot. During an interview on 03/19/26 at 12:10 P.M., the Administrator stated the facility performed smoking evaluations on the residents with admission and if a resident was to move from a secured unit to an independent unit, or if they had a significant change in health status. Review of the policy titled, Smoking Policy-Residents, dated October 2023, confirmed the facility has established and maintains safe smoking practices. Smoking is only permitted in the designated smoking areas. The policy stated that ashtrays are only emptied in designated receptacles. A resident's smoking status is evaluated upon admission.Review of the facility policy titled, Maintenance Service, dated December 2009, revealed maintenance shall be provided to all areas of the building. The maintenance department was responsible for maintaining the buildings, the grounds, and equipment in a safe and operable manner at all times. The maintenance department would maintain heating/cooling system, plumbing fixtures, and ensure lights are in good working condition. The maintenance director is responsible for inspection of the building.

Based on observation, staff interview, and policy review the facility failed to provide a clean, safe, and comfortable environment. This affected 31 (#682, #86, #127, #120, #122, #147, #146, #99, #134, #140, #142, #125, #136, #137, #128, #121, #138, #145, #123, #133, #135, #130, #124, #131, #148, #149, #144, #126, #129, #132, and #139) of 31 residents reviewed for environment residing in Building #2, and further affected four (#34, #50, #692 and #694) with the potential to affect all residents on the 2 west unit of Building #1. The facility census was 144. 1. Observations of Building #2 on 12/22/25 from 3:45 P.M. to 4:20 P.M. with Maintenance Assistant (MA #333) revealed the following: - Rooms 01, 05, 06, 07, 10, 12, 13, 14, 15, 16, and 17 did not having curtains or blinds on the ground level windows, affecting 19 Residents (#86, #99, #120, #121, #122, #125, #126, #127, #128, #129, #130, #131, #132, #133, #134, #140, #142, #144, and #145). - Rooms 08, 10, 12, and 14 revealed mold on the top of the window sill affecting eight Residents (#121, #122, #125, #126, #129, #130, #146, and #147). - room [ROOM NUMBER] revealed the inside window pane was broken, affecting Resident #138. - rooms [ROOM NUMBERS] contained ripped mattresses, affecting two Residents (#132 and #138). -The shower room reveal drywall off the walls and lying on the floor, no shower curtain to provide privacy, and no shower head to allow showering, affect all 31 (#682, #86, #127, #120, #122, #147, #146, #99, #134, #140, #142, #125, #136, #137, #128, #121, #138, #145, #123, #133, #135, #130, #124, #131, #148, #149, #144, #126, #129, #132, and #139) residents in the building that use the shower room. Interview with MA #333 verified all the of findings at the time of the observation. 2. Tour of Building #1 with Licensed Practical Nurse (LPN) #211 on 12/23/25 at 1:30 P.M. revealed unit shower on the 2 west unit was not in working condition according to LPN #211. Observation of the shower room revealed approximately one inch of standing water in the shower area as well as the dressing area, the shower walls had a dark substance that appeared to be mold, and the floors of the shower were dirty. LPN #211 confirmed the standing water, the dirty floor and the dark substance on the walls. LPN #211 revealed that residents on the women's unit did have access to another shower in a closed unit adjacent to the unit but the residents did not like to have to walk that far to take a shower. Interviews with Residents #34, #50, #692 and #694 on 12/22/25 and 12/23/25 revealed the residents wanted a clean and functioning shower and wanted to be able to shower on their unit and not have to walk down the long hallway to use another shower. Review of the Maintenance Service Policy dated 2001 revealed functions of maintenance personnel include but are not limited to maintaining the building in good repair, free from hazards, maintaining the heating/cooling system, plumbing fixtures, and wiring. This deficiency represents non-compliance investigated under Complaint Number 2694695.

Based on medical record review, observation, staff interviews, and review of a facility policy, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected 14 (#103, #69, #91, #95, #17, #27, #43, #87, #51, #58, #107, #18, #88 and #117) of the 25 residents who resided on the secured men's behavioral unit reviewed for call lights. The facility census was 118. Findings included: Review of the medical record for Resident #18 revealed the resident was admitted on [DATE]. Diagnoses included traumatic brain injury (TBI), kidney cancer, anemia, morbid obesity, hypertension, cerebrovascular accident with left (non-dominant) hemiplegia/hemiparesis, bipolar disease, depression and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #18 revealed the resident was cognitively intact. Resident #18 required supervision for eating and was dependent on staff for all other activities of daily living (ADLs). Observation of the facility during the initial tour on 06/11/25 at 9:30 A.M., revealed Resident #18's call system cord was lying on the floor at the foot of the bed. Further observation noted there was no call system in the resident's room for the call system cord to be plugged into. The call system box that the cord plugged into was not present on the wall. Interview on 06/11/25 at 10:57 A.M. with Resident #18, revealed no information as to how long the call light system was not present. Interview on 06/11/25 at 11:10 A.M. with Registered Nurse (RN) #305 and Maintenance Assistant #210, verified there was no call system available in the room of Resident #18 and unknown how long the call light system was not active. Continued observation of the facility on 06/11/25 between 12:50 P.M. and 1:15 P.M., revealed each room on the men's secured behavioral unit were double occupancy rooms. Residents #103 and #69 were in the same room with a single pull cord between the beds. Residents #91 and #95 were in the same room with a single pull cord between the beds. Residents #17 and #27 were in the same room with a single pull cord between the beds. Residents #43 and #87 were in the same room with a single pull cord between the beds. Residents #51 and #58 were in the same room with a single pull cord between the beds. Residents #107 and #18 were in the same room with a single pull cord between the beds and Residents #88 and #117 were in the same room with a single pull cord between the beds. The resident rooms had a call system with a single pull cord located in the middle of the wall between where the head of the two beds would be and when pulled, the call light was activated. The single cord was out of reach for the residents when they were in their beds. There was not a call system cord available for each resident and an individual cord that could be activated if the resident was in bed. Interview on 06/11/25 at 12:50 P.M. with the Administrator, verified there was no call system in Resident #18's room. The Administrator also verified Residents #103, #69, #91, #95, #17, #27, #43, #87, #51, #58, #107, #18, #88, and #117 did not have a call system in place that provided each resident with an individual access to the call system. Review of an undated facility policy titled, Answering the Call Light, revealed staff should be sure the call light was plugged in at all times and when the resident was in bed or confined to a chair, be sure the call light was within easy reach of the resident. Staff should report all defective call lights to the nurse supervisor promptly, and some residents may not be able to use their call light, so be sure to check these residents frequently. This deficiency represents non-compliance investigated under Master Complaint Number OH00165496.

Based on medical record reviews, observation, staff interviews, and policy review, the facility failed to ensure residents were provided with a safe, clean, comfortable and homelike environment. This affected two (#11 and #18) of the seven residents reviewed for environmental concerns. The facility census was 118. Findings include: 1) Review of the medical record for Resident #11 revealed an admission date of 06/10/23. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic congestive heart disease, and acute kidney failure. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #11, revealed the resident was cognitively intact. Observation of Resident #11's room on 06/12/25 at 2:00 P.M., with Maintenance Director #200, revealed an air conditioning (AC) unit sitting in an opening in the outer wall. The AC unit did not fit properly in the opening. The sky and the surrounding buildings were visible through the large gap at the top and sides of the wall opening. Interview on 06/12/25 at 2:03 P.M. with the Maintenance Director #200, verified the AC unit sitting in an opening in the outer wall in Resident #11's room, did not fit properly and the sky and the surrounding buildings were visible through the gap at the top and sides of the wall opening. 2) Review of the medical record for Resident #18 revealed the resident was admitted on [DATE]. Diagnoses included traumatic brain injury (TBI), kidney cancer, anemia, morbid obesity, hypertension, cerebrovascular accident with left (non-dominant) hemiplegia/hemiparesis, bipolar disease, depression and anxiety. Review of the MDS quarterly assessment dated [DATE] for Resident #18, revealed the resident was cognitively intact. Resident #18 required supervision for eating and was dependent on staff for all other activities of daily living (ADLs). Observation during the initial tour on 06/11/25 at 9:30 A.M., revealed Resident #18's room had no pictures on the walls and the only window in the room had the drywall at the top of the inner window frame unattached from the wall framing and just barely hanging. There were no curtains or window blinds in place. The call system cord was lying on the floor at the foot of the bed and out of the reach of the resident. Further observation revealed there was no call system in the resident's room for the call system cord to be plugged into. The call system box that the cord plugged into was not present on the wall. Interview on 06/11/25 at 11:10 A.M. with Registered Nurse (RN) #305 and Maintenance Assistant #210, verified the condition of Resident #18's window inner frame drywall, no window coverings, and no call light system in the resident's room. Interview on 06/11/25 at 12:50 P.M. with the Administrator, verified the condition of Resident #18's window inner frame drywall, no window coverings, and no call system in the resident's room. Review of the facility policy titled, Homelike Environment-Quality of Life, dated 11/28/17, revealed residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible including but not limited to receiving treatment and supports for daily living safely. This deficiency represents non-compliance investigated under Master Complaint Number OH00165496.

Based on observation and staff interview, the facility failed to store foods in a manner to prevent spoilage and failed to ensure kitchen staff appropriately wore hair restraints while in the kitchen. This had the potential to affect all 119 residents at the facility. The facility census was 119. Findings Included: 1. Observation on 04/08/25 from 9:50 A.M. through 10:00 A.M. revealed an opened and undated quarter pound package of ham lunch meat, two halved tomatoes wrapped in plastic that were undated, an opened and undated package of yellow cheeses with a quarter pound left, and three ham sandwiches, three bologna sandwiches, and six peanut butter sandwiches individually packaged in plastic bags that were not labeled or dated in refrigerator. Interview on 04/07/25 at 9:58 A.M. with Food Service Director (FSD) #196 verified all the food items were not labeled or dated, and should have been, in the refrigerator. Review of the facility policy titled, Food Receiving and Storage, dated December 2008, revealed the facility foods shall be received and stored in a manner that complies with practices. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 2. Observation on 04/08/25 at 11:00 A.M. of Dietary Assistant (DA) #263 revealed she was wearing a hat with braided hair in a pony tail down to the middle of her back. The braided pony tail was not contained within the hat. Interview on 04/08/25 at 11:00 A.M. with DA #263 verified her hair down her back was not contained in her hat or by another means. Observation on 04/08/25 at 11:35 A.M. revealed [NAME] #287 entered the kitchen and had no hair net on when entering on the other side of the kitchen located at the dishwasher station. [NAME] #287 was also observed with a short cut beard and had no beard protector on his face. Interview on 04/08/25 at 12:48 P.M. with [NAME] #287 verified he did not have a hair net or beard protector on his face while in the kitchen.

Based on observation, resident and staff interviews, medical record review, review of service reports, and policy review, the facility failed to ensure residents were provided a homelike environment. This affected six (#29, #79, #88, #101, #109, and #118) of 17 residents reviewed for environmental concerns. The facility census was 119. Findings Include: 1. Review of the medical record for Resident #29 revealed an admitted [DATE] and diagnoses that included chronic obstructive pulmonary disease, chronic congestive heart disease, and acute kidney failure. Review of Resident #29's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Observation of Resident #29's room on 04/08/25 at 9:47 A.M. revealed an air conditioning unit sitting in an opening in the outer wall. The air conditioning unit did not fit properly in the opening. The sky and other buildings were visible through the gap at the top and sides of the wall opening. A thin plastic window covering was secured around the edges of the air conditioning unit with blue painter's tape and was noted to have holes in it. Interview with Registered Nurse (RN) #324 on 4/09/25 at 1:56 P.M. confirmed the air conditioner unit in Resident #29's room appeared to not be properly installed and light was visible around the top and sides of the unit. Interview with Resident #29 on 04/09/25 at 2:01 P.M. revealed the air conditioning unit was replaced and had never fit properly in the opening it sat in. Resident #29 reported the thin plastic around it did not keep the cold air out. On 04/09/25 at 2:10 P.M., interview with Maintenance Director (MD) #291 revealed Resident #29 had a new air conditioning unit placed about a year ago. The replacement unit was smaller than the opening in the wall for the previous unit but it was placed in the opening anyway. The new air conditioning unit was noted to have space around the top and sides that let light and air through. Clear window plastic was placed over the openings and secured with blue painter's tape in an effort to reduce the air flow from the gaps. MD #291 stated he would fix the gap around the unit with a bracket. Observation of the air conditioning unit in Resident #29's room on 04/10/05 at 8:15 A.M. revealed the thin plastic and painter's tape were not removed, but a plastic frame was placed in front of the plastic and affixed to the top of the opening with a single screw. Light continued to be visible and air was felt through the gap around the air conditioning unit. 2. Review of medical records for Resident #79 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, bipolar disorder, epilepsy, and schizoid personality disorder. Review of MDS assessment dated [DATE] revealed Resident #79 had mild cognitive impairment. Interview on 04/07/25 at 2:00 P.M. with Resident #79 stated some of the electrical outlets in his room did not work and he was unable to watch television in his room because it was mounted on the wall where the electrical outlets did not work. The resident stated the facility was aware of the issue but had not corrected it. Observation on 04/07/25 at 2:00 P.M. revealed Resident #79's room had outlets that did not provide electricity, including the outlets on the wall where his television was mounted. 3. Review of medical records for Resident #88 revealed an admitted d of 10/17/22 with diagnoses including chronic obstructive pulmonary disease (COPD), psychotic disorder with delusions, and traumatic brain injury. Review of the MDS assessment dated [DATE] revealed Resident #88 had mild cognitive impairment. Observation on 04/07/25 at 3:15 P.M. revealed Resident #88's room did not have electricity in some outlets in his room. 4. Review of medical records for Resident #101 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia and schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #101 had mild cognitive impairment. Interview on 04/07/25 at 1:20 P.M. with Resident #101 verified some of the electrical outlets did not work in her room. Observation on 04/07/25 at 1:20 P.M. revealed Resident #101's room did not have electricity in all outlets. 5. Review of medical records for Resident #109 revealed the resident admitted on [DATE] with diagnoses including osteomyelitis, acute embolism and thrombosis of deep veins, polyneuropathy, bipolar II, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #109 was cognitively intact. Interview on 04/07/25 at 1:40 P.M. with Resident #109 stated the electrical outlet in parts of his room did not work. Observation on 04/07/25 at 1:40 P.M. revealed Resident #109's room did not have electricity in all outlets. Interview on 04/07/25 at 4:30 P.M. with the Director of Nursing (DON) verified that not all electrical outlets were working in Resident #109, Resident #101, Resident #88, and Resident #79's rooms. 6. Review of medical records for Resident #118 revealed an admitted [DATE] with diagnoses of extradural and subdural abscess, osteomyelitis, and Arnold Chiari Syndrome. Review of the MDS assessment dated [DATE] revealed Resident #118 had mild cognitive impairment. Observation on 04/07/25 at 2:56 P.M. revealed Resident #118's room did not have electricity in all outlets. Interview on 04/08/25 at 11:00 A.M. with the DON verified the electrical outlets were not working in parts of Resident's #118's room. Review of a service report dated 02/17/25 revealed an electrical contractor identified a short in a wall that affected two rooms with no power. Review of the facility policy titled, Homelike Environment-Quality of Life, dated 11/28/17, revealed residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible including but not limited to receiving treatment and supports for daily living safely. This deficiency represents non-compliance investigated under Complaint Number OH00163411, Complaint Number OH00162927, Complaint Number OH00162789, and Complaint Number OH00162565. 44080

Based on medical record review, resident and resident family interview, staff interview, review of incident reports, and policy review, the facility failed to ensure care conferences were conducted timely as required and failed to ensure care plans were updated timely when new interventions were implemented. This affected six (#59, #79, #98, #116, #118, and #120) of 32 residents reviewed for care plans. The census was 119. Findings include: 1. Review of the medical records for Resident #79 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, bipolar disorder, epilepsy, and schizoid personality disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had mild cognitive impairment. Review of care conference documentation revealed conferences were held for Resident #79 on 03/12/24, 06/07/24, and 10/21/24. There was no documented care conference for the first quarter of 2025. 2. Review of Resident #98's medical record revealed an admitted [DATE] with diagnoses including chronic disease, seizures, and schizophrenia. Review of the MDS assessment dated [DATE] revealed Resident #98 was cognitively intact. Review of care conferences revealed conferences were held for Resident #98 on 03/25/24, 05/14/24, 09/17/24, and 04/01/25. There was no evidence of a care conference in the fourth quarter of 2024 or the first quarter of 2025. 3. Review of Resident #118's medical records revealed an admitted [DATE] with diagnoses of extradural and subdural abscess, osteomyelitis, and Arnold Chiari Syndrome. Review of the MDS assessment dated [DATE] revealed Resident #118 had mild cognitive impairment. Review of notes for Resident #118's care conference dated 03/13/25 revealed it did not happening due to the resident being unavailable and would be rescheduled but no follow up care conference was performed. Interview on 04/14/25 at 11:31 A.M. with MDS Registered Nurse (RN) #257 verified the documented care conferences for Resident #79 were the only care conferences that took place, and there was no evidence of additional care conferences. MDS RN #257 further verified care conference were not completed timely for Resident #98 and Resident #118 for the first quarter of 2025. 42492 4. Review of the medical record revealed Resident #120 was admitted to the facility on [DATE]. Diagnoses included Huntington's disease, unspecified dementia with behavioral disturbances, anxiety disorder, and unspecified depression. Review of the most recent MDS assessment dated [DATE] revealed Resident #120 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 11/04/24 revealed Resident #120 was at increased risk for falls related to deconditioning, weakness, impaired balance, poor safety awareness, medication use related to Huntington's disease, and dementia. Interventions included keeping the call light within reach, encouraging the resident to ask for assistance, therapy evaluations as ordered, observing for side effects to medications, providing activities of daily living (ADL) assistance as needed, and monitoring, documenting, reporting changes in mental status or pain. Review of the care plan dated 02/27/25 revealed Resident #120 had an actual unwitnessed falls with no injuries on 12/07/24 and 12/22/24, and an unwitnessed fall with a scalp laceration on 02/20/25. Interventions included monitoring, documenting, and reporting changes in pain or mental status for 72 hours, initiating neurological checks, and consulting with physical therapy for strength and mobility. Review of the progress notes revealed Resident #120 had an unwitnessed fall on 12/07/24 at 12:34 A.M. during which he sustained a laceration to the right upper eye. The nurse implemented non-skid socks immediately for fall prevention. Review of an incident report dated 12/07/24 revealed interventions recommended for Resident #120's fall prevention included monitoring for delayed injuries and pain, notifying therapy to assist with fall interventions, providing treatments as per orders, and consulting the pharmacy to evaluate medications. Review of incident report dated 02/20/25 revealed resident fell due to noncompliance with safety precautions and ambulating without assistance. Interventions included therapy consult and frequent (increased) monitoring to assist with transfers related to noncompliance with requesting assistance. During an interview on 04/10/25 at 3:13 P.M. the Director of Nursing (DON) verified the nursing intervention documented in the progress note for the fall on 12/07/24 for non-skid socks was not placed on the care plan. The DON stated typically when risk management reviewed falls and completed the root cause analysis (RCA), the interdisciplinary team (IDT) decide what intervention to put in place. The non-skid footwear was an immediate intervention the nurse initiated at the time of the fall, but was not the intervention the IDT team put in place. The intervention the IDT team put in placed was for a pharmacy/medication review. The DON stated after the fall on 02/20/25, the IDT team sent Resident #120 to the emergency room and placed increased monitoring to assist with transfers. The final intervention that was added related to the care plan was for a scoop mattress. The DON stated that was not included on the RCA because the facility had to order the mattress first. She stated it was added to the care plan on 02/24/25. During an interview on 04/14/25 at 8:27 A.M. the DON stated the intervention for Resident #120's fall on 12/07/24 was to have a pharmacy review for medications. The DON verified the intervention was not on the resident's care plan. The DON stated the intervention for Resident #120's fall on 02/20/25 was a scoop mattress. The DON verified that intervention was not created in the care plan until 04/10/25 although it was back-dated in the documentation to look like it was initiated on 02/24/25. 44080 5. Review of the medical records for Resident #116 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly MDS assessment dated [DATE] revealed Resident #116 had severely impaired cognition. Review of the medical records for Resident #116 revealed care conference were held on 08/01/24 with a daughter present and on 11/13/24 with no family member present. Interview on 04/08/25 at 8:27 A.M. with Resident #116's daughter stated she never had a care conference at the facility. Resident #116's daughter stated she had one call a month ago and was told Resident #116 fell . Resident #116's daughter stated she would like to attend care conferences since the facility did not answer the telephone when she called. Interview on 04/14/25 at 11:25 A.M. with MDS RN #257 stated she did not perform care conferences at the facility. MDS RN #257 verified Resident #116 only had two care conferences at the facility and should have had more. 51069 6. Review of the medical record for Resident #59 revealed an admitted [DATE] and diagnoses included stage III chronic kidney disease, type II diabetes mellitus, depression, and anxiety disorder. Review of Resident #59's MDS assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of care conference documentation revealed the facility scheduled care conferences for Resident #59 on 07/11/24, 10/14/24, and 03/27/25. Resident #59 was noted to be out of the facility on 10/14/24 and 03/27/25 and quarterly care conferences would be rescheduled. Further review revealed no care conferences were rescheduled for Resident #59. Interview 04/10/25 at 12:43 P.M. with Resident #59 revealed the resident did not recall having a care conference for a very long time. Interview 04/10/25 at 1:04 P.M. with Social Worker (SW) #173 confirmed Resident #59 had not had a care conference since 07/11/24 and care conferences scheduled for 10/14/24 and 03/27/25 were not completed. Interview with MDS Nurse #257 on 04/14/25 at 11:26 A.M. confirmed care conferences were to be held quarterly and should be rescheduled at the earliest convenience of the resident if the resident is out of the facility at the time of the scheduled care conference. Review of policy titled, Care Planning, dated December 2008, revealed the interdisciplinary team was responsible for the development of individualized comprehensive care plans and the resident, resident's family, and/or resident's representative were encouraged to participate in developing and revising the residents care plan during care plan meetings that were scheduled at times of day convenient to the resident and family.

Based on observation and staff interview, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This had the potential to affect five (#31, #54, #79, #84, and #109) of five residents observed in the hallway during medication administration. The facility census was 119. Findings Include: Observation on 04/09/25 at 9:00 A.M., during medication administration, Registered Nurse (RN) #260 was observed to discard two 300 milligram (mg) gabapentin capsules and one five (5) mg memantine tablet into the open trash receptacle on the end of the medication cart. RN #260 left the medication cart locked and unattended on four occasions to administer medications during observation. The medication cart was placed in a common area between the front entrance to the facility and the rehabilitation room. Five (#31, #54, #79, #84 and #109) residents were observed to be in the hallway when the medication cart was left unattended with three unsecured pills in the trash receptacle. Interview with RN #260 on 04/09/25 at 9:11 A.M. confirmed the three medications should not have been discarded in an unsecure trash receptacle and stated any resident who walked by had access to those medications. Interview with the Director of Nursing (DON) 04/09/2025 at 12:30 P.M. revealed no medications should be left unattended where residents had access to them.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to notify the physician of a resident's significant weight loss. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. Resident #116 required supervision or touching assistance for meals and dressing the upper body. Resident #116 required partial to moderate assistance for personal hygiene, dressing the lower body, placing shoes on and off the feet, and oral care. Resident #116 required substantial to maximal assistance for bathing and toileting. Resident #116 was self-ambulatory and needed no durable medical equipment. Review of the plan of care dated 02/05/25 revealed Resident #116 required assistance with activities of daily living (ADLs) related to vascular dementia and chronic obstructive pulmonary disease. Interventions included assistance as needed with showers, encourage the resident to participate to the fullest extent possible, give the resident one step commands for completion of ADLs tasks, personal hygiene assistance with weight bearing assistance, staff to assist with completion of ADLs on a daily basis, and therapy to evaluate. Review of a physician order dated 07/31/24 revealed Resident #116 had an order for a no added salt diet with regular texture and thin liquids. Review of the medical record revealed Resident #116 weighed 126.6 pounds on 07/31/24. Review of Resident #116's medical record revealed on 08/07/24 the resident weighed 126.6 pounds, on 08/14/24 weighed the resident weighed 125.4 pounds, on 08/21/24 the resident weighed 125.4 pounds, and on 09/10/24 the resident weighed 124.2 pounds. Review of a nutrition note dated 10/30/24 by Registered Dietician (RD) #705 revealed Resident #116 was on a no added salt diet, thin liquids, and oral intakes varied but were mostly between 75 percent (%) and 100%. The resident's weight for October 2024 was pending and it was reported Resident #116 had a good appetite. RD #705 documented the facility would continue to monitor Resident #116 for necessity of additional nutritional interventions. Review of the medical record revealed Resident #116's weight on 12/10/24 was 135.6 pounds. Review of a nutrition note dated 01/30/25 by RD #705 revealed Resident #116 remained on a no added salt diet with variable intakes, but mostly consumed between 50% and 100% of meals. Resident #116's January 2025 weight was pending and it was documented Resident #116 would be monitored for necessity of additional nutritional interventions. Review of the medical record for Resident #116 revealed on 02/19/25 the resident weighed 88.6 pounds and on 02/27/25 weighed 88.0 pounds. Review of a nutrition note dated 02/28/25 by RD #705 revealed it was recommended Resident #116 be reweighed indicating the documentation was likely inaccurate. Resident #116 was noted with significant weigh loss over 180 days. Review of the medical record for Resident #116 revealed on 04/10/25 the resident weighed 87.8 pounds. Review of the medical record between 07/31/24 and 04/14/25 revealed no documented evidence of Resident #116's physician being notified of the resident's significant weight loss. Observation on 04/07/25 from 11:30 A.M. through 4:30 P.M. revealed Resident #116 continuously walked around the facility. Resident #116 walked around the hallway, in rooms, and very rarely sat down. She walked by herself and used no durable medical equipment for assistance. Interview on 04/14/25 at 1:38 P.M. with the Director of Nursing (DON) verified she was not aware Resident #116 had lost so much weight in the last three months. Interview on 04/14/25 at 1:40 P.M. with RD #705 verified there were several months Resident #116 where the resident was not weighed including October and November 2024, and January and March 2025. RD #705 stated she asked for Resident #116 to be reweighed on 02/28/25 and the March 2025 weight was not reported. The next reported weight loss was on 04/10/25 when the resident was 87.8 pounds. RD #705 stated Resident #116 lost a lot of weight. RD #705 stated her January 2025 nutritional assessment was not complete because she never received the weight for Resident #116. RD #705 stated there was a hand full of residents that had inaccurate documentation and had weights that were not accurate because nurse aides at the facility put them incorrectly. RD #705 stated Resident #116's weights were not put in the medical record, and she could not put an intervention in place as it would not be correct. RD #705 verified there were no nutritional interventions for Resident #116 to address her significant weight loss. Interview on 04/14/25 at 2:10 P.M. with Physician #710 stated Resident #116 had seen some weight loss in the past months likely due to her diagnosis of dementia. Physician #710 stated she was not aware of all the weight loss for Resident #116. Physician #710 confirmed no one at the facility notified her of Resident #116's weight loss or the resident's weights not being obtained on a consistent basis.

Based on medical record review, resident and staff interview, and review of resident lists, the facility failed to ensure residents received follow-up care for audiology services. This affected one (#10) of six residents reviewed for ancillary services. The facility census was 119. Findings include: Review of the medical record revealed Resident # 10 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder bipolar type, unspecified anxiety disorder, unspecified impulse disorder, pseudobulbar affect, and type II diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 10 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #10 had adequate hearing with no hearing aids. Review of the care plan dated 01/30/24 revealed Resident # 10 had potential for inability to understand others related to decline in cognitive status. Interventions included to refer for an audiology evaluation as needed. Review of an audiologist visit document dated 05/30/24 revealed Resident # 10 had a history of impacted cerumen (ear wax) and currently had impacted cerumen bilaterally which completely occluded the ear canals. The audiologist instilled ear wax removal drops to both ears, but Resident #10 declined cerumen removal attempts. Recommendations included cerumen evaluation in four to six months. Further review of Resident #10's medical record revealed no further documentation provided regarding follow up appointments to address impacted cerumen since the appointment on 05/30/24. The facility provided a list of residents who had been seen for audiology services on 02/06/25, and Resident #10 was not seen. During an interview on 04/07/25 at 2:05 P.M., Resident # 10 stated his right ear kept clogging up and he had never seen an audiologist at the facility. During an interview on 04/10/25 at 3:32 P.M., Social Worker (SW) #173 verified Resident #10 had not been seen by audiologist since last appointment on record on 05/30/24. During an interview on 04/14/25 at 9:59 A.M., Care Referral Specialist #333 stated Resident #10 was not scheduled for or refused any audiology appointments since 05/30/24.

Based on observation, medical record review, staff interview, interview with local health clinic staff, review of hospital documentation, and policy review, the facility failed to recognize potential hazards related to residents attending community appointments unsupervised an failed to ensure a resident was properly assessed for use of a sit-to-stand lift for transfers. This affected one (#75) of one residents sampled for community appointments and one (#5) of 10 residents reviewed for accidents and hazards. The facility census was 119. Findings include: 1. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD), unspecified severe protein calorie malnutrition, unspecified anxiety disorder, unspecified psychosis, mixed adjustment disorder, psychotic disorder with delusion, and alcohol dependence. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had self-directed behaviors, did not reject care, and did not wander. Review of the care plan dated 06/06/23 revealed Resident #75 wanted to discharge to an apartment. Family had concerns about independent living and advised assisted living. The family indicated the resident had failed at independent living in the past and ended up homeless. Interventions included identifying barriers to discharge goals, educating the resident to assist with a successful discharge, identifying home service needs, identifying home equipment needs, and identifying the resident's desired location for discharge. Review of the care plan dated 10/28/24 revealed Resident #75 was at risk for elopement related to impaired safety awareness, hovering near exit doors, and expressing desires to return to the community. Resident #75 resided on a secured unit related to impaired cognitive function. Interventions included distracting the resident from wandering, identifying patterns of wandering, and monitoring for tailgating behaviors. Review of a secured unit evaluation dated 01/08/25 revealed Resident #75 did not wander, was able to ambulate independently, had combative behaviors that could be managed on a general unit, could perform activities of daily living (ADLs) independently or with one-person assistance, and residing on a secured unit was the least restrictive approach to ensuring his safety. Review of the progress notes revealed on 03/24/25 a 6:35 P.M., Resident # 75 went to an appointment at a health clinic via transport provided by the clinic. Upon noting Resident #75 had not returned to the facility, Registered Nurse (RN) #169 attempted to call both the clinic and the resident and received no answer from either. RN #169 notified the unit manager and Resident #75's daughter. On 03/24/25 at 8:58 P.M., Resident #75 contacted RN #169 and reported he was not coming back to the facility. The unit manager notified Resident #75's daughter and the provider on-call. On 03/26/25, Social Worker (SW) #173 attempted to call the local police department twice with no answer. On 03/26/25 at 4:02 P.M., SW #173 contacted adult protective services (APS) and informed the facility the family should contact the police and file a police report. When SW#173 contacted the family, Resident #75's daughter stated Resident #75 called her from another location in the same county as the facility. She reported the information to the police, but when police arrived at the location, Resident #75 was not located. On 03/27/25 at 6:31 P.M., RN #169 contacted the local police department, an officer came to the facility, and the facility filed a police report. During an interview on 04/03/25 at 9:30 A.M., RN #169 stated Resident #75 approached him on 03/24/25 between 12:30 P.M. and 1:00 P.M. holding papers in his hands and stated he had an appointment at a health clinic. The car was waiting outside to take him. RN #169 stated the appointment was a follow up to a lung examination. RN #169 stated Resident #75 had been to multiple appointments at that clinic in the past and would go unsupervised. In the past, the clinic sent either an Uber car or a marked van to pick him up and always returned Resident #75 to the facility after the appointments. RN #169 stated he became concerned when Resident #75 had not returned between 4:00 P.M. to 5:00 P.M. RN #169 stated when he attempted to contact the clinic, the clinic was closed, and after-hours staff were not able to provide any information. RN #169 stated he attempted to telephone and text message Resident #75 but got no response. Resident #75 telephoned RN #169 between 7:00 P.M. and 8:00 P.M. and stated he would not be returning to the facility. Resident #75 indicated he was unharmed. When RN #169 notified Resident #75's family, the daughter reported Resident #75 had already informed her he had left the facility and was not returning. She indicated Resident #75 was safe but did not know where he was staying or how he would get his medications. RN #169 stated the social worker had contacted APS and asked RN #169 to contact the police after her attempts were unsuccessful. RN #169 stated he contacted police and they came to the facility to file the report. During an interview on 04/03/25 at 3:05 P.M., the Director of Nursing (DON) stated the clinic sent an unmarked car to pick Resident #75 up for his appointment at the health clinic. RN #169 tried to call the clinic when Resident #75 did not return. The DON verified no one from the facility attempted to follow up further with the clinic after Resident #75 called and reported he was discharging himself against medical advice (AMA). The DON stated all appointments were kept in an appointment log. The DON verified Resident #75 did not have an appointment listed on the appointment log for 03/24/25 and told the nurse at the last minute about the appointment. The DON stated the incident was not reported as an elopement but was considered a case of a resident leaving AMA. The DON stated SW #173 informed her the procedure in the past for any resident who left AMA included reporting to APS and the police for safety when the resident went to an unknown location and had no access to medications, but that was not in any policy. During a telephone interview on 04/03/25 at 3:17 P.M. a Service Advocate at the health clinic stated Resident #75's last scheduled appointment was 03/10/25 at the clinic, and Resident #75 did not show up to the appointment. The service advocate stated Resident #75 did not have an appointment at the clinic on 03/24/25 and the clinic did not send a vehicle to the facility to pick Resident #75 up from the facility. The service advocate stated if the clinic had picked up a resident from a facility for an appointment, they would have returned the resident to his facility after the appointment as part of their service. During an interview on 04/03/25 at 4:12 P.M., RN #169 verified he was unaware Resident #75 had an appointment until Resident #75 told him he had an appointment on 03/24/25. RN #169 verified Resident #75 approached him with a bunch of papers in his hands and stated the car was outside to pick him up for his appointment at the clinic. RN #169 confirmed he did not look at the papers Resident #75 held in his hand to verify that the resident had an appointment before he allowed Resident #75 to leave the unit. RN #169 stated he watched Resident #75 get into the backseat of of an unmarked car which he assumed was an Uber provided by the health clinic. RN #169 verified he did not attempt to re-contact staff at the health clinic after Resident #75 reported he was not returning to the facility on [DATE]. Review of policy titled, Elopements, dated December 2007 revealed the facility investigated and reported all cases of missing residents. 2. Review of the medical record for Resident #50 revealed an admitted d 03/29/24. Diagnoses included cognitive communication deficit, chronic diastolic heart failure, chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, anxiety, and dementia. Review of an admission document dated 03/29/24 for Resident #50 revealed he was assessed as a two-person transfer in mechanical lift. Review of the hospital discharge summary dated 03/11/25 revealed Resident #50 was admitted to local hospital with onset of stroke-like symptoms that included leaning to the left side and was more confused and aphasic than his baseline. Resident #50 was negative for hemorrhage or evolving ischemia. Review of a quarterly MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 was assessed to require supervision or touching assistance for meals. Resident #50 required partial to moderate assistance for oral care. Resident #50 was dependent for dressing the upper and lower body, placing shoes on and off, personal hygiene, toileting, and bathing. Resident #50 used a wheelchair to ambulate with staff at the facility. Review of the plan of care dated 03/27/25 revealed Resident #50 was at risk for falls, having history of falls. Interventions included frequent monitoring for attempting to transfer self from the bed, air loss mattress overlay with bolsters, frequent monitoring for attempting to transfer self from bed, leave the door open if the resident allowed to visualize him, occupational therapy to evaluate related to increased weakness, provide activities that promote exercise, and physical consult for strength and mobility. Resident #50 was at risk for assistance with activities of daily living related to muscle weakness, dementia, aphasia, and congestive heart failure. Interventions included staff to assist with completion of activity of daily living on a daily basis, therapy to evaluate and treat, and the resident was transferring assist with weight-bearing assistance. Resident #50 used a wheelchair with staff ambulating him. Observation on 04/09/25 from 11:18 A.M. through 11:31 A.M. revealed Certified Nurse Aid (CNA) #165 and CNA #192 assisted Resident #50 with care, dressing, and providing a transfer out of the bed. CNA #165 and CNA #192 placed a sit-to-stand lift chest lift pad under Resident #50's arms and locked in the legs to both leg straps on each shin rest at the lower lift bar. Resident #50 was educated to stand and hold the handle grips on the sit-to-stand when being lift. Resident #50 held the sit-to-stand lift grip to the right hand tightly, and the left hand he lightly grabbed the bar under the bar handle. CNA #165 verified at 11:27 A.M. Resident #50 let go of his left hand and dangled his entire arm to the left side. Resident #50 transferred to the wheelchair by sit-to-stand with two nurse aides and in wheelchair. Resident #50 was leaning in wheelchair to the left side. Interview on 04/09/25 at 12:44 P.M. with Therapy Director (TD) #153 stated Resident #50 was not assessed for sit-to-stand lift to be used. TD #153 stated Resident #50 was private pay for the therapy. TD #153 stated the resident's power of attorney did not want to pay for his therapy. Resident #50 was a contact guard assist with about 25 percent (%) with hands with therapy. Resident #50 should have been transferred with a gait belt with two person assist at this time. TD #153 stated he was in the process of getting a new wheelchair with a splint to left arm due to weakness from a recent stroke a month ago. TD #153 stated if Resident #50 was not holding the handle grips on the sit-to-stand lift, then it was a concern since he would have left side weakness in his leg. TD #153 stated Resident #50 would need evaluation for using a lift with transfers. Interview on 04/09/25 at 1:01 P.M. with the DON stated she expected staff would assess Resident #50 when admitted to the facility. The DON stated he was assessed on admission with a nurse for a mechanical lift. Review of the facility document titled, Lift Transfer Reposition Evaluation, dated 03/29/25, revealed Resident #50 had an evaluation that he was a two-person transfer and was unable to provide 50% assistance during transfer or transfers without assistance using a slide board. Resident #50 can sit-to the side of the bed or have limited assistance to sit up, and the type of lift indicated was a sit-to-stand lift. Review of the facility document titled, Safe Lifting and Movement of Residents, dated October 2009, revealed in order to protect the safety and well-being of staff and residents, and to promote quality of care, the facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care of plan. Such an assessment shall include residents' preferences for assistance, mobility, residents size, weight-bearing ability, cognitive status, whether residents were usually cooperative with staff, and goals for rehabilitation. This deficiency represents non-compliance investigated under Master Complaint Number OH00164250, Complaint Number OH00162927, and Complaint Number OH00163411. 44080

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to provide timely assistance for a resident who was dependent for incontinence care. This affected one (#5) of one residents reviewed for incontinence. The facility census was 119. Findings Included: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Resident #5 required substantial assistance for meals, oral care, dressing the upper body, and personal hygiene. Resident #5 was dependent for putting on and taking off shoes, dressing the lower body, toileting, and bathing. Review of a plan of care dated 01/17/25 revealed Resident #5 was at risk for activities of daily living (ADLs) self-care performance deficit related to disease process. Resident #5 was at risk for decline in physical function related to osteoarthritis. Interventions included assistance as needed with showers twice weekly, encouraging the resident to participate to the fullest extent, and total dependence with showers and personal care. Review of the care plan dated 01/17/25 revealed Resident #5 had potential for impairment to the skin integrity related to incontinence and decreased mobility. Resident #5 was at risk for decline in his continence status related to his current medical condition, impaired cognition, and overall medical condition. Resident #5 required assistance from staff for toileting and was incontinent of bowel and bladder. Interventions included urinary incontinence brief use, clean peri-area with each incontinence episode, and check the resident for incontinence during rounds. Observation on 04/07/25 from 1:39 P.M. through 4:31 P.M. revealed Resident #5 was sitting in the main lobby watching television. During this timeframe, Certified Nurse Aide (CNA) #228 was moved to another hall and left the floor. Interview on 04/07/25 at 3:05 P.M. with Licensed Practical Nurse (LPN) #254 stated CNA #228 was pulled to another floor to work. Interview on 04/07/25 at 4:31 P.M. with LPN #254 verified Resident #5 was moderately saturated with urine in incontinent brief and was wet. LPN #254 also verified Resident #5 had an old scar area to the right upper buttocks. Interview on 04/09/25 at 11:54 A.M. with CNA #228 stated he left the floor on memory care unit at 3:00 P.M. and was pulled to another floor. CNA #228 stated Resident #5 was last changed for incontinence before lunch at 12:20 P.M. as the lunch was later that day. Review of the undated facility document titled, Perineal Care, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for any special needs of the resident. Also report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00162789.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to monitor weights on a consistent basis and failed to address and implement interventions for a resident with significant weight loss in a timely manner. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. Resident #116 required supervision or touching assistance for meals and dressing the upper body. Resident #116 required partial to moderate assistance for personal hygiene, dressing the lower body, placing shoes on and off the feet, and oral care. Resident #116 required substantial to maximal assistance for bathing and toileting. Resident #116 was self-ambulatory and needed no durable medical equipment. Review of the plan of care dated 02/05/25 revealed Resident #116 required assistance with activities of daily living (ADLs) related to vascular dementia and chronic obstructive pulmonary disease. Interventions included assistance as needed with showers, encourage the resident to participate to the fullest extent possible, give the resident one step commands for completion of ADLs tasks, personal hygiene assistance with weight bearing assistance, staff to assist with completion of ADLs on a daily basis, and therapy to evaluate. Review of a physician order dated 07/31/24 revealed Resident #116 had an order for a no added salt diet with regular texture and thin liquids. Review of the medical record revealed Resident #116 weighed 126.6 pounds on 07/31/24. Review of Resident #116's medical record revealed on 08/07/24 the resident weighed 126.6 pounds, on 08/14/24 weighed the resident weighed 125.4 pounds, on 08/21/24 the resident weighed 125.4 pounds, and on 09/10/24 the resident weighed 124.2 pounds. Review of a nutrition note dated 10/30/24 by Registered Dietician (RD) #705 revealed Resident #116 was on a no added salt diet, thin liquids, and oral intakes varied but were mostly between 75 percent (%) and 100%. The resident's weight for October 2024 was pending and it was reported Resident #116 had a good appetite. RD #705 documented the facility would continue to monitor Resident #116 for necessity of additional nutritional interventions. Review of the medical record revealed Resident #116's weight on 12/10/24 was 135.6 pounds. Review of a nutrition note dated 01/30/25 by RD #705 revealed Resident #116 remained on a no added salt diet with variable intakes, but mostly consumed between 50% and 100% of meals. Resident #116's January 2025 weight was pending and it was documented Resident #116 would be monitored for necessity of additional nutritional interventions. Review of the medical record for Resident #116 revealed on 02/19/25 the resident weighed 88.6 pounds and on 02/27/25 weighed 88.0 pounds. Review of a nutrition note dated 02/28/25 by RD #705 revealed it was recommended Resident #116 be reweighed indicating the documentation was likely inaccurate. Resident #116 was noted with significant weigh loss over 180 days. Review of the medical record for Resident #116 revealed on 04/10/25 the resident weighed 87.8 pounds. Review of the medical record between 07/31/24 and 04/14/25 revealed no nutritional interventions were implemented, including nutritional drinks or supplements, to address Resident #116's significant weight loss. Observation on 04/07/25 from 11:30 A.M. through 4:30 P.M. revealed Resident #116 continuously walked around the facility. Resident #116 walked around the hallway, in rooms, and very rarely sat down. She walked by herself and used no durable medical equipment for assistance. Interview on 04/14/25 at 1:38 P.M. with the Director of Nursing (DON) verified she was not aware Resident #116 had lost so much weight in the last three months. Interview on 04/14/25 at 1:40 P.M. with RD #705 verified there were several months Resident #116 where the resident was not weighed including October and November 2024, and January and March 2025. RD #705 stated she asked for Resident #116 to be reweighed on 02/28/25 and the March 2025 weight was not reported. The next reported weight loss was on 04/10/25 when the resident was 87.8 pounds. RD #705 stated Resident #116 lost a lot of weight. RD #705 stated her January 2025 nutritional assessment was not complete because she never received the weight for Resident #116. RD #705 stated there was a hand full of residents that had inaccurate documentation and had weights that were not accurate because nurse aides at the facility put them incorrectly. RD #705 stated Resident #116's weights were not put in the medical record, and she could not put an intervention in place as it would not be correct. RD #705 verified there were no nutritional interventions for Resident #116 to address her significant weight loss. Interview on 04/14/25 at 2:10 P.M. with Physician #710 stated Resident #116 had seen some weight loss in the past months likely due to her diagnosis of dementia. Physician #710 stated she was not aware of all the weight loss for Resident #116. Physician #710 stated no one at the facility notified her of Resident #116's weight loss or the resident's weights not being obtained on a consistent basis. Review of the facility policy titled, Weight Assessment and Intervention, dated December 2008, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for weight loss for the residents. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.

Based on medical record review and staff interview, the facility failed to obtain laboratory values as ordered by the physician. This affected three (#5, #116, and #118) of 32 resident medical records reviewed. The facility census was 119. Findings Included: 1. Review of medical records for Resident #5 revealed an admitted [DATE]. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for a complete blood count (CBC), renal panel, and Dilantin level every February, May, August, and November. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for fasting lipid panel, liver function test, hemoglobin A1C, and prostate specific antigen (PSA) yearly that was due April. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for a Phenytoin level every three months. Review of a facility document titled, Laboratory Result, dated 05/21/24, revealed Resident #5 had laboratory values obtained for a renal panel, lipid function panel, PSA, hemoglobin A1C, CBC, platelet level, and Phenytoin level. Review of a facility document titled, Laboratory Result, dated 10/03/24, revealed Resident #5 had laboratory values obtained for a renal panel, lipid function panel, hemoglobin A1C, CBC, platelet level, valproic acid level, and Phenytoin level. Review of a facility document titled, Laboratory Result, dated 04/01/25, revealed Resident #5 had laboratory values obtained for a renal panel, lipid function panel, CBC, and platelet level. Interview on 04/10/25 at 2:40 P.M. with the Director of Nursing (DON) stated she could not find anymore laboratory results for Resident #5 and stated all ordered laboratory values were not completed as ordered. 2. Review of medical records for Resident #116 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of physician order dated 08/02/24 revealed Resident #116 had an order to obtain a lipid panel and hepatic function every six months. Review of a facility document titled, Laboratory Result, dated 08/02/24, revealed Resident #116 had laboratory tests completed for a CBC with differential, platelet count, renal function, hepatic panel, lipid panel, thyroid stimulating hormone (TSH), and prealbumin. Review of a physician order dated 09/01/24 revealed Resident #116 had an order for CBC with differential and renal panel every three months. Interview on 04/10/25 at 2:00 P.M. with DON verified the laboratory results in Resident #116's medical record were the only values available and stated the tests were integrated with the laboratory company and show up in electronic chart. Interview on 04/10/25 at 2:40 P.M. with the DON stated there were no additional laboratory values available for Resident #16 and confirmed the laboratory tests were not completed as ordered. 40471 3. Review of the medical record for Resident #118 revealed an admitted [DATE] with diagnoses of extradural and subdural abscess, osteomyelitis, and Arnold Chiari Syndrome. Review of a physician order dated 03/22/25 revealed an order for a toxicology drug screen. Review of laboratory results revealed no toxicology drug screen was completed for Resident #118. Interview on 04/14/25 at 1:47 P.M. with the DON verified no toxicology drug screen was performed for Resident #118.

Based on observation, resident and staff interview, and medical record review, the facility failed to serve food in a form to to meet resident needs. This affected one (#28) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included dysphagia oropharyngeal phase, cognitive communication deficit, occlusion and stenosis of the right carotid artery, chronic diastolic heart failure, type two diabetes, atrial fibrillation, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of the physician order dated 11/04/24 revealed Resident #28 was ordered a regular diet with mechanical soft texture and thin liquids. Review of the care plan dated 04/14/25 revealed Resident #28 required monitoring of intakes, weight, skin, laboratory values, medication, diet tolerance, and to serve the diet as ordered. A registered dietitian was to evaluate and make diet change recommendations as needed. Observation on 04/07/25 at 5:20 P.M. revealed Resident #28 was served brussel sprouts that were sliced with the leaves whole, approximately three pieces of chopped meat in approximately one and one-half inch to two inch squares, and bow tie pasta in a sauce. Interview on 04/07/25 at 5:21 P.M., with Licensed Practical Nurse (LPN) #254 stated Resident #28 had squares of chicken or pork meat served with his meal and verified the resident was not to have that food. Observation on 04/07/25 at 5:25 P.M. revealed LPN #254 took Resident #28's plate so he would not eat the food. Interview with Resident #28 at the time of the observation revealed the resident was full and did not want another plate of food.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions. This affected one (#67) of three residents sampled for enhanced barrier precautions. The facility census was 119. Findings Include: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic viral hepatitis C, type II diabetes, morbid obesity, cannabis and other stimulant dependence, unspecified psychoactive substance abuse, unspecified anxiety and mood disorders, paraplegia, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of a care plan dated 05/08/24 revealed Resident #67 had an indwelling urinary catheter related to a neurogenic bladder. Interventions included enhanced barrier precautions, following up with urology as needed, and monitoring, documenting, and reporting signs of increased pain and/or infection. Observation on 04/09/25 at 6:44 A.M. revealed Certified Nurse Aide (CNA) #237 did not wear an isolation gown when emptying Resident #67's urinary catheter bag. During an interview on 04/09/25 at 6:48 A.M., CNA #237 verified he did not wear an isolation gown when he emptied Resident #67's urinary catheter bag. CNA #237 stated enhanced barrier precautions were placed for the first week or so after a resident came from the hospital or if a resident was sick. CNA #237 stated he did not know why Resident #67 had a pocketed display on the wall which held isolation gowns and stated Resident #67 was not in any infection control precautions. CNA #237 verified there was a sign for enhanced barrier precautions outside of Resident #67's room in the hand rail but denied having ever been educated on enhanced barrier precautions. Review of policy titled, Enhanced Barrier Precautions, dated 04/01/24, revealed staff were required to wear an isolation gown and gloves during high contact resident care activities including device care for an indwelling urinary catheter.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected two (#42 and #77) of three residents reviewed for call lights. The facility census was 119. Findings Included: Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included palliative care, schizoaffective disorder, dementia, borderline personality disorder, brief psychotic disorder, type two diabetes, and adult sexual abuse. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with mil;d cognitive impairment. Resident #42 required supervision or touching assistance for eating meals. Resident #42 required partial to moderate assistance for dressing the upper body. Resident #42 required substantial maximal assistance for dressing the lower body, putting shoes on and off, personal hygiene, bathing, and toileting. Resident #42 used a wheelchair with assistance from staff to ambulate at the facility. Review of a plan of care dated 03/06/25 revealed Resident #42 was at risk for falls related to deconditioning, dementia, osteoarthritis, chronic obstructive pulmonary disease, incontinence, and medication use. Interventions included be sure Resident #42's call light was within reach and encourage the resident to use it for assistance as needed, check and change on rounds, ensure the resident was wearing appropriate footwear or nonskid shoes, observe for side effects of medication, and physical therapy to evaluate and treat. Review of the medical records for Resident #77 revealed and admitted [DATE]. Diagnoses included cognitive communication deficit, dysphagia oropharyngeal phase, major depressive disorder, and anxiety disorder. Review of a quarterly MDS assessment dated [DATE] revealed Resident #77 had severely impaired cognition. Resident #77 required setup or clean up assistance for eating meals, oral care, toileting hygiene, dressing the upper body and lower body, putting on and off shoes, and personal hygiene. Resident #77 required partial to moderate assistance for bathing and used a walker self-ambulate. Review of a plan of care dated 02/26/25 revealed Resident #77 was at increased risk for falls related to a history of falls, muscle weakness, cognition, medication use, and chronic medical conditions. Interventions included be sure the resident's call light was within reach and encourage the resident to use, encourage the resident for activities, ensure the resident was wearing appropriate shoes, the resident needed a safe environment with even floors, free from spills, and clutter, and provide additional activity of daily living assistance post-fall as needed. Observation on 04/09/25 at 10:55 A.M. revealed Resident #77 was sitting on her bed and a call light was placed on the top of the bed. Interview with Resident #77 at the time of the observation stated she needed staff and was unable to get their attention because the call light was not working. Observation on 04/09/25 at 10:56 A.M. revealed Resident #42 was sitting on her bed and asking for help up. Interview with Resident #42 at the time of the observation stated she needed help with personal care. Observation and interview on 04/09/25 at 10:58 A.M. with Certified Nurse Aide (CNA) #165 confirmed both Resident #77 and Resident #42's call lights were not working. Interview on 04/09/25 at 11:07 A.M. with Unit Manager (UM) #175 verified Resident #77 and Resident #42 did not have working call lights or a silver bell to ring in their room. Review of an undated facility policy titled, Answering the Call Light, revealed staff should be sure the call light was plugged in at all times and when the resident was in bed or confined to a chair, be sure the call light was within easy reach of the resident. Staff should report all defective call lights to the nurse supervisor promptly, and some residents may not be able to use their call light, so be sure to check these residents frequently. This deficiency represents non-compliance investigated under Complaint Number OH00163411, Complaint Number OH00162927, Complaint Number OH00162789, and Complaint Number OH00162565.

Based on observation, resident and staff interviews and review of facility policy, the facility failed to maintain comfortable air temperatures and failed to provide a homelike environment. This affected 10 (#01, #02, #03, #04, #05, #06, #07, #08, #09, and #10) out of 123 residents that resided at the facility. The facility census was 123. Findings include: Observation of Maintenance Assistant (MA) #631 revealed he was obtaining air temperatures in resident rooms on 01/27/25 at 9:53 A.M. Further observation revealed Resident #02's room was 57.6 degrees Fahrenheit (F), Resident #06's room was 61.7 degrees F, Resident #07's room was 61.8 degrees F and the common shower room on the women's secured unit was 66.5 degrees F. Interview with MA #631 on 01/27/25 at 9:53 A.M. verified the air temperature in Resident #02's room was 57.6 degrees F, the air temperature in Resident #06's room was 61.7 degrees F, the air temperature in Resident #07's room was 61.8 degrees F, and the air temperature in the shower room on the women's secured unit was 66.5 degrees F. MA #631 confirmed the packaged terminal air conditioner (PTAC) units in Resident #02, Resident #06, and Resident #07's rooms were not working or putting out heat, and the shower room on the women's secured unit had a fan but did not have a heater. MA #631 reported Resident #01, Resident #02, Resident #03, Resident #04, Resident #05, Resident #06, Resident #08, Resident #09, and Resident #10 had their beds moved from their rooms to the dining room on the women's secured unit because there were concerns about air temperatures in the facility. Interview with Resident #02 on 01/27/25 at 10:00 A.M. revealed it was cold in her room and on the women's secured unit. Resident #02 reported she had to sleep in the dining room on the unit due to the air temperature. Interview with Resident #08 on 01/27/25 at 10:10 A.M. revealed she had to sleep in the dining room for approximately one week with all the other residents because the motor burned up in the heater in her room. Resident #08 stated she disliked sleeping in the dining room and it was cold in her room and on the women's secured unit. Interview with Certified Nurse Aide (CNA) #240 on 01/27/25 at 10:11 A.M. verified Resident #01, Resident #02, Resident #03, Resident #04, Resident #05, Resident #06, Resident #08, Resident #09, and Resident #10 had their beds moved from their rooms to the dining room on the women's secured unit last week because the temperature in their rooms was too cold. Interview with the Administrator and Maintenance Director (MD) #252 on 01/28/25 at 2:02 P.M. revealed the facility identified the PTAC units in Resident #02, Resident #06, Resident #07's rooms were not working on 01/21/25. MD #252 stated the facility's heating and cooling company assessed the units on 01/21/25 and it was determined that the units needed new motors. The Administrator stated all the residents on the women's secured unit had their beds moved to the dining room on the unit due to concerns with the heat in the facility on 01/21/25 when the facility had a break in the sprinkler pipe in a different area of the facility. MD #252 reported the residents were moved to the dining room because the dining room had a different heating system that was not impacted by the break in the sprinkler pipe. MD #252 stated the sprinkler pipe was repaired on 01/21/25 and heat was restored to all the rooms in the women's secured unit on 01/21/25 except for Resident #02, Resident #06, and Resident #07's rooms which had PTAC units that were not functioning properly. The Administrator and MD #252 verified Resident #01, Resident #03, Resident #04, Resident #05, Resident #08, Resident #09, and Resident #10's beds were not returned to their rooms on 01/21/25 after heat was restored and that their beds remained in the dining room on the women's secured unit. Further interview with MD #252 on 01/28/25 at 2:45 P.M. revealed he did not have any documentation of the PTAC units in Resident #02, Resident #06, and Resident #07's rooms were inspected in the past year. Review of the facility's homelike environment policy, dated August 2009, revealed the facility shall provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. The facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized homelike setting. These characteristics include comfortable temperatures. This deficiency represents non-compliance investigated under Complaint Number OH00161091.

Based on medical record review, staff interview, observation, and review of the facility policy, the facility failed to adequately assess residents' skin and failed to ensure adequate care and services were provided to residents to prevent the development and worsening of pressure ulcers. This resulted in Actual Harm for Resident #135 when the facility staff failed to adequately assess the resident's skin and failed to implement timely interventions for a pressure ulcer until the ulcer reached an advanced stage. Actual Harm also occurred for Resident #01 when the facility staff failed to assess the resident's skin and the resident developed an unstageable pressure to the right heel caused by a removable splint device. This affected two (Residents #135 and #01) of the three residents reviewed for pressure ulcers. The facility census was 128. Findings include: 1. Review of the medical record for Resident #135 revealed an admitted [DATE] with diagnoses including muscle weakness, need for assistance with personal care, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #135 dated 06/27/24 revealed the resident had intact cognition, had no pressure ulcers present, but was at risk for the development of pressure ulcers. Review of the care plan for Resident #135 most recently revised on 06/21/24 revealed the resident was at increased risk for pressure ulcer development. Interventions included the following: administer treatments as ordered and monitor for effectiveness, offer and assist with toileting on rounds and as needed, pressure reducing mattress to bed. Review of the weekly skin assessments for Resident #135 revealed there were no weekly skin assessments completed for the resident from 06/14/24 until 07/05/24. Review of the hospital emergency department visit note for Resident #135 dated 06/23/24 revealed the resident had superficial stage one sacral decubitus ulcers which did not appear infected with no surrounding erythema or discharge. Review of the nurse progress note for Resident #135 dated 06/23/24 timed 7:27 P.M. revealed Resident #135 returned to the facility from the hospital emergency department with no new orders. There was no skin assessment completed upon Resident #135's return from the hospital on 06/23/24. Review of the shower sheet for Resident #135 dated 06/26/24 revealed the resident had an area of redness to his sacral area. Review of the nurse progress note for Resident #135 dated 07/02/24 a State tested Nursing Assistant (STNA) called the nurse to the resident's room. The nurse arrived and noted an area to the resident's right buttocks which had eschar (dry, black, firm tissue which formed on full thickness wounds.) The resident voiced complaints of pain to his buttocks and the nurse administered as needed pain medication. The nurse notified the physician and the wound physician and received and implemented a treatment order for the wound to the resident's right buttocks. Review of the physician's orders for Resident #135 revealed wound treatment order for the pressure ulcer to the resident's buttocks was not initiated until 07/02/24. Review of the wound physician visit note for Resident #135 dated 07/05/24 revealed the resident had an unstageable pressure ulcer to the right buttocks which measured 8.8 centimeters (cm) in length by 4.7 cm in width with the depth unable to be determined because 50 percent (%) of the wound bed was covered with 50 percent slough (a yellow or white material that accumulates in a wound bed and is made up of dead cells, pus, and other debris.) The wound had a moderate amount of drainage. Interview on 08/27/24 at 11:10 A.M. with Unit Manager (UM)/Licensed Practical Nurse (LPN) #330 confirmed the facility had not completed skin assessments for Resident #135 from 06/14/24 through 07/05/24. UM/LPN #330 further confirmed Resident #135 was assessed to have stage one pressure ulcers present to the sacral area during a hospital visit on 06/23/24, and the facility staff did not assess the resident's skin upon the resident's return from the hospital on 06/23/24. UM/LPN #330 confirmed the facility staff did not identify and implement a treatment for Resident #135 until 07/02/24 when the resident presented with an unstageable pressure ulcer with eschar to the right buttocks, and by that time the resident's pressure ulcer had already reached an advanced stage. Review of the facility policy titled Pressure Ulcer Risk Assessment revised March 2005 revealed if pressure ulcers were not treated when they were discovered, they could quickly get larger, become very painful for the resident, and often become infected. Once a pressure ulcer developed, it could be extremely difficult to heal. Staff should routinely assess and document the condition of the residents' skin per the facility wound and skin care program for any signs and symptoms of irritation or breakdown. Staff should immediately report any signs of a developing pressure ulcer to the supervisor. Staff should assess resident's skin for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 2. Review of the medical record for Resident #01 revealed an admitted [DATE] with diagnoses including schizoaffective disorder, unspecified psychosis, and displaced bimalleolar fracture of the right lower leg. Review of the MDS assessment for Resident #01 dated 07/27/24 revealed the resident had mildly impaired cognition, had no pressure ulcers present, but was at risk for the development of pressure ulcers. Review of the care plan for Resident #01 dated 03/26/24 revealed the resident was at increased risk for pressure ulcer development. Interventions included the following: administer treatments as ordered and monitor for effectiveness, assist with turning and repositioning on rounds and as needed to relieve pressure areas, low air loss mattress to bed. Review of the hospital progress notes for Resident #01 dated 06/20/24 through 07/20/24 revealed the resident had a surgical procedure to the right ankle which required an ortho-glass splint with an ace wrap. Review of facility progress notes, physician's orders, and assessments for Resident #01 dated 07/20/24 to 08/16/24 revealed there was no documentation of a splint to the resident's right leg, ankle, or foot. Review of the wound physician visit note for Resident #01 dated 08/16/24 revealed the resident had an unstageable pressure ulcer which measured 3.1 centimeters in length by 2.6 cm in width covered with eschar to the right heel related to a medical device, a cast boot which was first identified on 08/15/24. Observation on 08/27/24 at 3:50 P.M. revealed Resident #01 had a dime-sized pressure ulcer to the right heel which was covered in eschar. Telephone interview on 08/28/24 at 11:40 A.M. with Wound Physician (WP) #601 confirmed facility staff reported Resident #01 had a cast or splint present to his right foot when he returned from the hospital following surgery on 07/20/24. WP #601 confirmed staff reported when the cast or splint was removed on 08/15/24 staff discovered a new pressure ulcer was present to the resident's right heel. Interview on 08/28/24 at 11:48 A.M. with UM/LPN #330 confirmed there was no documentation of a cast, splint, or other device being present on Resident #1's right foot following the resident's return from the hospital on 07/20/24. Interview on 08/28/24 at 2:20 P.M with Registered Nurse (RN) #431 confirmed Resident #01 returned from the hospital on 07/20/24 with a hard, splint type device in place to the right lower leg and heel which was held in place by an ace bandage. RN #431 confirmed the splint device was removable, but the staff had not removed the device until 08/15/24 when RN #431 removed the splint in order to remove the sutures Resident #01 had in place to the right ankle. RN #431 confirmed staff discovered Resident #01 had developed an unstageable pressure ulcer to the right heel underneath the splint. Review of the facility policy titled Pressure Ulcer Risk Assessment revised March 2005 pressure ulcers were usually formed when a resident remained in the same place position for an extended period of time causing increased pressure or a decrease in circulation to an area, which destroys tissue. Pressure could also come from splints, casts, bandages, or wrinkles in the bed linen. This deficiency represents noncompliance investigated under Complaint Number OH00157073 and Complaint Number OH00156967 and Complaint Number OH00156451.

Based on medical record review, staff interview, review of the facility's investigation, review of witness statements, review of the hospital records, and policy review, the facility failed to ensure residents were free from resident-to-resident abuse. This resulted in Actual Harm on 05/31/24 when Resident #52, a resident with a known history of aggressive behaviors towards other residents, intentionally ran over Resident #14 with his wheelchair. Subsequently, Resident #14 was sent to the local hospital where she was diagnosed with a closed fracture of the right tibial plateau initial encounter. The facility also failed to ensure Resident #60 was free from resident- to-resident abuse when Resident #52 intentionally ran into the resident with his wheelchair causing the two residents to become involved in a physical altercation. This affected two (#14 and #60) out of three residents reviewed for abuse. The facility census was 126. Findings include: 1) Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, difficulty in walking, muscle weakness, chronic obstructive pulmonary disease (COPD), osteoarthritis, psychotic disturbance, mood disturbance and anxiety, congestive heart failure, adult failure to thrive, anxiety disorder, alcohol dependence, retention of urine, acute kidney failure, schizoaffective disorder, and major depressive disorder. Review of Resident #14's activities of daily living (ADL) care plan dated 12/15/23 and revised 06/17/24, revealed Resident #14 required assistance with ADLs and Resident #14 does ambulate with her walker but is often non-complaint with using her walker and is a fall risk. Interventions included Resident #14 had a rollator walker and a wheelchair, but she did not use them daily, staff to assist with completion of ADLs on a daily basis and Resident #14 required weight bearing assistance with ambulation. Review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact. Review of Resident #14's late entry progress note dated 05/30/24 at 10:30 A.M., revealed Resident #14 returned from the hospital with a right tibia fracture and a urinary tract infection (UTI). New medications were updated on the medication administration record (MAR) and sent to Nurse Practitioner (NP) #550. Review of Resident #14's progress note dated 05/30/24 at 11:43 A.M., revealed Resident #14 was in the hallway trying to get her food order for lunch. Another resident (facility identified #52) ran over Resident #14 with his wheelchair and her leg was dislocated in the wheelchair and the resident hitting her head. NP #550 was at the facility and was aware and new orders were placed to initiate neurological checks, to get x-rays, and for Resident #14 to be sent out for evaluation. Review of Resident #14's hospital After Visit Summary (AVS) dated 05/30/24 revealed Resident #14 was seen due to her being an assault victim with diagnoses listed as assault, fall initial encounter, closed fracture of the right tibial plateau and urinary tract infection (UTI) without hematuria. Resident #14 was treated with antibiotics and pain medications, placed in a knee immobilizer and released back to the facility. Review of Resident #14's progress note dated 06/03/24 revealed another resident rolled into the resident with their wheelchair, resident expressed pain, the physician was called, and the resident was sent to the hospital on 05/30/24 where she was diagnosed with right tibia fracture and a UTI. Resident #14 had orders for Tramadol (narcotic pain relief), Norco (narcotic pain relief) and ibuprofen. The other resident (Resident #52) was moved to a different unit. Review of Resident #14's progress note dated 06/14/24 revealed Resident #14 had a follow up appointment scheduled with orthopedics on 06/18/24 at 2:00 P.M. 2) Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included COPD, acute and chronic respiratory failure with hypoxia, anemia, insomnia, sepsis, schizoaffective disorder and hypertension. Review of Resident #60's most recent MDS assessment dated [DATE], revealed the resident to be cognitively intact. Review of Resident #60's progress note dated 04/05/24 at 7:31 P.M. revealed the State tested Nurse Aide (STNA) (unknown and the facility was unable to verify) was observed separating the residents (the facility identified Resident #52 as being the other resident) and the STNA and Licensed Practical Nurse/Unit Manager (LPN/ UM) #167 deescalated the situation. Head to toe skin assessments were completed and no injury was notified. The physician and Resident #60's guardian were notified. Review of Resident #60's Interdisciplinary Team (IDT) note dated 04/12/24 at 4:24 P.M., revealed Resident #60 was involved in a physical aggressive incident on 04/05/24. Another resident (facility identified as Resident #52) aggressively rolled into Resident #60 with their wheelchair. Resident #60 then kicked the resident in the stomach. The two began to throw blows with closed fists. The residents were immediately separated and assessed for injuries. No injuries were noted at the time of initial assessment. Resident #60 was continually monitored with no complaints, signs, or symptoms of pain. The aggressor was placed on one-on-one, and no further incidents of aggression were noted. Review of the medical record for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, non-pressure chronic ulcer of other part of right foot, malnutrition, diabetes mellitus, schizoaffective disorder, cannabis dependence, depression, anxiety disorder and COPD. Review of Resident #52's physician order dated 02/19/24 revealed Resident #52 resided on a secured unit. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed the resident to be cognitively intact. Review of Resident #52's progress note dated 04/05/24 at 7:02 P.M., revealed STNA (unknown and the facility was unable to verify) was observed separating the residents and the STNA and LPN/UM #167 deescalated the situation. Head to toe skin assessments were completed with no injuries. The physician and Resident #52's guardian were notified. Review of Resident #52's behavior care plan dated 04/09/24 and revised 06/10/24, revealed Resident #52 exhibited verbal and aggressive behaviors at times. Interventions included medications as ordered, caregivers to provide an opportunity for positive interaction, consult behavioral services as needed, explain all procedures to the resident before starting and allow the resident time to adjust to changes, intervene as necessary to protect the right and safety of others, divert attention, remove from the situation, and monitor behavior episodes and attempt to determine underlying causes. Review of Resident #52's Psychiatric Consent to Treat, dated 04/26/23 revealed Resident #52 refused the consent. Interview of the IDT meeting note dated 04/12/24 at 4:35 P.M. revealed Resident #52 was a [AGE] year-old male with a history of schizoaffective disorder, depression, and schizophrenia. Resident #52 initiated the incident of physical aggression on 04/05/24. Resident #52 aggressively rolled his wheelchair into the back of another resident (facility identified as Resident #60). The other resident then kicked Resident #52 in the stomach. Both residents started throwing blows and were immediately separated and assessed for injuries. Skin assessment, neurological assessment, and pain assessments were initiated. No injuries or pain were noted. Resident #52 was placed on one-on-one. No further incidents of aggression were noted since the incident. Review of Resident #52's progress note dated 05/09/24 at 2:13 P.M. revealed Resident #52 had increased agitation, aggressively rolled his wheelchair on other residents, was cursing residents out, called other residents names and attempted to jump on them. Resident #52 did not eat for three days and refused his medications. The nurse redirected Resident #52, but it was unsuccessful. The physician was notified, and Resident #52 had a new order in place to send Resident #52 to the hospital for a psychiatric evaluation. All management staff were notified. Review of Resident #52's progress note dated 05/09/24 at 6:00 P.M., revealed transportation arrived to pick Resident #52 up and the resident refused to go to the hospital for a psychiatric evaluation. Review of Resident #52's progress note dated 05/30/24, revealed Resident #52 intentionally ran another resident (facility identified as Resident #14) over with his wheelchair. Resident #52 had no new injuries noted and refused to allow staff to take vital signs. NP #550 was made aware, and a new order was given to send Resident #52 out to the hospital for evaluation. Review of Resident #52's progress note dated 06/12/24 at 2:04 P.M., revealed Resident #52 returned to the facility from the hospital. A head-to-toe assessment was completed with no skin issues. The resident was in a pleasant mood with no complaints of pain or discomfort. Review of Resident #52's one-on-one observation forms dated 04/05/24 to 05/30/24, revealed Resident #52 was on a one-on-one monitoring from 04/05/24 at 10:15 A.M. to 04/12/24 at 12:45 A.M., on 05/09/24 from 1:00 A.M. to 05/10/24 at 12:45 P.M. and again on 05/30/24 from 10:00 A.M. to 10:30 A.M. Review of the facility's Self-Reported Incident (SRI) dated 04/05/24 at 3:37 P.M. for an alleged physical abuse, revealed Resident #52 and Resident #60 were involved in a physical altercation and both residents were separated for continued safety measures. Resident #52 was observed to be yelling aimlessly in the hallway in an aggressive manner. Resident #60 was exiting his room and Resident #52 was observed to roll into Resident #60. Resident #60 then turned and struck Resident #52 and Resident #52 grabbed Resident #60 by his collar as the two struck each other. Both residents were separated, and Resident #52 was placed on one-on-one monitoring. The SRI was unsubstantiated. Review of the facility's SRI dated 05/31/24 at 10:01 A.M. for alleged physical abuse, revealed Resident #52 was observed being aggressive towards Resident #14. Both residents were separated and continued safety measures. Resident #14 was knocked down on the ground and was taken to the emergency room for further evaluation. All responsible parties were made aware of the incident. Resident #52 was observed, to be unprovoked, and to use his wheelchair to intentionally knock over Resident #14. Resident #14 complained of pain in her right leg following the incident and was transferred to the emergency room for further evaluation. Resident #14 was transferred to the hospital and was diagnosed with a right tibia fracture and urinary tract infection. Resident #52 was transferred to the men's unit and was transferred to the hospital for psychiatric evaluation. The SRI was unsubstantiated by the facility as evidence indicated abuse did not occur. Review of STNA #138's witness statement dated 05/31/24, revealed STNA #138 was at the nurse's station charting when she noticed Resident #52 roll away from the nurse's station in the direction of Resident #14 and then rolled over her. When STNA #138 stood up, she noticed that Resident #14 was under Resident #52's wheelchair and Resident #14 began to complain of right knee and leg pain. The nurse on duty then began to administer aid to her after separating the two residents. Interview on 06/17/24 at 12:37 P.M. with LPN/UM #167 and the Director of Nursing (DON) revealed, LPN/UM #167 observed Resident #52 going down the hallway and Resident #60 was coming out into the hallway on 04/05/24. LPN/UM #167 stated he went to his office and staff called him out to the hallway and he witnessed Resident #52 holding onto Resident #60's collar and Resident #52 was swinging at him. LPN/UM #167 stated Resident #60 had his leg out kicking Resident #52. LPN/UM #167 stated Resident #52 was the aggressor in the incident because he intentionally rolled over Resident #60 with his manual wheelchair. LPN/UM #167 also stated Resident #52 had an additional incident on 05/31/24. LPN/UM #167 reported Resident #52 was in the hallway talking to the staff and Resident #52 ran over Resident #14 with his manual wheelchair. Resident #14 was sent to the hospital, and she was diagnosed with a closed fracture of the right tibial plateau. LPN/UM #167 stated Resident #14 was able to walk independently without a mobility device prior to the incident and she was walking without assistive device at the time of the incident. LPN/UM #167 reported Resident #14 was not able to walk since Resident #52 ran her over with his manual wheelchair on 05/31/24 and Resident #14 had a knee immobilizer that was put in place at the hospital on her right leg. Interview with STNA #138 on 06/17/24 at 12:49 P.M. revealed STNA #138 was behind the nurse's station charting and Resident #52 was mumbling but it was not towards anyone. STNA #138 stated Resident #14 was at the medication cart and Resident #14 went to walk past Resident #52 and he aggressively rolled her over with his manual wheelchair. STNA #138 stated that she ran out to assist Resident #14 and the nurse and physician came to assess Resident #14 before staff moved her to a wheelchair. STNA #138 stated Resident #14 was taken to her room and placed into bed until she was sent to the hospital. A telephone interview with NP #550 on 06/17/24 at 12:59 P.M., revealed she was at the nurse's station getting a report on the residents when she heard Resident #14 saying stop! stop! and she observed Resident #14 walk in front of Resident #52. NP #550 stated Resident #52 rolled Resident #14 over with his manual wheelchair and it did not appear accidental. NP #550 reported Resident #52 did not appear remorseful and NP #550 stated Resident #14 was ambulating with no assistive device at the time of the incident. NP #550 stated Resident #14 was sent out to the emergency room , and she sustained a fracture to her right leg as a result of the incident. NP #550 reported Resident #52 was sent out for a psychiatric evaluation on 05/31/24. NP #550 stated Resident #14 currently required a wheelchair and could not walk due to the fracture. Observation of Resident #14 on 06/17/24 at 1:13 P.M. revealed the resident was sitting in her room in a wheelchair wearing an immobilizer on her right knee. Interview with Resident #14 at the same time, revealed Resident #14 could not recall the date of the incident but stated a man was sitting in his manual wheelchair near the nurse's station and he decided to run her over with his manual wheelchair. Resident #14 stated the man was going back and forth over her with his manual wheelchair and she had pain in her right leg after the incident. Resident #14 reported the man was cursing prior the incident, but he was not cursing at her. Resident #14 stated she was able to walk prior to the incident and Resident #14 stated she was walking without an assistive device on the date of the incident, but she was not able to walk after the incident. Resident #14 stated she had a knee brace that she received at the hospital after she broke her leg. Observation of Resident #52 on 06/17/24 at 4:17 P.M. revealed Resident #52 was rolling himself in the hallway in his manual wheelchair by picking up his feet and using his arms to maneuver the wheelchair. Interview with Resident #52 at the same time, revealed Resident #52 accidentally hit Resident #14 with his manual wheelchair on 05/31/24. Resident #52 stated he did not intentionally hit Resident #14 and he denied any prior incidents or altercations at the facility. Observation of Resident #60 on 06/18/24 at 10:26 A.M. revealed Resident #60 was sitting in the common area on the unit. Resident #60 was observed to get up and ambulate independently. Interview with Resident #60 at the same, revealed the resident did not want to discuss the incident between him and Resident #52. Interview on 06/18/24 at 10:30 A.M. with the DON, verified the progress note on 05/09/24 stated Resident #52 attempted to run over residents with his wheelchair. The DON stated Resident #52 denied psychiatric care on 04/05/24 and he was ordered to go out to the hospital on 05/09/24 but he refused. The DON stated Resident #14 was placed on one-on-one monitoring from 04/05/24 to 04/12/24 and again on 05/09/24 to 05/10/24. Review of the facility's abuse investigation and reporting policy dated December 2016, revealed all reports of resident abuse shall be promptly reported to local, state and federal agencies as defined by current regulations and thoroughly investigated by facility management. This deficiency represents non-compliance investigated under Complaint Number OH00154689.

Based on record review, observation, resident interview, staff interview, review of hospital reports, and review of facility policy, the facility failed to ensure staff safely assisted residents with transfers. This resulted in actual harm when a staff person was pushing Resident #73 via wheelchair without the footrests in place. Resident #73 fell face forward and sustained a laceration to his head requiring emergency hospital transfer and sutures. This affected one (Resident #73) of three reviewed for accidents. The facility's census was 133. Findings include: Review of the medical record for Resident #73 revealed an admitted [DATE] with diagnoses including quadriplegia, anxiety disorder, bipolar disorder, and schizoaffective disorder. Review of the Minimum Data Set (MDS) for Resident #73 dated 04/01/23, revealed the resident was cognitively intact and was totally dependent upon the assistance of two staff with transfers and was non-ambulatory. Review of the fall risk assessment for Resident #73 dated 02/04/23 revealed the resident was at risk for falls. Review of the care plan for Resident #73 updated 04/11/23, revealed the resident was at risk for falls related to dependence on staff for transfers/mobility. Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, education for safety of foot pedals to be on and resident sitting in an upright position in wheelchair, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, follow facility fall protocol, and physical therapy to evaluate and treat as needed. Review of the nurse progress note for Resident #73 dated 03/24/23 per Licensed Practical Nurse (LPN) #250, revealed the nurse was at the nurse's desk and heard a loud thump noise and when she stood up, she saw the resident lying face down on the floor in front of his wheelchair. Resident #73 had a gash above his right eye, which was bleeding. The nurse applied pressure to the laceration and called 911. Emergency personnel arrived and wrapped Resident #73's head with an ace wrap and took the resident to the hospital. Review of hospital notes for Resident #73 dated 03/24/23 revealed the resident presented to the hospital with complaint of head injury and laceration over the right eyebrow from a fall at the facility. The resident was quadriplegic from a past history of trauma and he accidentally fell to the ground from his wheelchair and struck his head, causing bleeding from a laceration above the right eyebrow. Resident #73 received a tetanus shot and the laceration above the right eyebrow was noted to be six centimeters (cm) in length and required closure with ten sutures. Observation on 04/24/23 at 9:23 A.M. of Resident #73 revealed the resident was sitting in his custom high-back manual wheelchair with footrests in place and the resident's feet were positioned on the footrest. Resident #73 had a healing laceration noted above his right eyebrow which was approximately six cm in length. Interview on 04/24/23 at 9:23 A.M. with Resident #73 confirmed on 03/24/23, he was up in his wheelchair in the common area outside the therapy gym. His legs were not on the footrests, and they had been pushed to the side because he was getting ready to have therapy soon. Resident #73 confirmed Business Office Manager (BOM) #425 approached him in the hall because he had requested to have someone from administration discuss his finances. Resident #73 confirmed he did not want to discuss financial matters in the common area and BOM #425 suggested they talk in the resident's room. Resident #73 confirmed BOM #425 did not place the footrests back in position and did not place his feet on the footrests, and his feet were still dangling when BOM #425 began to push his wheelchair. Resident #73 confirmed he has quadriplegia and is unable to move his extremities. Resident #73 confirmed because his feet were not on the footrests, when BOM #425 pushed his wheelchair forward it caused him to fall face forward out of the chair and onto the floor. Resident #73 confirmed he did not lose consciousness and he felt a large amount of blood coming from a gash on his head. Resident #73 confirmed the nursing staff provided first aid and called 911. He went to the hospital and had to have a tetanus shot and stitches to close the gash to his right eyebrow. Interview on 04/24/23 at 1:40 P.M. with the Administrator, [NAME] President of Clinical Services (VPCS) #975, and Licensed Practical Nurse (LPN) #640 confirmed the facility conducted an investigation of Resident #73's fall on 03/24/23. Interview confirmed Resident #73 had quadriplegia and was unable to move his extremities himself. The resident used a high back custom wheelchair with footrests for mobility. Resident #73 was unable to propel his wheelchair himself. Interview confirmed BOM #425 pushed the resident's wheelchair forward without the footrests in place and the resident's feet were left dangling, causing Resident #73 to fall forward and sustain a laceration about his right eye, in which required hospitalization and sutures. Interview confirmed the facility's investigation determined the root cause of Resident #73's fall on 03/24/23, was due to an untrained staff member transporting him from one place to another without ensuring a safe transfer. Interview confirmed the facility's follow up intervention was to have LPN #635 provide education to BOM #425 on 04/25/23 to allow clinical staff to transfer residents. Interview on 04/24/23 at 2:30 P.M. with LPN #250 confirmed she was at the nurse's station on 03/24/23 when she heard a loud thump and stood up and saw Resident #73 on the floor face down in front of his wheelchair. Resident #73's footrests were not in place but had been pushed to the side. Resident #73 had a laceration to his head with a copious amount of blood. LPN #250 confirmed she applied pressure to the resident's head and called 911. LPN #250 confirmed Resident #73 said he fell face forward when a staff person pushed his wheelchair forward without his feet on the footrests and they got caught on the floor, which caused him to fall face forward out of his chair. Review of the facility policy titled, Falls Clinical Protocol, dated March 2018 revealed the facility would assess the resident's risk for falls, and the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on medical record review, review of facility self-reported incident (SRI), review of facility investigations, observations, staff and resident interviews, and review of a facility policy, the facility failed to ensure residents were free from abuse. This resulted in Actual Harm for when Resident #118 was physically abused by Resident #72 and subsequently required hospital evaluation/treatment for a right wrist fracture, and when Resident #117 was physically abused by Resident #95 and subsequently required hospital evaluation/treatment for a broken jaw. Additionally, the facility failed to ensure Resident #19 was free from staff-to resident abuse and failed to ensure Resident #41 and #53 were free from resident-to-resident abuse which placed the residents at risk for more than minimal harm that did not result in actual harm to the residents. This affected five (#19, #41, #53, #118, and #117) of 11 residents reviewed for abuse. The facility census was 121. Findings include: 1. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavioral disturbance, unspecified Alzheimer's disease, unspecified anxiety disorder, hypertension, peripheral vascular disease, and mild receptive-expressive language disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #118 was a one-person assist and required extensive assistance with bed mobility, transfers, and toileting, and supervision with dressing, eating, locomotion, and personal hygiene. Review of care plan dated 07/11/22 revealed Resident #118 had potential to exhibit physical and verbal behaviors to staff and other residents related to dementia with behavioral disturbance. Interventions included medications as ordered, anticipate needs, minimize potential for disruptive behaviors with tasks/diverting attention, and provide activities program. Additionally, Resident #118 had pain related to right upper arm related to fracture. Interventions included administer pain medications as ordered, assess pain level, assess for non-verbal signs of pain, offer medications prior to painful treatments offer relaxation techniques, assist to change positions as needed, and monitor for effects of pain medications. Review of hospital records dated 10/29/22 revealed emergency medical services (EMS) reported to the hospital that Resident #118 was in an altercation with another resident at the facility and was pushed down. Resident #118 presented to the emergency room (ER) with arm splinted by EMS. When the ER removed the splint, Resident #118's arm had a noticeable deformity to the right elbow. Resident #118 was holding his right elbow and grimacing with pain. On 10/29/22 the hospital completed diagnostic testing including x-rays to right humerus, right shoulder, right wrist, and bilateral elbows, and computerized tomography (CT) scans without contrast to head and cervical spine. Results of x-rays showed probable fracture to right radial head and proximal ulna. CT results showed no abnormalities. Review of progress notes revealed on 10/29/22 Resident #118 had an unwitnessed fall that may have involved a incident with another resident on the men's unit. Resident #118 was found getting up off the floor and complained of pain to his right arm. Resident #118's right arm did have some swelling at elbow, and the resident was walking with unsteady gait. Paramedics were called and the resident went to the hospital for evaluation and treatment. Review of SRI dated 10/31/22 revealed upon investigation, the facility substantiated allegations of resident-to-resident physical abuse on 10/29/22, when Resident #118 was pushed to the ground in the dining room by Resident #72 and sustained fracture to his right arm. On 10/29/22 it was noted that Resident #118 was observed getting himself up off of the floor in the dining room area. He presented with complaint of pain to his right elbow. Per the investigation, there had been an altercation between Residents #118 and #72, as Resident #72 had admitted to pushing Resident #118 down to the ground. Resident #118 was sent to the emergency room for his pain and swelling in the right elbow. Resident #72 was placed on one-on-one (1:1) supervision. Resident #118 was found to have a fracture to his right arm and returned back to facility with his right arm placed in a brace and sling in place. Staff were interviewed and no staff witnessed the altercation. No residents witnessed the altercation either. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavior disturbance, paranoid schizophrenia, generalized anxiety disorder, and schizoaffective disorder bipolar-type. Review of the most recent MDS assessment dated [DATE] revealed Resident #72 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #72 was a one-person assist and required extensive assistance with bed mobility, transfers, and toileting, and supervision with dressing, eating, locomotion, and personal hygiene. Review of care plan dated 10/31/22 revealed Resident #72 had a history of being physically aggressive and physically throwing chairs related to schizoaffective disorder-bipolar type and unspecified bipolar disorder. On 10/30/22 Resident #72 exhibited physical behaviors/aggression towards another resident causing injury. Interventions included medication as ordered, assist to develop appropriate methods of coping/interaction, intervene as necessary to protect the rights/safety of others, monitor behaviors to determine underlying cause, and provide activities to accommodate the resident. Review of witness statement dated 10/31/22 at 9:20 A.M. revealed Registered Nurse (RN) #126 stated The aides and I were talking in the hallway when we heard a commotion coming from the dining room. When I got to the dining room, (Resident #118) was getting up off the floor and (Resident #72) was standing there and shouting 'He's always bothering me'. When asked neither resident was able to verbalize what happened. The nurse stated she did not report the incident as a potential abuse allegation because she did not see anything happen. RN #126 charted that it might have been an incident between two residents because the two residents were present when the unwitnessed incident occurred. Observation on 11/14/22 at 12:38 P.M. revealed Resident #118 was seated in dining room eating lunch. Resident #118's right arm had a cast wrapped with ace bandage from wrist to mid upper arm. During an interview on 11/16/22 at 10:55 A.M. Corporate Registered Nurse (RN) #211 stated the nurse on duty reported to management that Resident #118 had fallen 10/29/22 and RN #126 did not indicate that the incident might have involved another resident. Corporate RN #211 stated she was reviewing the fall on 10/31/22 and interviewed Resident #118 who stated another resident (#72) had pushed him down. During an interview with the other resident, Resident #72 admitted to pushing Resident #118 because he was tired of dealing with him. During an interview on 11/16/22 at 11:09 A.M. the Director of Nursing (DON) stated she was notified on the weekend of 10/29/22 that Resident #118 was injured after a fall in the dining room and was sent out for treatment. When the DON came in on Monday, 10/31/22 she reviewed the progress notes and discovered there was a possible altercation between two residents. Upon interviewing the residents, Resident #72 indicated that he hit Resident #118 because Resident #118 thought the chairs in the dining room were his and accused Resident #72 of sitting in his chair. The DON stated staff collected statements and also notified the police. The local police seem to feel like the facility was a nuisance, so they did not come out. The DON stated Resident #72 was placed on 1:1 supervision until he could be evaluated by psych. Resident #118 was moved to a new room. Corporate RN #211 interviewed all staff and, there were no witnesses. The DON stated staff interviewed and assessed all residents, and there was no other harm noted. The DON stated the QAPI committee reviewed the incident because it was not reported appropriately, and Corporate RN #211 was completing daily audits of nursing notes since 10/31/22. The DON stated Resident #72 was normally a very calm, sweet person, and he had never shown any violent behaviors before the incident or after. During an interview on 11/17/22 at 2:25 P.M. the DON stated the interdisciplinary team concluded after investigation that based on the history of Resident #118's fixation on ownership of chairs, the cause of the unwitnessed incident on 10/31/22 between Residents #118 and #72 was related to Resident #118 making statements to Resident #72 about sitting in his chair. Resident #72 became upset and pushed Resident #118 down. The intervention for Resident #118 was to place his name on his chair. This intervention was proven ineffective because the resident moved the chair from the common area to his room and was temporarily using a wheelchair for mobility while his arm healed. Once the staff discovered the incident was related to a resident-to-resident altercation, Resident #72 was placed on 1:1 until he was evaluated by psych services. During an interview on 11/23/22 at 8:04 A.M. RN #66 stated the unwitnessed incident between Resident #72 and #118 was initially reported to management as a fall on 10/29/22. RN #66 was notified on the night of 10/29/22 that Resident #118 had fallen and was sent out for possible injury, and RN #66 did not find out until 10/31/22 that there had been an incident with another resident. RN #66 tried to interview staff to determine what had happened, and the nurse involved, RN #126, was suspended for not reporting suspicions of abuse. All residents were assessed for abuse on 10/31/22 and Resident #72 was placed on 1:1 pending psychiatric evaluation. Resident #72 was sent out for evaluation because he was visibly upset and pacing, and Resident #72 was removed from 1:1 supervision when he came back. The staff were going to put Resident #118's name on a chair in the dining room once his injuries healed and he no longer needed to use the wheelchair, to prevent further incidents from happening. Staff suspected Resident #118's fixation on ownership of dining room chairs had started the incident. 2. Review of the medical record review revealed Resident #117 was admitted to the facility on [DATE]. Diagnoses included dementia with behaviors, chronic obstructive pulmonary disease, Alzheimer's disease, hypertension, anxiety, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed an assessment for cognitive status was not able to be completed as resident was unable to answer questions. Resident #117 had behaviors directed towards others and behavioral symptoms not directed towards others, occurring one to three days during the seven-day assessment period. Resident #117 required limited assist for bed mobility, transfers, and supervision for toileting and eating. Resident #117 was assessed with no loss of liquids or solids from mouth when eating, did not hold food in mouth or checks, and no complaints of difficulty when chewing or swallowing. Resident #117 weight was documented at 135 pounds. Resident #117 had weight loss of more than five percent in last month or loss of ten percent or more in last six months. Review of the plan of care for Resident #117 dated 07/14/22 revealed the resident exhibits behavioral symptoms that are not easily altered and potentially harmful to resident or others related to cognitive impairment and dementia with behaviors, poor impulse control and urinating on the floor and other residents furniture. Interventions include administer medications as ordered, monitor for adverse side effects, monitor mood, affects and behaviors, and psychology services as needed. Review of the plan of care for Resident #117 dated 11/03/22 revealed a risk for pain and alteration in comfort related to recent dislocation of jaw with altercation. Resident #117 had fluctuating cognitive deficits due to Alzheimer's disease, increasing difficulty to process current situations and safety awareness. Interventions include administer pain medications as ordered, monitor for breakthrough pain, and monitor for effects of analgesic administered. Review of the plan of care for Resident #117 dated 11/03/22 revealed a self-care deficit in eating related to chewing problems, resident has been diagnosed with a fracture jaw and in at risk for unintended weight loss. Interventions include diet per physicians' orders, adaptive diet as ordered, report immediately an difficulty chewing or swallowing, refer to speech therapy and occupational therapy, and reassess eating ability quarterly. Review of the plan of care for Resident #117 dated 11/08/22 revealed a risk for infection/complications due to laceration to forehead. Interventions include administer medications as ordered, evaluate pain, monitor for signs and symptoms of infection, and monitor vital signs. Review of the nurses' progress notes dated 11/02/22 at 5:12 P.M. revealed Resident #117 was observed exiting Resident #95's room by a State tested Nursing Assistant (STNA). Resident #117 was noted to be bleeding from forehead and distraught. First aide was provided by RN #57, vitals were obtained and range of motion was unchanged. Review of the nurse's progress note dated 11/02/22 at 10:33 P.M. for Resident #117 revealed resident was noted to be in a physical altercation with another resident and was assessed, physician was notified of resident laceration to the forehead by another resident . Incident was report to the state, police, resident's physician and emergency contact. Orders were obtained to send the resident to the hospital for evaluation and treatment. Resident #117 was unable to communicate what happened in the incident with the other resident. Review of the After Care Visit Summary from the hospital dated 11/02/22 for Resident #117 revealed instruction orders for liquid diet only and follow up with oral maxillofacial trauma surgery tomorrow morning related to jaw fracture. Review of the hospital progress notes dated 11/02/22 for Resident #117 revealed resident was punched in the head by another resident without loss of consciousness. Review of the radiology reports for a CT scan of the head revealed an acute displaced fracture of the right mandibular condyle. Further review of the progress note revealed a consult with a facial trauma physician was completed with recommendations to wait a week for repair of jaw and continue with a liquid diet. No other injuries were noted. Review of the SRI dated 11/02/22 at 6:52 P.M. revealed after investigation, the facility substantiated allegations of resident-to-resident abuse. The incident happened on 11/02/22 at 5:12 P.M. when Resident #95 reported Resident #117 entered Resident #95's room and would not leave. Resident #95 was trying to push Resident #117 out of the room. Resident #117 started to get Resident #95 off of him and an altercation occurred resulting in Resident #95 hitting Resident #117 in the head. A statement from Resident #95 admitting to the altercation with Resident #117 resulting in a fracture that required hospitalization and follow up care. An audit of like residents on the unit revealed no reports of feeling unsafe or had a physical altercation with any residents in the last week. Resident #95 was placed on 1:1 monitoring until he can be evaluated by psychology services. The police, the physician and the power of attorneys were notified of the incident. Review of the nurse's progress note dated 11/03/22 at 12:05 P.M. revealed Resident #117 returned to the facility with orders for liquid diet for six weeks until 12/15/22 related to dislocated jaw. Review of the nurses' progress note dated 11/03/22 at 12:11 P.M. revealed Resident #117 has a follow up appointment for treatment of a dislocated jaw on 12/15/22. Review of the nurse's progress note dated 11/03/22 at 2:34 P.M. revealed a thorough investigation and review of Resident #117 medical records including interviews with staff and residents revealed Resident #117 was in another residents' room watching television when he began going through the other residents' belongings and the other resident hit him. The STNA noted Resident #117 coming out of the room holding his face. The STNA assisted Resident #117 to the nurse for assessment. Resident #117 was noted as having a laceration to his forehead and pain to his jaw. Resident #117 was unable to state what happened to him when questioned. Resident #117 was sent to the hospital for evaluation and treatment. Resident #117's emergency contact was notified along with psych services. Resident #117 was moved off the men's secured unit a different secured unit. Resident #117 care plans have been updated. The dietician was notified of the new diet orders and the fractured jaw. Social services will follow up with resident. Resident #117 does not display any psychosocial issues at this time. Review of the After Care Visit Summary dated 11/07/22 for Resident #117 revealed a follow up appointment was completed with a follow up appointment in six weeks for treatment of facial injury due to closed fracture of condylar process of the mandible. Review of the active physician orders for Resident #117 revealed a pureed diet with thin liquids dated 11/11/22, speech therapy three times a week for thirty days dated 11/07/22, and oxycodone concentrate 100 milligrams/milliliter (mg/ml) give five mg by mouth every four hours as needed for pain for thirty days dated 11/03/22. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, diabetes, dementia, cognitive decline, hypertension, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #95 had intact cognition. Resident #95 was not coded with any behaviors. Resident #95 required extensive assist with bed mobility, transfers, and toileting. Resident #95 was independent with eating. Review of the plan of care for Resident #95 revealed the resident exhibits verbal and physically aggressive behaviors toward staff and residents related to schizophrenia, cognitive decline, bipolar disorder, and dementia with behaviors. Can become physically aggressive towards other residents and staff members when he feels his territory/space has been intruded upon/residents wandered into his room without his permission. Interventions include administer medications as ordered, monitor/document for side effects and effectiveness, anticipate the resident's needs, consult behavioral services as needed, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause. Review of the plan of care revealed Resident #95 exhibits behavioral symptoms that are not easily altered and potentially harmful himself and others. Interventions include resident noted to break/disassemble the furniture in his room, stop sign to doorway to help prevent other residents from entering. Give medications per physician order, monitor for adverse reactions of medications, monitor mood, affect, and behaviors with all hands on care and contacts, approach in a calm manner, allow resident to calm down before attempting to continue with care, attempt to identify and resolve basis for voiced/demonstrated anger and verbally abusive behaviors. Review of the progress notes for Resident #95 at 11/02/22 at 5:18 P.M. revealed resident admitted to punching another resident in face due to the other resident wandering into his room without consent and laying in his bed. Skin assessment completed, no complaints of pain. Police were notified. Review of the progress note dated 11/02/22 at 10:39 P.M. revealed Resident #95's physician and guardian were notified of the resident-to-resident incident. Resident #95 placed 1:1 to ensure no further incident. Psych services and social services to follow up with resident. Resident #95 is calm and watching television with his 1:1. Review of the progress notes dated 11/03/22 at 1:51 P.M. for Resident #95 revealed through a thorough investigation and a review of the resident's medical record including staff and resident interviews, it was noted that Resident #95 and another resident was watching television together and the other resident began searching through Resident #95 belongings, the resident asked him to stop, and he would not and Resident #95 stated I hit that [explicit term], he shouldn't have been watching television and not going through my [explicit term] belongings. Resident #95 was placed 1:1 and physician, guardian and psych services were notified of incident. Resident #95 was assessed by the nurse without any findings. As an intervention Resident #95 has a stop sign placed in front of door, and management staff presence has been increased on the men's unit. Resident #95 care plan was updated. Resident has not displayed any aggression since incident and continues 1:1. Review of the progress notes for Resident #95 dated 11/03/22 at 5:32 P.M. revealed the resident has been sent out to hospital for a psych evaluation, unit manager aware, physician aware, call placed to guardian no answer received voicemail left, will continue to monitor. Review of the psychology notes dated 11/09/22 for Resident #95 revealed the resident is alert and oriented to person, place, and time. Resident #95 stated he continues to hear voices. Further review of management notes revealed an investigation was completed and it was noted that Resident #95 hit Resident #117. Resident #95 was placed on 1:1 monitoring continuing. Observation on 11/14/22 at 1:02 P.M. revealed Resident #117 sitting at table in dining room eating pureed food without assist, no signs and symptoms of pain observed. Interview 11/22/22 at 8:54 A.M. with Behavioral Specialist #226 from psych services verified he has meet with Resident #95 regarding the altercation between the resident and Resident #117. Resident #95 has a history of physical abuse and has been physically abused himself. Resident #95 continues to receive services three times a week. Observation on 11/23/22 at 11:19 A.M. revealed Resident #95 continues to have 1:1 monitoring in place. Interview on 11/23/22 at 12:51 P.M. with Office Staff #225 verified Resident #117 does not have any scheduled surgery in the near future for repair of fractured jaw. Interview on 11/23/22 at 1:17 P.M. with RN #57 revealed the nurse assigned to Resident #117 on 11/02/22 (day of altercation) and stated Resident #117 was observed by staff exiting Resident #95's room holding his face. RN #57 stated Resident #117 does not have the ability to communicate what happened, just indicated that he was in pain. RN #57 obtained vital signs and contacted the physician for additional orders. RN #57 notified the DON and the Resident #117's emergency contact before transferring the resident to the hospital for evaluation. RN #57 stated Resident #95 admitted to punching Resident #117 in the face and was immediately placed into 1:1 monitoring. RN #57 stated Resident #117 returned to the facility the next day and was moved to another building. RN #57 stated Resident #95 remains on one-to-one monitoring. Interview on 11/23/22 at 1:45 P.M. with the DON verified the incident involving Resident #117 and Resident #95 was investigation and determined to be resident to resident abuse. 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, unspecified schizoaffective disorders, type II diabetes, generalized anxiety disorder, unspecified major depressive disorder, unspecified personality disorder, and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #19 was a one-person assist and required supervision with all activities of daily living (ADL's). Review of SRI revealed after investigation, the facility substantiated allegations of staff-to-resident emotional /verbal abuse. The incident happened on 11/16/22 at 5:55 P.M. Resident #19 reported on 11/17/22 that night nurse, Registered Nurse (RN) #88, kicked his prosthetic leg across the room following a fall. Upon interview, RN #88 admitted to kicking Resident #19's prosthetic leg because it was in his way. Resident #19's roommate (Resident #92) witnessed RN #88 kicking prosthetic leg. During an interview on 11/23/22 at 8:23 A.M. RN #66 stated the incident involving RN #88 and Resident #19 was first reported to staff on 11/17/22. RN #88 was doing two-hour rounds and found Resident #19 sitting on the floor in the bathroom against the wall. Upon interview Resident #92, Resident 19's roommate, stated RN #88 told Resident #19 to quit being a crybaby and kicked his prosthetic leg across the room. Resident #19 was not wearing his prosthetic leg at the time the incident occurred. When the nurse was questioned, RN #88 stated he kicked the leg because it was in his way. RN #66 stated RN #88 was immediately fired and the facility called the police. 4. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, unspecified psychosis, and history of traumatic brain injury. Review of the most recent MDS assessment dated [DATE] revealed Resident #41 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #41 required supervision and no physical assistance with ADL's. Review of the care plan dated 10/05/22 revealed Resident #41 had a mood problem related to history of traumatic brain injury, psychosis, and paranoid schizophrenia. Interventions included medication as ordered, reinforce strengths and positive coping skills, behavioral health consults as needed, encourage to verbalize feelings, institute 15-minute checks for 24 if changes in behavior demonstrate risk, and monitor/report behaviors. Review of SRI revealed after investigation, the facility substantiated resident-to resident physical abuse. The unwitnessed incident occurred on 11/08/22. Resident #96 stated the altercation started because Resident #41 (roommate) was going through his things. The facility was unable to determine who started it. Both residents sustained minor scratches and bruises and after times Resident #41 had a black eye. On 11/08/22, Resident #41 was moved to a private room on the same unit, and Resident #96 was moved to another unit on 11/09/22. Review of Resident #41's progress notes revealed both Residents #41 and #96 were in their shared room when a physical altercation took place. Resident #41 stated that Resident #96 socked him in the back of the head. Staff separated and assessed each resident. Resident #41 had a reddened area noted to the middle of his forehead, a scratch noted to the right side of his nose, and swelling noted to his right eye. Resident #41 stated that he was having some pain but didn't need medication. Review of the medical record revealed Resident #96 was admitted to the facility on [DATE]. Diagnoses included hypothyroidism, emphysema, glaucoma, and hypertension. Review of the most recent MDS assessment dated [DATE] revealed Resident #96 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #96 was a one-person assist and required extensive assist with bed mobility and transfers, and supervision with locomotion, eating, dressing, toileting, and personal hygiene. Review of care plan dated 07/20/22 revealed Resident #96 required the safety of residing on a secured unit due to impaired safety decisions and poor safety awareness. Interventions included provide activities of interest, provide redirection as needed, an resident to be supervised on a secures unit. Review of progress note dated 11/08/22 revealed Resident #96 got into a physical altercation with another resident while in his room. Resident #96 stated that resident was going through his drawer. The residents were separated and assessed. Resident #96 had a scratch noted to the left side of his neck and denied pain. Observation on 11/14/22 revealed Resident #41 had a visible purple bruise noted to his right eye. During an interview on 11/23/22 at 8:15 A.M. RN #66 stated he was on the unit when the incident happened and did not see the incident. Resident #41 came out his room, and sat down [NAME] the area, visibly upset. RN #66 walked up and asked what was wrong. Resident #41 pointed to Resident #96 and said Resident #96 had hit him. RN #66 asked and Resident #96 stated he hit Resident #41 because he was In my [explicit term]. Resident #41 stated he hit Resident #96 back. Upon assessment it was noted Resident #41 had a slight scratch on his nose and complained of pain to his nose. Resident #41 was worried because he had a history of previous fracture. The facility ordered an x-ray, completed 11/08/22,and it was negative for nasal fracture. By this time there was a noticeable bruise forming to Resident #41's right eye. The residents were placed in separated rooms, Resident #41 was moved to a private room and on 11/09/22, Resident #96 was moved to another building/unit. This was during the first week the facility had started their increased management presence on the unit in response to the incidents on the men's unit. 5. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, unspecified anxiety disorder, hypertension, unspecified epilepsy, and schizoaffective disorder bipolar type. Review of the most recent MDS assessment dated [DATE] revealed Resident # 53 had severely impaired cognition, had no behaviors, and did not reject care. Resident # 53 was a one-person assist and required extensive assistance with bed mobility, was independent with eating, and required supervision for transfers, dressing, toileting, and personal hygiene. Review of care plan dated 05/26/22 revealed Resident #53 had a behavior problem related to schizoaffective disorder and anxiety. Interventions included medication as ordered, anticipate needs, intervene as necessary to protect the safety of others, and monitor behaviors. Additionally, Resident # 53 was at risk for impaired psychosocial well-being related to witnessed aggressive events and other resident conflicts. Interventions included medication as ordered, monitor for adverse reactions, 1:1 counseling as needed, private room, and refer to psych services as needed. Review of progress notes revealed on 11/14/22 around 1:00 P.M. Resident #53 was verbally aggressive and spit on staff as she went into his room to collect his lunch tray. Around 3:40 P.M. the aide reported to the nurse Resident #90 had entered Resident #53's room and hit him. Resident #53 confirmed that Resident #90 had struck him but was unable to provide details regarding the altercation. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE]. Diagnoses included moderate hypoxic ischemic encephalopathy, pseudobulbar effect, diffuse traumatic brain injury, unspecified bipolar disorder, unspecified schizophrenia, and unspecified anxiety disorder. Review of the the most recent Minimum Data Set assessment dated [DATE] revealed Resident #90 had moderately impaired cognition, had no behaviors, did not wander, and [TRUNCATED]

Based on medical record review, staff interview, resident interview, hospital record review, review of a Self-Reported Incident (SRI), review of a police report, and review of facility policy, the facility failed to ensure a resident was free from verbal, and physical abuse. This resulted in actual harm when agency State tested Nursing Assistant (STNA) #150 ranted for 20 to 30 minutes, made threatening remarks towards Resident #49, and grabbed Resident #49 twisting her right hand, which resulted in Resident #49 becoming fearful of what agency STNA #150 may do next. Additionally, the resident required a hospital evaluation and was subsequently found to have a closed non-displaced fracture of the middle phalanx of the right index finger (the pointer finger) and right scaphoid fracture (a break in one of the small bones of the wrist). This affected one (Resident #49) of three residents reviewed for abuse. The facility census was 126. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE]. Resident #49's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's quarterly Minimum Data Set (MDS) assessment, completed on 08/17/22, revealed Resident #49 was cognitively intact, did not walk, and required extensive assistance of two staff for bed mobility, and transfers. Review of Resident #49's care plan, dated 04/24/22, revealed Resident #49 had an Activities of Daily Living (ADL) self-care performance deficit related to her disease process. Resident #49 required staff assistance to complete ADL tasks daily. Review of Resident #49's skin assessment, dated 08/26/22, revealed Resident #49 did not have bruising to the right index finger indicated on the assessment. Review of the SRI, dated 09/03/22, revealed on 09/03/22 at 2:00 A.M., Resident #49 expressed concerns which could rise to the level of physical abuse. Resident #49 stated a staff member (agency STNA #150) had injured her during the transfer process. The SRI indicated statements were obtained from staff, and an unidentified staff (agency STNA #150) was suspended. The SRI indicated a body assessment was being completed, the physician and family were called, and the police were contacted. The SRI indicated interviews were conducted again with staff and re-enactment was completed for leadership. The report indicated education was started, and although evidence was inconclusive, staff (agency STNA #150) was do not returned (DNR'd). Resident #49's care plan was reviewed and updated. The SRI did not include information regarding Resident #49 having been sent to the hospital on 09/03/22 and found to have sustained a closed non-displaced fracture of the middle phalanx of her right index finger. The SRI also did not include the name of the alleged perpetrator. Review of the statement obtained from agency STNA #150 on 09/03/22, revealed agency STNA #150 stated Resident #49 put on her call light and agency STNA #150 came in Resident #49's room. Agency STNA #150 indicated she entered Resident #49's room and introduced herself and said she was going to assist Resident #49 to bed. Agency STNA #150 stated she left Resident #49's room to get the Hoyer lift and came back Resident #49's room. Agency STNA #150 indicated Resident #49 was fully dressed and was sitting upright in the wheelchair facing her. Agency STNA #150 then proceeded to lock the Hoyer lift and open it, then Resident #49 began placing the Hoyer straps on the Hoyer arms, and then agency STNA #150 began to lock the wheelchair brakes. Agency STNA #150 stated Resident #49 stated don't lock my wheels, and she told Resident #49 she had to lock the wheels. Agency STNA #150 indicated she took out her phone and searched proper Hoyer technique, showed Resident #49, and Resident #49 said ok. Agency STNA #150 indicated she then went to try to lock the wheelchair again, and Resident #49 grabbed her left wrist as she was standing on Resident #49's left side. Agency STNA #150 indicated she dropped to her knees and asked Resident #49 to please let her go. Agency STNA #150 indicated Resident #49 grabbed her tighter, stared at her, and was shaking her head. She revealed she twisted her body and went under Resident #49's arm without touching Resident #49's arm or hand. Agency STNA #150 indicated Resident #49 had her left hand and the Hoyer remote was in agency STNA #150's right hand. As agency STNA #150 stood up, she was pushing the button on the Hoyer remote which was lifting the Hoyer. Agency STNA #150 indicated Resident #49 was calm. Agency STNA #150 then indicated she lifted Resident #49 with the Hoyer from the wheelchair and pushed the Hoyer over to Resident #49's bed. Agency STNA #150 looked in the hallway for assistance, and left Resident #49 on the bed in a safe position while going to look for another staff member to assist her. Agency STNA #150 indicated she found another aide (STNA #153) to assist her. Agency STNA #150 indicated she called the front desk and asked the receptionist where her nurse was and for the receptionist to listen to the way Resident #49 was treating her. She indicated as she was talking to the receptionist, Resident #49 was grabbing at her. She indicated she asked Resident #49 to please not grab her arm, as Resident #49 continued to scream for her to get out of her room. Agency STNA #150 indicated the other aide (STNA #153) asked Resident #49 what was wrong and asked Resident #49 to calm down. The statement indicated Resident #49 was upset and the aides left the room. Agency STNA #150 stated Resident #49 was yelling, screaming, and swinging. Agency STNA #150 indicated she left the room and called the unit manager. Agency STNA #150 indicated Resident #49 was in bed on the Hoyer pad with all her clothes on because she would not let staff provide care. Review of a statement obtained from Receptionist #02 on 09/03/22 revealed agency STNA #150 called and asked for the unit manager's phone number. During the conversation, Receptionist #02 heard Resident #49 state get out of my room, and agency STNA #150 never responded. Receptionist #02 indicated agency STNA #150 kept talking to him (Receptionist #02) and then he overheard agency STNA #150 state get off of me. Agency STNA #150 then said Resident #49 keeps grabbing me, as Receptionist #02 continued to listen. Receptionist #02 gave agency STNA #150 the unit manager's phone number. Receptionist #02 said agency STNA #150 came over and showed him her swollen arm. Review of Resident #49's incident note dated 09/03/22 at 4:05 A.M., indicated the writer (Licensed Practical Nurse [LPN] #64) was notified by an aide that Resident #49 was refusing proper care and that Resident #49 had claimed abuse. The writer entered the resident's room and asked was she ok. The resident stated no, she broke my finger and scratched on my arms. The aide (agency STNA #150) stated she twisted away as Resident #49 was holding her arm tightly. Resident #49 stated upon entry that the aide (agency STNA #150) had broken her finger by grabbing on her while trying to put her to bed. The resident also stated that she still allowed the aide to put her in bed after they figured out that she was right about the mechanics when using the Hoyer lift. Staff immediately removed the staff member (agency STNA #150) from the facility and assessed Resident #49 for safety. The writer notified the Unit Manager (LPN #64), Assistant Director of Nursing (ADON), physician, and family. It also noted a STAT (immediate) x-ray of Resident #49's finger was ordered, a skin assessment was done, and vitals were obtained. Review of Resident #49's skin assessment, dated 09/03/22, revealed Resident #49 had bruising to her right index finger. Review of Resident #49's progress note, written on 09/03/22 at 10:46 A.M., revealed the Resident experienced trauma to her right index finger prior to day shift. An x-ray was obtained of the area. The technician stated he could not tell if the finger was broken. Resident (#49) was sent to the hospital for evaluation and possible treatment. Review of Resident #49's progress note, dated 09/03/22 at 12:00 P.M., revealed Resident #49's x-ray result was a displaced right index finger fracture. The physician was notified, and an order was received for a referral to an orthopedic physician. Review of Resident #49's x-ray results, obtained on 09/03/22, revealed Resident #49 had a fracture involving the middle phalanx with displacement and there was associated soft tissue swelling. Review of the hospital report, dated 09/03/22, revealed Resident #49 presented to the emergency department on 09/03/22 at 11:05 A.M. for right finger pain and bilateral arm pain. It noted the patient was a resident of a nursing home and reported an aide (agency STNA #150) grabbed her arms that night and twisted her right index finger. It indicated the skilled nursing facility had filed a police report and the aide (agency STNA #150) no longer worked at the facility. The physical examination noted there was a mild amount of [CONDITION(S)] of the right index finger diffusely with some ecchymosis (a discoloration of the skin resulting from bleeding underneath) noted proximally. Resident #49 had a moderate amount of thrombotic [CONDITION(S)] purpura (TTP) (a rare disorder that causes blood clots to form in small blood vessels throughout the body) and decreased range of motion due to pain. Resident #49 also had ecchymosis to her scaphoid area (wrist) with moderate TTP. X-rays of the right hand and wrist were completed and showed a non-displaced right second middle phalangeal fracture. The report revealed there was a possibility of occult fracture of her thumb, and a thumb spica splint was ordered. The final impression was that she had a closed non-displaced fracture of the middle phalanx of the right index finger and right wrist pain. Review of the Police Department Incident Report, filed on 09/03/22 at 4:29 A.M., revealed the victim was Resident #49. The report indicated the offense involved patient abuse/neglect (simple assault). The report indicated Resident #49 sustained a minor injury but did not specify the location. Review of Resident #49's orthopedic consult report, dated 09/12/22, revealed she reported injuring her right index finger after having been assaulted by an aide at her assisted living facility. She stated the aide grabbed and twisted both of her arms. At the time of the injury, there was clear dislocation or malposition of the finger. The impression from radiographic evaluation was that Resident #49 had sustained recent displaced index finger middle phalanx shaft fracture(s) and presented requesting further treatment. Resident #49 also sustained radiographically inapparent but clinically suspected scaphoid fracture and presented requesting further treatment. The various treatment options were discussed with Resident #49 regarding her right scaphoid fracture and right index finger middle phalanx fracture. Interview with Resident #49 on 10/04/22 at 2:52 P.M., revealed it was late when agency STNA #150 came in her room. She revealed agency STNA #150 began to pull in the Hoyer lift. Resident #49 had already taken off her shirt, and agency STNA #150 put her gown on her. Resident #49 stated agency STNA #150 started locking the wheelchair and Resident #49 stated no, I don't do that. Agency STNA #150 stated yes I do, and Resident #49 told her No, that's not how I do it. Resident #49 indicated agency STNA #150 went into a rage and stated if Resident #49 understood how everything went then it would make things a lot easier. Resident #49 indicated agency STNA #150 got on her phone and was looking something up regarding wheelchairs and transfers. Resident #49 indicated Resident #49 said no and put her hands on the wheelchair lock. Agency STNA #150 left the room for a few minutes due to being aggravated then came back to Resident #49's room. She revealed agency STNA #150 twisted her fingers on her right hand. Resident #49 stated she felt agency STNA #150 put her nails into Resident #49's right hand. Resident #49 indicated agency STNA #150 then went to the other side and twisted her left arm. Agency STNA #150 eventually went ahead and transferred Resident #49 by herself with the Hoyer lift. Resident #49 indicated she did not grab agency STNA #150's arm. Resident #49 stated she reached for agency STNA #150 while in the Hoyer lift; however, agency STNA #150 backed away and stated you are not as fast as I am. Resident #49 stated she told agency STNA #150 she needed to put her (Resident #49) up in the bed, but agency STNA #150 left her there. Resident #49 stated she was not afraid when it first happened, but after she realized what agency STNA #150 had done to her finger, she (Resident #49) was not sure what would happen next. Resident #49 indicated she was lying on the bed after having been transferred by agency STNA #150 when agency STNA #150 ranted for 20 to 30 minutes about how black people were more important. Resident #49 indicated when agency STNA #150 took the lift, agency STNA #150 stated you better understand that black's rule and then said, you better understand that. Resident #49 indicated agency STNA #150 came back in her room with STNA #153. Resident #49 stated she told the other aide (STNA #153) what happened, and the other aide (STNA #153) said she was being too specific about her hand, then she noticed her finger was bent another way. Resident #49 indicated the injury was on her right hand. Resident #49 stated both aides left the room without taking care of her. Resident #49 revealed she went to an orthopedic specialist, and they wrapped her finger and thumb. Resident #49 stated her finger and thumb were broken. Resident #49 stated her right thumb hurt just as much as her right finger. Resident #49 indicated she did not feel afraid at the time of the interview but was afraid when the incident occurred. Interview via phone with LPN #64 on 10/04/22 at approximately 6:20 P.M., revealed agency STNA #150 told LPN #64 she was caring for Resident #49 and Resident #49 grabbed agency STNA #150's arm. Agency STNA #150 told LPN #64 she had to twist out of Resident #49's hold, then she got STNA #153 and went back to Resident #49's room. LPN #64 also indicated she spoke with STNA #153, and she said Resident #49 wanted agency STNA #150 out of her room because agency STNA #150 hurt her fingers. LPN #64 indicated agency STNA #150 stepped out of Resident #49's room and STNA #153 asked Resident #49 if there was anything else she could do. LPN #64 revealed she talked to Resident #49 and noticed Resident #49's fingers seemed out of place. Resident #49 told LPN #64 that agency STNA #150 grabbed her fingers. LPN #64 stated she made agency STNA #150 leave immediately and called the police. LPN #64 stated agency STNA #150 did not show LPN #64 any marks on agency STNA #150's arm. LPN #64 stated agency STNA #150 left the building immediately. LPN #64 indicated agency STNA #150 put Resident #49 in bed with a Hoyer lift and transferred Resident #49 by herself. LPN #64 indicated Resident #49 did not want to go to bed that night, but agency STNA #150 forced her to. LPN #64 stated Resident #49 told her she grabbed agency STNA #150. An interview was conducted with the Director of Nursing (DON) on 10/04/22 at 12:46 P.M. The DON stated she re-enacted the occurrence with agency STNA #150 and agency STNA #150 showed her how she spun herself under Resident #49 in order to release Resident #49's grip due to being taught in abuse training to never touch a resident. The DON stated agency STNA #150's arm was very swollen, and agency STNA #150 indicated she was trying to go get help to assist her with Resident #49. The DON indicated agency STNA #150 tried to call the receptionist first. An interview was conducted on 10/04/22 at 2:40 P.M. with the DON regarding the re-enactment with agency STNA #150. The DON stated agency STNA #150 indicated she never touched Resident #49's right hand, and that she demonstrated being grabbed by Resident #49's left hand. Interview via phone with Personal Crimes Detective #156 on 10/06/22 at 10:58 A.M., revealed he did not observe any swelling on agency STNA #150's arm. He revealed Resident #49 appeared to have swelling to her right and left wrists. Review of the facility policy titled Freedom from Abuse and Neglect Policy, dated 10/30/19, revealed the purpose was to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Further review revealed the facility would conduct an internal investigation and report the results to the enforcement agency in accordance with state law including the state survey and certification agency within five working days of the incident or according to state law. This is an example of continued non-compliance from the survey dated 07/26/22. This deficiency substantiates Complaint Number OH 227.

Based on medical record review, review of a Self-Reported Incident (SRI), staff and resident interviews, staff written statements, review of the local police report, review of the facility investigation, and policy review, the facility failed to ensure Resident #01 was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical and psychosocial harm for Resident #01, when on 07/09/22 from approximately 7:15 P.M. until 7:50 P.M., Licensed Practical Nurse (LPN) #200 was observed by three State tested Nursing Assistants (STNA) #300, #301, and #302, telling Resident #01 to sit down in the chair. LPN #200 attempted to force Resident #01 into a chair by twisting Resident #01's wrist, pushed, grabbed Resident #01 by the neck and choked the resident. LPN #200 then threw water on Resident #01, yelled no, sit down and you want to wrestle, and slammed Resident #01 multiple times, including to the ground, and then drug him across the floor. This affected one resident (#01) of four reviewed for abuse. The facility census was 135. On 07/18/22 at 9:50 A.M., the Licensed Nursing Home Administrator (LNHA) was notified Immediate Jeopardy began on 07/09/22 at approximately 7:30 P.M. when LPN #200 was observed physically abusing Resident #01 by three STNAs (#300, #301, and #302). LPN #200 was removed from the facility by the police, arrested, and charged with assault. The Immediate Jeopardy was removed on 07/19/22 when the facility implemented the following corrective actions: · On 07/09/22 at approximately 7:40 P.M., STNA #301 reported the incident to the facility Scheduler #400 who was on the grounds in the reception area that LPN #200 was physically abusing Resident #01. · On 07/09/22 at approximately 7:50 P.M., STNA # 302 was able to move Resident #01 to safety when STNA #300 and STNA #301 were able to redirect LPN #200. Scheduler #400 arrived on the locked unit at approximately 7:50 P.M., and immediately suspended LPN #200. LPN #200 was placed in a secure location where he was unable to interact with residents while waiting for the police, who were called at that time. The remaining residents were checked to ensure that the other residents were not abused by LPN #200. · On 07/09/22 at 8:00 P.M., LPN #215 completed a count of the medication cart with LPN #200 and took over the care of the locked unit. · On 07/09/22 at 8:10 P.M., Unit Manager (UM) #601 arrived and immediately started an investigation. · On 07/09/22 at approximately 8:30 P.M., UM #601 notified Medical Director #800 of the situation, of the impending Quality Assurance and Performance Improvement (QAPI) meeting and received an order to send Resident #01 to the emergency room . · On 07/09/22, Assistant Director of Nursing (ADON) #600 and UM #601 started observational rounds throughout the facility to ensure residents were free from abuse during care by staff. All residents with a Brief Interview of Mental Status (BIMS) of eight and above were interviewed with no concerns noted. All residents with a BIMS score below eight had head-to-toe skin assessments completed by ADON #600 and UM #601 and no signs of abuse were observed. · On 07/09/22 at 8:45 P.M., the local police arrived to investigate. LPN #200 was arrested for assaulting Resident #01. · On 07/09/22 at 9:00 P.M., the Administrator arrived at the facility. · On 07/09/22 at 9:19 P.M., Resident #01 arrived at the hospital for evaluation. · On 07/09/22 at 9:21 P.M., the allegation of abuse was reported to the Ohio Department of Health (ODH) by the Administrator. · On 07/09/22 at 9:45 P.M., ADON #600, arrived at the facility. UM #601 initiated a QAPI meeting at that time, approximately 9:45 P.M. The meeting included Executive Vice President and Chief Operations Officer (EVP/COO) #900, Senior Vice President of Clinical Services (SVPCS) #901, Registered Nurse (RN) #100, Senior Vice President of Operations (SVPO) #902, Vice President of Operations Eastern Region (VPOER) #903, the Administrator, and the DON. · On 07/09/22 at 10:30 P.M., Social Services (SS) #602 arrived at the facility and began psychosocial assessments of the residents. SS #602 performed all interviews of residents who were able to answer questions. · On 07/09/22, the Administrator, the DON, Housekeeping Manager #700, Dietary Manger #701, SS #602, and Maintenance Director #702 re-educated all facility staff and all agency staff on the facility's abuse policy and specifically to intervene immediately and to notify the Administrator and the DON as soon as the resident was moved to safety. Staff were in-serviced in person or via the telephone. Anyone not educated would be removed from the schedule and would not work a shift until education was completed. VPOER #903 re-educated the Administrator and the DON on the abuse policy. The Administrator and the DON educated Housekeeping Manager #700, Dietary Manager #701, SS #602, and Maintenance Director #702 prior to educating the staff. · On 07/10/22 at approximately 3:00 A.M., Resident #01 returned to the facility from the hospital with no new orders and no injuries noted from hospital evaluation. Resident #01's psychosocial needs were evaluated by facility nursing. Resident #01 was placed on one-on-one for exit seeking behaviors. · On 07/11/22, Resident #01 was moved from the locked unit to the memory care unit. Resident #01's psychosocial care plan was updated to reflect the focus psychosocial well-being problem related to cognitive impairment, Alzheimer's, and dementia with behavioral disturbances. Interventions included encouraging participation in activities, allow the resident to answer questions and to verbalize feelings, perceptions, and fears, and when conflict arises, remove the resident to a calm, safe environment. · Daily rounds will be completed by the DON, the Administrator and/or their designee to observe residents were free from abuse during care beginning on 07/09/22, on all shifts for four weeks, and the audit findings will be reviewed in the QAPI meeting for additional recommendations. Although the Immediate Jeopardy was removed on 07/19/22, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings included: Review of the medical record for Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severe cognitive impairment. Review of the care plan revealed Resident #01 was an elopement risk/wanderer as evidenced by history of attempts to leave the facility unattended. Interventions included distract Resident #01 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book; identify pattern of wandering; and provide toilet use, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of a progress note dated 07/09/22 at 9:19 P.M. revealed Resident #01 was sent to the local hospital emergency room (ER) due to an alleged assault. On 07/10/22 at approximately 3:00 A.M., Resident #01 returned to the facility with no new orders. Resident #01 was placed on one-to-one when he was awake due to his exit seeking. Review of the local hospital records dated 07/09/22 at 9:19 P.M. revealed Resident #01 reported his neck hurt after he was assaulted. Review of the SRI dated 07/09/22 and timed 9:21 P.M. revealed Resident #01 was attempting to stand and walk when LPN #200 told him to sit down in the chair. LPN #200 grabbed the resident and physically forced him to sit. Resident #01 was assessed, and a small abrasion was noted on his thumb. The local law enforcement, the Administrator, the DON, and UM #601 were contacted. Resident #01 was sent out for an evaluation. LPN #200 was escorted off the premises in the police car. The SRI revealed Resident #01 was immediately moved to another unit upon his return. Review of the facility's investigation revealed the following written statements: STNA #300 ' s written witness statement dated 07/09/22 revealed LPN #200 was really aggressive at the beginning of the shift, around 7:30 P.M. with Resident #01. LPN #200 grabbed Resident #01 by his shirt and was slamming him. STNA #300 observed fresh blood from a scratch coming from Resident #01 ' s hand. STNA #301 ' s written witness statement dated 07/09/22 revealed LPN #200 was physically abusive with Resident #01. He pushed, choked, slammed, and threw water on Resident #01. LPN #200 was very upset because Resident #01 would not sit in a chair. STNA #302 ' s witness statement dated 07/09/22 revealed Resident #01 attempted to stand and walk, and LPN #200 yelled No, sit down and started forcing him to sit in the chair. LPN #200 stated you want to wrestle and slammed Resident #01 multiple times. STNA #302 stated LPN #200 grabbed Resident #01 by his neck. Resident #01 ' s witness statement dated 07/09/22 revealed LPN #200 grabbed him by the neck and that his neck hurt. Interview on 07/13/22 at 9:02 A.M., the Administrator said three STNAs (#300, #301, and #302) reported LPN #200 grabbed Resident #01 by the neck. The facility called the police, who arrested LPN #200. The Administrator stated LPN #200 was scheduled to attend additional abuse training beyond the Crisis Prevention and Intervention (CPI) training on 07/08/22 but did not show up for the training. Interview on 07/13/22 at 9:45 A.M., Resident #01 said someone had him by the neck and it hurt, he had been in a bar fight in another city, and he didn ' t want to go back there. Interview on 07/13/22 at 10:24 A.M. with Scheduler #400 revealed she was present the night of 07/09/22 in her office when STNA #301 called. STNA #301 wanted to report an incident on the locked unit and reported LPN #200 tried to force Resident #01 into a chair and twisted his wrist. By the time Scheduler #400 arrived on the locked unit at approximately 7:50 P.M., STNA #300 and #302 had separated Resident #01 to a safe location. Scheduler #400 said Resident #01 reported LPN #200 put his hand on Resident #01 ' s throat. During the same interview, the DON stated at that time the DON suspended LPN #200 by phone. Interview on 07/13/22 at 5:26 P.M., STNA #300 stated he arrived on the locked unit at 7:30 P.M. and saw LPN #200 trying to isolate Resident #01 and put him in a chair. STNA #300 said he could not recall everything that happened in which order but verified LPN #200 grabbed Resident #01 by the shirt and slammed him around and threw Resident #01 to the ground and then dragged him on the ground. STNA #300 said STNA #301 left the unit to report the situation after the abuse had started, but he was unsure of the time. STNA #300 said he tried to intervene with little success. STNA #300 said he received no instructions from the facility related to who to contact in case of an emergency and had not received any additional training or information on how to handle a situation like this if it should happen again. Interview on 07/19/22 at 11:00 A.M., LPN #200 said when he arrived, LPN #215 told him Resident #01 was trying to elope. LPN #200 denied allegations of abusing Resident #01 or any other resident. LPN #200 stated that he took Resident #01 by the hand to lead him back to a chair. Interview on 07/19/22 at 11:26 A.M., STNA #302 said she arrived on the unit at approximately 7:10 P.M., and the situation began after that and escalated for 30 to 35 minutes. She said Resident #01 was in the common area and stood up, when LPN #200 told STNA #302 to stop him. STNA #302 tried to redirect Resident #01. LPN #200 grabbed Resident #01 and forced him back into the chair. Resident #01 tried to walk again, and LPN #200 started to choke Resident #01 and threw chairs around. She and STNA #301 tried to disengage LPN #200 from Resident #01, with little success. STNA #302 said LPN #200 used unnecessary force. STNA #302 verified LPN #200 slammed Resident #01 on the floor, like a wrestling move. LPN #200 picked up Resident #01 and slammed him to the floor. STNA #302 said she was not aware of who to report the incident to. STNA #302 said LPN #215 was on the unit for approximately 15 to 20 minutes and witnessed some of the behavior and had not intervened, just instructed Resident #01 to sit back down. STNA #302 said STNA #301 left the unit to get help and then Scheduler #400 arrived and intervened as well. STNA #302 denied being provided any abuse education the night of the incident or since the incident. STNA #302 subsequently worked with Resident #01 on his new unit and had no issues. STNA #302 verified that she had not received additional abuse training prior to returning to the facility to work additional shifts. Follow-up interview on 07/19/22 at 11:35 A.M., STNA #300 verified he worked on 07/18/22 night shift but had not received any additional training related to the facility ' s abuse policy or expectations. Interview 07/19/22 at 12:00 P.M., LPN #215 said she left the unit around 7:57 P.M., on 07/09/22. LPN #215 said she witnessed no abuse. LPN #215 said if there was an altercation, it couldn ' t have been too bad because she was unaware of the issue. She said she saw Resident #01 sitting in a chair, but LPN #200 was blocking Resident #01 with his body to prevent him from getting up out of the chair. LPN #215 said she was not present when Scheduler #400 arrived and at no time had anyone requested assistance from her related to the situation with Resident #01. She said nothing occurred while she was there that would have led her to believe LPN #200 would have been arrested. She also said she had not received additional abuse training after the incident but did complete her CPI training on 07/18/22, as planned. Review of the local police report dated 07/09/22 revealed the time of dispatch was 8:37 P.M., the time of arrival was 8:45 P.M., and LPN #200 was arrested at 9:30 P.M. for simple assault. Review of a policy titled Freedom from Abuse and Neglect Policy, dated 10/30/19 revealed a comprehensive policy that explained abuse was the willful infliction of injury, unreasonable confinement, intimidation of, punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated that all new and current employees received training to identify aspects of abuse prohibition, including identification of potential victims of abuse or neglect, interventions, and reporting, as well as staff indicators, i.e., stress that may lead to the potential for abuse, who mandatory reporters were, and that suspected abuse should be reported to the Administrator and other officials in accordance with State law. This deficiency substantiates Master Complaint Number OH 173 and Complaint Number OH 078.

Based on record review, observation, resident and staff interview, review of the hospital records, review of the facility's Self-Reported Incident (SRI), review of the written statements from staff, and review of the facility's policy, the facility failed to ensure staff provided appropriate care for residents with behavioral management concerns. This resulted in Actual Harm to Resident #74 when a staff member grabbed Resident #74's wrist to block a punch from the resident and when the staff let go, Resident #74 fell to the ground and sustained a wrist fracture. This affected one (#74) of three residents reviewed for behavior management. The facility census was 132. Findings include: Review of the medical record for Resident #74 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively impaired and required supervision and set up help with activities of daily living (ADLs.) Review of the care plan, last updated on 06/14/22, revealed Resident #74 had the potential to be physically and verbally aggressive toward other residents and staff related to [CONDITION(S)], mood disorder, anxiety, depression, and poor impulse control. Resident #74 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response was aggressive, staff to walk calmly away, and approach later. Review of the nursing progress note for Resident #74 dated 06/10/22 at 11:53 A.M. revealed the nurse was notified by a state tested nursing aide (STNA) that Resident #74 had fallen backwards landing on her bottom. The STNA reported Resident #74 was trying to punch a staff member and the staff member threw his hands up to protect himself from getting hit using a blocking motion which caused Resident #74 to fall back. Resident #74 fell on her right hand and her right hand was swollen. Resident #74 alleged the staff member pushed her and caused the fall, but another staff witnessed the incident and said that was not true. Resident #74's attending physician was notified and gave order for an x-ray to Resident #74's right hand. The nurse progress note dated 06/11/22 at 12:17 A.M. revealed Resident #74 was sent to the hospital related to the results of the x-ray to the right hand. The nurse progress note dated 06/11/22 revealed Resident #74 returned to the facility on [DATE] at 3:45 A.M. with a splint to her right wrist. Review of the hospital note dated 06/11/22 at 12:02 A.M. revealed Resident #74 presented to the emergency room via emergency transport with complaint of right wrist pain. Resident #74 reported she was pushed which caused her to fall. Resident #74 reported she was trying to break the fall with her hands out and sustained injury to right wrist. The x-ray showed Resident #74 had sustained a fracture to her right wrist. Review of the facility's Self-Reported Incident (SRI) control number 5 dated 06/10/22 revealed Resident #74 alleged STNA #550, grabbed her wrists and then threw Resident #74 to the ground. The facility's investigation did not substantiate abuse had occurred. The facility's investigation revealed Resident #74 was verbally aggressive and went to be psychically aggressive with STNA #550, and STNA #550 grabbed the resident's wrist and Resident #74 went to snatch away and threw herself on the ground causing pain to her wrist. Review of STNA #550's written statement dated 06/10/22 revealed STNA #550 pushed the meal cart onto the unit where Resident #74 resided and was joking with his coworker STNA #570 when Resident #74 began calling him names and then attempted to hit him. STNA #550 stopped Resident #74's hand from hitting his face and when STNA #550 let go of her hand, Resident #74 fell to the ground. Review of STNA #570's written statement dated 06/10/22 revealed STNA #570 was in the hallway and observed Resident #74 call STNA #550 names and then Resident #74 tried to hit STNA #550. STNA #550 attempted to block the hit and grabbed Resident #74's hands. Resident #74 yanked herself away from him and she fell on the ground. Review of the facility's fall investigation for Resident #74 dated 06/11/22 revealed factors contributing to resident's fall on 06/10/22 included interference with a staff member and resident behaviors due to resident's cognitive diagnoses. Observation on 06/23/22 at 3:50 P.M. of Resident #74 revealed her right arm was wrapped and she was wearing a sling to her right arm. Interview on 06/23/22 at 3:50 P.M. with Resident #74 confirmed she had sustained a fracture to her right wrist on 06/10/22 when allegedly STNA #550 threw her on the ground causing her to break her arm. Interview on 06/23/22 at 12:39 P.M. with the Director of Nursing (DON) confirmed the facility had investigated the incident on 06/10/22 in which Resident #74 had a fall and sustained a right wrist fracture. The DON further confirmed the facility's investigation did not substantiate abuse. DON confirmed STNA #550 received verbal re-education following the incident which involved the facility's abuse policy and how to respond to agitated and physically aggressive residents. Interview on 06/27/22 at 10:39 A.M. with STNA #550 stated he was pushing a meal cart onto the secured behavior unit where Resident #74 resided. He was not assigned to the unit. STNA #550 confirmed he was joking with STNA #570 when Resident #74 started calling him names. STNA #550 confirmed he told Resident #74 she was being disrespectful, and she began swinging her hands at up and he grabbed her hands to try to block her. STNA #550 confirmed when he let go of Resident #74's hands, Resident #74 fell backward. Resident #74 stated STNA #550 pushed her down. STNA #550 confirmed he received re-education following the incident from the facility's management. Facility management told him in the future he should step away or walk away if a resident was aggressive and not to take it personally if a resident calls you a name. Review of the facility's policy titled Behavior Assessment and Management, dated 06/25/17, revealed resident problem behaviors had both internal and external causes and staff should explore potential solutions including asking if staff can change reaction or approach to the behavior and to ensure responding in a calm and supportive way. Residents could exhibit aggressive behaviors which could be verbal (shouting, name calling), or physical (hitting, kicking) and might occur suddenly with no apparent reason or could result from a frustrating situation. The facility should develop an individualized care plan for residents with behavioral problems and should remember the following steps in responding to residents: remain flexible, patient and calm, respond to the emotion, not the behavior, don't argue or try to convince, try to identify the unmet need, acknowledge requests, and respond to them, look for reasons behind each behavior, and don't take the behavior personally. This deficiency substantiates Complaint Number OH 255.

Based on record review, observation, resident and staff interviews, review of the Self-reported incident (SRI), review of the facility investigation, and facility policy review, the facility failed to identify a resident who was in a mental health crisis and address escalated verbal and physical behaviors. This resulted in actual harm for one Resident (#09) as evidenced by a deterioration of the resident's mental wellbeing and escalation of unwanted verbal and physical behaviors which resulted in facial bruising and abrasions to the residents' lower extremities. This affected one Resident (#09) of three reviewed for behaviors. The facility identified 12 residents who resided on the behavior unit. The facility census was 132. Findings include: Record review revealed Resident #09 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had delusions and rejected care daily. The most recent behavior plan of care revealed the resident had behaviors including verbal and physical aggression with staff. The resident frequently urinated and defecated on herself in common areas and refused activity of daily living assistance. Staff should attempt to redirect the resident, return later to provide care, and document the refusals. Review of the behavior notes dated from 09/19/20 to 09/24/20 revealed the resident had refused to change soiled clothes and/or had refused medications on 09/19/20, 09/21/20 and 09/24/20 and had been cursing at staff. Review of the nursing note revealed a late entry by the Director of Nursing (DON) dated 9/25/20 at 2:52 P.M. revealed at 1:49 P.M., during an interview, Resident #09 reported she had been hit overnight and fell during the altercation twice. The assessment documented injuries of a bruised and swollen left eye, and open areas on the resident's bilateral lower extremities. The resident reported pain in her left eye when touched, but no pain otherwise. The physician was notified, and the resident was sent out to the local emergency room for evaluation. Observation on 10/06/20 at 9:00 A.M., Resident #09 was observed at the nursing station asking for cigarettes. She had a small amount of yellow green bruising around the left eye. The resident stated she was okay. The resident would not maintain direct eye contact. Resident #09 was observed wearing a hooded sweatshirt with the hood pulled down over her face. Interview on 10/08/20 at 10:08 A.M., LPN #19 revealed the resident had attacked her, and resident abuse did not occur. LPN #19 stated Resident #09 had called her by the name of her sister whom she did not get along with. This was the first time the resident had ever grabbed her. Interview on 10/14/20 at 2:36 P.M., the DON verified the staff did not follow the resident behavior plan and the nurse should have recognized the resident was mentally unstable and in crisis with her increased verbal and physical aggression. Interview on 11/03/20 at 1:59 P.M., LPN #79 stated during medication administration, Resident #09 was sitting in the dark in her room with a hood over her head and her head down. Resident #09 said she would not talk about what was wrong. LPN #79 revealed on 09/25/20, the nurse was notified by State tested Nursing Assistant (STNA) #136 about Resident #09's eye which was blackened. She verified LPN #19 had not mentioned the incident in report. LPN #79 revealed she went out and sat across from Resident #09 and saw her eye was swollen. Resident #09 started to cry and said the night nurse and aide jumped her. She said she was kicked in the eye and she said she had tried to defend herself. She had crying spells, and this was not normal for her. A follow up interview on 11/03/20 at 2:37 P.M., LPN #19 revealed she went back to the room after she cleaned herself up and she was at the door to see how Resident #09 was. LPN #19 stated she did not go near her the second time. STNA #28 was still there with her and STNA #28 was in the doorway. During the first incident, the nurse and resident fell on the bed and partly on the floor, the resident fell on top of LPN #19 with her full body weight. Resident #09 started to chase the nurse after she got out from under the resident and the resident fell to the floor. LPN #19 did not know if Resident #09 hit her head when she fell . LPN #19 ran to the staff bathroom for her own safety. LPN #19 revealed STNA #28 was still with Resident #09 when the nurse left the room. She further reported she never called any other staff in other parts of the building for assistance and she had not received any behavioral crisis training at the facility. Interview on 11/03/20 at 4:14 P.M., STNA #28 stated she kept going into Resident #09's room trying to get her to change her soiled clothes. LPN #19 came to help at the end of their shift. Out of nowhere, Resident #09 started swinging at LPN #19. The first time they fell to the bed or the floor. Resident #09 pulled LPN #19's wig off. The resident was on LPN #19 and had a hold of her wig. STNA #28 tried to remove Resident #09's hands out of the wig. Resident #09 pulled the wig off. The second time Resident #09 was sitting on the bed next to the door when she started swinging at LPN #19 again. Resident #09 was able to pull off the nurse's wig both times. She denied calling any other staff in other parts of the building for assistance. STNA #28 further reported the resident kept calling LPN #19 the name of her sister whom she disliked, and her behavior worsened each time she saw LPN #19. Review of the SRI dated 09/25/20 and timed 9:30 A.M., revealed the incident occurred at approximately 6:00 A.M. on 09/25/20. LPN #19 and the STNA #28 failed to inform the oncoming shift about the incident. It was reported to the day shift nurse when the day shift nurse aide took the residents out to smoke at or around 9:30 A.M., at which time the day shift nurse aide observed bruising around Resident #09's left eye. The injuries were reported to Administration. Review of the facility investigation dated 09/25/20 revealed STNA #28 was interviewed by the facility DON at 10:45 A.M. and reported she had gone into Resident #09's room throughout the night and the resident had refused to change her soiled clothing. STNA #28 tried one last time before the end of her shift around 6:00 A.M., she said the resident continued to refuse and at this time LPN #19 came into the room to assist. Resident #09 became agitated and began to swing at the nurse and grabbed the nurse's sewn in wig and would not let go. The resident began to yell bizarre things at both staff members such as she wanted them out of her room because those explicative had been in her room all night having sex. She then ripped the sewn in wig off LPN #19's head and the resident fell pulling LPN #19 to the floor. LPN #19 was able to get up and get her wig back and she left the room to allow the resident to calm down. STNA #28 went back to the door of the room and tried to get the resident to change her clothes and she was starting to complete the task when LPN #19 came to the doorway a second time to check on the resident. The resident became angry and went after the nurse again resulting in the resident grabbing the nurse's wig and pulling her to the ground a second time. STNA #28 said both times the resident pulled the nurse down to the ground and they fell between the bed and the dresser. She said she may have had an injury to her lip or nose as there was blood on the sheet, however she had not seen any bleeding on the resident. LPN #19 was interviewed by the facility DON at 3:54 P.M., and she reported Resident #09 had been cursing at STNA #28 so she went in to see if she could help. She said the resident began to call her the name of her sister whom she did not like and she continued to refuse so the nurse was going to leave the room when the resident came after her grabbed her by the laced in wig and pushed her to the bed and she kept pulling her wig. LPN #19 tried to get the resident off her because she could not breath. She stated she and STNA #28 were trying to remove the resident's hands from the nurse's wig. She reported she did not hit the resident. LPN #19 reported the resident just kept calling her by the sisters' name whom she did not get along with. She had never had a problem with Resident #09 before. Review of facility policy titled Abuse Prevention Program, dated 08/28/17, under section Policy Interpretations and Implementation, revealed number 6: Train staff through ongoing training and/or orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. This deficiency substantiated allegations in Complaint Number OH 7, OH 070 and OH 8.

Based on the unprecedented global pandemic that resulted in the Presidential Declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) COVID-19 Long Term Care Facility Guidance dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), observations, record reviews, review of the facility's infection control policies, and interviews with staff and the local health department, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 on the Lighthouse unit. On [DATE], 40 residents of the Lighthouse dementia unit were tested for COVID-19. Seven residents (#128, #129, #145, #146, #147, #150 and #153) tested positive for COVID-19. These residents were then moved to the Harmony unit, a dedicated unit which is currently being utilized to house residents who test positive for COVID-19. On [DATE], the facility received notification that 20 additional residents on the Lighthouse unit (#118, #120, #121, #122, #124, #125, #126, #127, #130, #131, #133, #134, #137, #140, #141, #143, #151, #152, #300 and #301) had tested positive for COVID-19. At this time, the seven residents originally moved to the Harmony unit were moved back to the Lighthouse unit. This resulted in Immediate Jeopardy on [DATE], as the Lighthouse unit had 12 residents (#117, #119, #123, #132, #135, #136, #138, #139, #142, #148, #149 and #154) that tested negative for COVID-19. These 12 residents were not removed from the unit or quarantined from the 27 residents who tested positive for COVID-19. Additionally, staff were observed with no direct access to Personal Protective Equipment (PPE) on the Lighthouse unit as the PPE was stored in the locked medication room at the nursing station, they were not wearing the required PPE to prevent the spread of COVID-19 per the facility policy and Centers for Disease Control (CDC) recommendations and staff were observed entering and exiting the rooms of all residents wearing only an N95 mask, regardless of their COVID-19 status. There were no bins on the Lighthouse unit in which to dispose of used PPE. The facility also failed to ensure social distancing during communal dining and activities and failed to ensure staff practiced proper hand hygiene when passing meal trays. On [DATE] at 12:53 P.M., an attempt was made to notify the Administrator of the Immediate Jeopardy that started on [DATE], however the Administrator refused the notification. During observations on [DATE], 12 residents (Resident #117, #119, #123, #132, #135, #136, #138, #139, #142, #148, #149 and #154) that had tested negative for COVID-19 were residing on the Lighthouse unit with 25 current residents (Resident #118, #120, #121, #122, #124, #125, #126, #127, #130, #131, #133, #134, #137, #140, #141, #143, #151, #152, #128, #129, #145, #146, #147, #150 and #153) that were positive for COVID-19. The facility did not have dedicated staff assigned only to care for those residents in isolation on the Lighthouse unit with confirmed cases of COVID-19. Staff failed to ensure the proper use of PPE and failed to ensure appropriate PPE was utilized when caring for a resident with COVID-19 in isolation (droplet) precautions and throughout the facility placing 40 residents in the Lighthouse unit at risk for contracting COVID-19 and experiencing the potential for serious harm associated with COVID-19 including hospitalization and/or death. The facility census was 144. The Immediate Jeopardy was removed on [DATE] at 3:53 P.M. when the facility implemented the following corrective actions: · On [DATE] through [DATE], all residents in the facility received a baseline test for COVID-19. Seven residents in the Lighthouse dementia unit tested positive and were immediately moved to Harmony, the COVID-19 positive unit. · On [DATE], all residents in the Lighthouse unit were tested and results on [DATE] through [DATE] showed more residents to be positive. All residents had either already tested positive or presumptive positive and droplet precautions continued in Lighthouse for all residents. · Harmony unit has been split by a plastic barrier for a COVID-19 positive/active side and a quarantine side for hospital admissions or presumptive positives due to exposure. · All staff on the Harmony unit will remain in full PPE, including use of N95 masks. All other units will use surgical/medical masks at all times. · The facility's policy related to COVID-19 droplet precautions, quarantine and discontinuation of precautions, titled COVID + Residents: Screening and Management was implemented on [DATE]. · As of [DATE], all of the Lighthouse residents have been removed from droplet precautions per CDC protocol and are now no longer on droplet precautions. They remain in the Lighthouse Unit. · PPE is available on every unit in the facility. It is maintained at the nursing station and replenished twice weekly and as needed. For PPE on isolation/quarantine units, staff are to call the unit and PPE is brought to the staff member so they can don before they enter. Staff are to doff and dispose of PPE as they leave the unit and dispose of it in red bins, which are located on each unit. Masks can be obtained at the check-in area at all times. Staff are to wear masks when they enter all care areas. · If an outbreak occurs on any other unit, residents will be moved to the Harmony COVID-19 unit. If there are not enough beds on the COVID-19 unit or the resident is not able to be moved due to the need for a secured environment (the Lighthouse Unit) residents will only be cohorted in rooms with other residents that have a positive COVID-19 [DIAGNOSES REDACTED]. · All staff in the facility will be in-serviced by the Director of Nursing (DON) or Infection Control nurse on the facility's policy on PPE, including correct use of PPE, donning and doffing PPE, and when PPE must be changed between resident care by [DATE]. · The DON and Infection Preventionist were in-serviced by the Corporate Clinical Liaison on [DATE] on the need to ensure that all residents in the facility will be placed in droplet precautions and cohorted in accordance with the facility policy. · The DON or Infection Preventionist will conduct daily observations of staff on all units to ensure that staff are using PPE appropriately, donning and doffing appropriately and disposing appropriately. The observations will be done for the next 4 weeks, twice weekly for two weeks, once weekly for one week, then to the Quality Assurance and Performance Improvement committee as needed. · The DON and Infection Preventionist will monitor all newly diagnosed residents to ensure that they are placed in the Harmony unit or cohorted appropriately. · During interview on [DATE] at 1:35 P.M., State tested Nursing Assistant (STNA) #201 stated he had access to plenty of PPE and did receive educational material on how to don and doff PPE. He reported that if PPE supplies were running low, he would tell the unit nurse and she would get it for him, and he also was able to get additional masks where he checked in each day at the front office. · During interview on [DATE] at 1:39 P.M., Licensed Practical Nurse (LPN) #5 stated she has enough PPE to care for the residents. She stated that staff can were a surgical mask or N95 mask when caring for residents that are not in isolation/quarantine, an N95 for residents in isolation/quarantine, but no cloth masks are to be worn by staff. · During interview on [DATE] at 1:44 P.M., STNA #3 stated he had received training on donning and doffing PPE and has sufficient PPE, disinfecting wipes, and alcohol-based hand rub when he needs it. STNA #3 was wearing an N95 mask and reported that staff are to wear the N95 masks on the Lighthouse and Harmony units but could wear surgical masks on the other units. · During interview on [DATE] at 1:55 P.M., LPN #250, working the 2 West unit, reported she has access to plenty of PPE. LPN #250 affirmed she has training recently on the proper way to don and doff PPE, that handouts with pictures on the proper sequence were provided. · During interview on [DATE] at 2:06 P.M., STNA #399, working the 2 West unit, stated he has received information and training on donning and doffing PPE and the head nurse on the unit watches him. He stated he had enough PPE available to take care of the residents, that there are supplies on the unit, and he can contact central supply staff if he needed more. · During interview on [DATE] at 2:15 P.M., STNA #323, working the men's side of the Leisure building, stated she did get recent training materials/handouts with pictorials on donning and doffing PPE correctly. She reported she had enough PPE and could get new/additional masks in the business office area. · During observation of the Central supply room on the first floor of the Leisure Building, on [DATE] at 2:25 P.M. revealed eight 24 count cases of pocket size hand sanitizers, multiple cases of caps, disposable isolation gowns, surgical masks, a large case of face shields, and gloves. In addition, there was an ample supply of alcohol bases hand rub refills for the dispensers. · During interview on [DATE] at 2:30 P.M., LPN #759 working the Harmony unit reported that there was a sufficient supply of PPE to provide care to the residents [DIAGNOSES REDACTED].#759 reported that all the required PPE is now in the drawers of the isolation cabinet in the airlock/anteroom at the entrance to the unit including gloves, shoe covers, hair covers, gowns, and face shield. He reported there were also additional supplies of each item on the unit. LPN #759 shared that he had all PPE needed to provide care on the unit and was in the process of re-organizing the closet containing the PPE. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #117's progress note dated [DATE] revealed test results were negative for COVID-19. Review of Resident #118's progress note dated [DATE] revealed test results were positive for COVID-19. Review of the physician's orders [REDACTED]. During observations on [DATE], Residents #117 and #118 remained roommates despite the fact Resident #118 tested positive for [MEDICAL CONDITION]. 2. Review of Resident #119's progress note dated [DATE] revealed test results were negative for COVID-19. Review of Resident #120's progress note dated [DATE] revealed test results were positive for COVID-19. Review of the physician orders [REDACTED]. During observation on [DATE], Residents #119 and #120 remained roommates despite Resident #118 testing positive for [MEDICAL CONDITION]. 3. Review of Resident #123's progress notes dated [DATE] revealed test results were negative for COVID-19. Review of Resident #124's progress notes dated [DATE] revealed test results were positive for COVID-19. Review of physician orders [REDACTED]. On [DATE], Resident #123 tested positive for COVID-19. During observations on [DATE], Residents #123 and #124 remained roommates, despite Resident #124 testing positive for [MEDICAL CONDITION]. 4. Review of Resident #148's progress notes dated [DATE] revealed test results were negative for COVID-19. Review of Resident #147's progress note dated [DATE] revealed resident tested positive for COVID-19. Review of physician orders [REDACTED]. Resident #147 was moved to the dedicated COVID-19 unit (Harmony unit) at this time. On [DATE], the resident was moved back to the Lighthouse unit. During observation on [DATE], Residents #147 and #148 remained roommates, despite Resident #147 testing positive for [MEDICAL CONDITION]. 5. Review of Resident #132's progress note dated [DATE] revealed test results were negative for COVID-19. Review of Resident #133's progress note dated [DATE] revealed test results were positive for COVID-19. Review of physician orders [REDACTED]. Review of Resident #134's progress note dated [DATE] revealed test results were positive for COVID-19. Review of physician orders [REDACTED]. During observation on [DATE], Residents #132, #133 and #134 remained roommates, despite Residents #133 and #134 testing positive for [MEDICAL CONDITION]. 6. Review of Resident #137's progress note dated [DATE] revealed test results were positive for COVID-19. Review of physician orders [REDACTED]. Review of Resident #138's progress note dated [DATE] revealed test results were negative for COVID-19. Review of Resident #139's nurses progress notes dated [DATE] revealed test results were negative for COVID-19. During observation on [DATE], Residents #137, #138 and #139 remained roommates, despite Resident #137 testing positive for [MEDICAL CONDITION]. 7. Review of Resident #142's nurses progress notes dated [DATE] revealed test results were negative for COVID-19. Review of Resident #143's progress note dated [DATE] revealed test results were positive for COVID-19. Review of the physician's orders [REDACTED]. During observation on [DATE], Residents #142 and #143 remained roommates, despite Resident #143 testing positive for [MEDICAL CONDITION]. 8. Review of Resident #154's progress note dated [DATE] revealed test results were negative for COVID-19. Review of Resident #153's progress note dated [DATE] revealed test results were positive for COVID-19. Resident #153 was moved to the dedicated COVID-19 unit (Harmony unit) at this time. On [DATE], the resident was moved back to the Lighthouse unit. During observation on [DATE], Residents #152 and #153 remained roommates, despite Resident #153 testing positive for [MEDICAL CONDITION]. 9. Review of Resident #149's nurses progress notes dated [DATE] revealed test results were negative for COVID-19. Review of Resident #150's nurses progress notes dated [DATE] revealed test results were positive for COVID-19. Physician orders [REDACTED]. Resident #150 was moved to the dedicated COVID-19 unit (Harmony unit) at this time. On [DATE], the resident was moved back to the Lighthouse unit. During observation on [DATE], Residents #149 and #150 remained roommates, despite Resident #150 testing positive for [MEDICAL CONDITION]. On [DATE], Resident #149's progress notes documented the resident was sent to the emergency room for evaluation due to the resident complaining of being weak, not eating and being more confused and disoriented. Resident #149 expired at the hospital on [DATE]. 10. Review of Resident #135's nurses progress notes dated [DATE] revealed test results were negative for COVID-19. Review of Resident #136's nurses progress notes dated [DATE] revealed test results were negative for COVID-19. During observation on [DATE], Residents #135 and #136 were roommates. Additional testing revealed Resident #136 was positive for COVID-19 on [DATE]. The physician order [REDACTED]. Review of the facility's list of residents that were positive for COVID-19, undated, revealed additional Residents #121, #122, #125, #126, #127, #130, #131, #137, #140, #141, #145, #146, #151, #152, #300 and #301 were positive for COVID-19 and remained on the Lighthouse unit, commingled with the residents who had tested negative for COVID-19. All residents reviewed had a plan of care for risk for contracting the COVID-19 virus due to the resident's age and chronic medical conditions. Protocols for COVID-19 screening and precautions were to be followed. Observation of the Lighthouse COVID-19 unit on [DATE] from 9:20 A.M. to 10:25 A.M. revealed no PPE supplies were available at either of the two entrances to the unit. There was also no PPE supplies observed outside of any resident rooms on the unit. There were no biohazard bins for doffing PPE at the entrances or inside or outside of any resident rooms. During observation of the Lighthouse unit [DATE] at 9:20 A.M., Housekeeper #01 was wearing a cloth face mask and no gown, booties, gloves or face shield. Housekeeper #01 left the unit and went into building three, 1-West unit. STNA #02 was wearing a surgical mask with no gown, booties, gloves or face shield. Interview with LPN #13 on [DATE] at 9:20 A.M. verified Housekeeper #01 and STNA #02 were not wearing an N95 face mask, gown, booties, gloves or face shield. During interview on [DATE] at 9:21 A.M., Housekeeper #01 stated the facility did not provide any PPE such as an N95 face mask, gown, booties, gloves or face shield. During interview on [DATE] at 9:21 A.M., STNA #02 stated the facility did not provide any PPE such as an N95 face mask, gown, booties, gloves or face shield. STNA #02 stated that the unit had both COVID-19 positive and COVID-19 negative residents with no separation of infected residents. During observation of the Lighthouse unit on [DATE] at 9:23 A.M., STNA #03 was wearing an N95 face mask but no gown, booties, gloves or face shield. During interview at the time of the observation, STNA #03 stated he was provided an N95 face mask but no gown, booties, gloves or face shield. During observation on [DATE] at 9:40 A.M., LPN #05 was working on the Lighthouse unit while wearing an N95 mask but no gown, gloves, booties or face shield. LPN #05 walked around the unit and spoke to Residents #135 and #136 while standing at the doorway to their room. She then went back to the nursing station to work on the computer, pulling her mask down below her nose to do so. Resident #147 was standing at the ledge of the nursing station talking on the telephone while LPN #05 was sitting on her computer with her mask pulled forward below her nose. Resident #147 asked LPN #05 to speak to the person on the telephone and LPN #05 put her mask back over her nose and proceeded to use the same telephone as Resident #147 without disinfecting it. LPN #05 gave the phone back to Resident #147 without sanitizing it. LPN #05 used a sanitizer wipe to disinfect the phone after Resident #147 was finished using it. LPN #05 continued to pull her mask down below her nose while at the nursing station. During an interview at the time of the observation, LPN #05 stated she had her mask below her nose because it did not fit correctly and fogged up her glasses. She verified she was not wearing a gown, gloves, booties or face shield and verified Resident #147 was positive for COVID-19 and had used the telephone at the nursing station. When questioned about the location of PPE, LPN #05 stated PPE was kept in the locked medication room. LPN #05 verified that there was no PPE outside the unit to don or biohazard bin outside the unit to doff PPE after use. LPN #05 also verified there was no PPE outside of the resident rooms. LPN #05 stated she dons and doffs PPE on the unit, and when she removes soiled PPE it is placed in the regular trash can. LPN #05 stated that the facility has both COVID-19 and non- COVID-19 residents on the unit and that the facility continues to keep positive and negative residents together as roommates. LPN #05 reported Resident #117, Resident #119, Resident #123, Resident #132, Resident #138, Resident #139, Resident #142, Resident #148, Resident #149 and Resident #154 were all negative for COVID-19 but had roommates that were positive for COVID-19. During observation on [DATE] at 9:40 A.M., Laundry Staff #06 was on the Lighthouse unit at the nursing station wearing an N95 face mask, but no gown, booties gloves or face shield. Laundry Staff #06 asked LPN #05 for a gown. LPN #05 unlocked the medication room and gave Laundry Staff #06 a gown. Observation of the Lighthouse unit on [DATE] at 9:45 A.M. revealed STNA #03 going in and out of the rooms of Residents #121, #122, #130, #131, #136, #137, #138, #142, #143, #144, #145, #146, #147, #148, #149, #150 and #151 wearing only an N95 mask to retrieve breakfast trays. STNA #03 was not wearing a gown, gloves, face shield or booties and did not wash or sanitize hands or don/doff any PPE between rooms. STNA #03 and LPN #05 were observed putting trash from breakfast trays that were collected by STNA #03 in a trash bag. LPN #05 was holding the bag with gloves and was wearing an N95 mask but no other PPE. STNA #03 was putting items from meal trays into the trash bag wearing an N95 mask, but no other PPE including gloves. Residents #136, #138, #142, #148 and #149 were COVID-19 negative; however, all other residents STNA #03 encountered during the observation were COVID-19 positive. During an interview at the time of the observation, STNA #03 stated she was not told which residents had been COVID-19 positive or negative but thought they all had it now. STNA #03 verified there were no bins to doff or don PPE, there was no PPE outside the unit and no PPE outside of the resident's rooms. During observation on [DATE] at 10:00 A.M., Housekeeper #01 returned to the Lighthouse unit and asked LPN #05 for a gown. LPN #05 again unlocked the medication storage room and provided Housekeeper #01 with a blue plastic gown. Housekeeper #01 proceeded to clean rooms wearing an N95 face mask under his cloth mask and a gown. He was not wearing any other PPE. During an interview at the time of the observation, Housekeeper #01 stated he did not know which patients had COVID-19 on the unit, but the facility used a bleach solution to clean. During observations on [DATE] at 10:22 A.M., STNA #03 walked with Resident #133 to the shower room wearing an N95 face mask but no gown, gloves, booties or face shield. Resident #133 was COVID-19 positive. At the time of the observation, LPN #05 verified STNA #03 was only wearing an N95 face mask. During a telephone interview on [DATE] at 6:15 P.M., STNA #40 stated she had symptoms of fever and chills on [DATE], then tested positive for COVID-19 on [DATE]. STNA #40 stated she worked on the Lighthouse unit prior to testing positive for COVID-19. She stated several residents tested positive for COVID-19 prior to her testing positive. She stated the facility provided the staff with a surgical mask to wear but did not provide them with an N95 face mask, face shield or gown. During interview on [DATE] at 7:20 A.M., Local Health Department (LHD) Staff #100 stated she had been working with the facility and had been in contact with the DON. LHD Staff #100 reported that she has requested a line list from the facility, but they have not provided it. LHD Staff #100 stated the facility originally had one unit that was for COVID-19 residents but then someone infected several residents on another unit. As a result, they opened a second COVID-19 unit. LHD Staff #100 stated the DON told her that they were moving all the positive cases to one area of the building and then the negative cases would remain on that unit in another area in a private room for 14 days. LHD Staff #100 reported she discussed the use of appropriate PPE including wearing N95 masks, gowns, gloves, face shield and booties with the facility for residents with COVID-19 and provided Centers for Disease Control (CDC) resources for the use of PPE. LHD Staff #100 stated facilities should never have positive and negative cases in the same room together. During telephone interview on [DATE] at 9:03 A.M., LPN Unit Manager #102 revealed she was the unit manager of the Lighthouse unit but worked everywhere in the facility. LPN Unit Manager #102 stated she has been working on the floor recently and had not been on the Lighthouse unit. She stated she had moved her office off the Lighthouse unit. The facility provides PPE, but staff do not always wear it. LPN Unit Manager #102 stated she thinks some of the staff want to get COVID-19 because they do not wear the PPE that is provided. During telephone interview on [DATE] at 2:48 P.M., Medical Director (MD) #01 revealed he was aware of cases of COVID-19 in the facility. MD #01 stated that the facility should be using precautions including the use of gowns, N95 face masks and gloves on the COVID-19 units. MD #01 stated he was at the facility on [DATE] and had a meeting with the facility regarding COVID-19 at that time. MD #01 stated the facility only had one COVID-19 unit at the time of his visit. MD #01 stated he was not aware of residents with positive and negative cases of COVID-19 being cohorted in the same rooms on the Lighthouse unit prior to [DATE]. During tour of the facility on [DATE] at 8:15 A.M. to 8:42 A.M., Activities Aide #12 and Activities Aide #21 were passing trays and assisting residents with setting up items on their trays while wearing cloth masks on the 2-West unit. Activities Aide #12 was wearing her cloth mask below her nose. Observation of the Leisure Women's unit revealed Maintenance Staff #10 walking around the building while wearing a cloth mask. Observation of the Leisure Men's unit revealed Housekeeper #25 in the dining room of the unit wearing a cloth mask. Interview with Administrative Assistant #20 on [DATE] from 8:15 A.M. to 8:42 A.M. verified Activities Aide #12, Activities Aide #21, Maintenance #10 and Housekeeper #25 were wearing cloth masks. Interview with the Director of Nursing (DON) on [DATE] at 8:47 A.M. revealed the Harmony and Lighthouse units were the quarantined units at the facility, with residents that had tested positive for COVID-19 residing on both units. The DON stated all staff are required to wear either homemade or surgical masks on the non-COVID units. Observation of Building 1, the lower floor offices, on [DATE] at 7:27 A.M. revealed State tested Nurse Aide (STNA) #459 was not wearing a mask and walking around talking to a staff member that was clocking out at the time clock. Interview on [DATE] at 7:27 A.M. with STNA #459 verified she was not wearing a mask while walking around in Building 1 lower floor offices. Observation of the Leisure Women's unit on [DATE] at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #578 wearing a cloth mask while in the nursing station on the unit. During observation on [DATE] at 7:55 A.M., no disposal bins or PPE was seen outside of the resident rooms or at either of the two doors to enter the unit. Interview with LPN #570 on [DATE] at 7:55 A.M. verified there was no red bins to doff PPE on the unit. LPN #570 also verified there was no PPE outside of resident rooms or located at either of two doors to enter the unit. Observation of the Lighthouse dining room on [DATE] at 8:05 A.M. revealed Resident #129 sitting at a table in the dining room continually coughing. Resident #153 was also observed sitting at a table in the dining room while coughing intermittently. Residents #118, #119, #120, #124, #125, #130, #133 #137, #138, #145 and #154 were also present in the dining room for communal dining with no social distancing in place. All residents were sitting within six feet of each other. STNA #571 and LPN #570 were serving trays to residents in the dining room without sanitizing their hands between each resident. Interview with LPN #570 on [DATE] at 8:05 A.M. verified Residents #129 and #153 were coughing in the dining room with the other residents present and verified all residents were present for communal dining in the dining room on the unit. Interview with STNA #40 and STNA #572 on [DATE] at 8:05 A.M. verified neither sanitized their hands while passing breakfast trays. They stated they did not have access to hand sanitizer. During observation of the COVID-19 Harmony unit on [DATE] at 8:30 A.M., STNA #456 went from room to room, serving breakfast trays, opening the Styrofoam boxes of food, taking lids off of cups and adjusting resident beds. STNA #456 did not sanitize hands between rooms. Housekeeper #458 was wearing a cloth mask and blue gown while mopping the hallway floor on the COVID-19 Harmony unit with doors to resident rooms open. Interview with STNA #456 on [DATE] at 8:30 A.M. verified she did not sanitize in between going in and out of rooms while delivering room trays. Interview with Housekeeper #458 on [DATE] at 8:30 A.M. verified he was wearing a cloth mask on the Harmony COVID-19 unit. Interview with the DON on [DATE] at 8:50 A.M. revealed no one in the Lighthouse unit is on quarantine due to being asymptomatic and having completed their 10-day quarantine. The DON stated Resident #119, Resident #120, Resident #129 and Resident #153 had coughs because they were smokers but verified they had tested positive for [MEDICAL CONDITION] and had not had any negative tests. On [DATE] at 12:30 P.M. during tour of the facility, six residents on the One West unit were sitting in the dining room, not social distancing. Only one resident was wearing a mask; five others were not. Interview with Licensed Practical Nurse (LPN) #250 revealed she asked for a mask earlier from the supervisor on duty that morning and no one has brought them. On [DATE] beginning at 11:09 A.M. and ending at 12:05 P.M., a tour of the facility was conducted with Admissions Director (AD) #744. On the secured men's Leisure Unit, Residents #53 and #08 were observed sitting next to each other, elbow to elbow, in the unit dining/activity room. Neither resident was wearing a mask. Nursing staff were in the general vicinity and were not redirecting the residents to practice social distancing. AD #744 affirmed the two male residents were sitting next to each other, not socially distant from one another and alerted nursing staff present. On the 2 West unit, Activity Staff (AS) #12 was observed sitting in the unit dining/activity room with her mask under her chin. There were six residents present in the unit activity/dining room. When asked if she was supposed to be wearing her mask over the mouth and nose, she replied that she was sitting away from the residents and the mask was not necessary as the unit did not have any COVID-19 positive residents. An interview was conducted with LPN #105 present on the 2 West unit regarding the mask wearing policy, and what was communicated by AS #12. LPN #105 reported that AS #12 should be wearing her mask at all times per facility policy. On the Lighthouse unit, Residents #145, #154, #152, and #118 were sitting around a table in the unit dining/activity room together, elbow to elbow. None of the four residents were wearing a mask. The residents were in full view of nursing staff present at the nursing station including LPN #759 and STNA's #40 and #2. AD #744 affirmed the four specified residents were sitting in close proximity to one another and not wearing masks. She alerted the nursing staff at the nursing station who then attempted to get the residents to spread out. During interview with LPN #759 on the Lighthouse unit, she stated staff were required to wear a surgical or N95 mask at all times. When queried regarding if information and training was given on how to care for the mask, or how many times it could be worn consecutively, LPN #759 reported that one mask could be worn for the entire week on days scheduled; typically staff work three days and the mask could be worn consecutive days in a row. She stated she could take the mask home, (TRUNCATED)

Based on observations, medical record review, review of the facility's investigation, interviews with facility staff, interview with the local police, review of the police report, and review of the facility's policy on elopement and wandering/unsafe resident, the facility failed to ensure staff provided adequate supervision to prevent a resident, with a history of exit seeking behavior, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and injury when she eloped from the facility without staff knowledge. The resident was missing for approximately 30 minutes and was found by the local police approximately 0.2 miles from the facility at a home where she was barefoot and banging on the doors asking to be let in as someone was trying to kill her. Additionally, the facility failed to complete an accurate and thorough investigation of Resident #01's elopement. This affected one (#01) of four residents reviewed for risk of elopement. The facility identified 26 current residents at risk for elopement. The facility census was 145. On 08/16/19 at 1:18 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/08/19 at approximately 2:30 A.M. when Resident #01 exited the secured unit without staff knowledge. Resident #01 was previously assessed as being at risk for elopement, exhibited exit-seeking behaviors almost daily and resided on a secured unit to ensure the resident safety. On 08/08/19 at 2:51 A.M., Resident #01 was found by the local police after receiving a nine-one-one (911) call by a homeowner who lived 0.2 miles from the facility reporting an unknown female was knocking on the door of a residence asking to be let in as someone was trying to kill her. The local police arrived at the homeowner's location at 3:12 A.M. and found Resident #01 barefoot. The local police suspected the resident was from the facility since she was barefoot. The resident identified herself but denied living at the facility. The facility was unaware Resident #01 was missing until 3:10 A.M. when licensed nursing staff were completing rounds. On 08/08/19 at 3:29 A.M., the local police brought Resident #01 back to the facility. The Immediate Jeopardy was removed on 08/16/19 when the facility implemented the following corrective actions: · On 08/08/19 at 3:17 A.M., Resident #01 was safely returned to the facility by the local police and was placed on one-on-one supervision until the resident was sent for a psychiatric evaluation on 08/15/19 at 12:25 A.M. · On 08/08/19 from 4:00 A.M. to 08/19/19 at 11:00 A.M., the Director of Nursing (DON), Unit Manager (UM) #61, the Administrator and designee in-serviced all the staff on the elopement policy and procedure, entering and exiting a secured unit and what to do if an alarm sounded and no one was around. There were 185 of the 209 staff in-serviced and the remaining 24 will be in serviced via phone by 3:00 P.M. on 08/20/19. · On 08/08/19 at 6:00 A.M., all 20 door alarms on all five units were checked by Maintenance Director #41. There were no negative findings. · On 08/08/19 at 6:30 A.M., all 20 door codes on all units were changed by Maintenance Director #41. · On 08/08/19 at 10:00 A.M., the DON, UM, Minimum Data Set (MDS) Nurse #149 or designee conducted wandering assessments on all 145 residents in the facility. There were 26 residents identified to be at risk for elopement. · On 08/08/19 at 10:45 A.M., Lock Company #750 came out and inspected all door alarms to ensure they were working properly. There were no negative findings. · On 08/08/19 at 3:00 P.M., all five elopement books were updated on all units with pictures and face sheets for the 26 residents identified at risk for elopement and the elopement policy by the DON, UM or designee. · On 08/08/19 at 3:00 P.M., MDS Nurse #149 and Licensed Social Worker (LSW) #215 updated all 26 resident's elopement risk care plans. · On 08/15/19, audits were initiated to check all door codes to make sure they were functioning properly for one time daily for two weeks by the DON, UM, Maintenance Director #41 or designee. · On 08/16/19 at 9:00 A.M., signs stating Do not allow anyone through these doors without the nurses permission were hung on all secured unit entrance and exit doors by the DON, UM, or designee. · On 08/16/19, audits of staff properly monitoring residents at risk for elopement began and will take place three times a week for two weeks, then two times a week for two weeks and then one time a week for four weeks. · On 08/16/19, the UM, the nursing staff and the social worker began individual behavior assessments for the 26 residents at risk for elopement to evaluate the cause of exit seeking behaviors and placing appropriate interventions in the care plan when behaviors are identified for theses residents at risk for elopement. · Elopement drills began on 08/16/19 and will be conducted four times a week for two weeks, two times a week for two weeks and then one time a week for four weeks by the DON, UM, or designee. · Audits began on 08/16/19 and will be conducted three times a week on all residents at risk for elopement ensuring they remain safe and will be completed by the DON, UM, or designee. · On 08/16/19, record reviews for four additional residents (#02, #03, #102 and #104), identified at risk for elopement, revealed they were assessed to be at risk for wandering and were on a secured unit. There were no concerns identified. · Multiple observations of the secured unit revealed on 08/16/19 at 2:10 P.M., Licensed Practical Nurse (LPN) #54 used her body to block vision of the keypad to the door alarm as she entered the code to leave the unit and she looked behind her to ensure no residents were following her. On 08/16/19 at 2:20 P.M., State tested Nursing Aide (STNA) #98 used her hand to block the code as she entered it to allow a family member to leave the unit and she looked behind her to ensure no residents left behind the family member. On 08/16/19 at 2:25 P.M., LPN #113 redirected Resident #79 from the exit doors and he was provided a snack. On 08/16/19 at 4:51 P.M., Resident #79 set off a door alarm and was immediately redirected from the door by LPN #61 who offered an activity. On 08/19/19 at 1:34 P.M., STNA #98 used her hand to block the code as she entered it for a family member to leave and she looked behind her to ensure no one left behind the family member. On 08/19/19 at 1:37 P.M., Activity Aide #211 covered the code with her hand as she entered the unit. On 08/19/19 at 1:58 P.M., STNA #80 covered the panel to enter the code to escort the resident into a secured outside area so they could smoke. · On 08/19/19, keypad guards were ordered and will be placed on all lock keypads to ensure the codes cannot be seen by anyone other than the user entering the code on the keypad. On 08/20/19, the keypad guards arrived and were installed by the maintenance department. · On 08/19/19 at 2:00 P.M., an observation was made of a sign on the door of the unit where Resident #01 resided noting Do not allow anyone through these doors without the nurse's permission. 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #01 revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the wandering risk assessment, dated 05/05/19, revealed Resident #01 was disoriented with a short attention span, was diagnosed with [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/29/19, revealed the resident had moderate cognitive impairment, she attempted elopement daily and she required supervision for eating, bed mobility and transfer. Review of the care plan, last revised 07/15/19, revealed the resident was deemed incompetent by the Probate Court related to her disease process and impaired safety awareness, and had a state appointed guardian. The state appointed guardian requested the resident reside on a secured unit for the resident's safety. The interventions included to monitor her location and ensure her safety, and monitor for tailgating behavior when visitors and staff were entering and exiting the secured unit. Resident #01 required staff assistance to exit the unit. Staff were to assist the resident with developing more appropriate coping methods, offering pleasant diversions, structured activities, food, conversation, reorienting strategies and opportunities for positive interaction. Review of the Behavior Assessment and Data Collection form, dated 08/01/19, revealed the resident had a history of [REDACTED]. Review of the nursing progress notes from 06/01/19 through 08/08/19 revealed the resident often went from exit door to exit door pushing on the doors until the alarm sounded to exit the facility unsuccessfully. The resident was not easily redirected. A progress note, dated 08/07/19, revealed the resident was exhibiting signs of exit seeking behavior and becoming physically aggressive with redirection. Review of the Incident Detail Report from the police department, dated 08/08/19 at 2:51 A.M., revealed a home owner called emergency 911 on 08/08/19 at 2:51 A.M. to report an unknown female was knocking on her door requesting to get in as someone was trying to kill her. The report further documented the female knocked on the door again at 3:01 A.M., the officers arrived at the residence at 3:12 A.M. and they escorted Resident #01 back to the nursing facility at 3:29 A.M. and closed out the case at 3:31 A.M. noting the subject walked away from the nursing home. The distance from the facility to the homeowner's address revealed it was 0.2 miles. Review of the nursing progress note, dated 08/08/19 at 5:48 A.M., revealed nursing staff were notified by a supervisor at 3:30 A.M. that Resident #01 had been escorted back to the facility by the local police officers. A head-to-toe assessment was completed which revealed no acute injuries, skin abnormalities or distress. Following the assessment of Resident #01, the note documented she was placed at the nursing station for one-to-one monitoring, there was a head count completed of all residents on the unit and all exit doors and alarms were tested and found to be in working condition. Review of the nursing progress note, dated 08/08/19 at 8:15 A.M., revealed the nursing staff noticed Resident #01 was not on the unit at approximately 3:00 A.M. and initiated elopement protocols to search for Resident #01 and secure all units. This time noted in the progress note was noted to be different from the facility's investigation and witness statements. Review of the facility's investigation revealed the investigation was initiated on 08/08/19. STNA #29, STNA #87 and LPN #137 observed Resident #01 in the hallway at 3:00 A.M. LPN #137 notified the staff to begin searching the unit and initiated the elopement protocol of sending an alert campus wide that Resident #01 was missing. The search for Resident #01 was completed inside the facility as well as outside on the grounds. During the outside search, police officers arrived with Resident #01 on 08/08/19 at 3:30 A.M. Review of the statement from STNAs #29 and #87 and LPN #137 revealed they all reported on 08/08/19 that Resident #01 was observed walking the halls at 3:00 A.M. STNA #29 and LPN #137 reported Resident #01 was identified as missing from the facility at around 3:10 A.M. STNA #87 reported about 15 minutes after they began searching for her, the local police pulled up to the facility with Resident #01. Review of the statement from Floor Technician #175, dated 08/08/19, revealed he completed his duties at 2:30 A.M. on Resident #01's secured unit and returned around 4:00 P.M. to continue working. He stated he only saw Resident #01 after she had been returned to the facility by the local police. On 08/12/19 at 2:21 P.M., an interview with LPN #137 revealed she saw Resident #01 walking down the hall toward her room around 3:00 A.M. and the resident had stated she was tired and was going to lay down. She stated a short time later, it was discovered she was not in her room and the alert was sent to all units to begin searching for her. She stated when they were outside searching the parking lot, the local police pulled up around 3:30 A.M. with Resident #01. She reported Resident #01 did not seem upset, had no injury and stayed up for a few hours after the incident with one-on-one supervision provided with her at the nursing station. She stated Resident #01 had never gotten out of the facility unsupervised before. On 08/12/19 at 2:24 P.M., an interview with the DON revealed on 08/08/19 Resident #01 got out one of the doors and left the facility. She stated she may have followed one of the housekeepers out who was buffing the floor or memorized the code for the door. She reported the door alarms on the three exit doors of the secured unit did not go off to alert staff when she had left the building on 08/08/19. However, the door alarms were checked and had been working after the incident. The DON stated it may have been about 15 minutes before they discovered she was missing. She reported her guardian and the doctor were notified right away and they began to search for her on and off grounds. She reported they believed she was gone for about 40 minutes and was returned to the facility by the local police who found her walking on the road where the facility was located. She stated Resident #01 sustained no injury while she was out of the facility. She reported all doors were inspected the next morning to ensure they were functioning, and the codes were changed by both the Maintenance Director and the company who installed the door alarms. The DON reported Resident #01 had a dementia [DIAGNOSES REDACTED].#01 had a history of [REDACTED]. The DON reported typically Resident #01 would go to the doors and try to push on them to get them to open, the alarm would go off and staff will redirect her to activities. She stated Resident #01 especially liked music and dancing but watching movies and eating snacks also helped to redirect her exit seeking behavior. The DON stated Resident #01 was admitted to the secured unit and had varying degrees of exit seeking behaviors since her admission with changes to her medication, but no medication regimen was very successful. She reported she had alarmed the doors in the past, but staff were always right behind her, she was always in sight and redirected immediately. She stated the resident had intermittent one-on-one supervision depending on the extent of her exit seeking behavior but after the incident on 08/08/19 she had one-on-one supervision until being sent out for a psychiatric evaluation on 08/15/19. On 08/12/19 at 3:04 P.M., an interview with Maintenance Director #41 revealed the first thing on the morning after Resident #01 eloped, he checked all the door alarms, and found them to be functioning. He changed all the door codes. He reported the company who installed the alarms also came out the day after the incident and checked all the delays on the doors and found no problems. He reported Resident #01 had figured out that she can push on the door for 15 seconds and it will open. He stated when this happened, the alarm went off and staff immediately redirected her away from the doors. On 08/12/19 at 4:55 P.M., an interview with LSW #215 revealed Resident #01 had serious exit seeking behaviors and had an appointment to see the Psychiatrist on 08/14/19 with the hope they could get a referral for an extended psychiatric stay to fully evaluate Resident #01's behaviors and medication. On 08/12/19 at 5:02 P.M., an interview with LPN #61 revealed she had been the consistent nurse for Resident #01 until (MONTH) when she had taken a promotion. She reported she had been off the unit for a while in training and Resident #01's exit seeking seemed to increase during that time. She reported Resident #01 was encouraged to stay in the common areas when awake and was checked every hour when sleeping. On 08/12/19 at 5:11 P.M., an interview with STNA #20 revealed Resident #01 engaged in exit seeking regularly and staff immediately intervened and redirected her to other activities. On 08/12/19 at 5:14 P.M., an interview with STNA #37 revealed Resident #01 consistently would exit seek. She reported there were times staff would stay at each end of the hall to better redirect her. She stated Resident #01 liked food and music and offering those options were the best way to redirect her. She reported Resident #01 would at times watch for when they were busy, push on the door until she heard the click and then would try to exit. She stated when Resident #01 tried to then leave through the door, the alarm would go off and staff would intervene. On 08/12/19 at 5:28 P.M., an interview with LPN #125 revealed Resident #01 will make her rounds going door to door trying to find one where she can get out. She stated she would watch and wait until staff were busy and then try to leave, the door would alarm, and staff would go immediately to intervene and redirect her. Observations on 08/12/19 between the hours of 4:30 P.M. to 5:30 P.M. revealed Resident #01 walking around to all exit doors with staff re-directing. Staff were successful re-directing her for five to ten minutes to listen to music and dance. After a few minutes, she began going to the doors again and continued this behavior until dinner was served. On 08/15/19 at 9:40 A.M., an interview with the DON and Administrator verified the facility's timeline for the incident with Resident #01. They verified Resident #01 was observed by multiple staff members at 3:00 A.M., then at 3:10 A.M., they identified Resident #01 was missing, and at 3:30 A.M., the local police returned the resident to the facility. They stated they began their protocol of searching for the resident. Before they had a chance to contact the police, the police had brought her back. The Administrator stated she reviewed the video and indicated she saw Resident #01 and it appeared the resident put in the security code to exit the secured unit without staff knowledge. On 08/15/19 at 9:53 A.M., an interview with STNA #87 revealed on 08/08/19 around 3:00 A.M., she was completing her rounds and saw Resident #01 pacing the halls near the nursing station and was headed toward her room. She stated a few minutes later, LPN #137 asked her if she had seen Resident #01 as she was not in her room. She reported then they began searching for Resident #01 both inside and outside the facility and while they were outside searching around 3:30 A.M. they noticed the local police arriving with Resident #01. On 08/15/19 at 10:40 A.M., an interview with STNA #29 revealed around 3:00 A.M. on 08/08/19 she observed Resident #01 walking the halls heading towards her room. She stated a few minutes later, LPN #137 told her they could not find Resident #01. STNA #29 stated she stayed inside the unit to monitor the other residents and Resident #01 returned to the facility around 3:30 A.M. to 3:40 A.M. She stated when Resident #01 was asked why she left, she stated she wanted to get away with no destination reported. She reported Resident #01 had been exit seeking since her admission and would push on the doors and wait for them to click to try to leave. She stated when she did this, the door usually alarmed but there was no door alarm that night of 08/08/19, so she was not sure how she got out. On 08/15/19 at 5:00 P.M., a subsequent interview with the Administrator verified she was able to watch the video but did not record the date and time when the last time Resident #01 was seen on the unit, the exact time you see her exiting the facility and what door she exited the facility. The Administrator verified these details were not in the facility's investigation. The Administrator stated she was unsure if the State Survey Agency would be able to watch the video coverage during the night of 08/08/19. On 08/16/19 at 6:18 A.M., an interview with Police Officer #380 revealed he recalled the incident on 08/08/19 around 3:00 A.M. He stated he received a dispatch call to a home very near the facility from a homeowner stating a lady was banging on their door and windows and didn't know who it was. The lady appeared as barefoot and he suspected she was from the nursing home (NH) as they have frequent walkaways. The lady could identify herself, (Resident #01), her date of birth and social security number. The Officer asked her where she lived, and she gave an address that wasn't the NH. He stated since she was barefoot, he suspected she might be from the NH. He specifically asked her if she was from the facility and she replied no. The resident got into his car with no difficulties. He brought her to the NH, and he went inside with the resident in his car. The officer stated staff rolled their eyes at him when he asked if this was their resident. They said yes, so he brought her inside. He stated the staff did not know she was missing. On 08/16/19 at 9:35 A.M., an interview with the Administrator revealed she reported there was a discrepancy in the facility's timeline and would be updating it. She reported the reason for the update was because a staff member said the State Survey Agency might be going to the police station to check on a report, so she called the police station to check if the State Survey Agency obtained any report. The local police said they found an incident report and they picked the resident up at 2:51 A.M. so that was the discrepancy in the timeline. She stated she couldn't explain the discrepancy except to say perhaps the staff did not look at their watch correctly. Review of the facility's updated timeline presented on 08/16/19 revealed the following changes were made. On 08/08/19, the local police received a 911 call and resident exited the facility at an unknown time prior to 2:51 A.M. per the police incident report. On 08/08/19, per the police incident report, the resident was noted at a home four minutes away knocking at the door and trying to get in. On 08/16/19 at 11:45 A.M., an interview with the facility's Information Technologist (IT) #385 revealed he was finished with the work at the facility and the Administrator now had access to all the cameras. He reported the videos were stored for 30 days so the 08/08/19 video should be available to review. He then asked what unit was needed. When he was told the video for Resident #01's unit name, he stated at some point the power went off in the storage room where the equipment was housed, he was not notified, and he discovered it when he came to document video locations for his records. He stated if the power went off around the needed date, a video would not have been recorded or been deleted. He stated the videos were correctly time stamped so the time on the video would be accurate to the correct time of the event. He reported he could contact the company who supplied the video equipment to determine the dates the power was not on to the camera on Resident #01 unit. On 08/08/19 at 12:20 P.M., he reported the system had been unplugged from 07/04/19 at 11:00 A.M. to 08/13/19 at 12:00 P.M., making it impossible that a video was recorded on 08/08/19, the date of the incident with Resident #01. On 08/16/19 at 12:25 P.M., an interview with the Administrator revealed she was trying to pull up the video from 08/08/19 to be viewed but could not access it for some reason and was unsure why as she now had access to the camera and reported she had viewed the video the day after the incident. She reported she viewed the video on 08/08/19 sometime after 8:00 A.M. on that date but did not document her findings. She stated she was looking at what was going on and did not look at timestamps. She stated her impression was the resident was at the door for a few seconds and exited and she felt she put in the code because of the way she stopped for longer than it would have been just to push the door open. She reported she saw no staff nearby when she viewed the video, so it didn't appear she followed anyone out. She stated she was not sure how the resident would have received the code. When the Administrator was told the IT staff stated the system was unplugged during the time of the incident, she stated she could not explain how she watched a video that could not have been recorded as the machine was unplugged. On 08/19/19 at 11:56 A.M., an additional interview with STNA #87 revealed she doesn't look at a clock but generally does her rounds every two hours. She reported she worked 11:00 P.M. to 7:00 A.M. on 08/08/19, and she did her rounds between 2:30 A.M. and 3:00 A.M. and saw Resident #01 walking the hall at some point during her rounds. On 08/19/19 at 1:20 P.M., an additional interview with STNA #29 revealed when she reported seeing Resident #01 at 3:00 A.M., she stated it was an approximate time. She reported she thinks Resident #01 may have pushed on the unit door until it alarmed as she had done in the past and they did not hear the alarm go off as the equipment the housekeeping staff was using to buff the floor was very loud. She stated when Resident #01 tried to get out, she walks very fast so she did not think it would take her very long to get off the grounds. She reported she had been notified by the nurse Resident #01 was missing and they were looking for her when the police brought her back, but she did not know what staff member brought her back. Review of the facility's policy on elopement, last revised 02/2014, revealed staff should promptly report to the charge nurse or Director of Nursing when it was suspected any resident was missing. If it was discovered the resident left the facility, a search should be initiated of the building and the premises and if the resident was not located, law enforcement should be contacted. When the resident returned to the facility, nursing should examine for injuries and the family and doctor should be notified and updated throughout the process. Review of the facility's policy titled Wandering, Unsafe Resident, last revised on 02/14/19, revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. A missing resident was considered a facility-wide emergency. If a resident was missing, the elopement protocol would be initiated. The facility was to determine if the resident was out on an authorized leave or pass and if the resident was not authorized to leave, they would initiate a search of the buildings and premises. If the resident was unable to be located, the Administrator, DON, the resident's legal representative, the Attending Physician, and law enforcement officials were to be notified. This deficiency substantiates Complaint Numbers OH 290 and OH 269.

Based on observation, medical record review, hospital record review, staff and resident interview, and review of the facility's policy, the facility failed to prevent the physical abuse of Resident (#8) by another Resident (#31), which resulted in actual physical harm to Resident #8 including a laceration to his left temple area that required three stitches, a subdural hematoma, and fractures of the zygomatic arch (cheekbone) and sphenoid sinus wall (side of the face near the optic nerve). This affected one (#8) of three residents reviewed for abuse. The census was 148 residents. Findings include: Review of Resident #8's medical record, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively aware but experienced delusions. The resident also displayed verbal behaviors towards others and rejected care. He required supervision of staff with bed mobility, transfers, walking, dressing, and eating tasks. He required minimal assistance of staff with toilet use and personal hygiene. Review of a care plan initiated on 06/21/18, indicated the resident had the potential to be physically aggressive related to dementia and [MEDICAL CONDITION] disorder. The resident had a history of [REDACTED]. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behaviors, give the resident as many choices as possible about care and activities, and provide a psychiatric consult as indicated. Review of Resident #31's medical record revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS completed on the resident. The resident had resided at another local nursing home prior to being admitted . The other nursing home sent admission paperwork that included his documented behaviors. The admission paperwork indicated the resident yelled, screamed, and used inappropriate language. He yelled obscenities when he became upset at others. He yelled racial slurs at others and threw random items. He threw water in other residents' rooms and bumped staff with his shoulder. He banged his bed against the wall and banged his head and fist on items. He aggressively jumped at people, exposed himself, and masturbated in common areas. He paced the halls and in his room. He would get on the floor and sit or lay. Review of the psychiatric nurse practitioner evaluation dated 04/04/19 indicated the resident had paranoid [MEDICAL CONDITION] and was unstable. Orders were written for an anti-psychotic medication, [MEDICATION NAME] 10 milligrams (mg). The resident was having auditory and visual hallucinations and he was agitated and impulsive. Review of a care plan initiated on 04/06/19 indicated Resident #31 had a behavior problem secondary to schizotypal disorder, paranoid [MEDICAL CONDITION], and ADHD. He was at increased risk for falls/injury related to overt behaviors exhibited as, extremely intrusive. He would take food and drinks from other resident's trays. He would also sit on the floor with legs crossed frequently. He paced the hallways back and forth. He would come to the nurse's station and presses his head against the window frequently. Interventions included offer coke or little Debbie snacks as these are the resident preferences, and for staff to accompany resident when pacing the halls. Review of the nurse's notes dated 04/08/19 at 10:11 A.M., revealed the resident was administered an as needed dose of an anti-psychotic, [MEDICATION NAME] 5.0 mg intramuscularly (IM) for the behaviors of yelling and pacing. On 04/08/19 at 5:49 P.M., the resident was documented as still yelling and pacing. A second dose of as needed [MEDICATION NAME] 5.0 mg was administered and documented as being ineffective. On 04/09/19 at 8:02 A.M., the resident was administered an IM dose of [MEDICATION NAME] 5.0 mg for anxiety as needed, related to paranoid [MEDICAL CONDITION]. At 10:30 A.M., the nurse documented the medication was ineffective. On 04/10/19 at 6:44 A.M., the nurse documented the resident was administered an IM injection for [MEDICATION NAME] 5.0 mg due to this resident's increased violent behaviors directed toward other residents. On 04/10/19 at 7:12 A.M., Resident #31 was documented as having increased violent/ impulsive behaviors at this time. Resident pushed another resident down onto the floor causing the other resident to hit his head. The other resident sustained [REDACTED]. An as needed dose of [MEDICATION NAME] 5.0 mg was administered earlier at 6:44 A.M. was ineffective. Temporary one to one supervision in effect to monitor Resident #31. On 04/10/19 at 8:58 A.M., the nurse documented the resident was walking in the hallways. He pushed staff down, and screamed he was going to hurt someone. Resident #31 walked up to other residents and took food and fluids from them. He continued to pace the hallways. The resident refused medication. He made threats towards anyone that walked past him. Resident remained on one to one supervision. On 04/10/19 at 11:44 A.M., an as needed dose of [MEDICATION NAME] 5 mg was administered to the resident IM for his behaviors. The resident was subsequently sent out to a psychiatric unit of the hospital. He remained at the hospital from 04/10/19 through 05/08/19. On 05/08/19 at 2:26 P.M., the nurse documented she spoke with hospital staff about the resident being discharged from the hospital. Resident was currently under a one on one supervision, at the hospital. Nurse documented the resident must be unsupervised for 48 hours prior to return to facility. This nurse called the hospital and left a voice mail message and requested a call back. Despite the above note, the resident was readmitted to the facility on [DATE] at 5:42 P.M. On 05/09/19 at 1:49 P.M., the nurse documented the resident was pacing the hallways, screaming, pushing staff out of his way, and trying to fight other residents. He was very disruptive while in the dining room and was throwing things. Staff offered resident activities of choice, but resident refused. Staff had resident in eye view. On 05/09/19 at 4:41 P.M., the resident continued to threaten other residents. He was pacing the hallways very fast, bumping into other residents, and screaming. A call was placed to the psychiatric hospital. The resident's profile was sent to the hospital via facsimile and the facility was awaiting a response. On 05/10/19 at 10:35 P.M., the resident was sent out to local hospital for psychiatric care. Review of the psychiatric hospital admission notes dated 05/11/19 indicated the resident had a history of [REDACTED]. He was a direct admission from nursing home. He reportedly had been pacing the hallways, screaming, pushing people out of his way and trying to fight other residents. He was very disruptive and throwing things while in the dining room. The resident was increasingly paranoid and was responding to internal stimuli. He was having extreme mood lability. He would not cooperate with this assessment. He was having repetitive incoherent and disorganized speech and was not making any sense. He required as needed medication upon arrival to the hospital. Resident #31 was admitted to the psychiatric hospital from 05/10/19 through 05/30/19 at 10:05 A.M., when the resident returned to the facility. On 05/30/19 at 6:22 P.M., the nurse documented the resident was compliant with medications. Resident was pacing through the hallway with ineffective redirection. Resident required close supervision due to aggressive behavior. On 06/05/19 at 6:01 P.M., the nurse documented the resident was adjusting to his room change without issue. (He was moved to a room closer to the nurse's office). On 6/10/19 at 10:10 P.M., the nurse documented while in front of the nurses' station, Resident #8 was threatening Resident, #31. Before staff could intervene Resident #31 punched Resident #8 in the face and Resident #8 fell to the floor and struck his head. Resident #8 was bleeding from the left temple and nose, with swelling and bruising noted under his left eye. Immediate interventions were completed, and the bleeding was controlled. Resident #8 was alert and responded to questions appropriately and was brought to a sitting position to a chair. Resident #8 was educated to hold pressure to the bleeding at left temple. Resident #8 remained in a chair in the television room, under supervision of staff while writer contacted transport and other appropriate individuals. The resident was subsequently sent to the hospital emergency room for an evaluation of his injuries. Review of the hospital physician's notes dated 06/11/19 not timed revealed Resident #8 had a history of [REDACTED]. He presented to the hospital after an altercation with another resident at the nursing home. He stated he got into an argument with one of the residents, and the last thing he remembered was getting hit in the face. He lost consciousness and hit his head on the floor. He initially was sent to a different hospital, and the scan there showed a small subdural hematoma between the frontal lobes. The scan also showed fractures of the zygomatic arch and sphenoid sinus wall. Neurosurgery was consulted and requested resident to be transferred to another local hospital for further management. Repeat scan of head was done at this hospital and showed stable appearance of the subdural hematoma. On 06/11/19 at 2:17 P.M., Resident #31 was placed on every 30-minute checks for other residents' safety. Resident continued to pace throughout the unit without understanding of the physical incident. On 06/11/19 at 7:29 P.M., the resident was taken into custody by the police and transported to jail due to assault of another resident. He was subsequently taken from the jail to a local hospital for psychiatric care. On 06/13/19 at 10:30 A.M., Licensed Practical Nurse (LPN) #62 was interviewed. She stated Resident #31 was unaware of his surroundings, he paced, screamed, hovered, and did not make eye contact. She believed Resident #8 was punched because he invaded Resident #31's personal space and yelled at him. On 06/13/19 at 10:45 A.M., Resident #8 was interviewed. He stated Resident #31 punched him in the nose. The resident was observed with swelling and bruising to his left eye. He also was observed with stitches in place on the left temporal side. The resident was on his way to a smoke break and walked with a slow shuffling gait. When asked why Resident #31 punched him, he answered the resident was scouting for money, after his money. He stated he tried to tell the other resident you have to be cool around here, act cool and do what the nurses ask you to do. He stated that is when Resident #31 punched him square in his nose. He denied being afraid to live on the men's locked unit. He did state he hoped Resident #31 didn't come back because he was a big and crazy and Resident #31 could beat anyone up. On 06/13/19 at 11:00 A.M., STNA #120 and LPN #176 were interviewed together. They stated they felt bad for Resident #31. They stated the resident just couldn't control his illness. He never sat down, and he was always moving. During interview with the Administrator on 06/13/19 at 1:52 P.M., he confirmed Resident #31 had multiple behaviors and was sent out for treatment for [REDACTED]. He stated he was working with the Ombudsman to discharge the resident from the facility. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property (undated) revealed if a resident is accused or suspected of abuse, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged victim, perpetrator, and/or other residents, room or staffing changes, and immediate discharge if indicated. The facility also will complete ongoing assessments and care planning for appropriate interventions and monitoring of residents with behaviors, including, but not limited to verbally aggressive behaviors, physically aggressive behaviors, taking or touching another's personal property, wandering into other's rooms, history of self-injurious behaviors, communication disorders, and those resident's dependent upon staff. This citation substantiates Master Complaint Number OH 915.

Based on observation, medical record review, hospital record review, staff and resident interview, and review of the facility's policy, the facility failed to implement their policy when they failed to prevent the physical abuse of Resident (#8) by another Resident (#31), which resulted in actual physical harm to Resident #8 including a laceration to his left temple area that required three stitches, a subdural hematoma, and fractures of the zygomatic arch (cheekbone) and sphenoid sinus wall (side of the face near the optic nerve). This affected one (#8) of three residents reviewed for abuse. The census was 148 residents. Findings include: Review of Resident #8's medical record, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively aware but experienced delusions. The resident also displayed verbal behaviors towards others and rejected care. He required supervision of staff with bed mobility, transfers, walking, dressing, and eating tasks. He required minimal assistance of staff with toilet use and personal hygiene. Review of a care plan initiated on 06/21/18, indicated the resident had the potential to be physically aggressive related to dementia and [MEDICAL CONDITION] disorder. The resident had a history of [REDACTED]. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behaviors, give the resident as many choices as possible about care and activities, and provide a psychiatric consult as indicated. Review of Resident #31's medical record revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS completed on the resident. The resident had resided at another local nursing home prior to being admitted . The other nursing home sent admission paperwork that included his documented behaviors. The admission paperwork indicated the resident yelled, screamed, and used inappropriate language. He yelled obscenities when he became upset at others. He yelled racial slurs at others and threw random items. He threw water in other residents' rooms and bumped staff with his shoulder. He banged his bed against the wall and banged his head and fist on items. He aggressively jumped at people, exposed himself, and masturbated in common areas. He paced the halls and in his room. He would get on the floor and sit or lay. Review of the psychiatric nurse practitioner evaluation dated 04/04/19 indicated the resident had paranoid [MEDICAL CONDITION] and was unstable. Orders were written for an anti-psychotic medication, [MEDICATION NAME] 10 milligrams (mg). The resident was having auditory and visual hallucinations and he was agitated and impulsive. Review of a care plan initiated on 04/06/19 indicated Resident #31 had a behavior problem secondary to schizotypal disorder, paranoid [MEDICAL CONDITION], and ADHD. He was at increased risk for falls/injury related to overt behaviors exhibited as, extremely intrusive. He would take food and drinks from other resident's trays. He would also sit on the floor with legs crossed frequently. He paced the hallways back and forth. He would come to the nurse's station and presses his head against the window frequently. Interventions included offer coke or little Debbie snacks as these are the resident preferences, and for staff to accompany resident when pacing the halls. Review of the nurse's notes dated 04/08/19 at 10:11 [NAME]M., revealed the resident was administered an as needed dose of an anti-psychotic, [MEDICATION NAME] 5.0 mg intramuscularly (IM) for the behaviors of yelling and pacing. On 04/08/19 at 5:49 P.M., the resident was documented as still yelling and pacing. A second dose of as needed [MEDICATION NAME] 5.0 mg was administered and documented as being ineffective. On 04/09/19 at 8:02 [NAME]M., the resident was administered an IM dose of [MEDICATION NAME] 5.0 mg for anxiety as needed, related to paranoid [MEDICAL CONDITION]. At 10:30 [NAME]M., the nurse documented the medication was ineffective. On 04/10/19 at 6:44 [NAME]M., the nurse documented the resident was administered an IM injection for [MEDICATION NAME] 5.0 mg due to this resident's increased violent behaviors directed toward other residents. On 04/10/19 at 7:12 [NAME]M., Resident #31 was documented as having increased violent/ impulsive behaviors at this time. Resident pushed another resident down onto the floor causing the other resident to hit his head. The other resident sustained [REDACTED]. An as needed dose of [MEDICATION NAME] 5.0 mg was administered earlier at 6:44 [NAME]M. was ineffective. Temporary one to one supervision in effect to monitor Resident #31. On 04/10/19 at 8:58 [NAME]M., the nurse documented the resident was walking in the hallways. He pushed staff down, and screamed he was going to hurt someone. Resident #31 walked up to other residents and took food and fluids from them. He continued to pace the hallways. The resident refused medication. He made threats towards anyone that walked past him. Resident remained on one to one supervision. On 04/10/19 at 11:44 [NAME]M., an as needed dose of [MEDICATION NAME] 5 mg was administered to the resident IM for his behaviors. The resident was subsequently sent out to a psychiatric unit of the hospital. He remained at the hospital from 04/10/19 through 05/08/19. On 05/08/19 at 2:26 P.M., the nurse documented she spoke with hospital staff about the resident being discharged from the hospital. Resident was currently under a one on one supervision, at the hospital. Nurse documented the resident must be unsupervised for 48 hours prior to return to facility. This nurse called the hospital and left a voice mail message and requested a call back. Despite the above note, the resident was readmitted to the facility on [DATE] at 5:42 P.M. On 05/09/19 at 1:49 P.M., the nurse documented the resident was pacing the hallways, screaming, pushing staff out of his way, and trying to fight other residents. He was very disruptive while in the dining room and was throwing things. Staff offered resident activities of choice, but resident refused. Staff had resident in eye view. On 05/09/19 at 4:41 P.M., the resident continued to threaten other residents. He was pacing the hallways very fast, bumping into other residents, and screaming. A call was placed to the psychiatric hospital. The resident's profile was sent to the hospital via facsimile and the facility was awaiting a response. On 05/10/19 at 10:35 P.M., the resident was sent out to local hospital for psychiatric care. Review of the psychiatric hospital admission notes dated 05/11/19 indicated the resident had a history of [REDACTED]. He was a direct admission from nursing home. He reportedly had been pacing the hallways, screaming, pushing people out of his way and trying to fight other residents. He was very disruptive and throwing things while in the dining room. The resident was increasingly paranoid and was responding to internal stimuli. He was having extreme mood lability. He would not cooperate with this assessment. He was having repetitive incoherent and disorganized speech and was not making any sense. He required as needed medication upon arrival to the hospital. Resident #31 was admitted to the psychiatric hospital from 05/10/19 through 05/30/19 at 10:05 [NAME]M., when the resident returned to the facility. On 05/30/19 at 6:22 P.M., the nurse documented the resident was compliant with medications. Resident was pacing through the hallway with ineffective redirection. Resident required close supervision due to aggressive behavior. On 06/05/19 at 6:01 P.M., the nurse documented the resident was adjusting to his room change without issue. (He was moved to a room closer to the nurse's office). On 6/10/19 at 10:10 P.M., the nurse documented while in front of the nurses' station, Resident #8 was threatening Resident, #31. Before staff could intervene Resident #31 punched Resident #8 in the face and Resident #8 fell to the floor and struck his head. Resident #8 was bleeding from the left temple and nose, with swelling and bruising noted under his left eye. Immediate interventions were completed, and the bleeding was controlled. Resident #8 was alert and responded to questions appropriately and was brought to a sitting position to a chair. Resident #8 was educated to hold pressure to the bleeding at left temple. Resident #8 remained in a chair in the television room, under supervision of staff while writer contacted transport and other appropriate individuals. The resident was subsequently sent to the hospital emergency room for an evaluation of his injuries. Review of the hospital physician's notes dated 06/11/19 not timed revealed Resident #8 had a history of [REDACTED]. He presented to the hospital after an altercation with another resident at the nursing home. He stated he got into an argument with one of the residents, and the last thing he remembered was getting hit in the face. He lost consciousness and hit his head on the floor. He initially was sent to a different hospital, and the scan there showed a small subdural hematoma between the frontal lobes. The scan also showed fractures of the zygomatic arch and sphenoid sinus wall. Neurosurgery was consulted and requested resident to be transferred to another local hospital for further management. Repeat scan of head was done at this hospital and showed stable appearance of the subdural hematoma. On 06/11/19 at 2:17 P.M., Resident #31 was placed on every 30-minute checks for other residents' safety. Resident continued to pace throughout the unit without understanding of the physical incident. On 06/11/19 at 7:29 P.M., the resident was taken into custody by the police and transported to jail due to assault of another resident. He was subsequently taken from the jail to a local hospital for psychiatric care. On 06/13/19 at 10:30 [NAME]M., Licensed Practical Nurse (LPN) #62 was interviewed. She stated Resident #31 was unaware of his surroundings, he paced, screamed, hovered, and did not make eye contact. She believed Resident #8 was punched because he invaded Resident #31's personal space and yelled at him. On 06/13/19 at 10:45 [NAME]M., Resident #8 was interviewed. He stated Resident #31 punched him in the nose. The resident was observed with swelling and bruising to his left eye. He also was observed with stitches in place on the left temporal side. The resident was on his way to a smoke break and walked with a slow shuffling gait. When asked why Resident #31 punched him, he answered the resident was scouting for money, after his money. He stated he tried to tell the other resident you have to be cool around here, act cool and do what the nurses ask you to do. He stated that is when Resident #31 punched him square in his nose. He denied being afraid to live on the men's locked unit. He did state he hoped Resident #31 didn't come back because he was a big and crazy and Resident #31 could beat anyone up. On 06/13/19 at 11:00 [NAME]M., STNA #120 and LPN #176 were interviewed together. They stated they felt bad for Resident #31. They stated the resident just couldn't control his illness. He never sat down, and he was always moving. During interview with the Administrator on 06/13/19 at 1:52 P.M., he confirmed Resident #31 had multiple behaviors and was sent out for treatment for [REDACTED]. He stated he was working with the Ombudsman to discharge the resident from the facility. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property (undated) revealed if a resident is accused or suspected of abuse, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged victim, perpetrator, and/or other residents, room or staffing changes, and immediate discharge if indicated. The facility also will complete ongoing assessments and care planning for appropriate interventions and monitoring of residents with behaviors, including, but not limited to verbally aggressive behaviors, physically aggressive behaviors, taking or touching another's personal property, wandering into other's rooms, history of self-injurious behaviors, communication disorders, and those resident's dependent upon staff. This citation substantiates Master Complaint Number OH 915.

Based on observations, medical record review, review of a facility investigation, interviews with staff and interview with the police, review of police reports, review of employee files, review of National Weather Service report, and policy review, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident with severe cognitive impairment who was assessed as being at risk for elopement. This resulted in Immediate Jeopardy when one resident (#11) was placed at risk for serious harm and injury when the resident eloped from the facility without staff knowledge and was missing for approximately 12 hours, before being found by local police approximately 12 miles away from the facility. This affected one (#11) of three residents (#11, #15, #88) reviewed for risk of elopement. The facility identified 122 residents at risk for elopement. The facility census was 177. On 02/07/18 at 3:50 P.M., the Administrator, the Director of Nursing (DON), and Facility Manager #102 were notified Immediate Jeopardy began on 12/31/17 at 8:13 P.M. when State tested Nurse Aide (STNA) #02 exited the secured locked unit and failed to ensure the door securely locked prior to exiting the building. Subsequently, Resident #11 who was assessed at risk for elopement and required a secured behavior unit, trailed STNA #02 out of the unit before the door completely closed and exited the facility unsupervised without staff knowledge. Resident #11 had a known history of wearing her jacket, carrying personal items in a suitcase and sitting in the dining room adjacent to the secured unit's entrance door. The facility was unaware Resident #11 was missing until approximately one hour later, when Resident #11 independently exited the building into five (5) degrees Fahrenheit air temperatures. At the time of discovery, Licensed Practical Nurse (LPN) #20 notified the DON and the local police. Resident #11 was found by the local police approximately 12 hours later on 01/01/18 at 8:00 A.M., 12 miles from the facility at an apartment building. The Immediate Jeopardy was removed on 01/01/18 at 8:00 P.M. when the facility implemented the following corrective actions: · On 12/31/17 at 9:20 P.M., LPN #20 placed a staff member at the secured unit door to monitor and ensure residents were not able to leave unattended and notified maintenance to check the functionality of the door. · On 12/31/17 from 10:40 P.M. through 01/01/18 at 8:00 P.M., the Administrator, DON, Assistant Director of Nursing (ADON) #122, and Unit Managers in-serviced all staff on elopement procedures, wandering behaviors, and the facility policy and procedures for securing locked units. All facility staff were in-serviced by 8:00 P.M. on 01/01/18. · On 01/01/18 at approximately 9:20 A.M., Resident #11 was safely returned to the facility by the local police and was placed on 15-minute checks for twenty-four hours for increased supervision. After that, the facility resumed two-hour checks on Resident #11. · From 01/01/18 at 10:40 A.M. to 01/01/18 at 8:00 P.M., the DON and Minimum Data Set (MDS) Nurse #125 conducted wandering risk assessments on all 177 residents residing in the facility. · On 01/01/18, the facility completed three elopement drills at 10:40 A.M., 1:40 P.M. and 7:04 P.M. and there were no negative findings · On 01/01/18 at 11:00 A.M., the door alarms were re-checked by Maintenance Staff (MS) #77 and it was determined all doors were functioning properly. · On 01/03/18 at 8:00 A.M., routine rounding and audits were initiated to be completed three times weekly by the management staff. The rounding and audits consisted of checking doors, monitoring residents at risk for elopement, head counts of residents during different shifts, and reinforcing the facility's elopement policy. The weekly audits were completed on 01/24/18. · On 01/19/18, ADON #122 provided STNA #02 with a final written warning and in-service education for failing to secure the exit door to the secured unit. · On 02/06/18 and 02/07/18, record reviews and observations of two additional residents (#15 and #88) identified at risk for elopement, noted appropriate interventions in place in accordance with the facility's corrective actions taken. · On 02/08/18 between 3:30 P.M. and 4:30 P.M., interviews with LPN #20, #86, and #119 and STNAs #02, #85, #170, and #144, revealed they had been recently in-serviced on elopements, wandering behaviors, and securing locked units and could verbalize what the procedure was for leaving a locked unit. 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #11's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment dated [DATE] revealed she was at risk for elopement due to behaviors of wandering and verbalizing wanting to leave the facility. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition and required supervision with all care. Review of the resident's plan of care for elopement updated on 12/13/17 revealed interventions for the resident including residing on a locked behavior unit, staff to provide structured activities, and to monitor for tailgating (following staff or visitors out of the door.) Review of the nursing progress notes dated 12/31/17 at 11:45 P.M. revealed Resident #11 was not in the facility and the DON and Administrator were present and were aware the resident was not in the facility. It was noted the facility was working with Police Officer #15. Review of the police report dated 12/31/17 revealed the facility had contacted the police department at 10:00 P.M. about a missing resident. The officer arrived at the facility on 12/31/17 at 10:12 P.M. Review of the facility's investigation revealed the investigation was initiated on 12/31/17 and noted Resident #11 left the facility after following STNA #02 out the front door at 8:13 P.M. The resident was not identified to be missing by the facility until 12/31/17 at 9:00 P.M. LPN #20 began to search the behavior secured unit and was unable to locate the resident. LPN #20 then proceeded to include all staff on all units to search the facility and surrounding grounds for Resident #11. Resident # 11 was not found and LPN #20 notified the local police the resident was missing at 10:00 P.M. Review of the nursing progress notes for 01/01/18 at 9:20 A.M. revealed Resident #11 was brought back to the facility by the local police. It was documented the resident refused to have her vital signs taken and refused a head-to-toe assessment. Review of the police report revealed Resident #11 was returned to the facility on [DATE] at 9:20 A.M. Review of STNA #02's employee file revealed the STNA was in-serviced on ensuring the doors were cleared and locked after exiting the secured units by LPN #20 on 01/01/18. STNA #02 received a final written warning on 01/19/18 by ADON #122 for failing to secure the exit door to the secured unit. It was noted the STNA was previously educated on 04/20/17 and 01/01/18 to ensure the doors and elevators were secured prior to walking away to ensure there were no potential escape opportunities on secured units. Interview with STNA #02 on 02/07/18 at 1:12 P.M. verified he worked the night of 12/31/17. He stated he left the women's secured behavior unit on 12/31/17 at 8:13 P.M. to obtain ice. He stated he was unaware Resident #11 was behind him. He verified he did not look behind him when he went out the door. He noted he was disciplined for the incident and stated he did not agree with the disciplinary action he received. Interview with LPN #20 on 02/07/18 at 1:18 P.M. revealed she worked the night of 12/31/17 and Resident #11 was in the dining room where she usually sat. The resident had her suitcase and her stuffed dog with her. LPN #20 stated she went over to the connecting unit to use the copier and when she returned she noted the resident was not in the dining room. LPN #20 stated she went immediately to Resident #11's room to check on her and she was not there. LPN #20 noted she asked STNA #02 to help her search for the resident. The resident was not able to be located on the women's secured unit so she called a Code Green (wandering, unsafe resident policy). She stated she was very worried because of the frigid temperatures outside. During a telephone interview with Police Officer #15 on 02/07/18 at 6:00 P.M., he stated the night when Resident #11 left the facility it was very cold outside. He noted at approximately 1:45 A.M. on 01/01/18 someone from the facility called and gave him an address to check. The police officer went to check on the address given and no one answered the door. On 01/01/18 at an unspecified time, an anonymous caller called the police department and stated Resident #11 was at their house and gave an address where the resident was located at. The police located the resident outside the address that was provided by the anonymous caller and brought her back to the facility. Observations on 02/07/18 at 10:15 A.M. and 4:10 P.M. and on 02/08/18 at 9:15 A.M. revealed Resident #11 sitting in the dining room with a sweater on with her suitcase and her stuffed dog. Interview with LPN #10 on 02/08/18 at 9:35 A.M. revealed he was working the day shift on 01/01/18 when Resident #11 was brought back to the facility by the police. LPN #10 noted Resident #11 was quiet for about an hour when she returned to the facility and then she started to talk more. LPN #10 noted the resident refused to have her vitals taken or a head-to-toe assessment completed. During an interview with the Administrator on 02/08/18 at 3:00 P.M. she stated according to the video recorded on 12/31/17 at 8:13 P.M., Resident #11 left the facility through the front door of the women's secured behavior unit. The Administrator stated Resident #11 placed her hand in the door after STNA #02 put the code in and left the unit to get ice on another unit. Resident #11 put a blanket between the door to keep it open while she retrieved her suitcase from the dining room. The video noted the resident had two light weight blankets (bath blankets) wrapped around her when she excited the building. The Administrator stated the video was no longer available to view at the time of the survey. Review of the National Weather Service history report revealed the local weather temperature was a low of five (5) degrees Fahrenheit on the night of 12/31/17. Review of the facility's policy titled Wandering, Unsafe Resident last revised on 02/14 revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. A missing resident was considered a facility-wide emergency. If a resident was missing, the elopement/missing resident emergency would be initiated. The facility was to determine if the resident was out on an authorized leave or pass and if the resident was not authorized to leave, they would initiate a search of the buildings and premises. If the resident was unable to be located, the Administrator, DON, the resident's legal representative (sponsor), the Attending Physician, and law enforcement officials were to be notified. This deficiency substantiates Complaint Numbers OH 816 and OH 973.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital documentation, observations, staff interviews, and review of facility policies, the facility failed to ensure staff provided adequate supervision to prevent a cognitively impaired resident from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy when one resident (#168) was placed at risk for serious harm and injury when the resident eloped from the facility without staff knowledge and was missing for approximately three hours before being found at a convenience store, approximately 0.8 miles from the facility, by a staff member and was sent to the hospital due to altered mental status. This affected one (#168) of three (#156, #168 and #170) residents reviewed for risk of elopement. The facility identified three residents at risk for elopement. The facility census was 177. On 06/08/17 at 12:30 P.M., the Administrator was notified that Immediate Jeopardy began on 04/11/17 at 5:38 A.M. when Resident #168 walked past State tested Nursing Assistant (STNA) #403 who was sitting in the corridor with her head down on a bedside table covered by a blanket, got on the elevator as another resident was exiting the elevator, went down to the first floor and out the front door of building three. Resident #168 was found at a local convenience store approximately 0.8 miles away by facility staff nearly three hours later. The resident was brought back to the facility by the Director of Nursing (DON) and assessed for increased confusion and subsequently sent to a local hospital for altered mental status. The Immediate Jeopardy was removed and the deficient practice corrected on 04/14/17 when the facility implemented the following corrective actions: · On 04/11/17 at 8:10 A.M., the facility instituted a facility staff member at the elevator for continued surveillance until a new keypad could be installed inside the elevator. · On 04/11/17 at 8:30 A.M., the outside elevator keypad code was changed. · On 04/11/17 at 8:30 A.M., the facility initiated a head count every four hours, with two-hour resident checks, and end of shift rounds with on-coming and off-going shifts. · On 04/11/17 at 8:30 A.M., Resident #168 was found at a local convenience store by facility staff approximately 0.8 miles from the facility. · On 04/11/17 at 8:35 A.M., Resident #168 was assessed by the DON and placed on one-on-one supervision until sent to the hospital for evaluation. · On 04/11/17 at 9:00 A.M., the DON and Corporate Registered Nurse (CRN) #400 began in-service education for wandering risk residents, with emphasis on watching the elevator door opening and ensuring that it closed with no residents in it. In-service education continued to be provided for all facility staff. The in-service training was completed by 04/14/17. · On 04/11/17 at 1:54 P.M. until 04/14/17 at 2:25 P.M., Social Service Director (SSD) #275 initiated multiple elopement drills. These included two on 04/11/17, two on 04/12/17, two on 04/13/17 and two on 04/14/17. · On 04/11/17, the DON and CRN #400 conducted wandering risk assessments on all residents. The wandering risk assessments for all 177 residents were completed on 04/11/17. Care plans for all residents at risk were reviewed and updates were completed by 04/12/17. · On 04/11/17, STNA #403 who was sleeping while she was supposed to be monitoring residents, was terminated from employment with the facility. · On 04/12/17, audits were completed two times a week for three weeks, and weekly for four weeks. · On 04/14/17, a local electric company furnished and installed a second keypad inside the elevator and tested it with the elevator contractor and the DON. This installation now required two codes to leave the floor. · On 04/14/17, the facility's audits of elopement and check rounds were reviewed. The review revealed the facility completed audits of the elopement education and resident two hour checks with no problems identified. · Interviews on 06/08/17 with Licensed Practical Nurses (LPN) #199 and #240 and three STNAs (#122, #156 and #166) verified they were able to give detailed information regarding elopements and the new elevator system. · On 06/08/17 at 1:15 P.M., an observation of residents leaving to go to smoke revealed the nurses' had to open the elevator to allow the safe smokers to exit, and when the supervised smokers were taken, the nurse stood right next to the elevator to ensure no other residents but the ones who were clear to leave the floor, left. Findings include: Review of Resident #168's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 02/11/16 revealed Resident #168 was at risk for elopement/wandering related to dementia, cognitive deficits, and impaired safety awareness. Resident #168 resided on a secure unit to maintain safety. On 03/15/17, Resident #168 was assessed for wandering with a risk score of five, which the facility identified as high risk for wandering. Review of the Quarterly Minimum Data Set (QMDS) assessment dated [DATE] revealed Resident #168 was assessed to have cognitive deficits. The resident was assessed as wandering one to three days during the assessment period, and exhibited delusions. The resident also required supervision with locomotion on the unit, limited assistance with transfers, and locomotion off the unit. Review of a nursing note dated 04/11/17 at 8:04 A.M. documented the nurse was notified by an STNA that Resident #168 was not observed in his room, bathroom, or the dining room. The DON and Unit Manager were notified and the appropriate protocols were implemented. Review of the facility's investigation report dated 04/11/17 confirmed when the facility's video camera was reviewed it revealed on 04/11/17 at 5:38 A.M., Resident #168 walked past STNA #403 who had her head down on a bedside table with a blanket over her head and appeared to be sleeping. Resident #168 got onto the elevator, which had opened for another resident returning to the unit, allowing Resident #168 to leave the secured unit and subsequently walk out the front of building three of the facility. Resident #168 was not known to be missing until approximately 8:10 A.M. on 04/11/17 at which time the DON was notified. At 8:15 A.M., the code for a missing resident was initiated and at 8:20 A.M. staff were dispersed with assignments to search all units in the facility. Resident #168 was found at a local corner store by Central Supply Staff (CSS) #263 that was 0.8 miles away from the facility. The DON was notified and went to pick up Resident #168 and brought him back to the facility. The resident was put on one-to-one observation until 9:00 A.M. when he was transported to a local emergency room for evaluation related to confusion. Resident #168 returned to the facility at approximately 3:26 P.M. on 04/11/17. Review of the local emergency room report, dated 04/11/17 at 11:57 A.M., revealed Resident #168 had no emergency medical conditions and was deemed not to be an imminent threat of harm to self or others and was then discharged back to the facility. Review of the Employee Counseling Form dated 04/11/17 revealed STNA #403 violated policy and was terminated. Interview on 06/07/17 at 4:22 P.M. with the DON revealed he was notified that Resident #168 was missing from the facility around 8:10 A.M. on 04/11/17. The DON initiated the code for missing residents at 8:15 A.M. and started reviewing the films from the cameras placed in various spots around the facility for more information related to the elopement of Resident #168. The DON reported he was called around 8:30 A.M. by Central Supply Director (CSD) #263 that the resident was found. The DON left to pick up Resident #168 to bring him back to the facility. The DON reported Resident #168 was presenting with increased confusion so the resident's doctor gave the order to send Resident #168 to a local hospital for evaluation. The DON verified if staff had been doing their two-hour checks, as they were supposed to, Resident #168 would have been identified as missing sooner. The DON also verified it appeared STNA #403 had been asleep when Resident #168 walked past her, entered the elevator, and then left the facility. During a telephone interview on 06/08/17 at 11:28 A.M. with LPN #404 revealed she remembered an STNA sitting by Resident #168's room but was unaware of what or if she was monitoring. LPN #404 verified she didn't know the resident had left because she did not need to administer medications to the resident and she did not check on the resident. Interview on 06/08/17 at 1:15 P.M. with STNA #156 revealed she was working on 04/11/17 when it was identified Resident #168 was unable to be located. She reported a Code Green was announced a little after 8:00 A.M. and she was instructed to search the floor and monitor for any sign of Resident #168 and to start a resident head count on the unit. Observations throughout the survey dated 06/05/17 to 06/08/17 of building three's secured floor elevator revealed a keypad outside the elevator required a code to call the elevator and a second keypad inside the elevator requiring a second code to have the elevator close and move. Review of the Elopement Policy (dated 02/2014) revealed if an employee discovered that a resident is missing from the facility, he/she shall: determine if the resident is out on an authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building(s) and premises; if the resident is not located, notify the Administrator and the DON, the resident's legal representative, attending physician, law enforcements officials; provide search teams with resident information; initiate an extensive search of the surrounding area, and initiate the facility specific plan. Review of Routine Resident Check Policy (dated 07/2013) revealed to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each resident at least every two hours and at shift change, routine resident checks involve entering the resident's room and/or identify the resident elsewhere on the unit to determine if the resident's need are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident was sleeping, needs toileting assistance.

Based on record review, interviews, observation of videos and review of facility abuse policy, the facility failed to prevent staff to resident abuse, resulting in harm when an employee poured water over a resident's head making the resident fearful of ruining her cochlear implant (to improve hearing). In addition another staff member dragged the same resident down the hallway by the ankles. This affected one (#6) out of three residents reviewed for abuse. The unit census was 16 and the facility census was 173. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed mild cognitive deficits. The resident further was noted to require limited assistance with dressing, personal hygiene, she required supervision with mobility, locomotion, eating, transfers, toileting, and was continent of bowel and bladder. Review of the care plan dated 10/28/15 with revisions dated 06/30/16 and 07/06/16 revealed Resident #6 had behavior problems of hitting others when she became angry, throwing furniture, history of suicidal ideation, and verbally yelling out at others and staff. Interventions included, behavior reward program, if reasonable, discuss the resident's behavior. On 07/11/16 at 9:45 A.M. interview with Unit Manager #32 stated Licensed Practical Nurse (LPN) #33 reported on 06/29/16 at 8:07 P.M., Former Registered Nurse (FRN #39) offered Resident #6 a cup of water in which Resident #6 slapped the cup out of the nurse's hand. At this time FRN #39 poured the rest of the pitcher of water over Resident #6's head. Unit Manager #32 also stated Resident #6 was sitting against the exit door and was pushing on it until it opened and then just laid there. Someone was trying to get by and Former LPN #40 walked over and grabbed Resident #6 by the ankles and pulled her down the hallway out of the way, then dropped her feet and walked away. Unit Manager #32 reported she had seen the video of the resident being pulled down the hallway. On 07/11/16 at 12:01 P.M. interview with the Administrator and Regional Clinical Director #38 confirmed there were videos of the two incidents involving Resident #6, FRN #39 and FLPN #40. The Administrator stated FLPN #40 was pulled from the floor immediately and was terminated on 07/06/16 at the conclusion of the investigation. The Administrator stated FRN was put on immediate suspension pending an investigation and was terminated on 07/06/16 at the conclusion of the investigation. On 07/11/16 at 1:26 P.M. observation of two videos revealed at 8:04 A.M. on 06/29/16 FLPN #40 walked up to Resident #6 who was lying in the floor and grabbed her by the ankles and pulled her halfway down the hallway while she was on her back, FLPN then dropped the resident's feet and walked away. There was no evidence the FLPN tried to assist Resident #6 up or ask her to move away from the doorway, prior to her dragging her down the hallway. The second video was at 8:07 P.M. (12 hours later) on 06/29/16 and revealed Resident #6 was sitting in the dining room by the nurse's station when FRN #39 walked up to hand Resident #6 a cup of water and Resident #6 slapped the water out of her hand. The FRN then poured the pitcher of water over the top of Resident #6's head. The video revealed LPN #35 witnessed the entire episode. Interview with Resident #6 and a family member (grandmother) of Resident #6 on 07/12/16 at 2:13 P.M. revealed the she was not the resident's guardian, however was notified when a staff member poured water over the resident's head. Resident #6 stated she was fearful because she wore a cochlear implant due to being profoundly deaf and was afraid it would be damaged. Resident #6's grandmother further stated she was not notified of the incident where the resident was dragged down the hallway by her feet. She further stated she was unaware if the resident's father (guardian) was notified about either incident. The grandmother stated the resident's father lived out of state and she kept him informed regarding changes in condition of the resident. Review of Abuse and Neglect Protocol dated April of 2010 defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This deficiency sustantiates Complaint Number OH 401.