Every finding on record at Friends Extended Care Center

Based on record review, staff interview, and procedure review, the facility failed to maintain documentation of all routine activities related to maintenance, testing, and treatment of water systems. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: Review of the facility Legionella documentation revealed no documentation to support maintenance flushed the faucets of the unoccupied rooms weekly or if unoccupied for more than three days. Review of the facility document titled Monitoring Waterborne Organisms: Legionnaire's Disease, stated the departments would complete records of all routine and special activities related to maintenance, testing, and treatment of involved water systems. Review of Water Control Measures for Legionnaire's Disease stated the following would be completed: 1) Legionella testing on the water system would be done on an Annual basis 2) all ice machines would be tested on an Annual basis 3) any rooms that are unoccupied for more than 3 days would have all fixers flushed (hot and cold for 15 minutes) 4) whirlpool tub would be flushed (hot and cold) for 15 minutes every Wednesday 5) annually all shower hoses and faucet aerated outlet would be cleansed or replaced throughout the facility. Interview on 02/19/26 at 11:55 A.M. with Director of Building Services (DOBS) #124 stated the maintenance staff go to unoccupied rooms weekly and run water from faucets as part of the Legionnaire procedures. DOBS #124 stated the facility did not have documentation to show which rooms the maintenance staff had flushed the faucets weekly. BOBS #124 also confirmed the procedures called for unoccupied rooms to have all fixers flushed every three days and the facility had only done weekly.

Based on observation and staff interviews, the facility failed to maintain essential kitchen equipment in safe, working condition. This had the potential to affect all 49 residents residing in the facility. The census was 49. Findings include: An observation in the kitchen on 02/18/26 at 10:00 A.M. revealed the Dietary [NAME] (DC) #121 calling out the stove was on fire. Flames could be seen coming from under the lower left burner on the gas stove. Four of the six burners were on with lunch prep taking place. The Director of Environmental Services (DES) #122 heard DC #121 calling out, approached the stove and put the fire out using a fire extinguisher. During an interview on 02/18/26 at 10:14 A.M. with DC #121 stated she reported the fire was due to grease and other debris which had accumulated under the burners. DC #121 stated, look under there you can see how dirty it is. DC #121 reported the middle burners had caught fire about a week ago for Director of Dietary (DOD) #125. DC #121 stated she thought it was recommended the stove should be cleaned at that time, but she was not sure if that occurred. DC #121 mentioned since the middle burners had caught fire for DOD #125, she had not used those burners, which was why she was using the burners on the left and right. DC #121 stated now that the left burners had also caught fire, she did not feel safe using the stove and would need to provide an alternative meal for lunch that did not require being cooked on the stove. An observation on 02/19/26 at 11:50 A.M. revealed DES #122 using a drill and a scraper to remove debris from the left burner cover. DES #122 reported they had fully disassembled the stove and cleaned each part. During an interview on 02/19/26 at 11:56 A.M. with DOD #125 she stated there was no policy for cleaning the stove nor a log to document when it was cleaned. DOD #125 reported every weekend either herself or the assistant wiped down the burner covers and placed the under tray in the 3-sink sanitizer to wash but they never took the covers off to clean under the burners where the fire had originated.

Based on record review, observation, staff interview and policy review, the facility failed to assess and document wound descriptions including measurements. This affected one (#06) out of two residents reviewed for pressure ulcers/injuries. The facility census was 49. Findings include: Review of the medical record for Resident #06 revealed an admission date of 01/16/26 with diagnoses of non-stemi elevation (nstemi) myocardial infarction, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, acute respiratory failure with hypoxia, cellulitis of buttock, and essential (primary) hypertension. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact, resident was independent with eating, oral hygiene, and personal hygiene. Resident #06 required partial assistance with toileting hygiene, bathing, bed mobility, and ambulation. Further review revealed Resident #06 did not have a pressure ulcer or injury. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed resident had a stage three pressure ulcer. Review of the Skin Observation Tool dated 01/16/26 revealed resident had cellulitis to his right buttocks. Further review revealed there was no measurements documented. Review of the Continuity of Care Document from Medical Center #01 dated 01/16/26 revealed Resident #06 had sepsis secondary to cellulitis involving the buttocks with no evidence of abscess. Review of the Skilled Daily Note dated 01/16/26 at 10:19 P.M. revealed Resident #06 had cellulitis to buttocks. No measurements documented. Review of the Weekly Skin assessment dated [DATE] revealed only pre-existing wounds found. No measurements documented. Review of the Nursing Note dated 01/20/26 at 7:50 P.M. revealed no documentation of wound present. Review of the Skilled Daily Notes dated 01/26/26 at 4:57 P.M. revealed to continue with current treatment to sacral wound, wound is stable at this time. No measurements documented. Further revealed also revealed resident had a dressing to the right wrist with no measurements documented. Resident had multiple bruises to the right upper arm with no measurements documented. Residents had two bruises on the left forearm with no measurements documented. Review of the Nursing admission Form dated 01/27/26 revealed resident had cellulitis to the right buttocks. No measurements documented. Resident #06 had a surgical opening to the right wrist, well approximated. No measurements documented. Review of the Skin Note dated 01/28/26 at 1:17 A.M. revealed treatment to area on coccyx done per order, small open area remains. No measurements documented. Review of the care plan dated 02/02/26 revealed resident has a pressure ulcer with intervention of weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the Skin Note dated 02/02/26 at 2:59 P.M. revealed area to resident's buttocks has an open area with wound bed 100% granulation tissue measuring 1.5 cm x1.0 cm x 0.3cm. Review of the Wound Nurse Practitioner's noted dated 02/05/26 revealed Resident #06 with a stage three pressure wound to the pelvis buttocks right measuring 1 X 1.5 X 0.3=0.45 cm3 with 90% granulation tissue. Further review revealed a stage three pressure wound to the pelvis coccyx measuring 0.5 X 0.5 X 0.1=0.03 cm with 30% granulation tissue. Review of the Skin Note dated 02/08/26 at 6:00 A.M. revealed treatment done on cellulitis to buttocks. Open area remains. Wound bed pink with no drainage or odor noted. No measurements documented. Review of the Wound Nurse Practitioner's note dated 02/13/26 revealed Resident #06 with a stage three pressure wound to the pelvis buttocks right measuring 1.5 X 0.5 X 0.3=0.22 cm3. Further review revealed a stage three pressure wound to the pelvis coccyx measuring 0.5 X 0.5 X 0.1=0.03 cm3 Review of the Skin Note dated 02/15/26 at 5:58 P.M. revealed there was no skin issues noted. Interview on 02/18/26 at 2:24 P.M. with Director of Admission/Licensed Practical Nurse (LPN) #123 confirmed there was no wound measurements documented on Resident #06 on 01/16/26 for the wound to the buttocks. Interview also confirmed Resident #06 admitted to the facility on [DATE] with an open wound to the buttocks. Interview also confirmed there was no wound measurements documented on the cellulitis wound to the buttocks until 02/02/26 on a skin note. Interview also confirmed there was no other measurements documented on the wound by the facility staff. Interview also confirmed Resident #06 was not seen by the wound Nurse Practitioner (NP) until 02/05/26 at which time the resident was diagnosed with one stage three pressure ulcer to the right buttocks and one stage three pressure ulcer o the coccyx with measurements documented on the wound NP notes. Observation on 02/18/26 at 3:05 P.M. with Registered Nurse (RN) #131 of wound care to Resident #06 buttocks and coccyx area. RN #131 measured the coccyx wound as approximately 0.5 cm x 0.5 cm x 0.1 deep, with pink granulation tissue present. The right buttocks wound was open measuring approximately 1.5 cm x 1.0 cm x 0.2 cm with pink granulation tissue present. Review of the Wound Care policy, dated 2001 revealed the facility will provide care to promote wound healing. Review also revealed the facility will document the wound type, date, time, wound bed color, size, and drainage.

Based on interview and record review, the facility failed to ensure a resident was offered a Coronavirus (COVID-19) vaccine. This affected one resident (#17) out of five residents reviewed for immunizations. The facility census was 43. Findings include: Review of the Resident #17's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hyperlipidemia, type two diabetes mellitus, malignant neoplasm of prostate, major depressive disorder, and abnormal posture. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired. Review of Resident #17's COVID-19 vaccine consents revealed Resident #17 did not have a COVID-19 vaccine consent on file declining or accepting the vaccine. Review of Resident #17's COVID-19 vaccine history revealed Resident #17 did not have a history of receiving a COVID-19 vaccine. Interview on 06/21/23 at 9:36 A.M. with Registered Nurse (RN) #27 verified Resident #17 did not have a consent declining or accepting the COVID-19 vaccine and Resident #17 did not have any documentation that he received a COVID-19 vaccine prior to admission to the facility. Review of the facility's undated offering residents COVID-19 immunizations policy revealed the facility will notify all residents that the vaccination is available to them.

Based on record review, staff interview and review of a facility policy, the facility failed to ensure residents were offered pneumococcal vaccines. This affected two residents (#02 and #18) out of the five residents reviewed for immunizations. The facility census was 43. Findings include: 1. Review of the Resident #02's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral palsy, muscle weakness, hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD) and anemia. Review of Resident #02's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired. Review of immunization history for Resident #02, revealed the resident received a Pneumovax 23 vaccine on 12/27/07. Resident #02 had no education on pneumococcal vaccines, no consents on file, and there was no documented evidence Resident #02 was offered or received an updated pneumococcal vaccine since 12/27/07. Interview on 06/21/23 at 9:36 A.M. with Registered Nurse (RN) #27 verified Resident #02 received a Pneumovax 23 vaccine on 12/27/07 and Resident #02 did not have any updated consents offering Resident #02 an updated pneumococcal vaccine. 2. Review of the Resident #18's chart revealed Resident #18 admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, pain in the right hand, muscle weakness, anxiety disorder, anemia, hypothyroidism, other symbolic dysfunctions, and mixed hyperlipidemia. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired. Review of the immunization history for Resident #18, revealed the resident received a Pneumovax 23 vaccine on 01/01/16. Resident #18 had no education on pneumococcal vaccines, no consents on file and there was no documented evidence Resident #18 was offered or received an updated pneumococcal vaccine since 01/01/16. Interview on 06/21/23 at 9:36 A.M. with RN #27 verified Resident #18 last received a pneumococcal vaccine on 01/01/16 and Resident #18 did not have any updated consents offering Resident #18 an updated pneumococcal vaccine. Review of the facility's pneumococcal vaccine policy dated 10/26/15 revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections.

Based on record review, interview and policy review, the facility failed to test for Legionella in the hot water sources from the facility kitchen, shower room, and shower room for the rehabilitation unit. This had the potential to affect all residents who resided in the facility. The census was 54. Findings include: Review of the Legionnaire's Disease Testing documentation revealed no weekly testing of the hot water system for the kitchen sinks, main shower room, and the rehabilitation shower room. Interview on 08/26/21 at 1:55 P.M. Maintenance Director #85 verified the temperature checks had not been performed weekly. Review of the facility policy titled Monitoring Waterborne Organisms Legionnaires Disease, revised date 01/09/21 revealed water control measures: 1) Legionella testing on the water system will be done on an annual basis, 2) daily temperature check of mix valve for Extended Care Facility (ECF), 3) weekly visual inspection on the 6 inch water main, and 4) weekly temperature check of the hot water system for kitchen sinks, room sinks, shower room, and room shower (Rehabilitation).

Based on record review and interview, the facility failed to convey a resident's funds within 30 days of death. This affected one (Resident #403) of one resident reviewed who had expired. This had the potential to affect twenty-four residents with personal funds accounts. The facility census was 54. Findings include: Review of Resident #403's progress notes revealed the resident expired in the facility on [DATE]. Review of the facility's personal funds documentation revealed an undated letter to the Ohio Attorney General advising of the resident's death on [DATE]. The resident had a balance of $3153.00. The check was issued on [DATE], 16 months after the resident died . Interview on [DATE] with Administrator confirmed the facility had not timely refunded Resident #403's personal funds balance to the State Attorney General's office.

Based on record review, personal funds account review, facility policy review, family and staff interview, the facility failed to promptly notify the resident's representative when the resident's account reached $200 less than the maximum amount permitted a recipient for Medicaid. This affected one (Resident #32) of four residents reviewed for personal funds. This had the potential to affect twenty-eight residents with personal funds accounts. The facility census was 61. Findings include: Review of medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had impaired cognition. Review of Resident #32's account balances from 04/10/18 through 04/01/19 revealed the following amounts: 04/23/18 $1,926.47 04/30/18 $1,926.63 05/31/18 $2,248.79 06/15/18 $2,570.79 07/31/18 $2,892.97 08/21/18 $3,214.97 09/30/18 $3,537.39 10/31/18 $3,859.65 11/30/18 $4,181.96 12/31/18 $4,504.27 04/01/19 $5, 083.81 Interview on 04/01/19 at 4:30 P.M. with Administrative Accounts Payable staff (AAP) #53 revealed Resident #32 with an account balance of $5,083.81. AAP #53 confirmed a quarterly statement was sent to the resident's representative for the time-period of 10/09/18 through 12/31/19. AAP #53 identified a line on the bottom of the quarterly statement which identified Resident #32's account was over the amount necessary to remain Medicaid eligible. The statement requested the resident's representative to contact the Licensed Social Worker. Interview on 04/02/19 at 10:10 A.M. with Social Worker (SW) #85 revealed she was not aware of the statement on the bottom of the quarterly statement. SW #85 additionally stated she has never followed up on any personal funds accounts for any reason. Telephone interview on 04/04/19 at 10:57 A.M. with Resident #32's Power of Attorney (POA) did confirm knowledge Resident #32 being over the maximum amount. Resident #32 confirmed receiving quarterly statements which had a notice informing that Resident #32 exceeded the amount necessary to remain Medicaid eligible. Interview on 04/04/19 at 11:17 A.M. with Administrator confirmed no additional notifications were sent to Resident #32's other than the quarterly statements. Administrator confirmed resident was within the $200 dollars of exceeding the maximum amount on 04/23/19. Resident #32's representative did not receive a notice of spend down until 06/30/19 when the quarterly statements were mailed. Review of the facility policy titled, Management of Resident's Personal Funds dated (MONTH) of (YEAR) reveals if the facility manages the resident's funds, the facility will act as a fiduciary of the resident fund and hold, safeguard, manage and account for the personal funds of the resident.

Based on record review and staff interview, the facility failed to ensure a resident had a valid Ohio Comfort Care Do Not Resuscitate order. This affected one (Resident #24) of twenty-four residents reviewed during first stage of the survey. The facility census was 61. Findings include: Review of Resident #24's medical record revealed being admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 01/17/19, revealed the resident had a severe cognitive deficit. Review of Resident #24's undated Ohio Do Not Resuscitate (DNR) Comfort Care form revealed resident was a Do Not Resuscitate Comfort Care -Arrest (DNRCC-A). The form had resident's name, address and signature of resident's Power of Attorney. However, it did not have the physician's signature. The form did have a notation at the bottom of having been faxed to the physician on 12/16/18. Interview on 04/01/19 at 3:50 P.M. with Licensed Practical Nurse (LPN) #58 confirmed Resident #24's Ohio DNR Comfort Care order did not have a physician's signature. LPN #58 was not able to provide a signed form for Resident #24. Interview on 04/02/19 at 3:50 P.M. with Director of Nursing confirmed Resident #24 did not have a signed Ohio DNR Comfort Care Arrest order. Review of the facility policy titled, Advanced Directives, dated 10/29/15, revealed the nurse will notify the attending physician of the advance directives so that the appropriate orders can be documented in the resident's medical record.

Based on record review and staff interview, the facility failed to ensure a resident was provided with physician ordered medications. This affected one (#1) of three residents reviewed for medications. The facility census is 62. Findings include: Review of the medical record for the Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#1 was ordered [MEDICATION NAME] 0.5 milliliters (ML) every 4 hours and [MEDICATION NAME] 1000 milligrams (MG) for pain. Review of medication administration records (MAR) for 05/10/2018 revealed Resident #1 [MEDICATION NAME] was not administered until 8:00 P.M. It also revealed the Resident #1 was receiving Tylenol for pain only until his medications arrived at 7:30 P.M. Interview with the Director of Nursing (DON) and Licensed practical Nurse (LPN) #11 on 05/17/18 at 12:20 P.M. confirmed the Resident #1 was admitted back to the facility on [DATE] at approximately 4:00 P.M. The pharmacy delivered the Resident #1's medications on 05/10/18 at 7:30 P.M. which included his [MEDICATION NAME] for pain management. They also confirmed the facility ran out of the emergency supply of [MEDICATION NAME] the morning of the 10th so no [MEDICATION NAME] was given until 8:00 P.M. The Resident #1 received Tylenol until his medications arrived. This deficiency substantiates Complaint Number OH 958.

Based on record review and staff interview, the facility failed to implement/follow physician orders. This affected two (#43 and #55) out of of 18 residents reviewed during the survey. Facility census was 62. Findings Include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident additionally has had the [DIAGNOSES REDACTED]. Review of most recent quarterly minimum (MDS) data set [DATE] revealed the resident can make her self understood and is able to understand others, has a brief interview of mental status score of two out of 15 indicating the resident is severely cognitively impaired, the resident is coded as not having any behaviors, hallucinations or delusions during the review period. Resident #43 requires extensive assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident is dependent on staff for locomotion on and off the unit. The resident is coded as always incontinent of bowel and bladder. The resident is coded as having an [MEDICAL CONDITIONS], dysphasia, weakness, [DIAGNOSES REDACTED], and dementia. Review of telephone orders revealed the resident had new physician orders [REDACTED]. Further review of the medical record revealed there were no results of the ordered test in the medical record. During an interview with Licensed Practical Nurse (LPN) #8 on 02/27/18 at 11:28 A.M. it was verified there were no hemocult results in the medical record for Resident #43. LPN #8 stated the results could be in medical records if the chart was thinned and he/she would need to check with the Director of Nursing (DON). During an interview with the DON on 02/27/18 at 5:45 P.M. it was verified Resident #43 did not have a Vitamin D laboratory test completed nor did the resident have hemocult stool testing times three as ordered on [DATE]. 2. Review of Resident #55's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of most recent annual minimum data set, ((MDS) dated [DATE] revealed the resident has a brief interview of mental status score of six out of 15 indicating the resident is cognitively impaired, the resident had no hallucinations, delusions or behaviors during the review period. The resident requires extensive assist with dressing, limited assist with personal hygiene and supervision for all other activities of daily living. The resident is always continent of bowel and bladder. The resident is coded as receiving seven days of antianxiety medication, antidepressant medication, diuretic medication and anticoagulant medication. Review of Resident #55's medications revealed the resident is currently being administered [MEDICATION NAME] for rhinitis, Klor Con for [DIAGNOSES REDACTED], [MEDICATION NAME] for hypothryiodism, [MEDICATION NAME] for depression, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME]-HCTZ for cardiac arrhythmia, apiaxaban for arrhythmia, [MEDICATION NAME] for anxiety, [MEDICATION NAME] for dementia, [MEDICATION NAME] for dementia, [MEDICATION NAME] cream 0.1% for pain, Tylenol for pain, [MEDICATION NAME] gel 1% [MEDICATION NAME] for knee pain, [MEDICATION NAME] suppository as needed for constipation, Duo neb every six hours as needed respiratory difficulty, [MEDICATION NAME] as needed for constipation, and [MEDICATION NAME] as needed for nausea and vomiting. Review of the physician orders [REDACTED]. Additionally, the order states she should not be on both [MEDICATION NAME] and [MEDICATION NAME] therefore discontinue the [MEDICATION NAME]. The review revealed no nurse has signed off this order. The order is not dated, and not has been implemented. The order, on the same order sheet, above this order is dated 02/20/17. Review of resident progress notes revealed there is not note indicating a new order for [MEDICATION NAME] was obtained, and [MEDICATION NAME] was discontinued and the family was notified Review of physician progress notes [REDACTED].#55 on any of the progress notes. During ain interview with LPN #29 on 02/28/18 at 11:29 A.M. revealed the process for noting a physician order [REDACTED]. LPN #29 then stated the nurse signs the order, puts the order into the computer system, makes notifications to the family and charts the new order and notification in the progress note. During an interview on 02/28/18 2:00 P.M. with LPN #35 it was verified the order in Resident #55's medical record for the initiation of [MEDICATION NAME] and the discontinuation of [MEDICATION NAME] was not taken off, nor had it been implemented in the care of the resident. LPN #35 verified it was unclear as to the time frame when the order was was written as there was no date on the order, but did verify the order was on the same page as an order written [REDACTED]. During an interview with the DON on 02/28/18 at 2:11 P.M. it was verified the order did not appear to be taken off and stated she did not know when the order was written. This deficiency represents on going noncompliance from the complaint survey completed 01/08/18.

Based on record review and staff interview, the facility failed to disburse residents funds within 30 days of the date of the residents' death. This affected two (#350 and #375) of two residents reviewed. Facility census was 62. Findings include 1. Review of the medical record for Resident #350 revealed the resident expired on [DATE]. Review of Resident #350's Resident Fund Transaction History revealed the final disbursement of $184.56 to the State of Ohio did not take place until [DATE]. 2. Review of the medical record for Resident #375 revealed the resident expired on [DATE]. Review of Resident #375's Resident Fund Transaction History revealed final disbursement of $205.76 to the State of Ohio did not take place until [DATE]. Interview on [DATE] at 3:25 P.M. with the Director of Nursing (DON) verified funds for Resident #350 and Resident #375 were not disbursed in a timely manner.

Based on record review, staff interview and policy review, the facility staff failed to ensure a residents comprehensive care plan was updated following a [MEDICAL CONDITION]. This affected one (#43's) out of 18 resident's care plans reviewed during the survey. Facility census was 62. Findings Include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of most recent quarterly minimum (MDS) data set [DATE] revealed the resident can make her self understood and is able to understand others, has a brief interview of mental status score of two out of 15 indicating the resident is severely cognitively impaired, the resident is coded as not having any behaviors, hallucinations or delusions during the review period. Resident #43 requires extensive assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident is dependent on staff for locomotion on and off the unit. The resident is coded as always incontinent of bowel and bladder. The resident is coded as having a [MEDICAL CONDITIONS], dysphasia, weakness, [DIAGNOSES REDACTED] and dementia. Further review of Resident 43's progress note dated 01/30/18 revealed the resident right femur fracture with a displaced trochanteric [MEDICAL CONDITION] that was a non-surgical repair. The resident is non-weight bearing and remains bed bound, continues to have minimal hip pain. Repeat X-Ray was conducted on 01/30/18 of the hip which revealed the hip remained fractured with displacements and the resident is positive for [MEDICAL CONDITION] and has minimal healing. Review of Resident #43's care plan revealed the resident's fall care plan did not address the residents use of the hoyer lift for transfers, the floor mats that were beside the bed on the floor and the care plan states to keep the room free of clutter and pathways clear but the resident is non ambulatory. During an interview with the Director of Nursing (DON) on 02/27/18 at 5:20 P.M. it was verified Resident #43 was a one person transfer prior to her fall in October and would bear weight to assist with the transfer. The DON also verified the fall mats to the floor beside the bed in the residents room became part of the plan of care after the resident fell in October. During an interview on 02/28/18 at 2:26 P.M. interview with Registered Nurse (RN) #35 verified the care plan for Resident #43 has not been updated to reflect the residents current status and needs. Review of the policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed under number 13: Assessments of residents are on going and care plans are revised as information about the resident and the residents' condition change

Based on record review and staff interview, the facility failed to notify resident's and/or the resident's representative regarding a discharge or transfer from the facility. This affected two (#47 and #61) of two resident's reviewed for discharge. Facility census is 62. Findings Include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #47's progress notes revealed the resident was discharged to the hospital on [DATE] at 8:15 A.M. with complaints of pain in the lower left and lower upper quadrant of the abdomen with a pain rating of 10 out of 10. Additional progress note written on 01/21/18 at 8:34 P.M. revealed the resident was admitted for a possible bowel obstruction. Review of Resident #47's bowel and bladder elimination record revealed the resident had a medium bowel movement on 01/21/18 at 4:50 A.M. Review of the medical record revealed the record was silent to the resident or the resident's representative being informed of the residents transfer/discharge to the hospital on [DATE]. During an interview with the Director of Nursing (DON) on 02/27/18 at 510 P.M. it was verified the facility did not notify Resident #47 and/or the resident's representative in writing of the reason the resident was transferred to the hospital on [DATE]. The DON verified the facility did not send a copy of the notification of the transfer to the hospital to the Ombudsman when the resident was transferred to the hospital on [DATE]. 2. Review of medical record revealed Resident #61 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Nursing admission form dated 01/29/18 revealed Resident #61 was admitted from the hospital. Resident #61 was oriented to person and place. Resident #61 had a cast on the right arm, redness around the [DEVICE] and an intact dressing to the left hip and coccyx. Bowel sounds were present in four quadrants and the abdomen was soft and non-tender. Review of Skilled Charting on 01/30/18 revealed Resident #61's bowel function was unchanged, she was incontinent of bowel, bowel sounds were present, and her abdomen was distended. Resident #61 was alert but confused. Vital signs and oxygen saturation levels were within normal limits. Review of Health Status note dated 01/30/18 at 10:07 A.M. revealed Resident #61 did not respond to verbal and tactile stimulation. New orders were received for an X-ray of the kidney, ureter, and bladder (KUB), to discontinue the tube feeding, and to start [MEDICATION NAME] (a medication to treat nausea and vomiting). physician progress notes [REDACTED]. Resident #61 was sent to the emergency room (ER) on 01/30/18 at 5:48 P.M. for a possible bowel obstruction and was admitted to the hospital with [REDACTED]. Interview on 03/01/18 02:32 P.M. with the DON verified the facility did not notify Resident #61 nor the resident's representative in writing of the reason for the transfer/discharge to the hospital nor was a notice of the transfer/discharge sent to the Ombudsman as required.

Based on review of the staffing schedule and staff interview the facility failed to ensure Registered Nurse (RN) coverage was provided at least eight consecutive hours a day. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Review of the staffing schedule dated 01/27/18 revealed there was no RN scheduled to provide coverage for any shift Interview with the Director of Nursing (DON) on 02/05/18 at 3:04 P.M. confirmed there was no RN coverage on 01/27/18 and stated if staff needed an RN they would call her.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure complete and accurate documentation was completed for one (#45) of four residents reviewed. The facility census was 56. Findings include: Review of Resident #45's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. The assessment further revealed the resident was receiving a tube feed and a mechanically altered diet. Review of Resident #45's physician's orders revealed an order initiated on 09/03/17 to check the [DEVICE] placement and residual two time a day, at 8:00 A.M., and 8:00 P.M. Review of Resident #45's (MONTH) (YEAR)'s Treatment Administration Record (TAR) revealed the order was not signed off as being completed seven times (11/03/17 at 8:00 A.M., 11/09/17 at 8:00 A.M., 11/14/17 at 8:00 A.M., 11/23/17 at 8:00 A.M., 11/27/17 at 8:00 A.M. and 8:00 P.M. and 11/28/17 at 8:00 A.M.). Review of the (MONTH) (YEAR)'s TAR revealed the order was not signed off as being completed six times (12/11/17 at 8:00 A.M., 12/13/17 at 8:00 A.M., 12/15/17 at 8:00 A.M. and 8:00 P.M., 12/16/17 at 8:00 P.M., and on 12/30/17 at 8:00 P.M.). Review of the (MONTH) (YEAR)'s TAR revealed the order was not signed off two times (01/01/17 at 8:00 P.M. and 01/02/17 at 8:00 A.M.) as being completed. Interview with Licensed Practical Nurse (LPN) #700 on 01/08/18 at 3:49 P.M., confirmed the documentation in Resident #45's TAR for November, (MONTH) (YEAR), and (MONTH) (YEAR) was incomplete for the above mentioned dates. LPN #700 revealed the nurse responsible for the treatment and signing off the treatment no longer worked at the facility. Review of the facility policy titled Charting and Documentation dated (MONTH) (YEAR) revealed the policy is for all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial conditions, shall be documented in the resident's medical record. The policy further revealed treatments or services performed is to be documented in the resident medical record.

Based on closed medical record review, review of hospital summary, staff interview, and facility policy review, the facility failed to ensure physician orders were completed as ordered for one (#57) of four residents reviewed. The facility census was 56. Findings include: Review of the closed record for Resident #57 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Review of the hospital 'Patient After Visit Summary' dated 03/21/17 revealed an order for [REDACTED]. Review of the nurse's notes dated 03/21/17 at 5:37 P.M. revealed Resident #57 returned from his appointment with a new order for his pre-op instructions prior to surgery. The note further revealed the prescription was placed in the resident's medical record for the Mupirocin 2% ointment to bilateral nares two times a day for five days. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of an additional hospital 'Patient After Visit Summary' dated 03/27/17 revealed Resident #57's sutures should be removed 10-14 days after surgery, on or by 04/10/17. Review of the (MONTH) (YEAR)'s Treatment Administration Record (TAR) revealed Resident #57's sutures had been removed to his head, neck and abdomen. However, three staples remained in Resident #57's chest until 04/15/17. Interview with Licensed Practical Nurse (LPN) #700 on 01/08/18 at 2:32 P.M. confirmed Resident #57 had an order for [REDACTED].#700 further revealed she was unsure why there were three sutures left to Resident #57's chest after 04/10/17. LPN #700 confirmed all sutures should have been removed on 04/10/17. Review of the facility policy titled Medication and Treatment Orders policy dated (MONTH) (YEAR) revealed the policy is orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written orders of a person duty licensed and authorized to prescribe such medications in the state. This deficiency substantiates Complaint Number OH 367.

Based on observation, staff interview and review of facility policy, the facility failed to ensure clean reusable equipment was stored separately away from dirty items. This had the potential to affect all 53 residents. Findings include: Observation on 01/03/17 at 9:10 A.M., during the initial tour of the rehabilitation wing, the soiled utility room was observed to have seven intravenous (IV) poles (four with attached electronic pumps) with notes attached to them, dated and marked cleaned. Additional equipment dated and marked cleaned included one bedside commode (BSC), one geri chair, and one shower chair. Interview on 01/03/17 at 9:14 A.M. with State tested Nursing Assistant (STNA) #300 stated the items had been cleaned and were being stored in the soiled utility room. He stated they should be cleaned again before resident use. Observations on 01/04/17 at 3:25 P.M. of the soiled utility room on the rehabilitation wing revealed a padded shower chair with a note on it that indicated clean 01/04/17. The soiled utility room included swing lid hoppers labeled for biohazard items saturated with blood, personal items, trash, linen, family to do laundry hamper, one hand sink, and large rinse sink with spray hose in which spray could emit during cleaning to surrounding areas. Interview on 01/04/17 at 3:30 P.M. with Registered Nurse (RN) #200 indicated dirty equipment was cleaned and stored in a storage room. She further indicated items like shower chairs, IV poles, and BSC's are stored in the soiled utility room and then cleaned again before resident use. Interview on 01/04/17 at 3:32 P.M. with the Director of Nursing (DON) confirmed all equipment that was cleaned, goes into the clean utility storage. She also verified items a shower chair dated 07/2016 and a geri chair dated 09/01/16 were identified as clean and stored in the soiled utility room. The DON indicated those items should not be in the soiled utility room. Interview with the DON on 01/05/17 at 11:00 A.M. confirmed the clean equipment identified in the dirty utility room may be used by any resident in the facility. Review of a facility policy titled Night Shift Nurse Aide (NA) Cleaning Duties, dated 09/2015, indicated to disinfect dirty items in soiled utility and move to clean storage.

Based on observation, staff interview, and record review, the facility failed to maintain an odor free environment for two (#4 and #16) of 11 residents reviewed on Stage 2 of the survey. The facility census was 53. Findings include: Review of the medical record revealed Resident #4 had intact cognition and was continent of bladder. Observation of Resident #4 on 01/03/17 at 11:38 A.M., revealed Resident # 4 to have no signs of incontinence. Further observation of his room revealed a foul urine odor. The odor in Resident #4's room appeared to emanate from the adjoining bathroom shared with Resident #16. Interview with Employee #600 on 01/03/17 at 11:40 A.M., confirmed the bathroom adjoining Resident #4's room and Resident #16's room was cleaned that morning. Employee #600 confirmed the bathroom had a urine odor and explained that a special cleaner containing bleach was to be used; however, she did not use it when she cleaned this date. Interview and observation on 01/04/17 at 2:42 P.M. with Unit Manager #500 confirmed the odor was present in the bathroom adjoining Resident #4's room and Resident #16's room. The interview revealed the facility frequently cleans the bathroom and has placed a special mat on the bathroom floor to direct Resident #4 and Resident #16 where to stand while urinating. This was done in attempt to to eliminate the strong odor in the bathroom. Observation on 01/05/17 at 11:14 A.M. two surveyors observed a strong urine smell present in the adjoining bathroom of Resident #4 and Resident #16's rooms. No floor mat was present at the time of the observation. Interview with the Housekeeping Manager on 01/05/17 at 2:30 P.M. verified the odor in the bathroom adjoining Resident #4 and Resident #16's rooms.

Based on observation and interview, the facility failed to ensure hot water temperatures in resident rooms were less than 120 degrees F. This had the potential to affect seven (Residents #3, #5, #29, #34, #41, #51 and #82) of 14 resident rooms observed for hot water temperature. The facility census was 62. Observation on 11/08/15 at 4:51 P.M. revealed the hot water temperature in Resident #34's room was 128 degrees Fahrenheit (F). A tour with Maintenance Man (MM) #56 on 11/08/15 at 5:55 P.M. revealed the water temperature in Resident #3's room was 125.5 degrees F, Resident #5's room water temperature was 125.8 degrees F, Resident #29's room water temperature was 125.5 degrees F, Resident #34's room water temperature was 126.8 degrees F, Resident #41's room water temperature was 125.2 degrees F, Resident #51's room water temperature was 127.7 degrees F and Resident #82's room water temperature was 124.6 degrees F. Observation revealed the mixing valve for the hot water heater was set at 126 degrees F. Interview with MM #56 on 11/08/15 at 5:20 P.M. revealed the mixing valve on the hot water tank was supposed to be kept between 115 degrees F and 120 degrees F. Interview with Director of Nursing (DON) on 11/08/15 at 5:20 P.M. revealed there hasn't been any residents who have been burned by water in the facility in the past six months. Review of the facility policy titled Building Services, revised 11/09/15, revealed the hot water temperature in areas used by residents shall be maintained between 115 degrees F and 120 degrees F.

Based on observation, medical record review, staff and resident interview, the facility failed to adequately supervise one cognitively impaired resident (#50) who exhibited aggressive and wandering behaviors from repeatedly entering another residents room (#54) and frightening the resident and handling his personal belongings. This resulted in social/emotional harm to resident #54 who has experienced increased anxiety, a decline in socialization and willingness to leave his room, and subsequent initiation of a psychoactive medication to address his increased anxiety relative to the behavior of resident #50. This involved one resident (#54) of five sampled, out of a total facility census of 55. Findings include: Resident #50 was admitted to the facility in January of 2011. The resident had [DIAGNOSES REDACTED]. A comprehensive assessment (MDS 3.0) of the resident completed by the facility on 09/05/13 was reviewed. The assessors identified Resident #50 as having short and long term memory problems with severely cognitively impaired skills for daily decision making, and displaying physical, verbal and other behavioral symptoms nearly daily, and engaging in wandering behaviors and rejecting care daily. Resident #50 ambulated independently. Review of Resident #50's progress notes provided documentation the resident entered Resident #54's room unsupervised without the resident's permission on many occasions which caused Resident #54 undue distress. Resident #50 was located two rooms away from Resident #54, where he still resided as of 10/24/13. On 09/01/13 at 7:05 P.M., a licensed practical nurse (LPN) noted that Resident #50 entered Resident #54's room while the resident was inside and closed the door behind him, then stood over Resident #54 while he was seated in his wheelchair and stared at him, Resident #54 was able to leave his room and report this to the nurse but stated "I was scared he was going to beat me up." On 09/02/13 at 6:46 A.M., Resident #50 attempted to enter resident #54's room twice while he was sleeping and peeled a sign off the resident's door. On 09/19/13, at 7:31 A.M., a registered nurse (RN) documented that Resident #50 was wandering the halls throughout the shift, hovering at Resident #54's door, and entered Resident #54's room and was redirected. On 09/21/13, at 6:36 A.M., a LPN documented that Resident #50 attempted to enter Resident #54's room several times during the night and was a little more difficult to redirect than usual. On 09/21/13 at 2:00 P.M., an LPN noted that Resident #50 was attempting to enter Resident #54's room uninvited, and the resident was angry when she intervened, stormed off and was pacing the hallways. On 09/24/13 at 5:30 A.M., a LPN documented that Resident #50 was trying to enter Resident #54's room several times, and during the last attempt Resident #50 charged at the LPN after she told him it was not his room. On 09/25/13 at 7:48 A.M., a LPN noted that Resident #50 rested in bed until 5:00 A.M. then was up walking in hallways at that time and attempted to enter the room belonging to Resident #54 several times, and became more agitated and difficult to redirect each time that staff intervened and attempted to assist the resident to his own room. On 09/26/13 at 6:09 P.M., a LPN documented that Resident #50 entered Resident #54's room and stood in his doorway and when the nurse explained to Resident #50 that it was not his room he stated that he knew that in an angry voice. On 09/27/13 at 12:29 A.M., a LPN noted that Resident #50 made several attempts today to go into Resident #54's room, and is still scaring Resident #54. On 09/28/13 at 6:27 P.M., a LPN documented that Resident #50 attempted to open the door to Resident #54's room several times. On 10/03/13 at 1:41 A.M., a RN noted that Resident #50 was wandering the halls throughout the shift and hovering at the door of Resident #54 several times, and was redirected. On 10/05/13 at 1:36 A.M., a LPN documented that Resident #54 came to the nursing station to report that Resident #50 had come into his room and he told him to leave. Resident #54 stated to the nurse that Resident #50 was compliant with his request but very "scary." On 10/07/13 at 10:13 P.M., a LPN noted that Resident #50 had went to Resident #54's door and opened it and set of the alarm (door alarm on Resident #54's door) multiple times in the last 30 minutes, and became agitated when redirected. On the following dates and times nursing staff documented in Resident #50's nursing progress notes the resident was either hovering at Resident #54's door and/or attempting to enter his room one or multiple times during their shift of duty: 10/05/13 at 7:38 A.M., 10/06/13 at 6:40 A.M., 10/06/13 at 12:30 P.M., 10/07/13 at 6:58 A.M., 10/07/13 at 9:00 P.M., 10/10/13 at 11:31 A.M., 10/17/13 at 1:46 A.M., and on 10/23/13 at 6:49 P.M. Resident #50 was observed on 10/23/13 at 10:46 A.M. lying in bed in his room. The resident was wearing street clothes and watching television. An attempt to interview the resident was unsuccessful due to Resident #50's memory problems, and he appeared wary of the surveyors visit. Resident #50 was not observed wandering the halls of the facility at the time of the survey. There was no one staff person observed to be specifically assigned to supervise the resident at that time. Resident #54 was admitted to the facility in in August of 2007. He had [DIAGNOSES REDACTED]. A comprehensive assessment (MDS 3.0) of the resident completed by the facility on 07/16/13 was reviewed. The assessors identified Resident #54 as alert and oriented with good memory and recall. Resident #54 mobilized himself about the facility via a wheel chair. An interview was conducted with Resident #54 on 10/24/13 at 10:20 A.M. The resident was dressed in street clothes, lying in bed looking out the window. The door to his room was open. During the interview, Resident #54 shared that Resident #50 came into his room in September and took some of his compact discs which were later returned by a friend of Resident #50. He stated that two nights after that incident Resident #50 came into his room and took a vase off his cabinet and threw a framed photo of him and his sister on the floor. He stated that Resident #50 often tried to sneak into his room but has not bothered him since an incident a few night ago on 10/21/13. He stated he has an alarm on his door which he sets to let him know if Resident #50 is trying to come in. On a written note the resident provided to the surveyor, Resident #54 documented the following "the following frightening time came about two nights ago. I had just finished my supper and I took my food to the kitchen cart - then I washed my hands at the sink. Resident #50 swiftly opened the door and grabbed me. I managed to break loose and I finally opened the door and called for help and three nurses came to the rescue." He stated that the incident occurred at approximately 6:30 P.M. Further interview with Resident #54 revealed that Resident #50 started frequently attempting to come in to his room, or actually entering his room, uninvited the first part of September. He stated that he had talked to licensed social worker (LSW) #9 who told him "they" (the facility) was going to solve the problem. Resident #54 also reported that LSW #9 had talked to him again the other night and told him they were working on the problem of Resident #50 coming into his room but there has been no solution. When asked if he was afraid of Resident #50 he stated "sure I am, he is pretty strong." Resident #54 reported that he left a bruise on the top of his hand when he grabbed him and showed this surveyor an approximately one inch by one and a half inch black/purple bruise on the top of his right hand, at the base of his thumb. He reported that Resident #50 accidentally hit his hand when he grabbed him from behind, demonstrating that Resident #50 wrapped his arms around him from behind while he was sitting in his wheel chair. Resident #54 communicated that he has seen Resident #50 going in and out of other resident's rooms also. He stated multiple times during the interview that he was afraid of Resident #54, and reported staying in his room more now as he is afraid Resident #50 will come into his room and steal his possessions. Resident #54 specified that he now eats his meals in his room, he used to go to the dining room, but needs to stay in his room to protect his belongings. Review of Resident #54's nursing progress notes revealed the nurses documented in the notes on the following dates and times of Resident #54's complaints of Resident #50 being in his rooms, and verbalizing fear of the resident: 09/26/13 at 6:45 A.M.; 10/03/13 at 6:15 A.M., 10/06/13 at 8:55 P.M., and on 10/21/13 at 6:30 P.M. On 10/21/13 at 6:30 P.M., LPN #11 noted in Resident #54's progress noted that the resident was sitting in his room, upset, stating that a peer entered his room and grabbed his arm. Staff entered the room behind Resident #50 but only witnessed the resident hold onto the hand grips on the back of Resident #54's wheel chair. Resident #50 was redirected back to his room with minimal assistance, and staff remained with Resident #54 for emotional support. No redness or injuries were noted to Resident #54's arm. Resident #54's progress notes completed by Nurse Practitioner (NP) #18 were reviewed. Review of the progress notes revealed documentation by NP #18 on 09/25/13 that nursing staff reported to him that another resident had entered Resident #54's room several times and he is now not leaving his room. When NP #18 questioned Resident #54 directly about this, the resident admitted to him that another resident had been entering his room and he no longer wants to participate in activities or leave his room in fear of having his personal items stolen. This has been going on for approximately two weeks. NP #18 noted that nursing staff is actively working on correcting this issue. In the assessment/plan section of the 09/25/13 progress note, NP #18 documented that the resident exhibited anxiety, and the resident's anxiety has worsened with the concern of the other resident entering his room. On 10/22/13 NP #18 assessed Resident #54 and documented the resident was having difficulty with another resident and has been hyper-vigilant. Resident #54 has a door alarm and is getting out of his room less stating to NP #18 that he had to protect his room. NP #18 documented that the resident has been frightened and is able to verbalize his concerns. In the assessment/plan section of the progress note, NP #18 documented the resident exhibited anxiety, intrinsic and with exacerbation due to situational circumstances beyond his control. with interactions of another resident who has been hostile towards Resident #54. An interview was conducted with RN #3 on 10/23/13, at 11:07 A.M., regarding Resident #50's behaviors and staff interventions. RN #3 was the nurse assigned to Resident #50 during the day shift of duty. RN #3 reported that Resident #50 did have behavioral issues for which 1 on 1 supervision was provided when the resident was agitated. At that time, on 10/24/13, she reported the resident was only on 30 minute checks due to being calm and not having any behaviors. She communicated Resident #50 did a lot of wandering and would go into others rooms, and would be redirected back to his room. She stated sometimes redirection was effective and sometimes it was not, and Resident #50 would get agitated when asked to leave other resident's rooms and would tense up, get in your personal space and exhibit anger. She denied ever seeing the resident strike anyone. She verbalized that Resident #50 liked to go into Resident #54's room, but did not know or understand why. RN #3 stated Resident #54 has an alarm on his door because of this. She shared Resident #50 does walk in and out of other resident's rooms, but not as much as Resident #54' room. She affirmed that Resident #54 has told her that Resident #50's presence in his room makes him nervous. RN #3 reported that earlier in the week while she was here, she heard Resident #54 yelling and went into the resident's room, two other nurses also responded. She stated that when she went in Resident #50 was standing behind Resident #54 holding on to his wheel chair. Resident #50 was verbally redirected to his room, and she reported that she was unaware of any injury to Resident #54 at that time. RN #3 stated Resident #50 was put on 1 on 1 supervision at that time. Resident #50's comprehensive care plan for behaviors dated 05/03/13, with an addition to the care plan initiated in September of 2013 per the Director of Nursing (DON), was reviewed. The care plan identified the resident as exhibiting the following behaviors; resistance to care, socially inappropriate behaviors including getting in others personal space, verbally abusive threatening others at times, potential for aggressiveness towards others, wandering into others rooms and having unawareness of safety needs. One of the interventions on 05/03/13 care plan was to address the wandering behavior by walking with the resident, redirect form inappropriate area, attempt to engage in activity of interest, and provide security bracelet to prevent elopement. The update to the behavior care plan of 09/21/13 by the DON specified that as part of Resident #50's care plan the DON would personally assign specific caregivers for the resident. During the 7:00 A.M. through 7:00 P.M. shift one state tested nurse aide (STNA) would be assigned to work 1 on 1 with Resident #50 only. During the 7:00 P.M. through 11:00 P.M. shift one STNA would be assigned 1 on 1 to work with Resident #50 only if there was enough staff to do so. After 11:00 P.M. there would be no 1 on 1 with the resident. The plan of care developed included implementation of a 15 minute check form to show the resident was being checked on often. The 09/21/13 plan of care did not provide staff instruction on what to do related to Resident #50's wandering behaviors or fixation on Resident #54 and his room/possessions. An interview was conducted with the DON on 10/24/13, at 3:45 P.M., regarding Resident #50's behaviors and his documented fixation on Resident #54 and his room. She affirmed that Resident #50 did fixate on Resident #54 and his room, and has entered his room multiple times uninvited. She reported that a new care plan was put in place, sometime in September potentially on 09/21/13, and provided a copy to the surveyor. The three page addition to Resident #50's care plan was not dated. The care plan specified that Resident #50 was to be supervised 1 on 1 during the hours of 7:00 A.M. through 7:00 P.M. by a STNA. However, the DON reported that there was not always sufficient staff to provide 1 on 1 supervision of Resident #50 relative to the number of STNA's scheduled, so other individuals were sometimes assigned including a medical records staff person, a restorative staff person, and a scheduling staff person. The DON also communicated, that 1 on 1 supervision specific to Resident #50 did not necessarily mean staying with or near the resident at all times or shadowing the resident. When queried who was assigned to work 1 on 1 with Resident #50 during the evening of 10/21/13 she provide copies of the daily working schedule with assignments. Resident #50's name had been written next to scheduling staff person (SS) #21's name. When Resident #54 was interviewed at 10:20 A.M. he did not report SS #21 as being present, or responding, when he called out for help the evening of 10/21/13 at 6:30 P.M., but specifically named RN #3, LPN #25, and one additional staff which was not SS #21. The daily working schedule for 10/24/13 was requested from LPN #33 after entering the facility. The 10/24/13 did not include written designation of a nursing staff person or any other staff person as being responsible to provide 1 on 1 supervision, or to work 1 on 1 with Resident #50 during the day shift of duty; 7:00 A.M. through 7:00 P.M. This deficiency substantiates Complaint Control Number OH 315.

Based on review of a facility self-reported incident (SRI) report, witness statements, medical record review, staff interviews, and review of the facility's abuse policy, the facility failed to develop an abuse policy and procedure that included training of employees in abuse prevention, prevention of abuse, identification of abuse, investigation of abuse and protection of residents from harm during an abuse investigation. Failure to have a comprehensive abuse policy and procedure that staff could operationalize resulted in Immediate Jeopardy for one resident (#25) of eight sampled residents who was sexually abused by State tested Nurse Aide (STNA) #43 and placed all 43 residents of the facility in jeopardy of abuse. On 07/22/11 at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/16/11 at 11:25 A.M. when charge nurse, Licensed Practical Nurse (LPN) #88 failed to take action after STNA #75 alleged STNA #43 sexually abused Resident #25. Both STNA #75 and LPN #88 left the building and STNA #43 continued to provide care and services to Resident #25 as well as other residents residing on the North Unit. The Immediate Jeopardy was removed and corrected on 07/27/11 when the facility implemented the following corrective actions: ? On 07/16/11 at 1:00 P.M., STNA #43 was removed from the facility. He was not permitted to return to work or return to the grounds of the facility. The facility initiated an investigation that included notification of the local police. Resident #25 was sent to the hospital emergency department for examination. Resident #25 was assigned only female caregivers. ? STNA #43 was terminated from employment with the facility on 07/16/11. ? On 07/27/11, the facility developed and implemented a new abuse policy entitled, "Abuse, Neglect, and Mistreatment" dated 07/27/11 that included screening of potential employees, training of new employees on the facility abuse policy, how to prevent abuse, identification of abuse, investigation of abuse, protection of the resident during investigation of an alleged abuse allegation and reporting of abuse to the proper authorities. ? All staff was provided education on 07/27/11 about the facility's new abuse policy. ? The Director of Nursing and Administrator are monitoring staff 's ability to articulate the abuse protocol on a daily basis by randomly questioning staff about the abuse protocol. This will be done weekly for six months. ? All new hires are being immediately trained on the facility's abuse protocol. ? On 08/12/11, four nurse aides and two licensed practical nurses were interviewed. All stated they had been trained on the facility's new abuse policy and were able to articulate what the policy stated and how to appropriately respond to an allegation of sexual abuse. Findings include: The physician order [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #25 had moderate cognitive impairment and required the extensive assistance of one staff for bed mobility and transfers, was not ambulatory and required the use of a mechanical lift for transfers. The assessment further stated the resident was always incontinent of bowel and bladder. Review of the facility's self reported incident, dated 07/16/11, revealed that STNA#75 walked in Resident #25's room and found STNA #43 on top of Resident #25. Resident #25 was not clothed. STNA #43 was observed with his clothes on his upper body, but could not be seen from his waist down. During interview on 07/22/11 at 1:45 P.M. with the DON, she stated STNA #75 observed Resident #25's door was shut around 11:30 A.M. which made her feel uncomfortable, so she opened the door and found the resident lying in bed nude and STNA #43 was on top of her. She shut the door leaving STNA #43 in the room with the resident and went to tell LPN #88, who was the charge nurse. LPN #88 asked LPN #58 to observe STNA #43 as he continued to give care while she made phone calls. Immediately after being seen by STNA #75, STNA #43 proceeded to get Resident #25 out of bed, into her wheelchair, and to the dining room for lunch. While LPN #88 was making phone calls, STNA #43 was in the dining room serving lunch to other residents. Once the DON arrived and talked to the staff, she made STNA #43 leave the facility around 1:00 P.M. She stated that when she initially interviewed Resident #25, she denied anything occurring, but later admitted to the police she had sexual intercourse with STNA #43. The DON stated after she was notified of the alleged sexual abuse, she should have instructed charge nurse LPN #88 to send STNA #43 home immediately and not allow him to remain in the facility. LPN #88 stated during interview on 07/22/11 at 2:45 P.M. she was in the break room when STNA #75 had informed her that she found STNA#43 on top of Resident #25 having sex with her. LPN #88 stated she and STNA #75 left the facility and went to the facility's assisted living unit, which is separated from the nursing home by a driveway. LPN #88 said she wanted to get STNA #75 away from STNA #43, as STNA #75 was afraid and upset by what she had witnessed. Once inside the Assisted Living unit, she called LPN #58 and told her to watch STNA #43. She stated she called the DON and another nurse, LPN #77, who was on call. She stated she and STNA #75 stayed in the Assisted Living unit while they waited for the DON to arrive. She stated she did not protect the resident from STNA #43 or assess her for any possible injuries. She did nothing other than take STNA #75 over to the Assisted Living unit to get away from STNA #43. She stated she had the authority to send staff home if abuse is alleged and she nor LPN #58 sent STNA #43 home after sexual abuse was alleged against him. Review of a written facility witness statement dated 07/16/11, no time given, completed by LPN #88, affirmed the information given in her interview. The statement documented STNA #75 was very distraught after the incident, so LPN #88 instructed STNA #75 to come to the Assisted Living Unit with her. LPN #58 stated during interview on 07/22/11 at 3:15 P.M. she was informed by LPN #88 a STNA had opened the door to the room of Resident #25 and found STNA #43 on top of the resident. After LPN #88 telephoned her from the Assisted Living area of the facility and notified her of the allegation of sexual abuse, LPN #58 never entered the room of Resident #25. She allowed STNA #43 to dress Resident #25, transfer her from her bed to the Broda chair and escort her to the dining room for lunch. She stated that she "kept an eye on" STNA #43, as this incident occurred at lunch time. STNA #43 was answering call lights and passing meal trays to other residents from the time STNA #75 observed STNA #43 in bed with Resident #25 until the Director of Nursing arrived at the facility, which was at least 30 minutes. LPN #58 stated she did not have STNA #43 in full visual view the entire time he was answering resident call lights and passing meal trays. She stated she failed to send STNA #43 home because she was in total disbelief and in shock. She stated she did not do a physical assessment on the resident because she did not want to destroy physical evidence. She stated she did not physically assess the resident; she only questioned the resident in the dining room and asked her if she was "ok". She stated the resident has confusion and will easily forget what she is talking about. STNA #75 stated during a telephone interview on 07/22/11 at 3:50 P.M. she was looking for STNA #43 because she needed assistance with another resident. She stated she opened the door to the room of Resident #25 and asked STNA #43 if he was almost done. She stated she observed Resident #25 nude in bed with STNA #43 lying on top of the resident between her legs. She stated that the resident is not able to move her legs and STNA #43 had her legs in a straddle position. She stated she did not enter the room, but shut the door and went immediately to inform LPN #88, the charge nurse. She stated she did not enter the room, but shut the door and went immediately to inform LPN #88. LPN #88 told her she was going to the assisted living unit, separate from the nursing home, to telephone the Director of Nursing and nurse on call.. STNA #75 returned to the nursing home portion of the facility, and at that time, STNA #43 asked her (STNA #75) to help him with care for Resident #25. STNA #75 left the nursing home, going back to the assisted living area of the facility without assisting STNA #43. During interview, facility staff was not able to verbally articulate the proper action to take if sexual abuse was witnessed. Four STNA's were interviewed on 07/23/11 at 9:45 A.M. and when queried, three of the four STNA's stated they would close the door to the room and report the incident to the nurse without intervening to stop the abuse and protect the resident. Only one nurse aide said she would intervene to stop the abuse and protect the resident, then report the incident to the charge nurse. Two housekeepers stated during interview on 07/23/11 at 10:20 A.M. they would report the abuse; one said she would report it to the "first person she saw" and the other stated she would report to the charge nurse. Neither stated they would first protect the resident from the abuser. Review of the facility's undated policy and procedure entitled "Policy for abuse, neglect and misappropriation of property" revealed the policy stated the facility's mission was the respect for the needs of each individual and the provision of total health care which includes the physical, mental, emotional and spiritual needs of each resident. The facility policy stated it "strives to accomplish our mission through the following systems: " which included "training for resident rights is offered at least yearly to employees", but didn't state any specific training was provided to address resident abuse. Under the policy subheading "Definitions", the policy stated the definition of abuse "means knowingly causing physical harm, pain, intimidation or recklessly causing serious physical harm to a resident by physical contact with the resident or by use of physical or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment." The policy did not define verbal, sexual or mental abuse. Under the subheading "Internal Investigation", the policy stated "an internal investigation of abuse, neglect, misappropriation will be conducted by the Department Manager, Director of Nursing, and/or Licensed Social Worker and/or any other person designated by the Administrator. The facility will act to ensure resident safety during the investigation." The policy did not indicate what specific actions were required by facility staff to ensure resident safety. During interview with the DON on 07/22/11 at 2:15 P.M., she stated the undated, "Policy for abuse, neglect and misappropriation of property" was the only abuse policy used by the facility. She further confirmed the policy did not include all seven components necessary to prevent occurrences of abuse. This citation substantiated Complaint Number OH 618.

Based on record review, review of a facility self-reported incident (SRI) report, staff interviews, and review of the facility's abuse policy, the facility failed to immediately protect residents after Resident #25 was observed being sexually abused by State tested Nurse Aide (STNA) #43. This resulted in Immediate Jeopardy for one (Resident #25) of eight sampled residents and seven additional residents residing on the North Unit. The additional residents were placed at risk for Immediate Jeopardy because STNA #43 continued to provide care and services after the allegation of sexual abuse. On 07/22/11 at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/16/11 at 11:25 A.M. when STNA #75 observed STNA #43 on top of Resident #25. Resident #25 was nude with STNA #43 lying between her legs. STNA #75 reported the allegation to charge nurse, Licensed Practical Nurse (LPN) #88. Licensed Practical Nurse (LPN) #88 failed to take action after STNA #75 alleged STNA #43 sexually abused Resident #25. LPN #88 and STNA #75 left the building due to reported fear of STNA #43; however, STNA #43 was left alone with Resident #25 and got her dressed and took her to the dining room. STNA #43 was permitted to remain on patient care duty until 1:00 P.M. on 07/16/11. STNA #43 continued to provide care and services to Resident #25 as well as other residents residing on the North Unit. The Immediate Jeopardy was removed and corrected on 07/27/11 when the facility implemented the following corrective actions: ? On 07/16/11 at 1:00 P.M., STNA #43 was removed from the facility. He was not permitted to return to work or return to the grounds of the facility. The facility initiated an investigation that included notification of the local police. Resident #25 was sent to the hospital emergency department for examination. Resident #25 was assigned only female caregivers. ? STNA #43 was terminated from employment with the facility on 07/16/11. ? On 07/27/11, the facility implemented a new abuse policy entitled, "Abuse, Neglect, and Mistreatment " dated 07/27/11 that included screening of potential employees, training of new employees on the facility abuse policy, protection of the resident during investigation of an alleged abuse allegation and reporting of abuse to the proper authorities. ? All staff was provided education on 07/27/11 about the facility's new abuse policy. ? The Director of Nursing and Administrator are monitoring staff 's ability to articulate the abuse protocol on a daily basis by randomly questioning staff about the abuse protocol. This will be done weekly for six months. ? All new hires are being immediately trained on the facility's abuse protocol. ? On 08/12/11 four nurse aides and two licensed practical nurses were interviewed. All stated they had been trained on the facility's new abuse policy and were able to articulate what the policy stated and how to appropriately respond to an allegation of sexual abuse. Findings include: The physician order [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #25 had moderate cognitive impairment and required the extensive assistance of one staff for bed mobility and transfers, was not ambulatory and required the use of a mechanical lift for transfers. The assessment further stated the resident had [MEDICAL CONDITION] and lower extremity impairment on both sides. Review of the facility's self-reported incident, dated 07/16/11, revealed that STNA#75 walked in Resident #25 ' s room and found STNA #43 on top of Resident #25. Resident #25 was not clothed. STNA #43 was observed with his clothes on his upper body, but could not be seen from his waist down. During interview on 07/22/11 at 1:45 P.M. with the DON, she stated STNA #75 observed the door to the room of Resident #25 was shut around 11:30 A.M. which made her feel uncomfortable. She opened the door and found the resident lying nude in bed and STNA #43 was on top of her. She shut the door leaving STNA #43 in the room with the resident and went to tell LPN #88, who was the charge nurse. LPN #88 asked LPN #58 to observe STNA #43 as he continued to give care while she made phone calls. Immediately after being seen by STNA #75, STNA #43 proceeded to get Resident #25 out of bed, into her wheelchair, and to the dining room for lunch. While LPN #88 was making phone calls, STNA #43 was in the dining room serving lunch to other residents. Once the DON arrived and talked to the staff, she made STNA #43 leave the facility around 1:00 P.M. The DON stated after she was notified of the alleged sexual abuse, she should have instructed charge nurse LPN #88 to send STNA #43 home immediately and not allow him to remain in the facility. Interview with charge nurse, LPN #88 on 07/22/11 at 2:45 P.M. revealed she was in the break room when STNA #75 informed her that she found STNA#43 on top of Resident #25 having sex with her. LPN #88 stated she and STNA #75 left the facility and went to the facility's assisted living unit, which is separated from the nursing home by a driveway. LPN #88 said she wanted to get STNA #75 away from STNA #43, as STNA #75 was afraid and upset by what she had witnessed. Once inside the Assisted Living unit, she called LPN #58 and told her to watch STNA #43. She stated she called the DON. She stated she and STNA #75 stayed in the Assisted Living unit while they waited for the DON to arrive. She stated she did not protect the resident from STNA #43 or assess her for any possible injuries. She did nothing other than take STNA #75 over to the Assisted Living unit to get away from STNA #43. She stated she had the authority to send staff home if abuse is alleged and neither she nor LPN #58 sent STNA #43 home after sexual abuse was alleged. Interview with LPN #58 on 07/22/11 at 3:15 P.M. revealed she was informed by LPN #88 that an STNA had opened the door to the room of Resident #25 and found STNA #43 on top of the resident. After LPN #88 telephoned her from the Assisted Living area of the facility and notified her of the allegation of sexual abuse, LPN #58 never entered the room of Resident #25. She allowed STNA #43 to dress Resident #25, transfer her from her bed to a specialized chair (Broda) and escort her to the dining room for lunch. She stated that she "kept an eye on " STNA #43, as this incident occurred at lunch time. STNA #43 was answering call lights and passing meal trays to other residents from the time STNA #75 observed STNA #43 in bed with Resident #25 until the DON arrived at the facility, which was at least 30 minutes. LPN #58 stated she did not have STNA #43 in full visual view the entire time he was answering resident call lights and passing meal trays. She stated she failed to send STNA #43 home because she was in total disbelief and in shock. She stated she did not physically assess the resident; she only questioned the resident in the dining room and asked her if she was "ok". Telephone interview with STNA #75 on 07/22/11 at 3:50 P.M. revealed she was looking for STNA #43 because she needed assistance with another resident. She stated she opened the door to the room of Resident #25 and asked STNA #43 if he was almost done. She stated she observed Resident #25 nude in bed with STNA #43 lying on top of the resident between her legs. She stated that the resident is not able to move her legs and STNA #43 had her legs in a straddle position. She stated she did not enter the room, but shut the door and went immediately to inform LPN #88. LPN #88 told her she was going to the assisted living unit, separate from the nursing home, to telephone the Director of Nursing and nurse on call. STNA #75 returned to the nursing home portion of the facility, and at that time, STNA #43 asked her (STNA #75) to help him with care for Resident #25. STNA #75 left the nursing home, going back to the assisted living area of the facility without assisting STNA #43. During a follow up interview on 07/22/11 at 4:45 P.M., with the DON, she stated the charge nurse has the authority to send accused staff home without consulting the DON or Administrator first. During interview, facility staff was not able to verbally articulate the proper action to take if sexual abuse was witnessed. Four STNA's were interviewed on 07/23/11 at 9:45 A.M. and when queried, three of the four STNA's stated they would close the door to the room and report the incident to the nurse without intervening to stop the abuse and protect the resident. Only one nurse aide said she would intervene to stop the abuse and protect the resident, then report the incident to the charge nurse. Two housekeepers stated during interview on 07/23/11 at 10:20 A.M. they would report the abuse; one said she would report it to the "first person she saw" and the other stated she would report to the charge nurse. Neither stated they would first protect the resident from the abuser. Review of the facility's undated policy and procedure entitled "Policy for abuse, neglect and misappropriation of property" revealed the policy stated the facility's mission was the respect for the needs of each individual and the provision of total health care which includes the physical, mental, emotional and spiritual needs of each resident. The facility policy stated it "strives to accomplish our mission through the following systems: which included "training for resident rights is offered at least yearly to employees", but didn't state any specific training was provided to address resident abuse. Under the policy subheading "Definitions", the policy stated the definition of abuse "means knowingly causing physical harm, pain, intimidation or recklessly causing serious physical harm to a resident by physical contact with the resident or by use of physical or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment." The policy did not define verbal, sexual or mental abuse. Under the subheading "Internal Investigation", the policy stated "an internal investigation of abuse, neglect, misappropriation will be conducted by the Department Manager, Director of Nursing, and/or Licensed Social Worker and/or any other person designated by the Administrator. The facility will act to ensure resident safety during the investigation." The policy did not indicate what specific actions were required by facility staff to ensure resident safety. This citation substantiated Complaint Number OH 618.

Based on review of a facility self-reported incident (SRI) report, observation, medical record review, review of a police report, staff and resident interviews, and review of the facility's abuse policy, the facility failed to ensure Resident #25 was free from sexual abuse by State tested Nurse Aide (STNA) #43. This resulted in Immediate Jeopardy for one (Resident #25) of five sampled residents. This had the potential to affect 27 residents as STNA #43 was unsupervised and providing care to the residents before and after the abuse incident. The facility census was 43. On 07/22/11 at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/16/11 at 11:25 A.M. when STNA #75 observed STNA #43 on top of Resident #25. Resident #25 was nude with STNA #43 lying between her legs. STNA #75 reported the allegation to charge nurse, Licensed Practical Nurse (LPN) #88. LPN #88 and STNA #75 left the building due to reported fear of STNA #43; however, STNA #43 was left alone with Resident #25 and got her dressed and took her to the dining room. STNA #43 was permitted to remain on patient care duty until 1:00 P.M. on 7/16/11. The Immediate Jeopardy was removed and corrected on 07/27/11 when the facility implemented the following corrective actions: ? On 07/16/11 at 1:00 P.M. STNA #43 was removed from the facility. He was not permitted to return to work or return to the grounds of the facility. The facility initiated an investigation that included notification of the local police. Resident #25 was sent to the hospital emergency department for examination. Resident #25 was assigned only female caregivers. ? The employment of STNA #43 was terminated on 07/16/11. ? On 07/18/11, the facility purchased 16 two-way radios. All nurses and STNA's will carry the two-way radio during their shift for communication and notification of whereabouts of staff at all times. ? On 07/19/11 and 07/20/11, all residents in the facility were screened to determine if they had been abused by any staff in the facility. ? On 07/19/11, all staff was educated on reporting abuse by the local police department. ? On 07/23/11, five residents were identified under the age of 65, including Resident #25. Of those five, three alert and oriented residents under the age of 65 were interviewed and it was determined STNA #43 had not attempted any sexual contact with them. ? On 07/27/11, the facility implemented a new abuse policy entitled "Abuse, Neglect, and Mistreatment" dated 07/27/11, that included screening of potential employees, training of new employees on the facility abuse policy, how to prevent abuse, identification of abuse, investigation of abuse, protection of the resident during investigation of an alleged abuse allegation and reporting of abuse to the proper authorities. ? All staff was provided education on 07/27/11 about the facility's new abuse policy. ? The Director of Nursing and Administrator are monitoring staff 's ability to articulate the abuse protocol on a daily basis by randomly questioning staff about the abuse protocol. ? All new hires are being immediately trained on the facility's abuse protocol. ? On 08/12/11, four nurse aides and two licensed practical nurses were interviewed. All stated they had been trained on the facility's new abuse policy and were able to articulate what the policy stated and how to appropriately respond to an allegation of sexual abuse. Findings include: Review of the physician order [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #25 had moderate cognitive impairment and required the extensive assistance of one staff member for bed mobility and transfers, was not ambulatory and required the use of a mechanical lift for transfers. The assessment further stated the resident had [MEDICAL CONDITION] and lower extremity impairment on both sides. Review of the facility's self reported incident dated 07/16/11 revealed STNA #75 walked in Resident #25's room and found STNA #43 on top of Resident #25. Resident #25 was not clothed. STNA #43 was observed with his clothes on his upper body, but could not be seen from his waist down. Review of the police report dated 07/17/11, provided by Police Officer #107, revealed on 07/16/11 at approximately 6:55 P.M., she was advised to contact the DON of the facility regarding a rape that occurred. Police Officer #107 went to the facility and interviewed the three staff (STNA #75, LPN #88 and LPN #58) that was present when the incident occurred. She met with Resident #25 who informed the officer that she (Resident #25) had sexual intercourse with male staff member, STNA #43. She stated she had never met him before. She further stated that he (STNA #43) told her he would lose his job if he got caught doing this. Resident #25 told him she felt "dirty and guilty and didn't like doing it because he had a wife." She stated she "felt sick, it was nasty and she felt dirty." STNA #43 told her again not to tell anyone so he wouldn't lose his job. Police Officer #107 was able to contact STNA #43 who admitted to sexually assaulting Resident #25. Review of a letter from Physician #86 dated 07/18/11 revealed Resident #25 has been a resident at the facility for the past eleven years. Her underlying medical condition is [MEDICAL CONDITION], which is a disease of the brain and nervous system. She is completely dependent for her personal care due to paralysis of her lower extremities and weakness and limitation of her upper extremities. She has had impairment of memory function and judgment. She lacks the ability to make consensual judgments for herself and would not have the ability to resist or be aware of her personal safety or endangerment. She also has enough mental and cognitive impairment that her statements on any matter would be inconsistent on other occasions. Interview with the DON on 07/22/11 at 1:45 P.M. revealed STNA #75 observed Resident #25's door shut around 11:30 A.M. which made her feel uncomfortable. She opened the door and found the resident lying nude in bed and STNA #43 was on top of her. She shut the door; thereby, leaving STNA #43 in the room with the Resident #25. She went to LPN #88, who was the charge nurse and informed her of the observation. LPN #88 asked LPN #58 to observe STNA #43 as he continued to give care while she made phone calls. Immediately after being seen by STNA #75, STNA #43 proceeded to get Resident #25 out of bed, into her wheelchair, and to the dining room for lunch. While LPN #88 was making phone calls, STNA #43 was in the dining room serving lunch to other residents. The DON arrived and talked to the staff about the incident. She made STNA #43 leave the facility around 1:00 P.M. She stated when she initially interviewed Resident #25, she denied anything occurred; however, later admitted to the police she had sexual intercourse with STNA #43. The DON stated after she was notified of the alleged sexual abuse, she should have instructed charge nurse LPN #88 to send STNA #43 home immediately and not allow him to remain in the facility. Interview with charge nurse, LPN #88 on 07/22/11 at 2:45 P.M. revealed she was in the break room when STNA #75 informed her that she found STNA#43 on top of Resident #25 having sex with her. LPN #88 stated she and STNA #75 left the facility and went to the facility's assisted living unit, which is separated from the nursing home by a driveway. LPN #88 said she wanted to get STNA #75 away from STNA #43, as STNA #75 was afraid and upset by what she had witnessed. Once inside the assisted living unit, LPN #88 called LPN #58 in the nursing home and told her to watch STNA #43. She called the DON and another nurse, LPN #77, who was on call. She stated her (LPN #88) and STNA #75 stayed in the Assisted Living unit while they waited for the DON to arrive. LPN #88 stated she did not protect Resident #25 from STNA #43 or assess her for any possible injuries. She did nothing other than take STNA #75 over to the Assisted Living unit to get away from STNA #43. She stated she had the authority to send staff home if abuse is alleged; however, neither she nor LPN #58 sent STNA #43 home after the allegation by STNA #75. Interview with LPN #58 on 07/22/11 at 3:15 P.M. revealed she was informed by LPN #88 that an STNA had opened the door to the room of Resident #25 and found STNA #43 on top of the resident. LPN #58 stated she never entered the room of Resident #25 after the abuse allegation. She allowed STNA #43 to dress Resident #25, transfer her from the bed to the special chair (Broda) and escort her to the dining room for lunch. She stated that she "kept an eye on" STNA #43, as this incident occurred at lunch time. STNA #43 was answering call lights and passing meal trays to other residents from the time STNA #75 observed STNA #43 in bed with Resident #25 until the DON arrived at the facility, which was at least 30 minutes. LPN #58 stated she did not have STNA #43 in full visual view the entire time as he was answering resident call lights and passing meal trays. She stated she failed to send STNA #43 home because she was in total disbelief and in shock. She stated she did not do a physical assessment on Resident #25 because she did not want to destroy physical evidence. She stated she did not physically assess the resident; she only questioned the resident in the dining room and asked her if she was "okay" . She stated the resident has confusion and will easily forget what she is talking about. Telephone interview with STNA #75 on 07/22/11 at 3:50 P.M. revealed she was looking for STNA #43 because she needed assistance with another resident. She stated she opened the door to the room of Resident #25 and asked STNA #43 if he was almost done. She stated she observed Resident #25 nude in bed with STNA #43 lying on top of the her (Resident #25). STNA #43 was lying between her legs. She stated the resident is not able to move her legs and STNA #43 had her legs in a straddle position. She stated she did not enter the room, but shut the door and went immediately to inform charge nurse, LPN #88. LPN #88 told her she was going to the assisted living unit, separate from the nursing home, to telephone the Director of Nursing and nurse on call. STNA #75 returned to the nursing home portion of the facility, and at that time, STNA #43 asked her (STNA #75) to help him with Resident #25. At that time, STNA # 51 approached and offered to help STNA #43 with Resident #25. STNA #75 left the nursing home, going back to the assisted living area of the facility. During a follow up interview on 07/22/11 at 4:45 P.M., with the DON, she stated the charge nurse has the authority to send accused staff home without consulting the DON or Administrator first. Resident #25 was observed and interviewed on 07/23/11 at 10:45 A.M., while lying in bed, well groomed, dressed in a gown. The resident was alert, but not oriented to time. She stated she was in the facility because she had [MEDICAL CONDITION]. She said she had resided in the facility since 1973, stated her favorite resident was the oldest woman in the facility, but then stated she was the oldest person in the facility, and stated she was born in 1995, all of which is inaccurate. She stated she had sexual intercourse with STNA #43, it was the only time she had intercourse with him, and she has not seen him since it happened. She stated she knew STNA #43 was an employee. (Resident #25 initially told the police investigator on 07/16/11 she did not know the STNA and stated she thought he was a visitor). Review of the facility's undated policy and procedure entitled "Policy for abuse, neglect and misappropriation of property" revealed the policy stated the facility's mission was the respect for the needs of each individual and the provision of total health care which includes the physical, mental, emotional and spiritual needs of each resident. The facility's policy did not address sexual abuse nor did the policy include guidelines on prevention of abuse, identification of abuse and/or protection of the resident from abuse. This citation substantiated Complaint Number OH 618.