Every finding on record at Garden Park Health Care Center

Based on observation, staff interview, and record review, the facility failed to follow contact precautions to help prevent the transmission of communicable infections. This affected two residents (Residents #44 and #78) of four residents reviewed for wound care. The facility census was 50.Findings include:Record review revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included methicillin resistant staphylococcus aureus (MRSA) infection bacteremia. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact.The physician orders for Resident #78 dated 03/30/26 revealed an order for contact isolation due to MRSA bacteremia, a highly transmissible pathogen requiring a single room isolation where all services are rendered in room only. An order dated 03/29/26 revealed to cleanse wound to left lower calf, apply silver alginate, and cover with bordered foam gauze every day. Resident #78 also had an order dated 03/30/26 for daptomycin intravenous solution 640 milligrams (mg) intravenously at bedtime for MRSA bacteremia until 05/14/26. Observation on 05/14/26 at 9:07 A.M. revealed personal protective equipment in three plastic drawers outside Resident #78's room. No contact isolation sign was posted outside Resident #78's door. Resident #78 had a roommate, Resident #44 and Resident #44 was observed asleep in bed. Licensed Practical Nurse (LPN) #403 entered into their room to complete wound care for Resident #78. LPN #403 donned gown and gloves after entering Resident #78's room.Interview on 05/14/26 at 9:20 A.M. with LPN #403 confirmed she did not put on gown or gloves until she entered into Resident #78 and #44's room. LPN #403 stated she was not aware Resident #78 had a physician order for contact isolation and confirmed there was no sign on the door. Interview on 05/14/26 at 9:20 A.M. with Assistant Director of Nursing (ADON) #500 confirmed Resident #78 and #44 were currently roommates. ADON #500 confirmed there was no sign outside Resident #78 and #44's door for contact isolation precautions. ADON #500 stated she removed the contact precautions sign a day prior when the walls were getting painted and only put back a Enhanced Barrier Precautions (EBP) sign.Interview on 05/14/26 at 9:40 A.M. with the Director of Nursing (DON) confirmed Resident #78 had active diagnosis of MRSA and active order for contact isolation single room. The DON confirmed Resident #44 did not have any diagnosis of MRSA.Review of the facility policy titled Isolation- Categories of Transmission-Based Precautions revised October 2018 revealed staff and visitors will wear gloves and disposable gown when entering the room of resident on contact precautions.This deficiency represents non-compliance investigated under Complaint Number 2994321.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were delivered and administered in a timely manner. This affected one (Resident #11) two residents reviewed for medication administration. The facility census was 52 residents. Findings include:Review of the medical record for Resident #11 revealed an admission date of 02/27/26 with diagnosis including infective endocarditis, hepatitis C, severe sepsis, and pneumonia. Review of the physician's orders for Resident #11 revealed an order dated 02/28/26 at 1:53 A.M. cefazolin sodium IV solution two grams per IV three times a day for infection until 03/31/26. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 03/03/26 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.)Review of the care plan for Resident #11 dated 03/06/26 revealed the resident was on intravenous (IV) medications related to endocarditis.Review of the Medication Administration Record (MAR) for Resident #11 dated February 2026 and March 2026 revealed the resident was not administered her first dose of cefazolin sodium until 03/01/26 at 10:00 P.M. Resident #11 missed the following six doses of IV medication: 02/27/26 at 10:00 P.M., 02/28/26 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., 03/01/26 at 6:00 A.M. and 2:00 P.M.Review of the nurse progress notes for Resident #11 dated from 02/27/26 to 03/02/26 revealed the notes did not include documentation of notification to the physician regarding the missed doses of cefazolin nor was there documentation of contact with the pharmacy regarding delivery of the medication. Interview on 04/01/26 at 10:45 A.M. with Pharmacist #30 confirmed the pharmacy delivered cefazolin sodium IV solution for Resident #11 on 03/01/26 at 12:49 P.M.Interview on 04/01/26 at 11:00 A.M. with the Director of Nursing (DON) confirmed Resident #11 had missed doses of cefazolin sodium IV solution and the resident's MAR showed six missed doses. The DON further confirmed Resident #11's medical record did not include documentation of notification to Resident #11's physician of the missed doses nor did it include documentation of contact with the pharmacy regarding delivery of the medication.Review of the facility policy titled Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Number 2801711.

Based on medical record review, observations, staff interview, and policy review, the facility failed to administer medications per physician orders resulting in four medication errors out of 41 opportunities or a 9.75 percent (%) medication error rate. This affected three (#4, #5, and #17) out of five residents observed for medication administration. The facility census was 46. Findings include: Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: left ventricular failure, muscle weakness, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require supervision or touching assistance for eating, oral hygiene, and toileting. Partial/moderate assistance for dressing and personal hygiene. Resident is always continent of bladder and occasionally incontinent of bowels. Record Review for Resident #4 revealed an order for Potassium 10 milliequivalents (meq) two capsules orally daily for hypokalemia and Buprenorphine eight milligrams (mg) one tablet sublingual for opioid dependence. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: localization-related (focal)(partial) symptomatic epilepsy and epileptic syndrome with complex partial seizures, intractable, without status epilepticus, chronic obstructive pulmonary disease, and anxiety disorder, and other manic episodes. Review of the MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a BIMS score of 13. This resident was assessed to require setup or cleanup assistance for eating, set up or clean up assistance for oral hygiene, setup or cleanup assistance for toileting, setup or cleanup assistance for shower/bathing, setup or cleanup assistance for dressing, and setup or cleanup assistance for personal hygiene. This resident is occasionally incontinent of urine and always continent of bowels. Record Review for Resident #5 revealed an order for Zoloft Oral Tablet 25 mg dated on 02/08/24 and to be given daily. Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: atherosclerotic heart disease, diabetes mellitus type II, and convulsions. Review of the MDS assessment dated [DATE] revealed this resident had severe cognitive impairment evidenced by a BIMS score of five. This resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, dependent on staff for toileting, dependent for shower/bathing, dependent for dressing, and dependent for personal hygiene. Resident is always incontinent of bowel and bladder. Record for Resident #17 revealed an order for Levetiracetam oral tablet 1000 mg dated on 06/05/2024 to be given two times a day for seizures. Observation on 12/18/25 at 9:03 A.M. of medication pass with Licensed Practical Nurse (LPN) #104 revealed Resident #5's Zoloft was omitted from the morning medication administration due to not having the medication. Interview on 12/18/25 at 9:04 A.M with LPN #104 confirmed Resident #5's Zoloft was omitted from the morning medication administration due to not having the medication. Observation on 12/18/25 at 9:44 A.M. of medication pass with LPN #104 revealed Resident #17's levetiracetam was omitted from the morning medication administration due to not having the medication. Interview on 12/18/25 at 9:45 A.M with LPN #104 confirmed Resident #17's levetiracetam was omitted from the morning administration due to not having the medication. Observation on 12/18/25 at 10:16 A.M. of medication pass with LPN #104 revealed Resident #4's Potassium and Buprenorphine HCL was omitted from the morning administration due to not having the medication. Interview on 12/18/25 at 10:18 A.M with LPN #104 confirmed Resident #4's Potassium and Buprenorphine HCL was omitted from the morning administration due to not having the medication. Review of the facility policy titled, Medication and Treatment Orders revealed medications must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available. This deficiency represents non-compliance investigated under Complaint Number 2586417.

Based on personnel record review, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received annual performance evaluations. This had the potential to affect all of the residents residing in the facility. The facility census was 48 residents.Findings include: Review of the personnel file for Certified Nursing Assistant (CNA) #213 revealed a hire date of 03/27/23 with no performance evaluations from 03/27/24 to 08/07/25. Review of the personnel file for CNA #224 revealed a hire date of 08/29/23 with no performance evaluations from 08/29/23 to 08/07/25. Interview on 08/07/25 at 8:47 A.M. with Human Resources #202 verified the facility had not completed annual performance evaluations for CNAs #213 and #224. Review of the facility policy titled Performance Evaluations dated September 2020 revealed the job performance of each employee should be reviewed and evaluated at least annually.

Based on personnel record review, staff interview, and review of the facility policy, the facility failed to implement their tuberculosis (TB) control plan for tuberculosis testing of newly hired employees. This had the potential to affect all of the residents residing in the facility. Based on observation, staff interview, and review of the facility policy, the facility also failed to ensure staffed practiced appropriate hand hygiene during medication administration. This affected four (#11, #31, #36, and #47) of four residents observed for medication administration. The facility census was 48 residents.Findings include:1.Review of the personnel file for Certified Nursing Assistant (CNA) #213 revealed a hire date of 03/27/23 with no two- step TB skin test upon hire. Review of the personnel file for CNA #110 revealed a hire date of 11/01/24 with no two-step TB skin test upon hire. Review of the personnel file for Licensed Practical Nurse (LPN) #227 revealed a hire date of 09/26/24 with no two-step TB skin test upon hire. Review of the personnel file for Housekeeper #247 revealed a hire date of 05/05/25 with no two-step TB skin test upon hire. Review of the personnel file for Admissions Director #201 revealed a hire date of 03/13/23 with no two step TB skin test upon hire. Interview on 08/07/25 at 8:18 A.M. with Human Resources (HR) #202 confirmed the facility had not conducted a TB skin test upon hire for the following employees: CNA #213, CNA #110, LPN #227, Housekeeper #247, AD #201. HR #202 confirmed the facility should conduct a two-step TB skin test on employees upon hire. Review of the facility policy titled Employee Screening for Tuberculosis dated July 2010 revealed all employees should be screened for TB infection and disease using a two-step TB skin test. 2.Observation on 08/05/25 of medication administration from 10:33 A.M to 11:38 A.M. to Residents #11, #36, #47, and #41 per Registered Nurse (RN) #258 revealed the nurse placed the residents' medications into med cups using her bare hands. Interview on 08/05/25 at 11:40 A.M. with RN #258 confirmed she had touched Residents #11, #36, #47, and #41's medication with her bare hands prior to administration. Review of the facility policy titled Administering Oral Medications dated October 2010 revealed staff members should not touch residents' medications with their ungloved hands.

Based on personnel record review, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received at least twelve hours of in service annually. This had the potential to affect all of the residents residing in the facility. The facility census was 48.Findings include:Review of the personnel file for Certified Nursing Assistant (CNA) #209 revealed a hire date of 05/20/80 with no documented in-service education from 05/20/24 to 08/07/25.Review of the personnel file for CNA #213 revealed a hire date of 03/27/23 with no documented in-service education from 03/27/24 to 08/07/25Review of the personnel file for CNA #224 revealed a hire date of 08/29/13 with no documented in-service education from 08/29/23 to 08/07/25.Interview on 08/07/25 at 8:47 A.M. with Human Resources (HR) #202 confirmed the facility did not have documentation of twelve hours of annual in-service education for CNAs #209, #213, and #224. Review of the facility policy titled In-Service Training undated revealed all CNAs employed by the facility must complete a minimum of 12 hours of in-service training annually.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility incident investigations, resident interview, staff interview, and review of the facility policy, the facility failed to report allegations of resident-to-resident sexual abuse to the state agency within 24 hours. This affected four (Residents #2, #8, #11, #36) of four residents reviewed for abuse. The facility census was 48 residents.Findings include:1.Review of the medical record for Resident #36 revealed an admission date of 03/22/22 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety disorder, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 07/03/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #36 dated 07/12/25 at 6:12 P.M. revealed staff witnessed the resident sitting in the lap of another peer and kissing him. Staff separated Resident #36 removed them from the environment and educated the resident on personal space and understanding boundaries. Review of the behavior care plan for Resident #36 dated 07/16/25 revealed the resident had been sexually inappropriate with another male resident. Interventions included the following: administer medications as ordered, monitor and document side effects and effectiveness, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction, educate the resident, caregivers and families on successful coping and interaction strategies, intervene as necessary to protect the rights and safety of others and monitor behavior episodes and attempt to determine an underlying cause. Review of the medical record for Resident #11 revealed an admission date of 02/12/25 with diagnoses including radiculopathy, schizoaffective disorder, bipolar disorder, and congestive heart failure. Review of the care plan for Resident #11 dated 03/10/25 revealed the resident had altered behaviors including being verbally disruptive, resistive to care, violence, anger and noncompliance. Interventions included the following: administer prescribed medications, observe for side effects, monitor for effectiveness, allow resident to pace where he can be observed, as needed medication given after non pharmacological approach attempted, assess for internal and external contributors to rule out delirium, be careful to not invade the resident’s personal space, consult with psychiatric services if needed and as requested by the resident, family and physician, convey acceptance of the resident during periods of inappropriate behavior, and encourage family support and involvement. Review of the MDS assessment for Resident #11 dated 05/21/25 revealed the resident was moderately cognitively impaired and required staff assistance with ADLs. Review of the progress note for Resident #11 dated 07/12/25 at 6:17 P.M. revealed staff witnessed a peer sitting in the resident’s lap and started to kiss him. Staff separated the residents and educated Resident #1 on the importance of setting boundaries for personal space. Review of the facility SRI initiated 07/16/25 at 12:50 A.M. revealed the facility investigated an allegation of sexually inappropriate conduct which had occurred between Resident #36 and Resident #11 on 07/12/25 at 6:15 P.M. The facility did not substantiate abuse. Review of the undated facility investigation of the incident between Resident #36 and Resident #11 which occurred on 07/12/25 revealed the incident was mentioned in morning report meeting on 07/12/25 but the employee on duty was not sure if the incident needed to be reported to administration. The facility provided one-on-one coaching with the employee regarding immediate reporting of abuse allegations. Interview on 08/04/25 at 12:25 P.M. with Resident #11 confirmed the resident did not recall kissing or being kissed by any resident at the facility and the resident denied being sexually abused at the facility. Interview on 08/04/25 at 1:24 P.M. with Resident #36 confirmed the resident did not recall kissing or being kissed by any resident at the facility and the resident denied being sexually abused at the facility. Interview on 08/05/25 at 11:44 A.M with the Director of Nursing (DON) confirmed the DON saw the progress notes about Resident #11 and Resident #36 kissing on 07/12/25 when she reviewed the 72-hour report on 07/14/25. The DON reported that the staff working did not report the incident to her or other administrative staff. The DON verified that the incident occurred on 07/12/25 and an SRI was not filed until 07/16/25. Interview on 08/06/25 at 11:17 A.M. with Licensed Practical Nurse (LPN) #228 confirmed the nurse could not recall the date of the incident but stated she was called to the secured unit by Certified Nursing Assistant (CNA) #211. LPN #228 stated CNA #211 reported Resident #11 and Resident #36 were at the nurses’ station and Resident #36 sat on Resident #11’s lap and started to kiss him. LPN #228 stated Resident #11 and Resident #36 were separated by CNA #211 prior to LPN #228 arriving on the unit. LPN #228 confirmed the DON was notified. Interview on 08/06/25 at 11:24 A.M. with CNA #211 confirmed the aide could not recall the date of the incident, but she was coming out of another resident’s room when she saw Resident #11 sitting on his rollator walker by the nurse’s station. CNA #211 stated Resident #36 was standing over Resident #11 and was straddling him on his walker. CNA #211 reported Resident #36 was holding Resident #11’s head and Resident #36 was kissing Resident #11 on the lips. CNA #211 confirmed she reported the incident to the nurse. 2. Review of the medical record for Resident #8 revealed an admission date of 04/06/25 with diagnoses including cirrhosis of the liver, alcohol abuse, and cocaine abuse. Review of MDS assessment dated [DATE] for Resident #8 revealed the resident had mild cognitive impairment and was independent with ADLs with minimal set-up assistance. Review of the progress note for Resident #8 dated 06/22/25 at 8:32 A.M. revealed the resident was sitting on the porch, resident smoking area, involved in sexual activity with a female resident from another unit of the facility. Both residents were physically exposed and other residents complained. The nurse explained to Resident #8 the porch was a public area and was not an appropriate place for sexual activity. Resident #8 told the nurse he wound have sex anywhere he wanted and when he wanted and then began cursing and verbally threatening the nurse. Review of the medical record for Resident #2 revealed an admission date of 07/29/24 with a diagnosis of paraplegia. Review of the MDS assessment for Resident #2 dated 07/01/25 revealed the resident was cognitively intact and independent with ADLs. Review of the progress note for Resident #2 dated 06/22/25 at 8:30 A.M. revealed the resident was observed on the smoking porch engaged in sexual activity with another resident in the presence of other residents. The nurse explained to Resident #2 that sexual activity could not take place on the porch or other public areas, but Resident #2 laughed and stated the nurse could not stop them. Review of the facility SRIs dated 08/06/25 revealed the facility investigated an allegation of resident-to-resident sexual abuse between Residents #8 and #2. The facility did substantiate abuse. The Surveyor attempted an interview on 08/06/25 at 2:00 P.M. with Resident #8, but the resident declined the interview. Interview on 08/06/2025 at 2:51 P.M. with the Administrator confirmed staff had not reported the incident regarding Residents #8 and #2 on 06/22/25. Interview on 08/06/25 at 2:55 P.M. with the DON confirmed staff reported on 06/23/25 that Residents #8 and #2 had been kissing and talking nasty on the smoking porch on 06/22/25. The DON confirmed the facility had not investigated the incident to determine if sexual abuse had occurred nor had the facility reported the allegation immediately to the state agency as required. The DON confirmed the regional nurse told her the facility didn’t have to file an SRI because the residents were consenting adults, and the residents’ capacity to consent was presumed and was not investigated Review of the facility policy titled Abuse, Neglect and Exploitation dated 01/22/25 revealed the policy defined sexual abuse as nonconsensual sexual contact of any type with a resident, and the facility would report all allegations of abuse to the state agency within required timeframes. This deficiency represents noncompliance investigated under Complaint Number 2571800.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility incident investigations, resident interview, staff interview, and review of the facility policy, the facility failed to thoroughly and timely investigate allegations of resident-to-resident sexual abuse This affected four (Residents #2, #8, #11, #36) of four residents reviewed for abuse. The facility census was 48 residents.Findings include:1. Review of the medical record for Resident #36 revealed an admission date of 03/22/22 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety disorder, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 07/03/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #36 dated 07/12/25 at 6:12 P.M. revealed staff witnessed the resident sitting in the lap of another peer and kissing him. Staff separated Resident #36 removed them from the environment and educated the resident on personal space and understanding boundaries. Review of the behavior care plan for Resident #36 dated 07/16/25 revealed the resident had been sexually inappropriate with another male resident. Interventions included the following: administer medications as ordered, monitor and document side effects and effectiveness, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction, educate the resident, caregivers and families on successful coping and interaction strategies, intervene as necessary to protect the rights and safety of others and monitor behavior episodes and attempt to determine an underlying cause. Review of the medical record for Resident #11 revealed an admission date of 02/12/25 with diagnoses including radiculopathy, schizoaffective disorder, bipolar disorder, and congestive heart failure. Review of the care plan for Resident #11 dated 03/10/25 revealed the resident had altered behaviors including being verbally disruptive, resistive to care, violence, anger and noncompliance. Interventions included the following: administer prescribed medications, observe for side effects, monitor for effectiveness, allow resident to pace where he can be observed, as needed medication given after non pharmacological approach attempted, assess for internal and external contributors to rule out delirium, be careful to not invade the resident’s personal space, consult with psychiatric services if needed and as requested by the resident, family and physician, convey acceptance of the resident during periods of inappropriate behavior, and encourage family support and involvement. Review of the MDS assessment for Resident #11 dated 05/21/25 revealed the resident was moderately cognitively impaired and required staff assistance with ADLs. Review of the progress note for Resident #11 dated 07/12/25 at 6:17 P.M. revealed staff witnessed a peer sitting in the resident’s lap and started to kiss him. Staff separated the residents and educated Resident #1 on the importance of setting boundaries for personal space. Review of the facility SRI initiated 07/16/25 at 12:50 A.M. revealed the facility investigated an allegation of sexually inappropriate conduct which had occurred between Resident #36 and Resident #11 on 07/12/25 at 6:15 P.M. The facility did not substantiate abuse. Review of the undated facility investigation of the incident between Resident #36 and Resident #11 which occurred on 07/12/25 revealed the incident was mentioned in morning report meeting on 07/12/25 but the employee on duty was not sure if the incident needed to be reported to administration. The facility provided one-on-one coaching with the employee regarding immediate reporting of abuse allegations. The investigation did not include witness statements or witness interviews and/or staff interviews regarding the incident between Resident #11 and Resident #36 which occurred on 07/12/25. Review of the facility investigation revealed the facility interviewed seven residents related to abuse with no findings. Interview on 08/04/25 at 12:25 P.M. with Resident #11 confirmed the resident did not recall kissing or being kissed by any resident at the facility and the resident denied being sexually abused at the facility. Interview on 08/04/25 at 1:24 P.M. with Resident #36 confirmed the resident did not recall kissing or being kissed by any resident at the facility and the resident denied being sexually abused at the facility. Interview on 08/05/25 at 11:44 A.M with the Director of Nursing (DON) confirmed the DON saw the progress notes about Resident #11 and Resident #36 kissing when she reviewed the 72-hour report on 07/14/25. The DON reported that the staff working did not report the incident to her or other administrative staff. The DON verified that the incident occurred on 07/12/25 and an SRI was not filed until 07/16/25. The DON confirmed the investigation of the incident did not start until 07/14/25. The DON reported she interviewed Resident #11 and Resident #36 after she discovered the incident on 07/14/25 but neither resident recalled the incident. The DON verified the facility did not obtain any staff statements related to the incident. Interview on 08/06/25 at 11:17 A.M. with Licensed Practical Nurse (LPN) #228 confirmed the nurse could not recall the date of the incident but stated she was called to the secured unit by Certified Nursing Assistant (CNA) #211. LPN #228 stated CNA #211 reported Resident #11 and Resident #36 were at the nurses’ station and Resident #36 sat on Resident #11’s lap and started to kiss him. LPN #228 stated Resident #11 and Resident #36 were separated by CNA #211 prior to LPN #228 arriving on the unit. LPN #228 confirmed the DON was notified. Interview on 08/06/25 at 11:14 A.M. with CNA #211 confirmed the aide could not recall the date of the incident, but she was coming out of another resident’s room when she saw Resident #11 sitting on his rollator walker by the nurse’s station. CNA #211 stated Resident #36 was standing over Resident #11 and was straddling him on his walker. CNA #211 reported Resident #36 was holding Resident #11’s head and Resident #36 was kissing Resident #11 on the lips. CNA #211 confirmed she reported the incident to the nurse. 2. Review of the medical record for Resident #8 revealed an admission date of 04/06/25 with diagnoses including cirrhosis of the liver, alcohol abuse, and cocaine abuse. Review of MDS assessment dated [DATE] for Resident #8 revealed the resident had mild cognitive impairment and was independent with ADLs with minimal set-up assistance. Review of the progress note for Resident #8 dated 06/22/25 at 8:32 A.M. revealed the resident was sitting on the porch, resident smoking area, involved in sexual activity with a female resident from another unit of the facility. Both residents were physically exposed and other residents complained. The nurse explained to Resident #8 the porch was a public area and was not an appropriate place for sexual activity. Resident #8 told the nurse he wound have sex anywhere he wanted and when he wanted and then began cursing and verbally threatening the nurse. Review of the medical record for Resident #2 revealed an admission date of 07/29/24 with a diagnosis of paraplegia. Review of the MDS assessment for Resident #2 dated 07/01/25 revealed the resident was cognitively intact and independent with ADLs. Review of the progress note for Resident #2 dated 06/22/25 at 8:30 A.M. revealed the resident was observed on the smoking porch engaged in sexual activity with another resident in the presence of other residents. The nurse explained to Resident #2 that sexual activity could not take place on the porch or other public areas, but Resident #2 laughed and stated the nurse could not stop them. Review of the facility SRIs dated 08/06/25 revealed the facility investigated an allegation of resident-to-resident sexual abuse between Residents #8 and #2. The facility did substantiate abuse. The Surveyor attempted an interview on 08/06/25 at 2:00 P.M. with Resident #8, but the resident declined the interview. Interview on 08/06/2025 at 2:51 P.M. with the Administrator confirmed staff had not investigated the incident involving Residents #8 and #2 which had occurred on 06/22/25 until 08/06/25. Interview on 08/06/25 at 2:55 P.M. with the DON confirmed staff reported on 06/23/25 that Residents #8 and #2 had been kissing and talking nasty on the smoking porch on 06/22/25. The DON confirmed the facility had not investigated the incident to determine if sexual abuse had occurred nor had the facility reported the allegation immediately to the state agency as required. The DON confirmed the regional nurse told her the facility didn’t have to file an SRI because the residents were consenting adults, and the residents’ capacity to consent was presumed and was not investigated Review of the facility policy titled Abuse, Neglect and Exploitation dated 01/22/25 revealed an immediate investigation was warranted when a suspicion of abuse occurred. Written procedures for an investigation included the following: identify the staff responsible for the investigation, exercise caution in handling evidence that could be used in a criminal investigation, investigate different types of alleged violations, identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations, focusing the investigation on determining if abuse occurred, the extent and the cause an providing complete and thorough documentation of the investigation. This deficiency represents noncompliance investigated under Complaint Number 2571800.

Based on medical review, staff interview, and review of facility policy, the facility failed to notify the Ombudsman's office of resident hospitalizations and discharges from the facility. This affected one (Resident #56) of four residents reviewed for discharges. The facility census was 48 residents.Findings include:Review of the medical record for Resident #56 revealed an admission date of 02/28/25 with diagnoses including encephalopathy, opioid use, and chronic viral hepatitis C and a discharge date of 03/20/25. Review of the Minimum Data Set (MDS) assessment for Resident #56 dated 02/28/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs). Review of the medical record for Resident #56 revealed it did not include documentation of Ombudsman notification of the resident's hospitalization and discharge from the facility.Interview on 08/07/25 at 9:17 A.M with the Administrator confirmed the facility did not notify the Ombudsman of Resident #56's discharge from the facility on 03/20/25. Review of the facility policy titled Transfer or Discharge, Facility - Initiated dated on October 2022 revealed the facility was to provide notice of transfer to long term care Ombudsman as soon as practicable.

Based on medical record review, observation, resident staff interview, and review of the facility policy, the facility failed to ensure resident Minimum Data Set (MDS) assessments were accurately coded for falls and contractures. This affected one (Resident #31) of 14 residents reviewed for MDS assessment accuracy. The facility census was 48 residents.Findings include:Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia. Review of the progress note for Resident #31 dated 04/10/25 at 6:07 P.M. revealed the resident had a fall on the floor near the bed. Review of the interdisciplinary team (IDT) progress note for Resident #31 dated 04/11/25 revealed the resident was found on the floor on 04/10/25. Resident #31 stated he fell attempting to self-transfer himself to his wheelchair.Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/14/25 revealed the resident had no falls since admission and had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Review of the progress note for Resident #31 dated 04/15/25 at 11:19 A.M. revealed the resident was found kneeling on the floor in front of the toilet in the bathroom. Resident #31 stated he was trying to use the bathroom.Review of the IDT progress note for Resident #31 dated 04/16/25 revealed the resident fell on [DATE] and was found kneeling in front of his toilet.Review of the progress note for Resident #31 dated 06/01/25 at 9:27 P.M. revealed resident's left index finger was red and swollen. Resident #31 reported he fell in the shower room and staff obtained orders for an x-ray on the left hand.Review of the IDT progress note for Resident #31 dated 06/02/25 revealed the resident had an unwitnessed fall in the shower room on 06/01/25.Review of the progress note for Resident #31 dated 07/10/25 at 12:31 P.M. revealed the resident had an unwitnessed fall out of bed which resulted in a skin tear.Review of the IDT progress note for Resident #31 dated 07/11/25revealed the resident fell out of bed on 07/10/25 when trying to reposition himself.Review of the MDS assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), had one fall with injury since the MDS dated [DATE], and had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Observation on 08/04/25 at 11:47 A.M. of Resident #31 revealed the resident's left hand second digit was crossed over the third digit and the resident was not able to extend his third and fourth digits.Interview on 08/04/25 at 11:47 A.M. with Resident #31 confirmed the resident sustained an injury to his left hand prior to admission which had caused a contracture to the left hand which had been present during the resident's entire stay at the facility. Interview on 08/06/25 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #31 admitted to the facility with a previous hand fracture that caused a hand deformity. The DON verified the facility did not have any documentation of the previous hand injury nor did the facility have a care plan for Resident #31's left hand deformity. Interview on 08/06/25 at 12:28 P.M. with MDS Licensed Practical Nurse (LPN) #260 verified Resident #31's 04/14/25 and 07/15/25's MDS were not accurately coded for falls. MDS LPN #260 confirmed Resident #31's fall on 04/11/25 was not reflected on the resident's 04/14/25 MDS. MDS LPN #260 also confirmed Resident #31's 07/15/25 MDS was inaccurately coded because it indicated the resident #31 had one fall but the resident had three falls that occurred on 04/15/25, 06/01/25, and 07/10/25. Interview on 08/06/25 at 1:30 P.M. with Director of Therapy (DOT) #261 verified Resident #31 had a partial contracture of the left hand. DOT #261 confirmed Resident #31's second digit was crossed over his third digit and Resident #31 was not able to extend his third and fourth digits on his left hand. DOT #261 confirmed the facility did not have any documented therapy notes, assessments or recommendations for the contracture to Resident #31's left hand. Interview on 08/06/25 at 1:41 P.M. with MDS Licensed Practical Nurse (LPN) #260 confirmed the MDS assessments for Resident #31 dated 04/14/25 and 07/15/25 were not correctly coded regarding the resident's left-hand contracture. Review of the facility policy titled Certifying Accuracy of the Resident assessment dated [DATE] revealed any person completing a portion of the MDS assessment must sign and certify the accuracy of that portion of the assessment.

Based on medical record review and staff interview, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASARR) for newly admitted residents. This affected one (Resident #11) of two residents reviewed for PASARR completion. The facility census was 48 residents.Findings include:Review of the medical record for Resident #11 revealed an admission date of 02/12/25 with diagnoses including radiculopathy, schizoaffective disorder, bipolar disorder, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 05/21/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs).Review of the PASARR for Resident dated 01/17/25 revealed the resident's diagnosis of schizoaffective disorder was not included on the PASARR.Interview on 08/06/25 at 8:18 A.M with the Administrator verified Resident #11's diagnosis of schizoaffective disorder was not listed or marked on the PASARR. Interview on 08/06/25 at 9:47 A.M. with Social Services Designee (SSD) #259 verified Resident #11's diagnosis of schizoaffective disorder was not listed on the PASARR.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop a care plan for a hand contractures. This affected one (Resident #31) of 14 residents reviewed for care plans. The facility census was 48 residents.Findings include: Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia.Review of the care plan for Resident #31 initiated 04/07/25 revealed it did not include a care plan for hand contractures.Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/14/25 revealed the resident had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Review of the MDS assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Observation on 08/04/25 at 11:47 A.M. of Resident #31 revealed the resident's left hand second digit was crossed over the third digit and the resident was not able to extend his third and fourth digits.Interview on 08/04/25 at 11:47 A.M. with Resident #31 confirmed the resident sustained an injury to his left hand prior to admission which had caused a contracture to the left hand which had been present during the resident's entire stay at the facility.Interview on 08/06/25 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #31 admitted to the facility with a previous hand fracture that caused a hand deformity. The DON verified the facility did not have any documentation of the previous hand injury nor did the facility have a care plan for Resident #31's left hand deformity.Interview on 08/06/25 at 1:30 P.M. with Director of Therapy (DOT) #261 verified Resident #31 had a partial contracture of the left hand. DOT #261 confirmed Resident #31's second digit was crossed over his third digit and Resident #31 was not able to extend his third and fourth digits on his left hand. DOT #261 confirmed the facility did not have any documented therapy notes, assessments or recommendations for the contracture to Resident #31's left hand.Interview on 08/06/25 at 1:41 P.M. with MDS Licensed Practical Nurse (LPN) #260 confirmed the MDS assessments for Resident #31 dated 04/14/25 and 07/15/25 were not correctly coded regarding the resident's left-hand contracture.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to update care plans for residents who smoked cigarettes. This affected two (Residents #21 and #18) of four residents reviewed for smoking. The facility census was 48 residents. Findings include: 1.Review of medical record for Resident #21 revealed an admission date of 10/27/24 with diagnoses including multiple sclerosis, subdural hematoma, anxiety disorder, anti-social disorder, and spondylosis. Review of Minimum Data Set (MDS) assessment for Resident #21 dated 10/27/24 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of the smoking assessment for Resident #21 dated 10/27/24 revealed there was a box checked indicating the resident was to be supervised during smoking times. The assessment was unscored and did not indicate if the resident was an independent or supervised smoker. Review of the care plan for Resident #21 dated 11/26/24 revealed the resident was to be supervised during smoking times. Interview on 08/05/25 at 10:02 A.M with Resident #21 confirmed he knew of no set smoking times and that he smoked out on the smoking patio at will. Resident #21 confirmed he managed and maintained his own cigarettes and lighters and was actively rolling cigarettes during the interview. Interview on 08/06/25 at 12:33 P.M. with the Administrator confirmed the smoking assessment utilized by the facility had no mechanism for scoring to determine whether a resident was an independent smoker or required supervision for smoking. Interview on 08/06/25 at 8:24 A.M. with Activities Director (AD) #254 confirmed she completed smoking assessments for all the residents. AD #254 confirmed the assessment used by the facility did not include a scoring mechanism and she used her personal judgment to determine whether a resident was an independent smoker or required supervision. AD #254 confirmed the facility considered Resident #21 to be an independent smoker and the resident's care plan had not been updated to reflect the resident's smoking status. 2. Review of the medical record for Resident #18 revealed an admission date of 06/26/25 with diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory failure. Review of the smoking assessment for Resident #18 dated 06/26/25 revealed the assessment was unscored and it was not clear if the resident was to be an independent or supervised smoker. Review of Resident #18's care plan dated 06/26/25 revealed the resident was at risk of complication/injuries related to use of tobacco with a preference to smoke cigarettes. The only intervention was for staff to assist the resident to smoking areas as needed. Review of MDS assessment for Resident #18 dated 07/02/25 revealed the resident had mild cognitive impairment. Interview on 08/07/25 at 8:26 A.M. with AD #254 confirmed the smoking assessment for Resident #18 was unscored and did not clearly indicate whether or not the resident was to be supervised or independent. AD #254 confirmed Resident #18 was on oxygen and required assistance of staff to remove the tubing prior to smoking, light the resident's cigarettes, and hold the cigarettes due to the resident's hand tremor. AD #254 confirmed Resident #18's smoking care plan had not been updated with interventions for safe smoking. Review of facility policy titled Resident Smoking and Electronic Cigarette Use Policy undated revealed residents would be assessed to determine their ability to smoke safely and this information would be included in the resident's care plan.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide appropriate hand and nail hygiene for dependent residents. This affected one (Resident #15) of four residents reviewed for hand and nail care. The facility census was 48 residents.Findings include: Review of medical record for Resident #15 revealed an admission date of 12/28/23 with diagnoses including included cerebral infarction, diabetes, hypertension, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 02/13/25 revealed the resident had moderately impaired cognition and required staff assistance with bathing and personal hygiene. Observation on 08/06/25 at 8:44 A.M. of Resident #15 revealed the resident communicated via an iPad but had difficulty using the device because his fingernails were too long. The resident's nails also had debris underneath them. Interview on 08/06/25 at 8:47 A.M. with Resident #25 confirmed his nails were too long and staff had not offered to cut them, and the length of the nails made it difficult for him to use his communication device. Interview on 08/07/25 at 9:49 A.M. with the Director of Nursing (DON) confirmed nail care was to be done in conjunction with showers which were offered, at minimum, twice weekly to each resident. The DON confirmed there was no set schedule for hand or nail care outside the bathing schedule. Interview on 08/07/25 at 10:31 A.M. with Assistant Director of Nursing (ADON) #235 confirmed nail care should be occurring on shower days. Nurses were instructed to do the nail clipping of any resident who is diabetic. ADON #235 confirmed Certified Nursing Assistants (CNAs) should be charting if residents refused nail care or personal hygiene. Interview on 08/07/25 at 10:48 A.M. with Licensed Practical Nurse (LPN) #231 confirmed Resident #15 was in need of nail care to his hands due to the length of the nails and the dirt under his fingernails. Review of facility policy titled Care of Fingernails/Toenails dated October 2010 revealed nail care includes daily cleaning and regular trimming to prevent skin problems around the nail bed. This deficiency represents noncompliance investigated under Complaint Number OH00166418 (iQIES 1339328)

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide treatment for a resident contractures. This affected one (Resident #31) of two residents reviewed for limited range of motion and contractures. The facility census was 48 residents. Findings include:Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia.Review of the care plan for Resident #31 initiated 04/07/25 revealed it did not include a care plan for hand contractures.Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/14/25 revealed the resident had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Review of the MDS assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and had no impairment of the upper extremity including the shoulder, elbow, wrist and hand that interfered with daily functions or placed the resident at risk for injury.Observation on 08/04/25 at 11:47 A.M. of Resident #31 revealed the resident's left hand second digit was crossed over the third digit and the resident was not able to extend his third and fourth digits.Interview on 08/04/25 at 11:47 A.M. with Resident #31 confirmed the resident sustained an injury to his left hand prior to admission which had caused a contracture to the left hand which had been present during the resident's entire stay at the facility.Interview on 08/06/25 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #31 admitted to the facility with a previous hand fracture that caused a hand deformity. The DON verified the facility did not have any documentation of the previous hand injury nor did the facility have a care plan for Resident #31's left hand deformity.Interview on 08/06/25 at 1:30 P.M. with Director of Therapy (DOT) #261 verified Resident #31 had a partial contracture of the left hand. DOT #261 confirmed Resident #31's second digit was crossed over his third digit and Resident #31 was not able to extend his third and fourth digits on his left hand. DOT #261 confirmed the facility did not have any documented therapy notes, assessments or recommendations for the contracture to Resident #31's left hand.Interview on 08/06/25 at 1:41 P.M. with MDS Licensed Practical Nurse (LPN) #260 confirmed the MDS assessments for Resident #31 dated 04/14/25 and 07/15/25 were not correctly coded regarding the resident's left-hand contracture.Review of the facility's resident mobility and range of motion policy dated July 2017 revealed residents with limited range of motion will receive treatment and services to increase and prevent a further decrease in range of motion.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident fall prevention interventions were in place as ordered by the physician and per the resident care plan. This affected one (Resident #31) of four residents reviewed for falls. The facility census was 48.Findings include: Review of the medical record for Resident #31 revealed an admission date of 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia. Review of the fall risk assessment for Resident #31 dated 04/10/25 revealed the resident had one to two falls in the past three months and was at risk for falls. Review of the fall care plan for Resident #31 dated 06/04/25 revealed the resident had a potential for injuries and falls related to a balance deficit and a history of falls. The intervention of adding a fall mat to the right side of the bed was added to the care plan on 07/16/25. Review of the interdisciplinary team (IDT) progress note for Resident #31 dated 07/11/25 at 3:39 P.M. revealed the resident fell on [DATE] while attempting to reposition himself in his bed and rolled out of bed. An intervention was to add a fall mat to the right side of the bed. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 07/15/25 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #31 revealed an order dated 07/16/25 for a fall mat to the right side of the bed at all times when the resident was in bed. Observation on 08/05/25 at 11:31 A.M. of Resident #31 revealed the resident was lying in bed and did not have a fall mat next to his bed. Interview on 08/05/25 at 11:31 A.M. with Certified Nursing Assistant (CNA) #213 verified Resident #31 was lying in bed and the resident's fall mat was not in place. Observation on 08/06/25 at 11:26 A.M. of Resident #31 revealed the resident was lying in bed and did not have a fall mat next to his bed. Interview on 08/06/25 at 11:26 A.M with CNA #212 verified Resident #31 was lying in bed and the resident's fall mat was not in place. Interview on 08/06/25 at 11:28 A.M. with Licensed Practical Nurse (LPN) #228 confirmed Resident #31's care plan indicated the resident was to have a fall mat to the side of his bed. LPN #228 verified Resident #31's fall mat was not in place while Resident #31 was lying in bed. Review of the facility policy titled Managing Falls and Falls Risk undated revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to minimize complications from falling. This deficiency represents noncompliance investigated under Complaint Number OH00167474 (iQIES 1339329).

Based on observation and staff interview, the facility failed to ensure insulin pens were properly labeled and dated upon opening. This affected three (Residents #4, #38, #51) and had the potential to affect 11 facility-identified residents with orders for insulin. The facility census was 48 residents.Findings include: Observation on [DATE] at 4:16 P.M of medication cart #3 revealed it contained an unlabeled insulin pen with as an open date of [DATE]. Interview on [DATE] at 4:17 P.M with Assistant Director of Nursing (ADON) #235 confirmed there was an unlabeled insulin pen with an open date of [DATE] in medication cart #3. Observation on [DATE] at 4:25 P.M of medication cart #2 revealed it contained an open Lantus insulin pen for Resident #4 without an open date, an open Humalog insulin pen for Resident #51 with an open date of [DATE], a Lantus insulin pen for Resident #38 without an open date. Interview on [DATE] at 4:30 P.M with ADON #235 confirmed medication cart #2 contained Resident #4's open and undated Lantus insulin pen, Resident #51's open and expired Humalog insulin pen, and Resident #38's open and undated Lantus insulin pen. Review of facility policy titled Administering Medications dated on [DATE] revealed multi-dose medications are to be labeled with an open date and insulin pens are to be labeled with the corresponding residents' name.

Based on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and safe environment. This affected 36 residents (#01, #02, #03, #04, #05, #06, #078#08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, and #37). The facility census was 45. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses of thoracic spinal fracture with paraplegia, protein-calorie malnutrition and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #24 had no cognitive impairment. Observation during the initial tour on 01/30/25 from 5:30 P.M. to 6:15 P.M., revealed the following: 1) Resident #24's room had dirty linen spread all over the floor; the walls had large areas that needed patched, sanded and painted; the floor tile in the area in front of the closet was stained/dirty with a dark, sticky substance; there was a wall shelf that had been removed from the wall and was leaning in the corner near the large closet; and the small closet had no cove base around the entire area of the closet. 2) The main corridor had five light fixtures just above the floor level without covers which exposed the bulb/bulb socket and wiring. 3) The main corridor handrails did not contain endcaps. Interview with Resident #24 on 01/30/25 at 5:35 P.M., revealed she did not like how her room looked, especially the walls, the floor and the small closet. Interview with the Administrator and Maintenance Director #200 on 01/31/25 at 1:15 P.M. verified the condition of the walls, floor tile, wall shelf and cove base in the room of Resident #24; the five exposed corridor light sockets and the missing handrail end caps. Review of facility policy titled Quality of Life - Homelike Environment, revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00162166.

Based on observation and staff interview, the facility failed to ensure the facility's dishwasher was maintained in a manner to prevent foodborne illness. This affected 46 residents out of 46 residents that resided at the facility as the facility identified all residents received food from the kitchen. The facility census was 46. Findings include: Observation of the facility's kitchen on 01/08/25 at 12:17 P.M., revealed the facility's dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. Dietary Manager (DM) #502 was observed testing the chemical in the dishwasher and the dishwasher tested at zero parts per million (ppm). Interview with Dietary Manager (DM) #502 on 01/08/25 at 12:17 P.M., verified the dishwasher was 120 degrees Fahrenheit for the wash and rinse. DM #502 confirmed the dishwasher was a low temperature dishwasher and required chemical to sanitize dishes. DM #502 verified the dishwasher was running at zero ppm for chemical sanitizer This deficiency represents non-compliance investigated under Complaint Number OH00161042.

Based on record review, and staff interview, the facility failed notify the state mental health authority with a significant change Pre-Admission Screening And Resident Review (PASARR) for a resident with a change in their mental health condition. This affected two (#19 and #46) of three residents reviewed for significant change PASARR. The facility census was 46. Findings include: 1. Review of Resident #19's medical record revealed Resident #19 admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's PASARR dated 09/13/23, revealed Resident #19 had no diagnoses of mental disorders. Resident #19 had a diagnosis of opioid dependence. Resident #19 did not have indications of serious mental illness. Review of Resident #19's psychiatric note dated 09/19/23, revealed Resident #19 had a diagnosis of adjustment disorder. Review of Resident #19's record from 09/19/23 to 01/09/25, revealed Resident #19 did not have a significant change PASARR or notification to the state mental health authority of Resident #19's new diagnosis of adjustment disorder on 09/19/23. Review of Resident 19's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Interview with Social Services Director (SSD) #500 on 01/09/25 at 2:22 P.M., revealed Resident #19 received a new diagnosis of adjustment disorder on 09/19/23 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #19's new diagnosis of adjustment disorder on 09/19/23. 2. Review of Resident #46's medical record revealed Resident #46 admitted to the facility on [DATE] with diagnoses including respiratory disorders in diseases classified elsewhere, insomnia, chronic obstructive pulmonary disease, carpal tunnel syndrome, pneumonia, other ventricular tachycardia and hypertension. Review of Resident #46's PASARR dated 12/13/22, revealed Resident #46 had no diagnoses of mental disorders. Resident #46 had a diagnosis of alcohol abuse with withdrawal. Resident #46 did not have indications of serious mental illness. Review of Resident #46's psychiatric note dated 06/02/23, revealed Resident #46 had a diagnosis of depression. Review of Resident #46's chart from 06/02/24 to 01/09/25, revealed Resident #46 did not have a significant change PASARR or notification to the state mental health authority of Resident #46's new diagnosis of depression on 06/02/23. Review of Resident 46's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. Interview with SSD #500 on 01/09/25 at 2:22 P.M., revealed Resident #46 received a new diagnosis of depression on 06/02/23 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #46's new diagnosis of depression on 06/02/23. Review of the facility's PASRR policy dated 04/01/23 revealed the facility should follow regulations set forth by the Ohio Department of Medicaid (ODH) for PASARR. This deficiency represents non-compliance investigated under Complaint Number OH00161042.

Based on medical record review, interview with staff and the resident's representative, review of hospital records, review of information from MapQuest, review of a weather report, and review of a facility policy, the facility failed to assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors and level of supervision for newly admitted Resident #12, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 02/07/22 at 7:56 P.M., Resident #12 exited the facility, without staff knowledge, was found by police and taken to the hospital for evaluation. Resident #12 left the facility, walked approximately one mile, and was found wandering near a hospital. Staff were unaware Resident #12 was gone until the resident's representative called the facility to inform them the resident was at the hospital. Additionally, the facility also failed to investigate Resident #12's elopement to prevent the same action, situation, and/or practice from occurring in the future. This affected one (#12) of three residents reviewed for elopements. The facility census was 50. On 02/23/22 at 1:36 P.M., the Administrator was notified Immediate Jeopardy began on 02/07/22 at 7:56 P.M. when Resident #12 eloped from the facility without staff knowledge and was hospitalized due to hypothermia and altered mental status. Resident #12 was found by police wandering outside near the hospital and police brought him into the hospital for evaluation. Resident #12 was confused and was not able to explain how he got to the hospital or that he resided at the facility. Resident #12 was shivering with a body temperature of 93.2 degrees Fahrenheit (F). The temperature in the area on 02/07/22 in the evening was approximately 27 degrees F with a wind chill of 19 degrees F. Upon Resident #12's admission, the facility did not conduct a formal assessment or develop a care plan regarding the resident's cognitive status or his risk for wandering, exit seeking or elopement risk, and the facility staff were not aware he eloped from the facility. The facility also failed to investigate Resident #12's elopement to determine how the resident left the facility without staff knowledge. The Immediate Jeopardy was removed on 02/24/22 when the facility implemented the following corrective actions: · On 02/23/22, Assistant Director of Nursing (ADON) #150 and Assistant Regional Director of Clinical Operations (ARDCO) #175 audited all residents for completion of elopement risk assessment. ADON #150 and ARDCO #175 completed elopement risk assessments for residents without a current elopement risk assessment in their record by 02/23/22. · On 02/23/22, ADON #150 and ARDCO #175 audited all residents' medical records who were determined to be at risk for elopement to ensure the resident's care plan was updated regarding elopement risk factors and interventions to prevent elopement. Resident care plans were updated as appropriate. · On 02/23/22, Social Service Designee (SSD) #200 audited all residents' medical records to ensure they had a Brief Interview of Mental Status (BIMS) cognitive assessment and Section E of the Minimum Data Set (MDS) assessment related to behavior completed. SSD #200 completed a BIMS and Section E for residents without a current BIMS or Section E of the MDS in their record by 02/23/22. · On 02/23/22, ADON #150 and Licensed Practical Nurse (LPN) #225 completed education to all licensed nurses regarding the following content: all newly admitted residents and residents readmitted to the facility must have elopement risk assessment upon admission, any resident that exhibits new wandering or exit seeking behaviors must have an updated elopement risk assessment completed. The education was completed on 02/23/22. · On 02/23/22, ADON #150 and LPN #225 completed education to all staff regarding the following content: any staff who witness any resident with wandering or exit seeking behaviors must report to nurse so new elopement risk assessment can be completed. The education was completed on 02/23/22. · Education was completed in person for staff present in the facility by 02/23/22 and via telephone for staff not in the facility. · On 02/23/22, the Administrator completed education with SSD #200 regarding the following content: all new residents must have BIMS completed upon admission and that any resident that exhibits new wandering or exit seeking behavior has a new BIMS completed. · On 02/24/22, the Director of Nursing (DON) or designee began audits of all new admissions to ensure that elopement risk assessment is complete. Audits will be conducted daily for four weeks, then ongoing as needed. · On 02/24/22, the DON or designee began audits of any resident that has new wandering or exit seeking behaviors for completion of updated elopement risk assessment. Audits will be conducted daily for four weeks, then ongoing as needed. · Results of audits to be reviewed at monthly Quality Assurance Performance Improvement (QAPI) meeting to ensure if plan is effective or if additional interventions will need to be added. · Review of current medical records for Residents #02, #03, and #31 revealed the residents' records included a current cognitive and behavioral assessment (Sections C and E) of the MDS, an updated elopement risk assessment, and a care plan for elopement risk when appropriate. · Interviews on 02/24/22 at 11:31 A.M. with SSD #200 and at 4:00 P.M. with LPN #425 confirmed they received education and were knowledgeable regarding the importance of assessing residents' cognitive and behavioral status and completing elopement risk assessments. · Interview on 02/24/22 at 11:28 A.M. with State tested Nursing Assistant (STNA) #400 confirmed they received education to notify the nurse immediately if a resident exhibits new onset of wandering or exit-seeking behaviors. Although the Immediate Jeopardy was removed on 02/24/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include Coronavirus Disease 2019 (COVID-19), [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of the preadmission hospital records for Resident #12 dated 01/20/22 revealed the resident was admitted to the hospital with a chief complaint of confusion when his family went to check on him in his home in the community. Resident #12 was admitted with severe [CONDITION(S)], tested positive for COVID-19, and had acute metabolic [CONDITION(S)] with an unclear etiology. Review of face sheet for Resident #12 revealed Resident's Representative #100 was the resident's power of attorney and was listed as resident's emergency contact. Review of the hospital preadmission diagnosis list provided to the facility for Resident #12 dated 01/25/22 revealed resident's hospital admission diagnoses included COVID-19, [CONDITION(S)], metabolic [CONDITION(S)], and dementia. Review of the care plan for Resident #12 dated 01/28/22 revealed it contained no documentation regarding the resident's cognitive and functional status and did not address the level of supervision needed for resident. Review of the admission nurse progress note for Resident #12 dated 01/28/22 revealed the resident was oriented with impaired cognition and the resident had trouble recalling the original complaint leading to his hospitalization and subsequent placement in this facility. Resident #12 was assessed to have normal active range of motion to his lower extremities. Review of the comprehensive admission MDS assessment dated [DATE] for Resident #12 revealed Section C regarding the resident's cognitive status/BIMS was coded as not assessed and Section E regarding resident's behavioral symptoms to include wandering behaviors was coded as not assessed. Further review of the MDS for Resident #12 revealed resident required limited assistance of one staff with transfers and ambulation and did not use assistive devices with ambulation. Review of the medical record for Resident #12 revealed it did not include an assessment of resident's risk factors for elopement. Review of the nurse progress note for Resident #12 dated 02/06/22 revealed the resident was oriented to person but unable to determine orientation to time and place. Further review of the note revealed Resident #12 exhibited memory loss, impaired decision-making ability, and confusion. Review of the nurse progress note for Resident #12 dated 02/07/22 timed at 9:06 P.M. per the DON revealed the facility received a call from Resident Representative #100 indicating the resident had been picked up and was out of the facility. Review of the nurse progress note for Resident #12 dated 02/07/22 timed at 11:11 P.M. per the DON revealed the facility received notification from Resident Representative #100 that the resident had been taken to the hospital. Review of the MDS assessment for Resident #12 dated 02/07/22 revealed the resident was discharged from the facility to the hospital. The resident was not returning to the facility as the family was seeking alternate placement. Review of the February 2022 Medication Administration Record (MAR) for Resident #12 revealed the resident consumed a nutritional supplement on 02/07/22 at 5:00 P.M. Review of the meal intake records for the facility revealed Resident #12 consumed supper on 02/07/22 at approximately 5:00 P.M. Review of hospital physician note for Resident #12 dated 02/07/22 timed at 7:56 P.M. revealed the resident was found wandering outside near the hospital and was brought in by police. Resident #12 was admitted to the hospital with a diagnosis of altered mental status and hypothermia. Resident #12 had a knot on his right forehead and multiple abrasions on his bilateral arms and elbows and was shivering with a body temperature of 93.2 degrees F. During an interview on 02/22/22 at 11:05 A.M. with the Administrator during the entrance conference, he was asked if there have been any recent resident elopements and the Administrator stated there had not been. Interview on 02/22/22 at 11:40 A.M. with LPN #125 confirmed Resident #12 eloped from the facility on 02/07/22 sometime in the evening and the facility was not aware he was missing. LPN #125 confirmed she was not Resident #12's nurse but Resident Representative #100 called and asked when she had last seen Resident #12. LPN #125 confirmed she had not seen Resident #12 and he was not in his room. LPN #12 confirmed she notified the DON and the local police that Resident #12 was missing, and the facility initiated a search at approximately 8:00 P.M. on 02/07/22. LPN #125 confirmed at approximately 8:30 P.M., the DON notified the staff Resident #12 had been found outside the facility and was taken to the hospital. LPN #125 confirmed the search for Resident #12 was halted and the police were notified of the same. LPN #125 confirmed she was not aware if Resident #12 was at risk for elopement or not. Interview on 02/22/22/at 3:40 P.M. with the Administrator confirmed the facility had not conducted an elopement risk assessment for Resident #12 upon admission nor had the facility conducted a formal investigation regarding Resident #12's elopement from the facility on 02/07/22. The Administrator further confirmed the facility did not consider Resident #12 leaving the facility without facility knowledge to be an elopement although staff were unsure how and exactly when he exited the facility. Interview on 02/23/22 at 8:16 A.M. with Resident Representative #100 confirmed she learned from the hospital that Resident #12 arrived at the hospital at approximately 7:50 P.M. on 02/07/22. Resident Representative #100 confirmed she was told by hospital staff Resident #12 had left the facility without notification, he was confused and was unable to explain how he got to the hospital or that he resided at the facility. Resident Representative #100 confirmed the hospital staff told her Resident #12 was not appropriately dressed for the weather because it was cold and snowing and he was being admitted with hypothermia and altered mental status. Resident Representative #100 confirmed Resident #12 was independent with ambulation, he did not use an assistive device and had exhibited increased confusion since his hospitalization prior to coming to the facility. Resident Representative #100 confirmed she called the facility and spoke to LPN #125 who told her they didn't know Resident #12 was missing but that LPN #125 checked the resident's room, and he was not there. Resident Representative #100 confirmed she called the DON because she was upset and wanted to know how Resident #12 could have exited the facility without the staff's knowledge and the DON said she didn't know. Resident Representative #100 confirmed she called the DON back and told her Resident #12 had been taken to the hospital because she didn't want them to keep searching or notify the police. Resident Representative #100 confirmed Resident #12 is still in the hospital and they are trying to find alternate placement because they do not want the resident to return to the facility. Interview on 02/23/22 at 9:37 A.M. with STNA #250 confirmed she worked night shift on 02/07/22 and she did not care for Resident #12 and wouldn't recognize him if she saw him. STNA #250 stated on 02/07/22 at approximately 6:40 P.M. on her way to work, she saw a disoriented looking man who was not wearing a coat. STNA #250 further stated it was snowy and cold, and this man was walking in the street adjacent to the facility. STNA #250 confirmed when she arrived at the facility, she asked the staff if any residents were missing because she was concerned the wandering man could possibly be a facility resident. STNA #250 confirmed she learned in report no one was missing, and she went to her assignment. STNA #250 stated at approximately 8:00 P.M. on 02/07/22, LPN #125 told her Resident #12 was missing and staff began to search for him. STNA #250 confirmed she went outside back to the street where she had seen the disoriented man, but he was no longer there. STNA #250 confirmed at approximately 8:30 P.M. on 02/07/22, LPN #125 told her they called off the search because Resident #12 had been found somewhere off the facility grounds and had been taken to the hospital for evaluation. STNA #250 confirmed she was not aware if Resident #12 was at risk for elopement or not. Interview on 02/23/22 at 9:54 A.M. with Registered Nurse (RN) #275 confirmed she arrived to work on 02/07/22 at approximately 7:15 P.M. and had not yet had a chance to see Resident #12 when LPN #125 informed her Resident Representative #100 called to check on the resident and LPN #125 found resident was not in his room. RN #275 confirmed the facility initiated a search on 02/07/22 at approximately 8:00 P.M. and did not find Resident #12 in or around the facility. RN #275 confirmed the DON notified the facility staff to halt the search because Resident #12 had been located off the facility grounds and taken to the hospital for evaluation. RN #275 confirmed she was not aware if Resident #12 was at risk for elopement or not. Interview on 02/23/22 at 10:17 A.M. with agency LPN #300 confirmed she worked dayshift on 02/07/22 but she was not Resident #12's nurse. LPN #300 confirmed she remembered Resident #12 was confused and was able to ambulate independently. LPN #300 confirmed she wasn't sure if Resident #12 was at risk for elopement or not. Interview on 02/23/22 at 10:26 A.M. with the DON confirmed she was at the facility during the day on 02/07/22 and Resident #12 consumed his dinner at approximately 5:00 P.M. along with a supplement which was signed off on the MAR. The DON confirmed Resident #12 was independent with ambulation and did not use an assistive device, but she rarely saw him leave his room. The DON confirmed the facility had not conducted an elopement risk assessment and his care plan contained no information regarding his cognitive and functional status. The DON confirmed Resident #12's admission MDS dated [DATE] revealed Section C regarding resident's cognitive status was coded as not assessed and Section E regarding the resident's behavioral symptoms to include wandering behaviors was coded as not assessed. The DON confirmed at approximately 8:00 P.M. on 02/07/22, LPN #125 called to notify her Resident #12 was missing and the facility had initiated the search and notified the police. The DON confirmed she was driving to the facility to assist with the search when Resident Representative #100 called her and was very upset Resident #12 had gotten out of the facility and asked how this could have happened. The DON confirmed she told Resident Representative #100 she wasn't sure because the facility had coded alarms on the doors. The DON confirmed on 02/07/22 at approximately 8:30 P.M. Resident Representative #100 called to tell her Resident #12 had been picked up off the facility grounds and taken to the hospital. The DON confirmed she instructed the staff to call off the search and notify the police of the same because Resident #12 was at the hospital. The DON further confirmed the facility did not consider Resident #12 leaving the facility without facility knowledge to be an elopement although staff were unsure how and exactly when he exited the facility. Review of online map website MapQuest revealed the hospital where Resident #12 was located was one mile from the facility. Further review of the information revealed it would take 23 minutes to walk from the facility to the hospital. Review of the online weather resource at https://world-weather.info/forecast/usa/cincinnati/07-February/ revealed the air temperature was 27 degrees F and the wind chill was 19 degrees F for the evening of 02/07/22 for the city in which the facility was situated. Review of the facility policy titled Elopements dated August 2018 revealed staff should investigate and report all cases of missing residents and staff should promptly report any resident with a history of wandering and would be a danger to themselves who tries to leave the premises or is suspected of being missing without notification to the Charge Nurse or DON. This deficiency substantiates Complaint Number OH 368.

Based on medical record review, review of hospital records, observation, staff interview, review of electronic mail (email) communication, review of the facility medication error log, review of a written statement and review of facility policy, the facility failed to administer resident medications as ordered resulting in significant medication errors. This resulted in Actual Harm when Resident #51 was given another residents medication and the resident was subsequently admitted to the hospital with altered mental status, low blood pressure (which can cause [CONDITION(S)] or dizziness because the brain doesn't receive enough blood) and required intravenous (IV) fluids. Additionally, the facility failed to ensure Resident #21's insulin was available for administration which placed the resident at risk for more than minimal harm. This affected two (#51 and #21) out of three residents reviewed for medication administration. The facility census was 50. Findings include: 1. Review of the medical record for Resident #51 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment in progress for Resident #51 dated 01/11/22 revealed resident was cognitively intact. Review of MDS assessment dated [DATE] for Resident #51 revealed the resident was discharged to hospital with return not anticipated. Review of the nurse progress note for Resident #51 dated 02/05/22 timed at 6:47 P.M. per an agency nurse #9 revealed the resident was given the wrong medication. The physician was notified and gave no new orders but advised staff should continue to monitor the resident. Resident #51 was alert and sleeping. Resident #51's blood pressure dropped to 90/58 millimeters of mercury (mmHg) and pulse was 85 beats per minute. Review of the nurse progress note for Resident #51 dated 02/05/22 timed at 9:47 A.M. per an agency nurse #10 revealed the physician gave an order to send the resident sent to the hospital. The Director of Nursing (DON) was notified. Review of emergency room notes (ER) for Resident #51 dated 02/05/22 timed at 8:57 A.M. revealed the resident arrived at the hospital with altered mental status (AMS) due to being given the wrong medications approximately 12 hours prior to presentation in the ER. A medication list from the other resident is presented which includes the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the facility report the plan after discovery of this medication error was to observe the Resident #51. Resident #51 reportedly began to develop a declining mental status this morning which prompted transfer to ER. At time of evaluation, Resident #51 is alert and has no acute complaint, though she appears somewhat tired or somnolent which could be consistent with an acute intoxication from the administered medications. Review of ER note for Resident #51 dated 02/05/22 timed at 9:43 A.M. revealed the resident's blood pressure dropped to 75/48 mmHg and resident received intravenous (IV) fluids. Resident #51 also had the following diagnostic work completed: blood tests, EKG (electrocardiogram), chest x-ray and consultation with poison control. Review of hospital physician note for Resident #51 dated 02/05/22 timed at 3:41 P.M. revealed the resident was admitted to the hospital with AMS related to facility staff giving the resident a different resident's medications last night which included [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Review of the medication error report for Resident #51 dated 02/05/22 revealed the resident received the wrong medication, and the on-call provider was notified and instructed staff to monitor the resident throughout the shift. Resident #51 slept through the night and the order was given in the morning of 02/05/22 to send the resident to the emergency room for an evaluation. Review of written statement per DON dated 02/05/22 revealed agency nurse #9 reported giving the wrong medication to Resident #51. Physician was notified and gave order to monitor Resident #51. Resident #51's vital signs were monitored, and the resident was sent out to the hospital the next morning for evaluation per physician's order. Review of medication error log dated 01/01/22 through 02/22/22 revealed there were no medication errors. Email communication on 02/22/22 timed at 2:05 P.M. from Assistant Administrator (AA) #375 revealed there were no medication errors 01/01/22 through 02/22/22. Email communication on 02/23/22 timed at 10:45 A.M. from AA #375 revealed the facility had a medication error for Resident #51 which was not listed on the medication error report. AA #375 further confirmed the facility administration learned late in the evening on 02/22/22 from the DON of the medication error involving Resident #51. Interview on 02/24/22 at 4:10 P.M. with AA #375 confirmed the facility did not have an investigation of the medication error resulting in hospitalization for Resident #51. AA #375 confirmed Resident #51 received another resident's medication but was unsure exactly what medications the resident received in error. AA #375 further confirmed the facility had not implemented measures to prevent recurrence. Review of facility policy titled Administering Medications dated April 2019 revealed the individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel. 2. Review of the medical record for Resident #21 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment for Resident #21 revealed the resident was cognitively impaired and required limited assistance of one staff with ADL's. Review of the care plan for Resident #21 dated 10/06/21 revealed resident had a potential for [CONDITION(S)] and [CONDITION(S)] related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included staff would administer insulin/medications per physician orders. Review of the monthly physician orders for Resident #21 revealed an order dated 12/29/21 for [MEDICATION(S)] insulin inject 45 unit subcutaneously in the morning for DM. Observation of medication administration for Resident #21 on 02/22/22 at 8:44 A.M. per Licensed Practical Nurse (LPN) #325 revealed the residents [MEDICATION(S)] insulin was not available for administration. LPN #325 reordered the insulin from the pharmacy. Interview on 02/22/22 at 8:44 A.M. with LPN #325 confirmed Resident #21's [MEDICATION(S)] insulin was not available for administration so she did not deliver the medication. Interview on 02/22/22 at 3:30 P.M. with LPN #325 confirmed Resident #21's [MEDICATION(S)] insulin had arrived from the pharmacy at approximately 12:00 P.M. on 02/22/22 but she did not administer the insulin because it was due at 9:00 A.M. Review of the facility policy titled Administering Medications dated April 2019 revealed medications are administered in accordance with prescriber orders, including any required time frame. This deficiency substantiates Complaint Number OH 984.

Based on medical record review, staff interview, resident interview, review of the fire department incident report, and review of the facility policy for smoking, the facility failed to ensure a resident, who was assessed as an independent smoker and was permitted to keep smoking materials, was appropriately assessed and supervised to ensure the safety of residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries when Resident #05 became agitated because he ran out of cigarettes, and set fire to the bulletin board located in the main hall with a lighter he had in his possession. This affected one (Resident #05) of nine residents reviewed for accidents and supervision and placed the other eight residents (#09, #10, #11, #12, #13, #14, #15, and #16) residing in the main hall, within the smoke compartment where the fire occurred, at risk for the likelihood of serious injury, impairment, or death due to [MEDICAL CONDITION]/or smoke inhalation as a result of the fire. The facility identified 26 other residents (#02, #03, #04, #07, #08, #10, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, and #33) who smoked independently and kept their own smoking materials in their possession. The faciity census was 58. On 09/25/19 at 2:58 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #100 were notified Immediate Jeopardy began on 09/23/19 at approximately 7:45 P.M. when Resident #05 was cursing at Assistant Director of Nursing (ADON) #75 about wanting more cigarettes. Resident #05 was left unsupervised, took his lighter, and set fire to the bulletin board in the main hallway. The fire activated the smoke detector. Staff observed flames and removed Resident #05 from the area of the fire. Staff also closed the door to Resident #16's room, as this resident utilized oxygen and the resident's room was located directly next to the location of the fire. Staff extinguished the fire prior to the arrival of the fire department. Immediate jeopardy was removed on 09/25/19 at 7:00 P.M. when the facility implemented the following corrective actions: · On 09/23/19 at 7:50 P.M., ADON #75 extinguished the bulletin board fire on the wall next to room [ROOM NUMBER]. Resident #05 was placed on one-to-one (1:1) supervision. · On 09/23/19 at 7:53 P.M., the fire department arrived at the facility to assess the situation. · On 09/23/19 at approximately 8:30 P.M., the police arrived at the facility. · On 09/23/19 at approximately 9:50 P.M., the police arrested Resident #05, charged the resident with Felony One Arson, and transported him to jail. Resident #05 was discharged from the facility. · On 09/25/19 at 4:00 P.M., the DON completed smoking assessments on all current residents (#02, #03, #04, #07, #08, #10, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, and #46) in the facility who smoked. · On 09/25/19 at 4:15 P.M., the Administrator implemented a new smoking policy to include those residents assessed as independent smokers identifying that they may keep their cigars and tobacco, but no resident shall carry any lighting materials. · On 09/25/19 at 5:00 P.M., all residents who smoked were educated and signed the new smoking policy by Social Service Designee (SSD) #88, Housekeeping Director (HD) #115, and Staffing Coordinator (SC) #150. All lighters were removed from the residents possession. No resident was permitted to carry any lighting materials in accordance with the new smoking policy. · On 09/25/19 from 5:10 P.M. to 7:00 P.M., all staff were educated and signed a copy of the new smoking policy for residents and were given access to a lighter if needed by the Administrator, DON, ADON #75, and SC #150. · On 09/25/19 at 5:15 P.M., the Medical Director was notified about the new smoking policy by the DON. · Agency staff will be educated and will sign a copy of the new smoking policy prior to their first day at work by the Administrator, DON, or ADON #75. · All new hired employees will be educated and will sign a copy of the new smoking policy during orientation by Human Resources (HR) #170, the DON, ADON #75, or Medical Records (MR) #210. · On 09/25/19, the Administrator implemented an audit tool to ensure staff monitoring of residents for lighters, and if any resident has a lighter, daily Monday through Friday for two weeks, three times a week for two weeks, and on-going as necessary. · Resident smoking will be discussed during the Quality Assurance Meeting next month (October 2019) and on-going as needed. · Observation on 09/25/19 at 5:54 P.M. revealed residents were smoking safely without lighting materials in their possession. · Interviews on 09/26/19 from 9:30 [NAME]M. to 9:40 [NAME]M. with State tested Nursing Assistant (STNA) #40 and two Licensed Practical Nurses (LPNs) #60 and #62 revealed they were educated and knowledgeable about the new smoking policy. · Interviews on 09/27/19 from 10:57 [NAME]M. to 11:27 [NAME]M. with two STNAs (#42 and #44) revealed they were educated and knowledgeable about the new smoking policy. · Interviews on 09/27/19 from 9:44 [NAME]M. to 11:04 [NAME]M. with five residents (#04, #19, #20, #21, and #22) revealed they were educated and knowledgeable about the new smoking policy. They denied having any lighting materials in their possession. · Observation on 09/27/19 at 10:55 [NAME]M. revealed residents were smoking safely, outside on the smoking patio, under the direct supervision of STNA #42. Although the Immediate Jeopardy was removed on 09/25/19, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, limited assistance was required with personal hygiene, and a wheelchair was utilized for mobility. Verbal behavior symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred one to three days. Further review of the medical record revealed a smoking policy dated 11/14/18 and signed by Resident #05 on 01/14/19. The smoking policy indicated any resident who was assessed as a safe smoker may keep their own cigarettes and get a lighter from the nurse on duty that can be taken to the front porch so they can light their cigarette. The resident must immediately return the lighter to the nurse on duty before returning to their room or going anywhere else within the facility. Review of Resident #05's smoking assessment dated [DATE] revealed Resident #05 was unable to communicate risks associated with smoking and was unable to smoke safely. Resident #05 required supervision to smoke and must request smoking materials from staff. Review of the mental health diagnostic assessment dated [DATE] revealed Resident #05 was referred secondary to facility staff's concerns regarding sexually inappropriate behaviors, mood swings, and memory problems. Resident #05 had a long-standing psychiatric history throughout his adult life with past [DIAGNOSES REDACTED]. Since admission to the facility, Resident #05 had exhibited problematic behaviors including verbally abusive to staff for not giving into his requests, pulling the fire alarm when not receiving the specific care requested, demanding the police be called due to feeling treated inappropriately by other residents, and soliciting sexual activity with other residents in possibly inappropriate ways. Primary mental health [DIAGNOSES REDACTED]. Review of the smoking safety evaluation dated 07/30/19, completed by the DON revealed Resident #05 had intact short and long term memory, no limits with mobility, manual dexterity of grasps/holds, and quick response reflexes. This smoking safety evaluation was not in the medical record but was located by the DON in a stack of papers in a nursing office. Further review of the smoking safety evaluation revealed judgement was not assessed and was left blank on the evaluation. Speech was clear with adequate vision and hearing. Direct observation revealed Resident #05 smoked in designated area, safely lit smoking material, held smoking materials safely, disposed of ashes in ashtray, responded quickly to fallen ashes, did not bring oxygen into smoking area, followed smoking guidelines per policy, was able to call for emergency assistance, and returned smoking materials to storage. Summary of the evaluation revealed Resident #05 was able to smoke unsupervised. Review of a nursing progress note dated 09/23/19 at 7:50 P.M. revealed Resident #05 was spotted near a bulletin board that had smoke and visible flames. Staff immediately pushed the resident away from the area. The fire alarm sounded, and the fire was immediately extinguished. Resident #05 was assessed and without injuries and denied inhaling any smoke. Resident #05 reported he made flames on the bulletin board because he was agitated. The resident was placed on one-to-one supervision. The fire department and police arrived at the facility. Resident #05 was charged with felony arson and taken to jail. Review of the fire department full incident report dated 09/23/19 revealed an alarm was received, and the fire department arrived at the facility on 09/23/19 at 7:53 P.M. A resident (#05) at the nursing home ignited papers on a bulletin board in the hallway. A nurse (ADON #75) on the scene extinguished the fire with an extinguisher. The fire was already extinguished upon arrival to the facility. The building was ventilated to clear the smoke and extinguishing agent. A written confession was obtained from the individual responsible for the fire who was arrested and transported to jail by the police. This was an incendiary fire with one adult arrest. Heat source was a cigarette lighter, material ignited included paper and cellulose. The cause was intentional by an unattended, unsupervised person. Observation on 09/24/19 at 8:46 [NAME]M. revealed a white substance on the carpet in the main hall along the wall extending out approximately 12 inches, in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. Interview on 09/24/19 at 9:14 [NAME]M. with Resident #06 revealed Resident #05 was angry and set the wall on fire last night (09/23/19) and the fire department had to come to the facility. Resident #06 reported the white substance all over the carpet in the hall was from the fire extinguisher. Interview on 09/24/19 at 9:25 [NAME]M. with the Administrator and ADON #75 confirmed there had been a fire at the facility the previous evening. Resident #05 had set the bulletin board on fire. Interview on 09/24/19 at 12:40 P.M. with Resident #07, an alert and oriented resident, reported he was in the hallway when Resident #05 started the fire. Resident #07 reported Resident #05 was mad because he wanted a pack of cigarettes and staff told him he would have to wait until the next day. Resident #05 then told staff he was going to set the place on fire, and he did. Resident #05 said he was going to burn the whole building down. At the time of the interview, Resident #07 was observed with cigarettes and a lighter in his possession. Resident #07 reported residents kept their own smoking materials, and Resident #05 smoked and kept his own lighter. Interview on 09/24/19 at 1:14 P.M. with ADON #75 revealed on 09/23/19 at approximately 8:00 P.M., Resident #05 wanted more cigarettes and was throwing a fit. Resident #05 was an independent smoker, was permitted to keep his own smoking materials, and had already received a full pack of cigarettes earlier in the day around 11:30 [NAME]M. ADON #75 informed Resident #05, he would have to wait and obtain more cigarettes the following day from the Administrator. ADON #75 reported Resident #05 was cursing at her and was following her down the hall as she was going to obtain a snack for the resident to attempt to calm him down. When asked if Resident #05 stated anything about burning the facility down, ADON #75 reported she didn't remember specifics of what Resident #05 said as she tuned him out. ADON #75 reported the next thing she knew, before she reached the end of the hall, an STNA (#40) yelled fire. ADON #75 turned around and flames were going up the bulletin board onto the wall. Resident #05 was seated in his wheelchair next to the bulletin board. ADON #75 asked what happened and Resident #05 replied he set this bit** on fire. ADON #75 immediately removed Resident #05 from the area of the fire, closed the bedroom door next to the fire as there was oxygen in the room, grabbed the fire extinguisher and put out the fire. The smoke alarm was sounding, staff were evacuating residents, nine-one-one (911) was called, and both the fire department and police responded quickly. Resident #05 had his own lighter and refused to hand it over but did give it to the Fire Marshall. The police arrested Resident #05 and took him away. Interview on 09/24/19 at 3:14 P.M. with STNA #40 revealed on 09/23/19 between 7:00 P.M. and 8:00 P.M. she observed smoke and fire by room [ROOM NUMBER]. STNA #40 didn't recall seeing any residents in the hallway but reported the bulletin board and papers were on fire. She reported there was a lot of smoke and fire, it looked like the entire wall was on fire all the way down to the floor. The smoke alarms were going off and ADON #75 came from the opposite end of the hall and extinguished the fire. The fire department responded within a minute. Interview on 09/25/19 at 2:25 P.M. with the DON revealed smoking assessments were to be completed quarterly and had been completed in (MONTH) 2019. Resident #05 was assessed to be an unsupervised smoker. When asked if Resident #05's [DIAGNOSES REDACTED]. Review of facilities undated Resident Smoking Policy, that was in effect at the time of the fire, revealed residents who chose to smoke will be assessed for ability to be an independent smoker by nursing staff. Residents assessed as independent smokers may keep their cigars, tobacco, and lighters on them. This is an incidental finding discovered during the investigation of Complaint Number OH 060.

Based on observation, medical record review, resident and staff interview, and review of facility smoking policies and procedures, the facility failed to implement facility smoking policies and procedures and provide adequate supervision of residents assessed as unsafe to manage smoking materials (cigarettes/lighter/matches) without supervision. This resulted in Immediate Jeopardy for one (Resident #20) resident who was assessed as requiring supervision with smoking and smoking materials of five residents sampled who were identified as smokers by the facility. 24 residents were identified as smokers at the facility. The facility census was 45. On 01/18/13 at 12:45 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified that Immediate Jeopardy began on 01/15/13 at 12:15 A.M. when Licensed Practical Nurse (LPN) #3 observed Resident #20 sitting on her bed in her room lighting articles of clothing with a butane lighter and tossing them onto the floor resulting in a small fire in the center of the room. LPN #3 summoned assistance from LPN #7 and State tested Nurse Aide (STNA) #26 who extinguished the burning clothing, while LPN #3 retrieved the lighter from Resident #20. The Immediate Jeopardy was removed on 01/15/13 at 12:30 A.M. when Resident #20 was placed on constant visual supervision by staff while awaiting transfer to the emergency department of a local hospital for psychological evaluation. Resident #20 was subsequently admitted to the hospital and remained an inpatient as of 01/22/13. There were no other residents identified by the facility as having behaviors of using ignition devices to light items other than cigarettes. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal that is not Immediate Jeopardy) until the deficiency was corrected on 01/22/13 at 12:15 P.M. when the facility implemented the following actions: ? On 01/17/13 at 4:47 P.M., the Administrator and the ADON initiated removal of all lighters/matches from all residents of the facility with their permission and placed the collected lighters in the locked medications carts. Resident rooms were also searched for lighters, with their permission, and any additional lighters placed in the locked medication carts. For those residents who refused to relinquish their lighters or have their room searched, nursing staff initiated 15 minute checks. ? On 01/17/13 the ADON began in-service education of all staff on duty regarding the new policy that no resident of the facility was to have a lighter/matches in their possession. In-service education of staff and the new policy which prohibited residents from carrying lighters/matches on their person continued through 01/19/13. ? On 01/18/13 at 9:18 A.M. a tour of the facility, and designated smoking areas revealed lighters were locked in the nurses medication carts and no residents were observed carrying lighters. ? On 01/18/13 the DON and ADON reconciled each of the 24 resident's smoking assessments and smoking care plans with the smoking supervision list, to ensure that residents were identified correctly as either supervised or unsupervised smokers. ? On 01/18/13 the Administrator conducted an in-service for all residents who smoked at the facility advising them of smoking policy changes including: no resident was to keep a lighter or matches on their person; nurses will keep lighters for lighting resident cigarettes; and rules (consequences) if policy was not followed by residents. The Administrator stated that residents would be kept informed of any additional changes to the smoking policy. ? On 01/18/13 at 12:25 P.M. an interview was conducted with Resident #8 who was smoking on the front porch, a designated smoking area. Resident #8 was identified on the smoking supervision list as an "unsupervised" smoker. Resident #8 was interviewed regarding the facility smoking policy. Resident #8 reported that he did not have a lighter and his cigarette was lit by an STNA. He reported that he did not carry a lighter, and per policy was not supposed to have a lighter. When asked what he would do if a resident asked for a light, or lighter, he stated he would tell them to go talk to the nurse. ? Revision of the formal Smoking Policy was initiated on 01/18/13 with a final version of the Smoking Policy provided on 01/22/13. The Smoking Policy specified that residents deemed a "supervised" smoker, based on their assessment, could not hold their cigarettes or lighter/matches on their person at any time. Residents deemed safe to smoke "unsupervised" are not to keep lighters/matches on their person, but were able to sign out a lighter from nursing staff while smoking and were required to sign the lighter back in with nursing staff after smoking. ? On 01/20/13 the ADON initiated in-service education of all staff related to the final version of the facility smoking policy. As of 01/22/13 at 12:15 P.M., the DON and ADON reported that all staff has been in-serviced regarding the new smoking policy and procedures with the exception of a few staff that are used on an "as needed" basis. The DON reported that those staff will be in-serviced prior to starting their next scheduled shift by the DON or ADON. ? On 01/22/13 STNA's #24 and #30 were interviewed regarding the facility's smoking policy and procedures. Both STNAs were able to communicate the newly implemented smoking policy and procedure as written regarding residents who were designated "supervised" vs. "unsupervised" smokers. ? On 01/22/13 at 9:57 A.M. Resident #16 was interviewed regarding the facility's smoking policy. Resident #16 was designated a "supervised" smoker on the smoking supervision list. Resident #16 reported that residents were not to keep lighters. He stated that he smokes supervised in the smoking room three times a day, and staff lights his cigarette in the smoking room. Resident #16 reported that he does not keep a lighter on his person, or in his room, and does not mind if staff want to check his room. Findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly safe smoking evaluations revealed the resident was assessed as being safe to smoke unsupervised on 08/14/12. The 08/14/12 assessment completed by the DON identified Resident #20 as alert, being able to smoke unsupervised in designated smoking areas, and able to maintain her own smoking materials per facility policy. On 10/16/12 the DON completed a smoking assessment of Resident #20. At this assessment the DON noted the resident refused to participate in the assessment, and the resident was now a supervised smoker, and must request smoking materials from staff. Review of Resident #20's comprehensive plan of care failed to reveal any mention of the level of supervision related to smoking and smoking materials, and the subsequent change from an unsupervised smoker to a supervised smoker on 10/16/12. Review of the Activities of Daily Living (ADL) directives, revised on 11/01/12, for Resident #20 did not include any information for nursing staff related to the level of supervision the resident required with smoking or use of smoking materials. On 01/07/13 the DON completed another smoking assessment of Resident #20. At this assessment the DON specified the resident must be supervised by staff, volunteer, or family members at all times when smoking; the resident must request smoking material from staff; and the resident was informed of the smoking evaluation results. The facility completed a comprehensive assessment of the resident's cognitive and physical functioning on 01/07/13. The comprehensive assessment identified Resident #20 as having short and long term memory problems, having fair recall, with moderately impaired decision making skills. Resident #20 needed the physical assistance of two staff persons for bed mobility, transferring, and toileting, and required the physical assistance of at least one staff person for wheel chair mobility, but also possessed the ability to propel herself. On 01/15/13 at 12:15 A.M., LPN #3 documented in Resident #20's nursing notes that she passed the resident's room and observed on the floor a pile of clothing up in flames. She responded immediately to contain the fire and called on assistance of an STNA close by (STNA #26), and the fire was contained without difficulty. While this was taking place, the resident was in bed with a lighter in her hand attempting to set an undisclosed item on fire. The lighter was quickly removed from the resident with the assistance of the Unit 1 nurse (LPN #7). The resident was advised the room had to be searched for any item that may cause harm and nothing was found at that time. The ADON was notified and directed LPN #3 to transport the resident to the emergency department of a nearby hospital for further evaluation due to the potential for harming herself and others. On 01/15/13 at 12:30 A.M., LPN #3 documented that Resident #20 was on constant watch for any further incident. The resident had transferred herself from bed to the wheelchair, and one to one supervision was ineffective. The resident was unresponsive to staff and was throwing objects while in the wheelchair. Resident #20 was advised she would be transferred to the hospital for further evaluation. On 01/15/13 at 1:00 A.M., LPN #3 noted constant watch of Resident #20 continues, and the resident did not present signs of harm to herself, was being monitored, and refuses vital sign check. Resident #20 left the facility at 1:15 A.M. and was transported to the local hospital. The only reference to smoking on the ADL directive for Resident #20 was a notation dated 01/16/13 by the ADON, at which time she documented Resident #20 would continue as a supervised smoker upon return. There was no documentation on the ADL directive or plan of care prior to 01/16/13 that either had been updated with Resident #20's status of being a "supervised" smoker as of 10/16/12. An interview was conducted with the Administrator and ADON on 01/17/13 at 2:00 P.M. and again at 3:05 P.M. regarding Resident #20 and the incident on 01/15/13, at which time the resident was found lighting articles of clothing on fire. The Administrator reported that at the time of the incident the lighter was taken away from Resident #20 and her room searched, with the resident present. The Administrator and ADON shared the 01/07/13 smoking assessment which specified the resident must be supervised by staff, must request smoking material from staff, and affirmed the assessment was current. The Administrator reported that no other lighter was found in the room, but the resident did have cigarettes in her purse. He was unsure how the resident had the lighter or cigarettes in her possession, or if the cigarettes found were the brand she smoked. The Administrator reported the resident did not have a roommate, the clothing fire was small and did not set off either the smoke detector in the room or the sprinkler, and did not require notification of the local fire department. Observation of Resident #20's room was made on 01/17/13. There was no visible scorching or burns to the floor of the room and no residual smoke odor. During an interview with LPN #3 on 01/18/13 at 8:53 A.M., she stated was walking down the hall on Unit 2 checking on residents, and noted a pile of clothing on the floor in Resident #20's room, noticeably smoking with a little flame. LPN #3 described the pile of clothing being on the floor in the middle of the room between her and the resident. She stated she summoned an STNA (#26) nearby who got something to contain the fire, a blanket, and extinguished the flame. LPN #3 stated the resident was still sitting up in bed with the lighter in hand attempting to light something else, but the lighter was taken from the resident. She stated that it happened fast and was over quickly, that everyone was calm, and did not panic. LPN #3 was then interviewed regarding where the resident got the lighter. She reported the resident was an unsupervised smoker at the time of the incident, and was able to manage her own smoking materials. An interview conducted with LPN #7 on 01/18/13 at 12:30 P.M. revealed a short time after midnight LPN #3 came and got her to come to Resident #20's room. She stated "you could smell smoke when you got to the unit". STNA #26 was with the resident and extinguishing the fire. At that time, the resident still had the lighter and was trying to light an article of what appeared to be clothing, but she was not sure. LPN #7 reported she quickly removed the item and smothered it with a towel. One of the other nursing staff in the room, LPN #3 or STNA #26, removed the lighter from the resident. LPN #7 stated when she saw the fire in the middle of the room it was small. LPN #7 stated she was unsure of the resident's level of supervision regarding smoking and smoking materials as she was not familiar with the resident, and cared primarily for the residents on Unit 1. An interview was conducted with STNA #42 on 01/18/13 at 10:30 A.M. who worked on Unit 2 and was familiar with Resident #20. STNA #42 was questioned as to what she believed was Resident #20 ' s level of supervision for smoking prior to the fire incident on 01/15/13. STNA #42 stated to the best of her knowledge if Resident #20 was outside she could smoke unsupervised, when inside in the smoking room she would be supervised, and that she was able to carry her own cigarettes and lighter. An interview was conducted with Registered Nurse (RN) #17 on 01/22/13 at 2:33 P.M. RN #17, familiar with Resident #20, was queried regarding the resident ' s smoking supervision status prior to the fire incident on 01/15/13 in which Resident #20 was involved. RN #17 communicated the resident should have been designated as a "supervised" smoker prior to 01/15/13, and affirmed the current ADL directive did not reflect the resident ' s correct status until 01/16/13. The resident would have been erroneously viewed as an "unsupervised" smoker prior to the 01/15/13 incident and the 01/16/13 ADL directive update. An interview was conducted with STNA #26 on 01/22/13 at 4:40 P.M. STNA #26 stated she had been on duty and present when the fire was discovered in Resident #20 ' s room. STNA #26 stated she was walking down the Unit 2 hall carrying linens sometime between 12:00 A.M. and 1:00 A.M., on 01/15/13, when LPN #3 alerted her there was a " fire " in Resident #20 ' s room. She observed a pile of what appeared to be burning clothing in the middle of the resident ' s room. STNA #26 reported she took one of the blankets she was carrying and smothered the fire. LPN #3 went to get the nurse on Unit 1, LPN #7, while she stayed with the resident. LPN #3 and LPN #7 then returned to the resident ' s room. STNA #26 communicated the resident was in her bed and had a strange look on her face. She was getting ready to light another piece of clothing/or cloth with a lighter. STNA #26 reported LPN #7 retrieved the item from the resident, and one of the two nurses took the lighter from the resident. STNA #26 stated the entire incident happened very fast. STNA #26 was interviewed regarding what level of smoking supervision Resident #20 required before the 01/15/13 fire incident. She reported the resident was an unsupervised smoker at the time of the incident, and would have been able to keep her cigarettes and lighter. STNA #26 also shared she had never observed or heard of Resident #20 attempting to light clothing or other items on fire, or use a lighter inappropriately prior to the 01/15/13 incident. Review of the facility Smoking Policy, revised 09/26/11, revealed residents deemed unsafe to smoke will not be allowed to hold their own smoking materials at any time, including cigarettes, lighters or matches. In April 2012, the facility Smoking Policy was updated at which time the policy related to the use and carrying of lighters by residents deemed safe to smoke unsupervised was not specified. The April 2012 Smoking Policy did specify residents deemed unsafe to smoke would not be allowed to hold their own smoking materials at any time including cigarettes, lighters, and matches. This deficiency substantiates Complaint Number OH 711.

Based on interviews with residents and staff, Ombudsman interview, record review, review of Self Reported Incidents (SRI) and investigations and review of the facility abuse policy and procedures, the facility failed to ensure residents were free of verbal and mental abuse. This affected one (Resident #40) of 12 sampled residents and one supplemental sampled resident (Former Resident #50) who were upset, hurt and had emotional responses when Registered Nurse (RN) #44 was verbally and physically abusive. Findings include: 1. Closed clinical record review included the Admission Information Document, which stated Resident #50 was admitted on [DATE] with history of suicide attempt in 2009. The Minimum Data Set (MDS) significant change assessment dated [DATE] included Resident #50 had [DIAGNOSES REDACTED]. The MDS further documented the resident had no memory problems, moderate cognitive impairment (required cues and supervision for decisions), periods of restlessness, [MEDICAL CONDITION] and deterioration in cognition, mood and activities of daily living. The MDS revealed the resident communicated with unclear speech, sign, gestures, was rarely or never understood and communication had deteriorated. The MDS further stated Resident #50 was dependent on staff for all activities of daily living. The Core Care Plan dated 04/26/10 for mood, psychosocial and [MEDICAL CONDITION] medications included interventions: determine the resident's expectations regarding health, happiness and life goals; do not criticize or talk down to the resident; praise for attempts to resolve conflicts; and visit regularly to establish a trusting relationship. A SRI dated 04/29/10 identified an allegation/suspicion of emotional/verbal abuse by staff on 04/28/10 at 3:45 P.M. The SRI stated RN#44 was in the resident's room talking to him about getting his treatment done. She had promised to do it earlier, but forgot. She got off duty at 3:00 P.M. She asked the oncoming nurse to do the treatment. The resident became upset and angry at RN #44, who was also trying to give him his medications. RN #44 touched Resident #50 "trying to calm him down" and told him she would do the treatment to calm him down and he just told her to forget it and to get away from him. RN #44 was reported as telling the resident he was "weird" and left the room. State tested Nurse Aide (STNA) #9 was listed as a witness to the incident. The SRI did not include a conclusion. The SRI stated, as a result of the investigation, the facility has done the following: RN #44 will be counseled regarding her communication with Resident #50. During interview on 07/08/10 at 3:00 P.M., STNA #9 stated on 04/28/10 Resident #50 had been asking for his dressing change since the morning and also requested his pain medication scheduled for 1:00 P.M. STNA #9 stated RN #44 told the resident she would get to his dressing and his medications when she was ready. STNA #9 further stated she saw Resident #50 at the nursing station (on 04/28/10 before 3:00 P.M.) requesting his 1:00 P.M. medications: he was angry. At that time, RN #44 told Resident #50 she would have the next nurse change his dressing because she was going home at 3:00 P.M. STNA #9 stated the resident was unhappy because he was not getting the medications or his dressing change. STNA #9 further stated RN #44 grabbed Resident #50 by the upper arm close to his shoulder and shook Resident #50 "three times" stating "listen to me, you listen to me." Resident #50 told RN #44 he was not going to take anything from her again and he left the nursing station, asking RN #44 to leave him alone. RN #44 followed Resident #50 his room and told him she would do the dressing and give him the medication. STNA #9 stated, "Resident #50 warned the nurse off," telling her he did not want anything from her. STNA #9 stated another staff took him outside to smoke and calm him down. When he came back inside, RN #44 approached Resident #50 again and he responded not to bother him. STNA #9 stated RN #44 then called the resident "weird," which made him upset and angry. STNA #9 further stated RN #44 re-approached the resident several times after calling him "weird" and she was told he did not want to take anything from her: he became more angry each time he was approached. RN #44 was interviewed regarding the 04/28/10 incident on 07/09/10 at 7:45 A.M. RN #44 stated she forgot Resident #50's dressing change and 1:00 P.M. medication on 04/28/10. She stated on 04/28/10 at 2:30 P.M., she realized she missed the resident's medication and dressing change and went to speak to the resident. RN #44 stated she told him she was going to let the nurse coming on duty at 3:00 P.M. do his dressing change. The nurse stated Resident #50 got out of bed into his wheelchair and came to the nursing station to ask for his medication. RN #44 stated the resident was angry about his medication and dressing and she put her hand on his shoulder to calm him down. She stated the resident threw her arm off and "they had more words." RN #44 affirmed she called the resident "weird". RN #44 stated she came to work on her next scheduled day, 05/04/10 and on 05/05/10, she had a meeting with the Director of Nursing (DON) who gave her a directive that she was not to give medications, do dressing changes or have any contact with Resident #50. RN #44 affirmed that after this meeting with the DON, she worked on the unit where Resident #50 resided, heard him request pain medication and offered the medication in conflict with the DON's directive to stay away from the resident. RN #44 affirmed Resident #50 became angry and stated he was taking nothing from her. The nurse stated she was suspended two days. During continued interview on 07/09/10 at 7:45 A.M., RN #44 affirmed she shook Resident #50 by the shoulder more than once and continued to interact with him after the resident told her to leave him alone. Interview with the Ombudsman on 07/08/10 at 9:19 A.M. revealed a meeting occurred on 05/14/10 with the Administrator, Resident #50, RN #44, the DON and the Ombudsman. The Ombudsman stated Resident #50 was so upset over the incidents, he cried. On 07/09/10 at 10:30 A.M., the Ombudsman stated Resident #50 cried and stated RN #44 was abusive and he would transfer to another facility because he "just wanted some peace." The Ombudsman further stated that Resident #50 told the Ombudsman that being called "weird" really upset him. Review of the facility's policy on Abuse, Neglect, and Exploitation of Residents revised 03/06/10 revealed all residents have the right to be free from Verbal, Sexual, Physical, and Mental Abuse. 2. Review of May 2010 physician orders [REDACTED]. The MDS assessment dated [DATE] revealed he was without memory problems, had moderate cognitive impairment (required cues and supervision for decisions) and behavior of resisting care (easily redirected). An interdisciplinary progress note dated 05/18/10 by Licensed Practical Nurse (LPN) #25 revealed she was asked to come to the resident unit by RN #44. RN #44 asked LPN #25 if she would give Resident #40 his medications as he was cursing and refusing. LPN #25 stated "No" and told RN #44 she needed to learn how to deal with the residents, and went to interview Resident #40. The note further stated Resident #40 was sitting on the porch smoking and LPN #25 asked him what was wrong. He stated he wanted his medications and the nurse made him wait while he was hurting. He further stated, when he asked for the medication, the nurse blew a [MEDICATION NAME] in his ear. The note further stated that RN #44 affirmed she did blow a [MEDICATION NAME] in the resident's ear as she felt threatened when he yelled at her and got too close. Review of RN #44's written statement regarding the 05/18/10 incident, she stated Resident #40 requested medication and she had an emergency. She returned ten minutes later and the resident re-approached her about pain medication. RN #44 told the resident she needed to take his blood sugar. After the blood specimen was obtained, the resident became "verbally combative" asking for his pain medication. RN #44 further stated, she explained the procedures necessary for avoiding a medication error. The nurse stated the resident "continued his anger tirade" and she asked him to leave the nursing station. He refused and "advanced on me" at which time she used her personal alarm ([MEDICATION NAME]) and he left. She later "allowed" him to come into the nursing station to be given his pain pill and insulin and explained to him not ever to talk to her in such a way again. The resident then refused to take the medications and went outside. During interview on 07/09/10 at 7:45 A.M., RN #44 stated on 05/18/10 Resident #40 asked for his medications and they were late. She further stated she was looking at the chart and he was complaining that she was taking too much time. She stated "he advanced on me" stating "I'm taking my meds." RN #44 stated the resident got in her "personal space, nose to nose" when she blew the [MEDICATION NAME] for staff to respond. RN #44 further stated the resident had no history of hitting anyone. Resident #40 was interviewed incident on 07/08/10 at 10:55 A.M. He stated he told RN #44 his medications were late and she told him to wait and she was getting to them. He said, "I told her, get to them then and she got into my face and blew a [MEDICATION NAME] right in my ear." He stated, "It startled and hurt me." Review of the facility's policy on Abuse, Neglect, and Exploitation of Residents revised 03/06/10 revealed all residents have the right to be free from Verbal, Sexual, Physical, and Mental Abuse. This deficiency substantiated Complaint Control Number OH 492.

Based on observation, record review and interview with staff and residents, the facility failed to ensure residents received necessary care and treatment to alleviate pain in accordance medical and nursing care plans. Resident #42 had unrelieved pain, deterioration in mood and behaviors and was observed with facial grimacing from pain. Resident #17 did not receive pain medications promptly to avoid distress. This affected two (Residents #42 and #17) of six sampled residents with pain. Findings include: 1. Review of Resident #42's significant change MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further documented Resident #42 had no memory problems, moderate cognitive impairment, required extensive staff assistance for transfers, bed mobility, dressing, toilet use and hygiene. The MDS also documented the resident deteriorated in mood (negative statements, persistent anger, health complaints, anxious complaints, sad worried pained expression not easily altered) and behaviors (verbally abusive). The MDS further stated Resident #42 had pain daily with times when the pain was horrible or excruciating, including joint pain, soft tissue pain and "other" pain. The Immediate Needs Care Plan for pain management was reviewed. The care plan included: notify the physician if pain persists despite interventions. Physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. The PRN [MEDICATION NAME] was administered 25 times between 07/01/10 and 07/08/10. The Pain Flow Record for 07/01/10 through 07/08/10 was reviewed. The Pain Flow Record documented the resident's pain assessments dated 07/01/10 through 07/07/10 revealed his pain was "9" on scale of one (very mild pain) to 10 (very severe pain). The form further stated the intensity after the pain medication was unchanged. Review of July 2010 Nurses' Notes did not include notification to the physician of the the residents' unrelieved pain. During interview on 07/07/10 at 8:05 A.M., Resident #42 stated he was in pain and he is always in pain. Observation at that time revealed he had a grimaced facial expression. On 07/11/10, Licensed Practical Nurse (LPN) #25 was interviewed and affirmed the nursing notes and pain flow records demonstrated the resident had persistent unrelieved pain and the physician was not notified in accordance with the care plan and the resident's needs. 2. Record review revealed Resident #17's admission physician orders [REDACTED]. The physician ordered medications to treat the pain: [MEDICATION NAME] (opioid [MEDICATION NAME]) 10 milligrams (mg) as needed (prn) every eight hours; [MEDICATION NAME] (opioid [MEDICATION NAME]) 50 mg every six hours (routine); and [MEDICATION NAME] sulfate (opioid [MEDICATION NAME]) 15 mg every 12 hours (routine). The resident's pain assessment of 04/19/10 revealed his pain was "8" on scale of one (very mild pain) to 10 (very severe pain). The assessment documented that Resident #17 described "very severe pain" was located in the right leg, caused by any movement and relieved by pain medication. The Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no memory loss, moderate cognitive impairment (required cues and supervision for decision making) and daily severe pain. The acute care plan for pain management dated 05/03/10 documented the resident had soft tissue pain of the left lower extremity resulting in complaints of pain daily and times when the pain is horrible or excruciating. Goals included: will be free of pain complaints; will report pain resolved with pain medication or other interventions; and, will report pain less than daily. Nursing interventions included: assess symptoms of pain every shift and as needed; give pain medications promptly to avoid emotional distress; provide quiet environment; offer music and TV; offer back rub and warm blankets. Observation during interview on 07/07/10 at 10:30 A.M. revealed Resident #17 was seated in a wheelchair, which he mobilized himself, and he was not in distress. The resident stated he did not receive his medications as ordered when LPN #64 passed medications. The resident stated he has chronic pain and when he does not receive his medications on time, the pain becomes severe. Review of LPN #64's personnel record revealed an investigation and counseling statement dated 06/16/10. The investigation stated Resident #17 complained to the Administrator and Director of Nursing (DON) about pain medication not administered timely. The record summarized documentation discrepancies in the Resident #17's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #17's MAR indicated [REDACTED]#55, #65: [MEDICATION NAME] sulfate on 06/12/10 at 5:00 P.M.; [MEDICATION NAME] and [MEDICATION NAME] on 06/25/10 at 5:00 P.M., [MEDICATION NAME] on 06/11/10 at 11:00 P.M., 06/17/10 at 5:00 P.M., 06/19/10 at 11:00 P.M., 06/23/10 at 5:00 P.M. and 11:00 P.M., 06/25/10 at 5:00 P.M. and 06/26/10 at 11:00 P.M. This was affirmed during interview with the DON on 07/12/10. The DON further stated, nurses did not give pain medications promptly to avoid emotional distress and did not implement other interventions included in the care plan for pain management. This deficiency substantiated Complaint Control Number OH 869.