Every finding on record at Hanover Healthcare Center

Based on observation, staff interview and resident interview, the facility failed to ensure its laundry machines and dryers were maintained in a working condition causing laundry and linens not to be returned in a timely manner. This had the potential to affect all residents in the facility. The facility census was 116. Review of the medical record for Resident #12, revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to: paraplegia, cellulitis of the left lower limb, non pressure chronic ulcer of the right foot and left foot, type two diabetes mellitus with diabetic neuropathy, depression, anxiety disorder unspecified, adjustment disorder, nicotine dependence, cannabis use, and generalized muscle weakness. The admission minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #12 required set up only with eating and upper body dressing, moderate assistance with bathing and toileting, and supervision with personal hygiene and lower body dressing. Resident 12's care plan initiated 04/21/26 and last revised on 08/08/26 revealed the resident was at risk for potential mood problems and had potential for behavior problem including verbal aggressive statements directed at staff and other residents. Resdient #12 refusal of medication, and needed assistance with Activities of Daily Living related to his paraplegia. Observation on 08/06/26 at 12:48 P.M. of Resident #12's room revealed dirty socks and other pieces of dirty clothes on the floor, including the same pair of dirty underwear near the head of the residents bed, that had been observed the previous day on 08/05/26 by the survey team in the same place. Resident #12 stated sometimes it takes weeks to get my clothes washed and back to me. Interview with alert and oriented residents (#12, #81, #14, and #71) during the survey revealed they had problems getting clean linens and their personal clothes items from the laundry in a timely manner, Observation on 08/06/26 at 1:45 P.M. with the Director of Housekeeping Services #5 revealed of the Laundry Dryer Room revealed four large dryers. Of the four dryers, dryer #1 worked as designed, dryer #2, worked part of the time, dryer #3 had not worked in years, and dryer #4 was not working and the facility was reportedly waiting for parts to be repaired. Observation of the room that contained the facility washers revealed he facility only had two of the four washers that were operational, washer #4 was reported to not have worked in years, washer #3 was reported to not work and the staff were waiting for the washer to be repaired at an uncertain time. The only working washers were washer #2 a washer that handled 135-pound loads and the smaller washer #1 which was designed to handle 95-pound loads. Interview on 08/06/26 at 1:30 P.M. with the Director of Housekeeping #5 revealed the housekeeping staff has been doing its best to keep up with the resident's linens and laundry but the laundry room has multiple broken machines that has slowed down the laundry process, despite having more staff working on trying to keep up with the laundry. Policy titled Resident/Patient Room Cleaning revised 02/01/25 revealed rooms are regularly cleaned and disinfected. This deficiency represents non-compliance investigated under Complaint Number 3108498 and 3105874.

Based on observation, resident and staff interviews, the facility failed to ensure a comfortable, homelike environment with comfortable sound levels and a facility that wasin good repair. This effected 30 residents, (#50, #53, #94, #35, #37, #115, #92, #28, #21, #65, #110, #39, #73, #18, #20, #104, #90, #7, #54, #56, #15, #52, #17, #61, #16, #26, #12, #81, #62, and #43). The facility census was 116. Findings include: Interview on 08/05/26 at 10:13 A.M. with Certified Nursing assistant (CNA) #212 revealed the over head paging frustrates the residents. It is not homelike. Some days the paging may only go off once, other days it is several times in the hour. Interview on 08/05/26 at 1:30 P.M. with Resident #81revealed the overhead paging goes on all day long. It is annoying. Even if you have your room door shut, it's so loud. It interferes with daily life, the noise is annoying, it keeps you up if you're trying to sleep. At home you don't have announcements blaring all day. They (the facility) don't care. Interview on 08/05/26 at 12:40 P.M. with Resident #12 revealed overhead announcements are all day long, and at night, it feels constant. The overhead announcements are so loud. It's annoying, and it takes so long for them to turn the announcement off. You can't relax without it going off at some point. What is going on that there is constantly announcement about doors? Observation on 08/06/26 revealed the overhead paging system announced six separate announcements between 8:00 A.M. and 12:00 P.M related to checking doors. Interview on 08/10/26 at 10:18 P.M. with Resident #43 revealed he hates the overhead announcements. The resident stated sometimes the alarms go off at strange hours, and it will wake you up. He also stated he would like to know what they are for, it worries you a little, is something wrong, why hasn't it been turned off yet? Resident #43 stated at this point he has the alarms memorize the Resident #43 stated please check [NAME] trot fire door. Interview on 08/10/26 at 12:27 P.M. with Resident #62 revealed the overhead announcements are so loud, it startles you, you cannot even hear you television and stated she would shut her door to block out some of the noise, but she gets a bit claustrophobic, and she feels trapped in or locked in if her room door is shut. Interview on 08/06/26 at 1:11 P.M. with CNA #82 confirmed the facility uses overhead announcements frequently. This does annoy the residents, some more than others, however there are some residents, every time the announcement starts they complain about it. CNA #82 confirmed overhead announcements are not a comfortable homelike environment. Review of the undated facility policy titled Overhead Paging revealed overhead paging announcements made over a loudspeaker/ intercom system that all areas of the facility may hear. It is the policy of this facility or provide resident centered care that meets the psychosocial, physical safety and emotional needs and concerns of the residents. The facility will prohibit the use of unnecessary overhead paging except for matter of urgent public safety or urgent clinical operations. The facility prohibits use of overhead paging systems for routine announcements. Use of overhead paging is permitted for matters of urgent public safety or urgent clinical operations. 2.Interview with alert and oriented residents during the survey revealed Resident #12, #14, and #71 stated they thought the facility was in disrepair and not well kept. Observation of the first and second floor resident rooms and communal spaces on 08/05/26 between 3:40 P.M. and 4:11 P.M. with the Administrator and the Regional Nurse #200 revealed the following findings that were verified in a concurrent interview with the Administrator: The room occupied by Resident #53 had large unpainted white wall plaster repair approximately 20 inches in size. The room occupied by Resident #35 had multiple scraped areas on the door. The room occupied by Resident # 37, had numerous scraped areas on the room door and on the bathroom door. The room occupied by Resident #94 had numerous scraped areas on the bathroom door. The room occupied by Resident #50 had significant gouges in the door to the bathroom that were approximately 1/8 of an inch deep. Observation of the activity/dining room in the memory care unit revealed significant areas of the wall board around the air conditioning unit that were crumbling or gouged. This deficiency represents non-compliance investigated under Complaint Numbers 3108498 and 3105874.

Based on observation, resident interviews, medical record review, and exterminator record reviews, the facility failed to maintain an effective pest control program so the facility was free of pests and maggots were not observed in Resident #93's wound This affected five residents' (Resident #93, #43, #66, #69, and #62.). The census was 116 Findings include:1.Record review revealed Resident #93's admitted to the facility on [DATE] with diagnoses including cellulitis, chronic ulcer of left lower leg (LLE), chronic ulcer of the right lower leg (RLE), heart failure, necrotizing fasciitis, gangrene, open wound of the LLE, open wound of the RLE, mental and behavioral disorder, gout, and hypertension. Review of Resident #93 quarterly minimum data set (MDS) completed 05/18/26, a brief interview for mental status score of 13 indicating intact cognition The resident used a wheelchair and had mobility impairment on one side of the lower extremities. The resident was depending on staff for toileting, refused showering. Bathing required maximal assistance for upper body dressing and personal hygiene, the resident was dependent on staff for putting on and taking off footwear and lower body dressing. The resident was always continent of urine and frequently incontinent of bowel. The resident had a wound infection to the foot. The resident was at risk for pressure ulcers/injuries, the resident had two venous and/or arterial ulcers surgical wounds, pressure reducing device for bed, applications of nonsurgical dressings other than to the feet, and dressing applications other than to the feet. The resident was on an antibiotic.Review of Resident #93 progress note dated 08/01/26 at 4:08 P.M. revealed the resident continued to demonstrate a pattern of refusing wound care, declining scheduled dressing changes on multiple occasions despite repeated education from nursing staff regarding risks of infection, delayed healing, and tissue breakdown associated with non-compliance. During care today [08/01/26], A certified nurses aide (CNA) was performing a bed bath and identified a maggot crawling on and/or around the resident. This finding was immediately reported to the nurse, who assessed the resident and confirmed visible larvae.Interview on 08/05/26 at 9:08 A.M. with CNA #08 confirmed Resident #93 was found to have maggots in his wound. On the day Resident #93 was found to have maggots in his wound, he asked for them to be picked off and refused to go to the hospital. It took a few attempts and different staff for Resident #93 to finally consent to go to the emergency department.2.Interview on 08/10/26 at 10:18 A.M. with Resident #43 revealed he has concerns related to the flies in his room. His mother brought him in a fly swatter [resident then holds up a green fly swatter]. Resident points to one fly flying around the bed, and one fly on the bedside table, and then attempts to smack the fly with the fly swatter. Resident #43 stated there always seems to be a few flies in his room, its frustrating.Observation on 08/10/26 at 10:19 A.M. revealed a fly flying around Resident #43's room. A second fly was observed crawling on the bed next to the resident's pillow.3.Interview on 08/10/26 at 10:51 A.M. with Resident #66 revealed there are several flies everywhere [in his room] and it is annoying, you hear them, see them. He would like to have a fly swatter. 4.Interview on 08/10/26 at 12:08 P.M. with Resident #69 revealed there are a lot of flies in the facility, but they are also all over your room. The flies will buzz around you, and when your food comes, they swarm [the flies], its gross. Resident #69 stated she got flowers delivered and couldn't keep them long because it caused so many gnats in the room. 5.Interview on 08/10/26 at 12:27 P.M with Resident #62 revealed there is a fly problem in the building. It feels like there are thousands of them [flies]. Resident #62 stated she would like a fly strip in her room. Resident #62 stated the flies are all over her, and when meals come, its gross, they're everywhere, you have to swat them away from your food. It is very gross, and bothersome.Interview on 08/10/26 at 11:52 A.M. with CNA #28 confirmed some residents are bothered by the flies in the building; it has gotten worse this summer with the warm weather. CNA #28 confirmed some residents have flyswatters. CNA #28 revealed they are unsure exactly why/ how there is an issue with the flies, but it gets worse at mealtimes with them (flies) flying around the food. Review of Pest control company service record revealed a date of 05/01/26 revealed a pest note problem area of fruit flies.Review of facility policy dated 09/15/21 revealed the facility will be sprayed by pest control of facility choice. To establish a regimented time each month for spraying and eliminate pests in the center. All areas in the center will be sprayed monthly by a duly licensed agent. If a problem is developed, the environmental services director will contact the pest control company for additional visit. Pest control company will report any problems or changes to the environmental services director.This deficiency represents non-compliance investigated under Master Complaint Number 3133997 and Complaint Numbers 3108498 and 3105874.

Based on record review, observation, resident and staff interviews, review of the facility assessment, and facility policy review, the facility failed to provide sufficient nursing staff to provide nursing and related services in accordance with the facility assessment. This affected seven residents, ( #81, #12, #89, #43, #66, #69, and #62) and had the potential to affect all residents residing in the facility. The census was 116. Findings include:Observation on 08/05/26 of the second floor [unit E and H] at 8:45 A.M. revealed one Certified Nursing Assistant for hall E and hall H. Observation revealed twenty-eight residents currently admitted between hall E and H, for one CNA to provide care to.Interview on 08/05/26 at 8:50 A.M. with CNA #212 confirmed they were the only CNA to provide resident care for residents residing on hall E and hall H. CNA #212 confirmed there are approximately 28 residents between the two halls. CNA #212 confirmed there were to be two CNAs for hall E and H per the schedule, but the other scheduled CNA was pulled to do a resident transport.Interview on 08/05/26 at 12:57 P.M. with Resident #12 revealed The staffing is inadequate, there is one aide for unit E and H [second-floor unit, thirty beds]; thirty people and one aide. You [the residents] have to wait sometimes an hour if you need something. Resident #12 stated he misses showers due to staff not being able to get it done, and this does not make him feel good, he doesn't feel clean. Stated he missed at least two showers in July. You will not get your water filled or changed, ice isn't passed, rounds aren't done. You don't get any help unless you press your light, but then it takes so long for someone to respond. Resident #12 stated medications are always late; nighttime is the worst. The residents' medications will come an hour and a half to two hours late. Stating 11:00 P.M. medications are brought at 1:00 A.M .and you're woken up to take them, it's frustrating. The staffing and lack of communication is a major concern for Resident #12 because he stated if it was happening to him, it is happening to other people, and that worries him because those other people may not be able to advocate for themselves, or even be aware of what was happening. Resident #12 stated he has brought up several concerns to the Administrator, and other people but nothing gets done, they just do not seem to care about the issues, you don't even hear an update or get any feedback. Resident #12 stated he feels like he is in prison, it has not been a good experience. Interview on 08/05/26 at 1:30 P.M. with Resident #81 revealed the Administrator does not seem to care about the residents or their problems. The facility is understaffed. The CNAs are severely understaffed; you wait a long period of time for call lights to be answered. Sometimes you just have to come into the hall, you have to go out yourself and find someone. The CNAs can only handle so much, and they have to much on their plate as it is. Management and corporate don't care, they're not the ones working or waiting [they are not the staff working on the floors or the residents who require assistance with Activities of daily living or other care]. Interview on 08/06/26 at 12:20 P.M. with Resident #89 revealed the facility is not sufficiently staffed to meet their needs. Resident #89 stated call lights take a long time to be responded to. Resident #89 stated two to three times a week she waits on the call light for so long, she ends up being incontinent, it is not a good feeling, feeling drenched. It makes you feel bad. Resident #89 stated when she becomes incontinent, she feels gross, then everyone has to clean her, and it takes so long to change her and the bed sheets that she misses out on smoking. Missing out on smoking makes her mad because this is something she looks forward to. Even though you only get two cigarettes it is still something that makes you feel a little normal, and you get to go outside, it is enjoyable, and you have to miss out.Interview on 08/10/26 at 7:22 A.M with certified nurses assistant (CNA) #82 revealed confirmed there is a staffing issue and its affecting the residents and they are the ones who are suffering. The residents are late for their smoke times, they don't get showers, their call lights take forever to be responded to, medications are late, things like this are happening and the residents are frustrated. One task for the CNAs is to take residents outside during smoking times, you can be outside for a good 30-45 minutes, sometimes even an hour depending on how many residents come out to smoke. During this time an aide is pulled off the floor, and the needs of residents are not being met timely. Lunch trays arrive to the floor around 12:50 P.M. Smoking time is at 1:00 P.M., so, you must decide if trays are late or if the smoking time is late, which is not fair to the residents. You don't have enough time to pass ice sometime. Call lights regularly take thirty to forty-five minutes to respond to. The CNAs are running around non-stop trying to get everything done, there just is not enough help. CNA #82 revealed residents' showers are also not being completed as they should, sometimes they get pushed to the next shift, other times they just don't get completed at all. CNA #82 confirmed staff is struggling to provide timely, quality care under the current staffing circumstances.Interview on 08/10/26 at 9:55 A.M. with Dialysis Technician #202 revealed staffing seems to be an issue in the facility. Often residents come late to their scheduled dialysis times. Also, when their treatment is completed, no one is available to come and get them. The dialysis staff will go out to the floor, go down every hall, and every hall and the nurse's station is empty. They will try to call, and no one will answer, no one is available to answer. The residents sit for over an hour in the dialysis room waiting to go back to their room. If the dialysis staff can assist a resident back to their room, the resident sits in the dialysis chair for another hour or more until someone is available to assist them to their personal chair/ wheelchair, or bed, wherever it is they need transferred to. Resident #39 will come to dialysis smelling strongly of urine, not in a way where they may have just had an episode of incontinence but worried they are not receiving required care, [showering, clothing / linen change, timely incontinence care] .Interview on 08/10/26 at 10:18 P.M. with Resident #42 revealed the residents could use more help, the facility needs more staff. Resident #42 stated there is a problem, but what can you do, it is the way it is. Friday [08/07/26] someone [does not want to say who] brought him back from dialysis, he was still in a chair, and they said they would put him to bed when they found help. They [staff member] left the room, didn't give him a call light, he waited and waited for someone to show up, it scared him, he didn't know when/if anyone would come back . Eventually, after about 45 minutes he saw someone walk by the door and yelled for them to help [he yelled for help] due to not having the call button and not being able to reach it. When he is finished with his dialysis treatment there is an issue with communication between the dialysis staff and the facility staff. The dialysis staff will call the nurses' station, and no one answers the phone. It takes a while for someone to bring him back to his room after his treatments are done. Resident #42 stated it takes a while for call lights to be answered, they [CNAs] have other people to take care of, and other things to do, there just is not enough of them . The CNAs are rushed around, they want them to take people to dialysis, to smoke, to go there, and do other things, they are rushed around. Resident #42 revealed getting to dialysis on time is a problem; dialysis expects you to be on time to your appointment and when you're late they get frustrated because that makes the next person late and so on. Resident #42 revealed sometimes your bed bath may be late, or a different day because there is not enough help to get everyone completed. Resident #42 stated smoking times are delayed a lot because the aides are the ones who have to take the residents out, and then that delays other care because they have to be outside with the residents during the entire smoking time. There is to many things to get done, and to many people who need help for the number of aides working at once.Interview on 08/10/26 at 10:51 A.M. with Resident #66 revealed the facility does not provide adequate staffing. This affects the residents and the staff, he stated. Resident #66 stated it is very frustrating when you need help and you cannot help yourself, and then no one is there to help you. Resident #66 revealed its difficult going from being independent to needing help with so many things, he just can not help himself anymore. No one deserves to sit in their own feces; you can tell someone you need to get help, you hope you will receive help in ten, fifteen minutes, even 20 minutes at times, but you can sit with your light on for over an hour and no one will help. All you hear is excuses such as there was a new admission, someone required help and it took a long time, they are understaffed, there is only one aide on the wing/hall etc., it is very frustrating. Resident #66 revealed its extremely difficult for any facility staff to answer dialysis phone calls when he is done with dialysis. Resident #66 stated after his dialysis treatment is completed the dialysis staff will call the nurses station for a facility staff member to come and get him and take him back to his room, but, the floor staff are not timely in answering the phone. Finally, someone may answer the phone, or the dialysis staff will take you to your room but they can not put you back into your bed so he will have to wait in his door way, halfway in the hall way for someone to see him and help him into bed. Resident #66 revealed he has to sit in the door way because if he sits all the way in his room he will be ignored. It is frustrating to be in the dialysis chair waiting to get assistance to bed via mechanical lift for thirty to forty-five minutes, it is ridiculous. Resident #66 revealed what is most concerning and frustrating are when his medications are late. Resident #66 revealed he has nerve pain in his left lower extremity (LLE) due to amputation and diabetic ulcers. If he is in distress and needs pain medication, he does not know how long he will be waiting until someone responds to his light; and even after that it takes even longer for the nurse to get to you with the medication, and you are sitting there in pain. Resident #66 stated when you are in pain it needs addressed soon, it gets worse, and worse, and you keep hurting, and you keep pressing your light. Resident #66 revealed there are also times where your scheduled medications will be late too; you might not get your 8:00 A.M. medications until 11:00 A.M. and that just messed everything up when your 12:00 medications are due, its very worrisome.Interview on 8/10/26 at 12:08 P.M. with Resident #69 revealed she does not feel like she is being treated right in the facility. Resident #69 revealed when you press your call button for assistance it takes a long time for anyone to come, and sometimes no one comes or the staff say they will be back and you don't see them again. Resident #69 revealed she does not know exactly how long she typically waits for her call light to be responded to but she does know it is a very long time; so long that she has been incontinent while waiting for staff. Resident #69 revealed when she has to use the bathroom, she requires help to get out of bed, but several times she has waited so long she is incontinent of stool; this physically and emotionally hurts, she stated. Resident #69 revealed being incontinent hurts her feelings, it is embarrassing. Resident #69 stated it also physically hurts to have to turn over- back and forth- and get cleaned up, it is degrading.Interview on 08/10/26 at 12:27 P.M. with Resident #62 revealed the facility needs more staff working on the floor specifically, more CNAs. Resident #62 revealed the CNAs are constantly having to do other things when there are already not enough working to help the residents; the CNAs must take residents out to smoke and that takes theCNA off of the floor for at least an hour, easily, and the smoke breaks occur multiple times a day. When the CNAs are removed from the floor everything is short, and everything falls behind. The CNAs are made to take residents out during smoking times, and it takes up so much time out of the day. Resident #62 also revealed CNAs are often pulled off the floor and outside of the facility for hours upon hours at a time to accompany residents on transportation to appointments. Resident #62 revealed the CNAs are constantly away from the floor and away from resident's so they are not able to provide timely care. Resident #62 stated they go to dialysis, the treatment gives her anxiety and once over she eagerly anticipates going back to her room but because there is inadequate staff she has had to wait for an hour for someone to come pick her up and take her back to her room from dialysis. Resident #62 stated waiting to go back to her room post-dialysis treatment makes her 'so' anxious. The dialysis staff will call the nurses station over and over and no one will answer the phone. Resident #62 revealed on some occasions [cannot recall exact dates] they have waited an hour for their call light to be responded to and while waiting Resident #62 had an episode of bowel incontinence; this has happened on more than one occasion. Resident #62 revealed being incontinent makes her feel horrible; stating a nursing facility that is supposed help you and provide care, this is not how she expected her care to be.Interview on 08/11/26 at 9:02 A.M. with CNA #8 revealed there is inadequate staffing to meet the needs of the residents. The CNAs are constantly pulled for appointments, smoking times etc. There are several shifts with only one CNA on a hall, its impossible when you have two assist residents or residents who require feeding assistance during mealtimes. Residents are saturated, they don't get ice water passed, trash is left in the room, showers are not getting done. The care is not quality for the residents. One aide is expected to do checks and changes, showers, mechanical lifts, feeding assistance, smoking times, and do it all on your own. Having to get pulled to do resident transport takes an aide off of the floor, and smoking times as well. When you're pulled to transport the rest of the staff will struggle short all day sometimes; and when you are pulled for smoking times it takes up an hour, its taking away from necessary resident care on the floor.Review of REsident #12's shower documentation for the month of July 2024 revealed Resident #12 had no showers or documented refusals on 07/01/26, 07/02/28, 07/03/26 and on 07/15/26, 07/16/26, and 07/17/26. The Resident was on Leave of Absence on 07/04/26 and 07/05/26. Interview on 08/06/26 at 12:30 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence Resident #12 refused or received a bed bath/ shower on the required shower days. Review of Resident #17 shower sheets from 07/01/26 to 08/04/26 revealed the resident received only three documented showers during the time period. The resident given a shower on 07/01/26, 07/02/26, and 7/15/ 26; and refused showers on 07/19/26, 07/26/26, 07/29/26, and 08/02/26. No other showers or refusals were documented. Interview on 08/10/26 at 1:30 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence Resident #17 refused or received a bed bath/ shower on any other required shower days. Review of the facility assessment dated [DATE] revealed based on the facility resident population and their needs for care and support, the facility's approach to staffing is to ensure each of the nursing facility residents has the minimum direct care staff to meet the needs of the residents at any given time. The facility offers in-house dialysis with an onsite dialysis provider that performs dialysis services on Mondays, Wednesdays, and Fridays. Resident populations requiring dialysis receive transportation services to the contracted community dialysis center. Communication from facility to dialysis center occurs with each resident dialysis service pre and post visit. Specific care or practices the facility provides include bathing/ showering, incontinence prevention and care, responding to requests for assistance to the bathroom/ toilet promptly in order to maintain continence and promote resident dignity, administration of medications, and pharmacological management of pain.Review of the undated facility policy titled routine resident care revealed routine resident care is care that is not necessarily medically or clinically based but necessary for quality-of-life promoting dignity and independence, as appropriate. It is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle and preferences. Licensed staff will include the following services based upon their scope of practice, but not limited to administration of medications, bowel and bladder management, and provide routine daily care. Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse; routine care by a nursing assistant includes but is not limited to bathing, toileting, assisting with transfers, or transport to clinic appointments.This deficiency represents non-compliance investigated under Complaint Number 3105874.

Based on record review, staff and resident interview interview the facility failed to ensure two resident (#12 and #17) of four residents reviewed received showers as scheduled.The facility census was 116. Findings include: Review of the medical record for Resident #12, revealed he was admitted to the facility on [DATE] with diagnoses that inlcuded but were not limited to: paraplegia, Ccllulitis of the left lower limb, non pressure chronic ulcer of the right foot and left foot, type two diabetes mellitus with diabetic neuropathy, depression, anxiety disorder unspecified, adjustment disorder, nicotine dependence, cannabis use, and generalized muscle weakness. The admission minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #12 required set up only with eating and upper body dressing, moderate assistance with bathing and toileting, and supervision with personal hygiene and lower body dressing.Resident 12's Care Plan initiated 04/21/26 and last revised on 08/08/26 revealed the resident had a potential for mood problems, potential for behavior problem including verbal aggressive statements directed at staff and other residents, and refused medications. Interventions included medications as ordered, behavioral consults as needed, encourage resident to express feelings, notify physician of any change or increases in mood or behavior, and the resident had a community councilor that he connects with via phone,. The care plan also revealed the Resident #12 had paraplegia and was to be provided assistance with Activities of Daily Living (ADLs)Review of Resident #12's shower sheets for the month of July 2026 revealed the the resident had no shower documentation or refusal of a shower on 07/01/26, 07/02/28, 07/03/26 and on 07/15/26, 07/16/26, and 07/17/26. The Resident was on Leave of Absence on 07/04/26 and 07/05/26.Interview on 08/06/26 at 12:30 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence Resident #12 refused or received a bed bath/ shower on the required shower days. 2. Review of the medical record for the sampled resident , Resident #17, revealed he was admitted to the facility on [DATE]. Resident #17 was admitted with diagnoses that included unspecified dementia with psychotic disturbance, essential hypertension, and major depression.The admission minimum data set (MDS) dated [DATE] revealed a BIMS score of two indicating the resident was severely cognitively impaired. Resident #17 was coded to require moderate assistance with bathing.Review of Resident #17's shower sheets from 07/01/26 to 08/04/26 revealed the resident received only three documented showers during the time period. The resident received a shower on 07/01/26, 07/02/26, and 07/15/ 26; and refused showers on 07/19/26, 07/26/26, 07/29/26, and 08/02/26. No other showers or refusals were documented. Interview on 08/10/26 at 1:30 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence Resident #17 refused or received routine bed bath/ showers as scheduled. This deficiency represents non-compliance investigated under Complaint Number 3105874.

Based on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to ensure one resident, (#12) received medication as ordered. The census was 116.Findings include:Review of Resident #12's record revealed an order dated 07/11/26 for Meropenem (antibiotic) solution reconstituted 1 gram, use 1 gram intravenously (IV) three times a day for bacterial infection for seven days. Review of Resident #12's medication and treatment administration record revealed on 07/11/26 Resident #12's Meropenem was due to be administered at 11:00 P.M., documentation shows the medication as being administered at 2:10 A.M., three hours past the due time.Review of Resident #12's medication and treatment administration record revealed on 07/14/26 Meropenem was due to be administered at 11:00 P.M., documentation shows the medication as being administered at 2:39 A.M., three and a half hours past the due time.Review of Resident #12;s medication and treatment administration record revealed on 07/15/26 Meropenem was due to be administered at 11:00 P.M., documentation shows the medication as being administered at 6:14 A.M., seven hours past the due time.Review of Resident #12's medication and treatment administration record revealed on 07/16/26 Meropenem was due to be administered at 11:00 P.M., documentation in the resident's medical record shows the medication as being administered at 6:37 A.M., seven and a half hours past the due time.Review of Resident #12's medical record including progress notes, medication and treatment administration record, revealed no documented evidence the resident was out of the facility and unable to timely receive their intravenous antibiotic on 07/11/26, 07/14/26, 07/15/26, 07/16/26.Review of Resident #12's medical record revealed no documented evidence of the resident refusing their intravenous antibiotic on 07/11/26, 07/14/26, 07/15/26, 07/16/26.Interview on 08/10/26 at 10:40 A.M. with facility Assistant Director of Nursing (ADON) #24 revealed for medication administration, staff have one hour prior to the due time, or one hour past the due time; if a resident is out of the facility staff is expected to contact the provider for orders to administer the medication upon return.Interview with Resident #12 on 08/05/26 at 12:57 P.M. until 1:30 P.M. revealed medications are always late; nighttime is the worst. Staff will come in an hour and a half, up to two hours late. 11:00 P.M. Medications are brought into the room at 1:00 A.M and you're woken up to take them, it's frustrating.Regional Nurse #200 confirmed via email on 08/10/26 at 4:54 P.M. regarding Resident #12 intravenous antibiotic, the documentation of the IV antibiotic [Meropenem] appears late on the record. There is no documented evidence the resident received the IV medication at the scheduled time.Review of facility policy dated 12/08/25 titled Medication administration revealed the medication administration record is a legal documentation for medication administration. It is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The five rights of medication administration include the right resident, right time, right medication, right dose, right route.This deficiency represents non-compliance investigated under Complaint Number 3105874.

Based on observation, staff interviews and policy review, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 118 out of 119 residents who consumed meals from the facility's kitchen, as one resident (Resident #44) out of 119 residents received nothing by mouth. The census was 119.Findings include:Tour of the kitchen on 03/09/26 from 6:06 A.M. to 6:25 A.M. revealed in the prep area the microwave had dried food inside and the table it sat on was dirty with food crumbs. The shelf underneath had rice Krispies, cheerios, corn flakes, and frosted flakes in containers that were not dated. The reach-in refrigerator had five rusty shelves with shredded cheese not labeled or dated and butter that was in a one sixth hotel pan that was not wrapped properly, labeled or dated. The serving area had grease on the table where the toaster was placed. The plate warmer and pellet warmer had food splatter on them. The steam table had dried food on seven out of ten steam table wells with five lids dirty with dried food and gravy. The dish area had cracked [NAME] floor tiles. The clean area of the drain board of the dish machine had dried food and a salt packet on it. In the cooking area, the slicer had dried meat on it near the blade, the robot coupe had dried food around the base of the machine. There were cracked tiles and a hole in the wall where the food carts were stored. This was verified by [NAME] #575 on 03/11/26 at 6:25 A.M.Observation on 03/10/26 at 10:43 A.M. revealed [NAME] #536 rinsed out the robot coupe in the three-compartment sink without the proper washing and sanitizing process and revealed she only rinses it out.Review of the policy entitled Operation and Sanitation dated 05/20/20 revealed operating instructions and cleaning procedures are developed for all dining services equipment.Review of the closing checklist revealed that all equipment should be cleaned, and all food is wrapped, labeled and dated.This deficiency represents non-compliance investigated under Complaint Number 2746141.

Based on observation, interview, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect six residents (#4, #15, #66, #73, #77, and #104) who were prescribed pureed diets of 118 residents who consumed meals from the facility's kitchen.Findings include:Interview on 03/09/2026 at 8:20 A.M. with Resident #15 revealed the food tastes bad and the texture was not correct and sometimes the pureed food could be consumed through a straw.Observation of puree preparation on 03/10/26 at 10:56 A.M. with [NAME] #536 pureeing pasta revealed [NAME] #536 pureed pasta then put it in a one third hotel pan and stated that she was done with pureeing the pasta. The pasta had chunks of pasta in it. Regional Dietary Manager (RDM) #900 tasted the pureed pasta and verified that the puree pasta had chunks in it. [NAME] #536 had to puree the pasta more.Review of the undated pureed pasta recipe revealed that the pasta should be put in a processor and blend until smooth. Observation of the lunch try line on 03/11/26 from 11:15 A.M. through 12:45 P.M. revealed that the food was on the steam table and tray line started. Observation on 03/11/26 at 11:26 A.M. of the pureed ham revealed that there were dark chunks in it. Dietary Manager (DM) #531 tasted the pureed ham and verified that the puree ham had chunks in it. DM #531 stopped the try line to puree the ham.Review of the undated pureed ham recipe revealed that the ham should be put in a processor and blend until smooth.

Based on medical record review, facility policy review, equipment and resident observations, and resident and staff interviews the facility failed to ensure appropriate respiratory care was provided for Residents #6, #12, #44, and #126. The affected four residents (Residents #6, #12, #44, and #126) of five residents reviewed for respiratory care. The facility census was 125. Findings Include: 1. Review of the medical record for Resident #126 revealed admission to the facility on [DATE] with diagnoses including acute respiratory failure, lung disease, bipolar disorder (a mood disorder leading to periods of depression and mania), depression, anxiety, smoker, diabetes, heart failure, end stage renal disease with hemodialysis, and fibromyalgia (chronic generalized pain). Further review of the medical record for Resident #126 revealed a brief interview for mental status completed on 03/04/26 with a score of 15/15, indicating that Resident #126 was cognitively intact. Review of the medical record for Resident #126 revealed an order provided by the primary care physician (PCP) #651 dated 03/04/26 for Resident #126 to have oxygen at 1-4 liter(L)/min(M) via nasal canula continuously. There were no parameters listed on the order to indicate when to adjust the oxygen flow rate from 1 L/M to 4 L/M. Further review of the medical record for Resident #126 revealed pulse oximeter readings from 03/09/26 through 03/17/26 indicating oxygen levels between 90% to 99% on room air without oxygen use. Interview on 03/17/26 at 11:56 A.M. with the clinical manager, Registered Nurse (RN) #526 confirmed there were no parameters for oxygen adjustment for Resident #126. Interview on 03/17/26 at 11:56 A.M. with RN #526 revealed that the facility does not have standing orders for oxygen parameters to adjust oxygen flow of residents. RN #526 revealed she would use her clinical judgement to adjust the oxygen flow from 1-4 L/M to keep the average resident's oxygen level greater than 92% based on pulse oximeter readings. RN #526 further reported she would adjust oxygen flow for residents with history of chronic lung disease if the oxygen level greater than 90%. RN #526 also admits that staff do not always request parameter clarification orders from the providers. She further revealed that Resident #126 was not always compliant with wearing her ordered oxygen. RN #526 verified that all entries on the pulse oximeter log from 03/09/26 through 03/17/26 indicated that Resident #126 was not wearing oxygen as prescribed and was on room air. Observation and interview on 03/17/26 at 12:11 A.M. with Resident #126 revealed resident had been transferred to a new room on 03/16/26 and now in a private room on the second floor resting in bed without oxygen on. No acute respiratory distress noted. Resident #126 denied shortness of breath at that time. Resident #126 further revealed that she does not always wear her oxygen and only when she feels she needs it. Resident #126 reported that the facility staff do check her oxygen levels with the pulse oximeter frequently. Further observation revealed no oxygen equipment in the room and Resident #126 reported the staff were supposed to be bringing it up to her new room. Continued observation revealed that Resident #126 required assistance of two persons to set on side of bed for lunch meal and transfers. Interview on 03/17/26 at 12:25 P.M. with Licensed Practical Nurse (LPN) #504 revealed Resident #126 had been transferred to new room yesterday. LPN #504 verified that there was no oxygen equipment in Resident #126 room and that it must have gotten left at dialysis yesterday evening. LPN #504 reported she would find oxygen equipment and provide it to Resident #126. LPN #504 reported that she was not aware of any oxygen parameters to determine when to adjust oxygen levels from 1-4 L/M. She continued to report that she would adjust oxygen levels based on nursing assessment of lung sounds and if resident was displaying respiratory distress such as shortness of breath. LPN #504 further reported that she would notify a medical provider if a resident's oxygen level went below 92% but did not recall a specific facility parameter to notify medical providers of low oxygen levels. LPN #504 also indicated that Resident #126 now required the use of a manual lift and staff assistance for transfers and mobility. Review of the facility policy for medical oxygen use undated revealed no guidance related to range orders oxygen flow or parameters for adjusting oxygen liter flow. 2. Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnosis that included obstructive sleep apnea, heart failure, muscle weakness, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was able to understand and be understood, had adequate vision with glasses, was cognitively intact, did not reject care, was dependent on staff for most activities of daily living, and utilized a non-invasive mechanical ventilator (a respiratory support device that uses positive pressure to assist breathing) such as a continuous positive airway pressure (CPAP) machine (a machine used to help treat sleep apnea. Review of the physician orders revealed an order dated 12/09/2025 for a CPAP with a full-face mask every night for obstructive sleep apnea (OSA) and the absence of orders to clean the CPAP machine, face mask, or tubing. Review of the care plan dated 01/07/26 revealed Resident #12 had sleep apnea and required a noninvasive mechanical ventilation at night related to sleep apnea with a goal to verbalize less difficulty breathing. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/01/2026 to 03/16/26 revealed the absence of documentation for cleaning the CPAP machine or checking it was in working order. An interview on 03/09/26 at 8:40 A.M. with Resident #12 revealed she had a broken CPAP machine and that she had reported it multiple weeks prior. An interview on 03/09/26 at 9:15 A.M. with Registered Nurse (RN) #655 verified Resident #12's CPAP was not in working order. An interview on 03/17/26 at 11:57 A.M. with Licensed Practical Nurse (LPN) #526 revealed there was to be a physician order to clean CPAP machines weekly and that cleaning was to be documented on the TAR. LPN #526 verified the absence of a physician order to clean Resident #12's CPAP and the absence of cleaning in the TAR. Review of the undated facility policy titled APaP, BiPaP, CPaP, VPaP, Cleaning and Maintenance, revealed the facility was to provide resident centered care that meets needs of the residents, safety is a primary concern, CPAP's required thorough cleaning, machines were to be cleaned at least once per week, and parts were to be visually inspected for deterioration. 3. Review of Resident #44's medical record revealed admission date 02/27/26 with diagnoses including but not limited to acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy. Review of Resident #44's physician orders revealed an order dated 03/04/26 for tracheostomy care every shift, an order dated 03/12/26 for cool air mist via trach collar every shift with oxygen titrated at 6 liters, and an order dated 03/12/26 at 3:06 P.M. to check level of humidification bottle and refill if needed, every 4 hours. Review of Resident #44's care plan dated 03/06/26 revealed tracheostomy using Shiley (type of tracheostomy) size six extra large with humidified air via trach collar. Observation on 03/12/26 at 2:20 P.M. revealed Resident #44 laying in bed with trach collar in place with oxygen set at six liters, the trach collar tubing was attached to an empty humidifier bottle. Registered Nurse (RN) #526 performed trach care for Resident #44 including suctioning Resident #44's trach several times due to increased phlegm. RN #526 replaced the trach collar which was still attached to the empty humidifier bottle. Interview on 03/12/26 at 2:42 P.M. with RN #526 confirmed Resident #44's humidifier bottle was empty of distilled water. RN #526 stated when there's no humidified air being delivered via a trach collar Resident #44 will have increased phlegm production and the nurses should be monitoring the humidifier bottle for appropriate water level. 4. Review of the medical record for Resident #6 revealed orders dated 06/12/26 to perform trach care every shift and as needed. Review of the medical record for Resident #6 revealed orders dated 06/13/26 to replace inner cannula during trach care every day. Review of the medical record for Resident #6 revealed orders dated 06/25/25 to have the same sized trach (endotracheal tube or ETT) and one sized smaller at bedside at all times. Review of the medical record for Resident #6 revealed orders dated 11/21/25 for the resident to have 5XL cuffed Shiley endotracheal tube (ETT). On 03/10/26 at 8:40 A.M., an observation of Resident #6 room failed to reveal a 5XL cuffed Shiley ETT. There was one 5XL cuffless Shiley noted. There were no smaller ETT in the room. The humidifier for the oxygen was noted to have been changed 02/25/26, 13 days prior. These observations and the resident's physician orders for trach care were confirmed by Licensed Practical Nurse (LPN) #642 on 03/10/26 at 8:55 A.M. On 03/10/26 at 8:45 A.M., an interview with Resident #6 revealed he had a difficult time getting any supplies from the facility. He reported he had to do all of his endotracheal care on his own because he got an infection in the past and he did not think the staff understood how to care for his ETT. On 03/10/26 at 8:55 A.M., an interview with LPN #642 confirmed the resident did not have the needed supplies in his room. She reported they could not get supplies or smaller ETT, and she thought the 5XL Shiley cuffless was what had been ordered, but confirmed the order read for a cuffed 5XL Shiley. LPN #642 also confirmed the humidifier had not been changed since 02/25/26. She reported she could not confirm when the last time had been since she had observed the resident's tracheotomy area or change the dressing. She had educated him about cleanliness, but had not done the ETT care as ordered.

Based on observation, interview, and record review the facility failed to prevent a fall while using a mechanical lift for Resident #123 and failed to ensure smoking interventions were followed for Residents #105 and #127. This affected one resident (Resident #123) of five residents reviewed for falls and affected two residents (Resident #105 and Resident #127) of four residents reviewed for smoking. The facility census was 113.Findings include: 1. Review of the medical record for Resident #123 revealed she was admitted to the facility on [DATE] with diagnoses that included right foot fracture, morbid obesity, back pain, diabetes mellitus type 2, and bipolar disorder. She was discharged from the facility on 07/11/25. Review of the care plan dated 05/03/25 revealed Resident #123 was at risk for falls related to impaired mobility, morbid obesity, and the mechanical lift tipped over interventions included to provide assistive devices as needed. Review of the Fall Risk Observation tool dated 05/20/25 at 6:33 A.M. revealed Resident #123 was at risk for falls and was a total mechanical lift for all transfers. Review of the progress note dated 05/22/25 at 3:10 P.M. revealed the mechanical lift tipped over while Resident #123 was being transferred from the bed to a stretcher for an orthopedic follow-up appointment. Review of the fall investigation dated 05/22/25 at 3:10 P.M. revealed Resident #123 fell to the floor while still connected to the mechanical lift. Review of the witness statement from Certified Nurse Aid (CNA) #612 dated 05/22/25 at 3:10 P.M. revealed that when Resident #123 was transferred with the mechanical lift it lost balance while turning and tipped over, Resident #123 had to be lifted from the floor. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #123 was cognitively intact, did not reject care, required maximal assistance for transfers, and had fallen while admitted to the facility. An interview on 03/16/2026 at 10:59 A.M. with CNA #612 verified that Resident #123 had fallen while being transferred using a mechanical lift. Review of the undated policy titled Mechanical Lift and Transfers revealed the facility would meet the psychosocial, physical, and emotional needs of residents and safety is a primary concern. 2. Review of the medical record for Resident #127 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (lung disease), respiratory failure, heart disease, and amputation of the right hand. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #127 did not have sensory deficits, was cognitively intact, required setup assistance for eating and oral hygiene, and was dependent on staff for dressing, transferring, and bathing. Review of the smoking assessment dated [DATE] at 4:38 P.M. revealed Resident #127 was a supervised smoker that required a smoking apron due to a dexterity problem. An interview on 03/11/26 at 4:00 P.M. with Resident #127 revealed during his last smoking time staff did not provide a smoking apron. An interview on 03/11/26 at 4:38 P.M. with CNA #608 verified she did not put a smoking apron on Resident #127 on that smoking time. Review of the undated smoking policy titled Resident Smoking Guidelines, revealed the facility was to promote resident centered care, a safe smoking area for supervised smokers, and staff were to monitor supervised smokers. 3. Review of Resident #105's medical record revealed admission date 02/07/23 with diagnoses including but not limited dementia, traumatic amputation at right and left elbows with use of prosthesis, Chronic Obstructive Pulmonary Disease (COPD), and nicotine. Review of Resident #105's smoking care plan dated 11/26/25 revealed Resident #105 uses a smoking apron and is a supervised smoker. Review of Resident #105's annual MDS dated [DATE] revealed Resident #105 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 14 out of possible 15 and required assistance from staff for completion of Activities of Daily Living (ADL) tasks. Review of Resident #105's smoking assessment dated [DATE] revealed Resident #105 requires adaptive equipment, one on one supervision, and to wear a smoking apron (a fire-resistant apron used to cover the torso or body and lap to aid in preventing cigarette ashes or dropped cigarettes from igniting clothing). Observation on 03/09/26 at 11:10 A.M. revealed Resident #105 sitting in his wheelchair in the smoking area with CNA #564 passing out cigarettes and assisting resident with lighting of their cigarettes. Resident #105 began smoking his cigarette without having a smoking apron in place, Resident #105 was observed scrapping the cigarette ashes off the end of his cigarette by using his left prosthesis with the ash falling on his lap and upper thighs. Interview on 03/09/26 at 11:25 A.M. with CNA #564 confirmed Resident #105 did not use a smoking apron while he was smoking a cigarette. CNA #564 stated she didn't know of anyone needing to use a smoking apron while smoking. Review of the facility policy titled Resident Smoking Guidelines undated revealed a Smoking Apron is a fire-resistant apron used to cover the torso or body and lap to aid in preventing cigarette ashes or dropped cigarettes from igniting clothing. It is the policy of this facility to promote resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking behaviors either independently or with supervision. This deficiency represents non-compliance investigated under Complaint Number 2746141 and 2726816.

Based on record review, observations, interviews, and facility policy review the facility failed to ensure call lights within reach of residents. This deficient practice affected three residents (Residents #45, #112, and #116) out of three residents reviewed for call light use. The facility census was 113. Findings Include: 1. Review of Resident #112's medical record revealed admission date 11/22/24 with diagnoses including but not limited to dementia, depression and high blood pressure. Review of Resident #112's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #112 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of possible 15 and required limited assistance from staff for completion of Activities of Daily Living (ADL) tasks. Review of Resident #112's care plan dated 12/04/24 revealed Resident #112's primary language was Spanish and Resident #112 had self-care deficit requiring staff assistance related to language barrier and impaired mobility. Observation on 03/09/26 at 9:55 A.M. revealed Resident #112's bed located against the wall and Resident #112 was laying in the bed sleeping. Resident #112's call light was observed attached to the privacy curtain across the room for Resident #112's bed. Interview on 03/09/26 at 10:14 A.M. with Registered Nurse (RN) #576 confirmed Resident #112's call light was attached to the privacy curtain across the room for where Resident #113 was sleeping in bed. 2. Review of Resident #116's medical record revealed admission date 03/05/24 with diagnoses including but not limited Alzheimer's disease, depression, anxiety, and high blood pressure. Review of Resident #116's annual MDS dated [DATE] revealed Resident #116 had impaired cognition with a BIMS score of five out of possible 15 and required staff assistance with ADL tasks. Review of Resident #116's care plan dated 03/06/24 impaired communication related to dementia, functional incontinence of bowel and bladder, and impaired mobility requiring staff assistance. Observation on 03/09/26 at 9:15 A.M. revealed Resident #116 sleeping in bed with no call light in reach. Further observation revealed both call lights were attached to the roommate's bed. Interview on 03/09/26 at 10:14 A.M. with RN #576 confirmed Resident #116's call light was attached to the roommate's bed and not in reach for Resident #116 to use if needed. Review of the facility's policy tilted Resident Rights undated revealed the right to have a method to communicate needs to staff, call light or bell access will be within reach of the resident as one method to communicate needs to staff. 3. On 03/09/26 at 7:30 A.M., an observation of the call light for Resident #45 revealed it was wound up over the call light actuator box near his recliner, and he could not reach it from the bed. His bed controller was on the floor at the foot of the bed, out of his reach. On 03/09/26 at 7:40 A.M., Director of Nursing confirmed Resident #45 could not reach his call light from his bed. He placed the call light within reach.

Based on record review, interview and facility policy review the facility failed to updated Preadmission Screening and Resident Reviews (PASRR) when residents had a change in condition. This deficient practice affected two residents (Resident #10 and #85) out of five residents reviewed for PASRR. The facility's census was 113. Findings Include:1. Review of Resident #10's medical record revealed an admission [DATE] with diagnoses including but not limited to schizoaffective disorder, anxiety, bipolar disorder, and major depressive disorder.Review of Resident #10's physician orders revealed an order dated 04/08/25 for antipsychotic medication Seroquel oral tablet 50 milligram (MG) give one tablet by mouth two times a day for schizoaffective disorder and an order dated 04/08/25 for Depakote oral capsule 125 MG give two capsules by mouth two times a day for bipolar disorder.Review of Resident #10's PASRR dated 05/05/2017 revealed there was no antipsychotic medication marked for Resident #10.Interview on 03/12/26 at 3:39 P.M. with Social Services #557 confirmed Resident #10's PASRR was not updated to reflect the use of antipsychotic medications.2. Review of the medical record for Resident #85 revealed admission [DATE] with diagnoses including but not limited to psychotic disorder with delusions (04/25/25), dementia with psychotic disturbance, major depression disorder (04/25/25) and anxiety.Review of Resident #85's PASRR dated 11/25/25 revealed panic or other Severe Anxiety Disorder was marked as the only diagnosis.Interview on 03/12/26 at 3:50 P.M. with Social Services #557 confirmed Resident #85 did not have an updated PASRR reflecting the diagnoses of psychotic disorder with delusions and major depression disorder.Review of the facility policy titled PASRR - Pre-admission Screening and Resident Review undated PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.

Based on observation, interview, and record review the facility failed to ensure the environment was maintained in a sanitary and working manner. This affected two residents (#12 and #71) out of thirteen residents reviewed for environmental concerns. The facility census was 113. Findings include: 1. An observation on 03/09/26 at 10:44 A.M. revealed areas of grime and dirt on the side rails of Resident #71's bed. An observation on 03/11/26 at 7:32 A.M. revealed the same areas of grime and dirt on the side rails of Resident #71's bed. An observation on 03/11/26 at 11:53 A.M. revealed extensive dried food debris on the legs and post of the bedside table, the same areas of grime and dirt on the side rails, and the bed frame was visibly soiled with a large amount of splatter marks. An interview on 03/11/26 at 12:02 P.M. with Licensed Practical Nurse (LPN) #506 revealed any staff member could clean up messes on the floor, side rails, bedside table, and bed frame. LPN #506 verified the above findings at that time. An interview on 03/11/26 at 2:15 P.M. with the Director of Nursing (DON) revealed housekeeping is responsible for cleaning the residents room, bedside table, and side rail. Review of the facility policy titled Resident/Patient Room Cleaning dated 02/01/25 revealed the facility was committed to providing a clean and hygienic environment for residents in accordance with best practices, rooms would be cleaned regularly with a focus on high use surfaces such as bed rails, and visible soil was to be removed prior to disinfection. 2. On 03/09/26 at 8:48 A.M., an observation of Resident #12's bathroom revealed a sign on the toilet which read DO NOT USE. At the time of the observation, Resident #12 stated the toilet had been broken for several months. She had been told there was a crack or something in it and when it was used it would flood the entire bathroom. She said maintenance had been in several times to fix the issue, but they never seemed to get it corrected. This was confirmed by Registered Nurse (RN) #655 on 03/09/26 at 9:15 A.M. This deficiency represents non-compliance investigated under Complaint Number 2691714.

Based on record review, observations, interviews, and facility policy review the facility failed to maintain infection control by not disposing of used tracheostomy supplies and by not performing hand hygiene during incontinence care. These deficient practices affected two residents (Resident #12 and #44) out of nine residents reviewed for infection control. The facility census was 113.Findings Include: 1. Review of Resident #44's medical record revealed admission date 02/27/26 with diagnoses including but not limited to acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy. Review of Resident #44's physician orders revealed an order dated 03/04/26 for tracheostomy care every shift. Review of Resident #44's care plan dated 03/06/26 revealed tracheostomy using Shiley (type of tracheostomy) size six extra-large with humidified air via trach collar. Review of Resident #44's Treatment Administration Record (TAR dated) 03/04/26 to 03/12/26 revealed the order for trach care was completed as ordered. Observation on 03/12/26 at 2:20 P.M. during trach care for Resident #44 revealed used trach collar with attached tubing laying on the table in the corner of Resident #44's room. There was a white washcloth laying on top of the used trach collar and no barrier underneath to where the used trach collar was laying on the tabletop. Interview on 03/12/26 at 2:40 P.M. with Registered Nurse #526 confirmed the used trach collar and attached tubing was laying on the table without a barrier underneath it between the tabletop and the trach collar. RN #526 stated the nurse must have removed the trach collar and tubing prior to Resident #44 going to dialysis. Review of the facility policy titled Infection Prevention Infection Control undated revealed standard precautions are universally applied in care and treatment of all residents regardless of their known or unknown infectious status. 2. On 03/09/26 at 8:49 A.M., an observation of incontinence care for Resident #12 revealed hand hygiene was not followed throughout the process. Certified Nurse Aide (CNA) #589 cleansed under the resident's panniculus (dense layer of excess subcutaneous fat and skin hanging from the lower abdomen) with gloves on. The area was reddened with chunks of old skin and powder being removed by the CNA. She proceeded to apply barrier cream to the resident and then to clean the resident's perineal area without performing hand hygiene or changing her gloves. She cleaned the resident, rolled her to her side, and with the assistance of CNA #587, she removed the resident from the bedpan. At that time she cleaned the bedpan, washed her hands and changed her gloves. She completed the remainder of the incontinence care including cleaning the resident's gluteal area without further hand hygiene until she had completed the care. On 03/09/26 at 9:10 A.M., an interview with CNA #589 confirmed she only completed hand hygiene one time during incontinence care for Resident #12. She stated she had been educated about hand hygiene but she could not remember when that was. Review of an undated facility policy titled Perineal Care-Male and Female, provided by the Director Nursing (DON), revealed the purpose of the policy was to provide personal care to promote a sense of well being and meet hygiene standards of care. The policy identified completing hand hygiene before applying gloves and beginning care. Hand hygiene would be performed after completing skin care and new gloves applied before completing bed care such as repositioning and cleaning the area. Once all care and clean-up was completed, the staff member should remove gloves and complete hand hygiene. Review of an undated facility policy titled Standard Precautions and Transmission Based Precautions, provided by the DON, revealed gloves were to be changed between clean and dirty tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Hand hygiene was to be performed each time gloves were removed and/or changed.

Based on observation, interview and record review, the facility failed to provide individualized activities of interest to Resident #18. This affected one resident (Resident #18) out of three residents reviewed for activities.Findings include:Review of the medical record for Resident #18 revealed an admission date of 09/15/27 with diagnoses to include Alzheimer's disease, major depressive disorder, and ataxia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severe cognitive impairment and was dependent for activities of daily living. Music and doing things with other people was somewhat important to her and it was very important to do her favorite activities. Review of the activity preference assessment dated [DATE] revealed Resident #18 enjoys talking.Review of Resident #18's care plan dated 01/18/24 with a revision date of 02/06/24 revealed Resident #18 may continue to participate in group and/or 1:1 activity of her choice as tolerated. Review of Resident #18's medical record revealed no evidence the resident participated in 1:1 visits. Review of the activity department 1:1 list revealed Resident #18 was not on the list to have 1:1 visits.Observation and interview on 03/10/26 at 8:58 A.M. revealed Resident #18 was lying in bed with the bed against the wall, and the television (TV) was located on the opposite wall not within the resident's view. Resident #18 revealed activity staff do not visit her in her room.Interview on 03/11/26 at 3:20 P.M. with Activity Director (AD) #588 revealed activities are documented in the electronic chart and there was a one on one (1:1) visit binder. She stated she visits residents for 1:1 visits two to three times a week. AD #588 revealed Resident #18 used to come to BINGO, but the past several weeks she has been staying in bed due to pain. AD #588 revealed activities did not visit her on a 1:1 visit since she was staying in her room. There was no documentation that she was offered activities except for on 02/13/26 for a Valentines Day celebration. Interview on 03/11/26 at 4:35 P.M. with Activity Assistant (AA) #630 revealed she kept her own book of the residents she completes 1:1 visits for. AA #630 verified that Resident #18 was not on her list. Review of the undated facility policy titled, Activities Program, revealed that the facility will provide resident center care that meets the psychological, physical, and emotional needs and concerns of the residents.This deficiency represents non-compliance investigated under Complaint Number 2791091.

Based on medical record review, facility policy review, and staff interviews the facility failed to provide a written baseline care plan to Residents #125 and Residents #126. The affected two residents (Resident #125 and Resident #126) of two residents reviewed for new admissions to facility in less than 14 days. The facility census was 125.Findings Include:1.Review of the medical record of Resident #125 revealed admission to facility on 03/06/26 with diagnoses including aftercare for surgical amputation of the left leg above the knee, heart failure, high blood pressure, end stage renal disease with dialysis, atrial fibrillation (irregular heart rate), lung disease, anxiety, gastric reflux, and delirium (confusion).Further review of the medical record for Resident #125 revealed a brief interview for mental status completed on 03/06/26 with a score of 08/15, indicating that Resident #125 had moderate cognitive impairment (forgetfulness).Observation on 03/17/26 at 10:27 A.M. of Resident #125 revealed Resident #125 smiling and pleasantly confused in no acute distress and denied pain. Review of the medical record for Resident #125 revealed a care conference note dated 03/10/26 at 12:30 PM authored by Licensed Social Worker (LSW) #557 indicating resident #125, daughter of resident #125, speech therapist, an aide, and LSW were present for the care conference. There was a section that reads: Review of Care Plan: Daughter [NAME] here. She shared living will and medical power of attorney documents. Discharge plan is to go home where he lives with daughter. Daughter is eager to see him gain strength through therapy. There was no evidence in the medical record that the baseline care plan was provided in writing to Resident #125 or his daughter within 48 hours.Further review of the medical record revealed a Nursing admission Evaluation-V 13 completed and signed on 03/06/026 by the Director of Nursing (DON). The Nursing admission Evaluation included initial care planning areas needing addressed and immediate interventions established. It was also noted on page 18 or 19 for the care plan signature page to be printed and all signatures be obtained and the page to uploaded to electronic the medical record. Interview on 03/16/26 11:42 A.M. with the Director of Nursing (DON) revealed that the interdisciplinary team (IDT) meets within 72 hours (3 days) of resident admission to facility and discusses the care plan for each new resident. The team includes nursing, dietary, therapy, speech, activities and the social worker. The DON verified that the Nursing admission Evaluation-V 13 includes the baseline care plan embedded within the assessment. The DON also verified that there was to be a signature page printed off and signed and uploaded to the electronic medical record. The DON revealed he was unaware of the regulation of a baseline care plan being completed within 48 hours and a copy being given to the residents/representative. Interview on 03/16/26 at 3:30 P.M. with the DON revealed confirmation that there was no evidence that a care plan was provided to Residents #125 within 48 hours.Review of the facility policy undated and titled Baseline Care Plan/ 48 Hour Care Plan, revealed the baseline care plan will be printed and shared with the resident or resident representative and once all signatures are affixed, the care plan signature page will be uploaded into the electronic medical record.2. Review of the medical record for Resident #126 revealed admission to the facility on [DATE] with diagnoses including acute respiratory failure, lung disease, bipolar disorder (a mood disorder leading to periods of depression and mania), depression, anxiety, smoker, diabetes, heart failure, end stage renal disease with hemodialysis, and fibromyalgia (chronic generalized pain).Further review of the medical record for Resident #126 revealed a brief interview for mental status completed on 03/04/26 with a score of 15/15, indicating that Resident #126 was cognitively intact.Review of the medical record revealed a Nursing admission Evaluation-V 13 started on 03/04/026 and completed and signed on 03/08/26. The Nursing admission Evaluation included initial care planning areas needing addressed and immediate interventions established. It was also noted on page 18 or 19 for the care plan signature page was to be printed and all signatures be obtained and then the page was to be uploaded to electronic the medical record.Interview on 03/16/26 11:42 A.M. with the DON revealed that the interdisciplinary team (IDT) meets within 72 hours (3 days) of resident admission to facility and discusses the care plan for each new resident. The team includes nursing, dietary, therapy, speech, activities and the social worker. The DON verified that the Nursing admission Evaluation-V 13 includes the baseline care plan embedded within the assessment. The DON also verified that there was to be a signature page printed off and signed and uploaded to the electronic medical record. The DON revealed he was unaware of the regulation of a baseline care plan being completed within 48 hours and a copy being given to the residents/representative. Interview on 03/16/26 at 3:30 P.M. with the DON revealed confirmation that there was no evidence that a care plan was provided to Resident #126 within 48 hours.Review of the facility policy undated and titled Baseline Care Plan/ 48 Hour Care Plan, revealed the baseline care plan will be printed and shared with the resident or resident representative and once all signatures are affixed, the care plan signature page will be uploaded into the electronic medical record.

Based on medical record review, facility policy review, review of facility contracts, resident observation and interviews, and staff interview the facility failed to provide appropriate post dialysis evaluations for Residents #55 and #126. This affected two residents (Resident #55 and Resident #126) of two residents reviewed for dialysis care. There were 12 residents receiving dialysis care at the facility and the facility census was 125. Findings Include: 1. Review of the medical record for Resident #126 revealed admission to the facility on [DATE] with diagnoses including acute respiratory failure, lung disease, bipolar disorder (a mood disorder leading to periods of depression and mania), depression, anxiety, smoker, diabetes, heart failure, fibromyalgia (chronic generalized pain), and end stage renal disease with hemodialysis (a life saving treatment for individuals with severe kidney failure when blood is filtered outside of the body to remove waste and excess fluid). Further review of the medical record for Resident #126 revealed a brief interview for mental status completed on 03/04/26 with a score of 15/15, indicating that Resident #126 was cognitively intact. The minimum data set (MDS) comprehensive assessment was not yet completed with all items answered at time of the survey due to recent admission date of 03/04/26. Observation and interview on 03/17/26 at 12:11 A.M. with Resident #126 revealed resident resting in bed in no acute distress. Resident #126 confirmed that she was on dialysis and was receiving treatments downstairs at the dialysis center at the facility. Resident #126 confirmed that she is not always assessed after she returns from dialysis and further confirmed that the facility nurses do not check her vital signs when she has returned from dialysis. Review of the medical record for Resident #126 revealed she had refused dialysis treatments on 03/12/26 and alternate day of 03/13/26. The dialysis center was unable to provide dialysis on site on 03/14/26 and due to Resident #126 having a critical potassium level of 6.2 the dialysis center recommended Resident #126 be sent to the emergency room for emergency dialysis treatment. Resident #126 did receive dialysis treatment at the local emergency department and returned back to the facility the same day on 03/14/26. Further review of the medical record for Resident #126 revealed the treatment administration record (TAR) for 3/14/26 had no post dialysis vital signs or assessment completed. There was a post dialysis assessment completed by the facility on 03/05/26 and 03/07/26. There were no post dialysis assessments documented in the electronic medical record for 03/14/26. There were two communication hand-off sheets from the dialysis center dated 03/07/26 and 03/16/26 scanned into the medical record. Further review of the medical record revealed that the communication hand-off sheet completed on 03/16/26 had three sections: first section was for pre dialysis assessment and vitals signs and weights and area for added notes to be completed by the nursing home nurse, second section was to be completed by the dialysis nurse post treatment with updated vital signs, weights, and any recommendations, and the third section was to be completed by the nursing home nurse with follow up post dialysis vital signs, weight, and assessment findings. The communication hand-off sheet completed on 03/16/26 for Resident #126 did not have anything documented on section three for post dialysis vital signs, weights, or assessment. Interview on 03/17/26 at 9:12 A.M. with Licensed Practical Nurse (LPN) #542 revealed that Resident #126 had been refusing dialysis and ended up having to for emergency dialysis treatment at the hospital on [DATE] but returned the same day. Interview on 03/17/26 at 10:45 A.M. with Assistant Director of Nursing (ADON) revealed she had brought all post dialysis communication forms and assessments for Resident #126 and had no other documents. ADON further reported that their facility only completes post dialysis assessment notes/UDA notes for residents who receive dialysis off site. Interview on 03/17/26 at 12:25 P.M. with LPN #504 revealed that Resident #126 had recently transferred to her unit yesterday 03/16/26. LPN #504 reported that Resident #126 did go to dialysis on site yesterday and returned in the evening. LPN #504 reported that all dialysis residents are to have a pre dialysis assessment of vital signs, weight, site access, bruit/thrill assessment. LPN #504 continued to report that post dialysis residents are to be assessed with vital signs and site access checked. LPN #504 produced the communication hand-off form for Resident #126 dated 03/16/26 and verified that the third section was not completed and that staff document on the TAR any vital signs and assessments completed and not on the communication form. 2. Review of the medical record for Resident #55 revealed they were admitted to the facility on [DATE] with diagnoses that included left femur fracture, end stage renal disease, dependence on renal dialysis, and diabetes mellitus type 2. Review of the five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was able to understand and be understood, had adequate vision with glasses, was cognitively intact, did not reject care, required maximal assistance for most activities of daily living, and received dialysis. Review of the care plan dated 02/13/26 revealed Resident #55 was currently on dialysis therapy with the goal to be free from complications. Interventions included report abnormal findings to the medical provider and nephrologist (kidney doctor), coordinate resident care with the dialysis center, and evaluate the resident following dialysis treatment. Review of the current physician orders revealed the absence of an order for post-dialysis assessment for Resident #55. Review of the progress notes from 02/27/26 to 03/16/26 revealed the absence of post-dialysis assessment documentation. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/28/26 to 03/16/26 revealed the absence of post-dialysis assessment documentation. Review of the dialysis communication sheets from 03/02/26, 03/04/26, 03/06/26, 03/09/26, and 03/11/26 revealed the absence of a resident assessment post-dialysis, only the access site was assessed post treatment. An interview on 03/16/26 at 3:35 P.M. with the DON revealed the facility didn't assess residents' post-dialysis, the facility used the last set of vital signs from the dialysis center located on the dialysis communication sheet. An interview on 03/16/26 at 4:07 P.M. with Licensed Practical Nurse (LPN) #656 revealed the facility didn't assess vital signs on residents' post-dialysis, the facility used the last set of vital signs from the dialysis center on the dialysis communication sheet and only assessed the access site post-dialysis. Review of the undated facility policy titled Hemodialysis Care and Monitoring, revealed the facility was to provide resident centered care, safety was a primary concern, the facility was to collaborate to develop and implement a dialysis care plan, and medication management required evaluation of vital signs before giving medications post-dialysis. The facility was also responsible for completing a post-dialysis evaluation by a nurse when the resident returned from the dialysis center which was to include access site monitoring, pulse in the access limb, blood pressure in the non-access arm, pulse in the non-access limb and respirations. The facility was also responsible for sharing communication with the dialysis center which was to include providing post-dialysis documentation to evaluate the resident's response to treatment and update the care plan accordingly. Review of the facility contract dated 05/05/2022 titled Dialysis Services Agreement revealed the facility was to comply with applicable practice and documentation standards, the dialysis provider was to provide training in monitoring residents post-dialysis, and the facility was to conduct post-dialysis assessments.

Based on record review, observation, interview and facility policy review the facility failed to accommodate a resident with prosthetic arms which required assistive devices for self-feeding. This deficient practice affected one resident (Resident #105) out of one resident reviewed for activities of daily living. The facility census was 113. Findings Include:Review of Resident #105 medical record revealed admission date 02/07/23 with diagnoses including but not limited to dementia, traumatic amputation at right and left elbows, and Chronic Obstructive Pulmonary Disease (COPD).Review of Resident #105's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #105 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 14 out of possible 15 and required staff assistance with setting up for eating.Review of Resident #105's physician orders revealed an order dated 01/15/26 for bilateral upper arm prosthetic device on prior to breakfast and off immediately after dinner meal, as tolerated. Check skin integrity before application and after removal every shift.Review of Resident #105's Occupational Therapy (OT) service notes dated 12/03/25 to 02/06/26 revealed OT discharge recommendations for self-feeding including stand-by-assist by staff and use of a scoop plate.Observation on 03/09/26 from 7:30 A.M. to 8:05 A.M. revealed Resident #105 sitting at the dining room table with bilateral upper arm prosthesis, with bilateral grabber hooks, in place. Breakfast meal was served consisting of French toast and cold cereal with milk, cup of coffee and cup of milk with straws for use by Resident #105. On the bilateral upper arm prosthetics there were red and white colored plastic utensils attached to the prosthesis by loose fitting straps. Resident #105 pushed both plastic utensils up each of the prosthesis, out of the way of the grabber hooks. Resident #105 then bent over the plate of French taste and started eating without using any type utensil, scooping the food up with his mouth. Activities Assistant #605 approached Resident #105's table and encouraged him to use the utensils hanging from the prosthetic arms. Resident #105 continued to scoop food from the plate with his mouth.Observation on 03/10/26 at 7:50 A.M. revealed Resident #105 sitting at the dining room table eating breakfast meal using a regular spoon to eat cold cereal with milk. Resident #105 then put the spoon down, bent over the plate and started eating scrambled eggs by scooping them up with his mouth and not using utensils. Staff did not come over to assist Resident #105 or encourage him to use a fork. Interview on 03/12/26 at 1:15 P.M. with Therapy Director #601 revealed the red and white utensils are to be used when Resident #105 does not have the prosthesis on. Resident #105 prefers to use thin handled utensils and can hold the utensils with the grabber hooks on the prosthesis.Interview on 03/12/26 at 3:05 P.M. with Certified Nursing Assistant (CNA) #564 confirmed Resident #105 does not use utensils to eat with and prefers to scoop the food up with his mouth. CNA #564 stated it appears easier for Resident #105 to not use utensils and just eat the food right off the plate. CNA #564 stated Resident #105 has to be encouraged to use a spoon or fork daily.Reviewed the facility's policy titled Routine Resident Care undated revealed provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse, routine care by a nursing assistant includes but not limited to the following, assisting or provides for personal care, eating and hydration.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment for all residents. This affected three residents (#6, #45, and #85) reviewed for environment. The facility census was 113. Findings include:1. On 03/09/26 at 7:30 A.M., an observation of Resident #45 in bed. Observation of the room revealed disarray and smelled of urine. He had dirty clothes on a chair with clean linen on top. There were soiled underwear in the corner and trash on the floor. His bed controller was on the floor at the foot of the bed, out of his reach. On 03/09/26 at 7:40 A.M., an interview with the Director of Nursing (DON) confirmed the urine smell in Resident #45's room, as well as dirty linens, dirty clothes, trash, and general disarray of the room. 2. On 03/10/26 at 8:40 A.M., an observation of Resident #6's room revealed the sheets at the head of the bed were soiled with dark substance. The medical equipment, which included two suction machines and an oxygen concentrator were splashed with dark substances, and the canister of one of the suction machines had fluid in it. The top of the refrigerator had a layer of dust on it. The inside of the refrigerator had sticky substances covering most of the surfaces of the refrigerator. On 03/10/26 at 8:41 A.M., an interview with Resident #6 revealed most of the time he changed his own sheets if they were changed. He indicated he had asked for his clothing to be washed for over a week and this had not been done. He was down to his last clean shirt and pair of pants (which were visibly soiled), and his dirty clothes were stacked up in his closet. On 03/10/26 at 9:00 A.M., an interview with Licensed Practical Nurse (LPN) #642 verified the observations of Resident #6's room. LPN #642 stated the resident had asked her to get his clothing washed and she had not had a chance to let anyone know. She indicated the certified nurse aides (CNA) changed the resident room linens, and she was not sure who was responsible for making sure the medical equipment was clean. On 03/10/26 at 9:05 A.M., an interview with housekeeper (HK) #571 revealed she had cleaned Resident #6's room about one hour before. She indicated housekeeping cleaned the floors, dusted the surfaces of cabinets, dressers, and refrigerators, and on deep cleaning days, they would change the privacy curtains of the rooms. HK #571 stated CNAs were responsible for changing bed linens, but she was not sure who was supposed to clean the medical equipment. 3. On 03/09/26 at 1:24 P.M., an interview with Resident #85 revealed she had fallen twice in the bathroom a couple weeks ago due to toilet seat not being attached to the toilet. She stated a work order was put in for it to be fixed. She also stated the toilet would not flush and she had to use a plunger every time. In addition, she said the sink leaked onto the floor because the pipe just hung down under the sink. On 03/09/26 at 1:40 P.M., an observation Resident #85's bathroom revealed a toilet with a loose set that slid to the side when pressure was placed on the hand rails over the toilet seat. This was confirmed by DON at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number 2726816 and 2691714.

Based on medical record review and interview, the facility failed to provide sufficient staff to provide restorative nursing programs on a consistent basis. This affected three (Residents #26, #82, and #96) of three residents reviewed for restorative services. The facility identified 41 residents with orders for one or more restorative programs (Residents #1, #2, #3, #4, #6, #7, #11, #15, #18, #24, #26, #32, #34, #37, #41, #42, #43, #48, #51, #56, #61, #67, #68, #69, #70, #73, #75, #79, #81, #82, #86, #87, #90, #91, #92, #93, #94, #95, #96, #98 and #100). Findings include: 1. On 06/18/25 at 11:55 A.M., Resident #26 was observed sitting in a recliner in her room with three daughters visiting. All four individuals were in agreement that Resident #26 did not walk well and they had a fear she would fall. Review of Resident #26's medical record revealed diagnoses including cerebrovascular disease, hypertension, dizziness and giddiness, type two diabetes mellitus, unsteadiness on her feet, lumbar region intervertebral disc degeneration, discogenic back pain, and generalized weakness related to a stroke. A Physical Therapy (PT) Discharge summary dated [DATE] revealed a restorative nursing program had been completed for ambulation with the interdisciplinary team to facilitate Resident #26 maintaining her current level of performance and to prevent decline. A care plan initiated 03/14/25 indicated Resident #26 was on a restorative ambulation program to increase confidence and safety with gait once daily six to seven times per week for 15 minutes per day. Stand by assistance and verbal cues were to be provided with ambulation 125 to 200 feet as tolerated with staff offering encouragement and reassurance. Review of restorative program delivery notes revealed in the prior 30 days, Resident #26 received the ambulation program once on 05/28/25 at which time she was recorded as ambulating 240 feet. A restorative evaluation dated 06/12/25 indicated Resident #26 participated in the restorative ambulation program with a goal to maintain strength and be without decline. The restorative ambulation program was to be continued. On 06/23/25 at 8:54 A.M., Resident #26 stated she used to ambulate with Restorative Aide #265 but she retired and nobody else did the program. On 06/23/25, Certified Nursing Assistant (CNA) #270 verified the restorative aide had retired. CNA #270 stated there was not enough time for aides to provide restorative programs in addition to all the other care residents required. On 06/23/25 at 10:45 A.M., Regional Nurse #275 verified Resident #26's documentation revealed she received the restorative ambulation program once in the past 30 days. Upon investigation, she discovered the ambulation program was entered into the aides' task section to provide the service as necessary instead of six to seven times a week for 15 minutes a day. On 06/23/25 at 12:57 P.M., CNA #280 stated she was unsure which residents were on restorative programs or the type of programs which were to be provided. CNA #280 stated the only way nurse aides would have time to provide restorative programs was if there were always two aides to each hall which did not happen on a consistent basis. 2. Review of Resident #82's medical record revealed diagnoses including hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebrovascular disease, diabetes mellitus, chronic kidney disease, depression, chronic obstructive pulmonary disease, anxiety disorder, low back pain, peripheral vascular disease, and cognitive communication deficit. A plan of care initiated 12/09/24 indicated Resident #82 was on a restorative ambulation program to ambulate 50 to 100 feet with a quad cane with contact guard assistance to minimum assistance to maintain strength in lower extremities once a day for 6-7 days a week. Resident #82 required minimal instruction but staff were to encourage and praise participation. One of the interventions was to reassess quarterly and as needed. Review of restorative ambulation program delivery records revealed the week of 05/25/25 - 05/31/25 the service was offered/provided five times. The week of 06/01/25 - 06/07/25, the service was provided three times. The week of 06/08/25 - 06/14/25, the ambulation program was refused once. There was no other indication of the program being offered. The week of 06/15/25 to 06/21/25, the program was documented with one refusal and no other offers to provide it were documented. Review of a restorative evaluation dated 06/13/25 indicated Resident #82 participated in the program as ordered. The goal was to maintain current ambulation status and be without decline by the next review date. The program would be re-evaluated quarterly and as necessary. On 06/23/25 at 12:36 P.M., the Director of Nursing (DON) acknowledged records did not reflect Resident #82's restorative ambulation program was offered in accordance with orders/plans of care/assessments. 3. Review of Resident #96's medical record revealed diagnoses including hemiplegia (paralysis/weakness of one side of the body) affecting the right dominant side, type two diabetes mellitus with diabetic neuropathy, morbid obesity, need for assistance with personal care, generalized anxiety disorder and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 was cognitively intact with no rejection of care. Resident #96 had impaired functional ROM of both the upper and lower extremity on one side of her body. Review of a care plan initiated 02/27/23 indicated Resident #96 was on a restorative program for active/passive range of motion. Interventions indicated passive range of motion (PROM) (movement of a joint or body part without any effort from the individual) to the right upper extremity in all planes once a day, six to seven days for 15 minutes a day to increase range of motion to the right upper extremity. The care plan indicated Resident #96 required maximal assistance with minimal verbal cues. Interventions included reassessment of the program quarterly and as needed. Review of restorative program delivery records revealed the program was delivered five times the week of 05/25/25 - 05/31/25, four times the week of 06/01/25 and 06/07/25, five times the week of 06/08/25 and 06/14/25, and five times the week of 06/15/25 to 06/21/25. A restorative evaluation dated 06/13/25 indicated Resident #96 participated in the restorative PROM program as ordered. The goal was to maintain current ROM and be without decline. The assessment indicated Resident #96's restorative program would be re-evaluated quarterly and as necessary. On 06/23/25 at 12:36 P.M., the Director of Nursing (DON) verified documentation did not reflect the program was offered a minimum of six times a week in accordance with the order and care plan. The facility identified 41 residents with orders for one or more restorative programs (Residents #1, #2, #3, #4, #6, #7, #11, #15, #18, #24, #26, #32, #34, #37, #41, #42, #43, #48, #51, #56, #61, #67, #68, #69, #70, #73, #75, #79, #81, #82, #86, #87, #90, #91, #92, #93, #94, #95, #96, #98 and #100). This is an incidental finding disovered during the investigation.

Based on observation, medical record reviews, review of facility Self-Reported Incidents (SRI), facility policy review and interview, the facility failed to implement the facility abuse policy related to allegations of physical and emotional abuse by allowing alleged perpetrators continued access to the specified victims and/or other vulnerable residents and failed to timely initiate an investigation regarding the allegations of abuse. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. when Activity Director (AD) #400 witnessed State tested Nursing Assistant (STNA) #300 grab and force Resident #78 to sit in her specialty tilt-in-space wheelchair (a specialty wheelchair that offers both a tilting function and a reclining function and should not be considered an independent mobility device due to their size and weight) while yelling at the resident to sit down. STNA #300 then positioned the tilt-in-space wheelchair with the resident's feet in the air and her head pointing toward the ground. The resident was observed to be tearful and crying out I'm scared of you while attempting to get out of the inverted specialty wheelchair. The resident remained in this position until approximately 3:30 P.M. when Activity Assistant (AA) #301 responded after hearing STNA #300 yelling at the resident. STNA #300 was not immediately removed from the facility and an immediate investigation was not initiated despite reports of the allegation to leadership staff placing residents on the secured dementia unit, including Resident #78 at risk for further abuse. The Immediate Jeopardy and actual physical harm continued on 09/07/24 at approximately 11:00 A.M. when STNA #200 was physically abusive to Resident #71. On 09/07/24 while STNA #200 was assisting Resident #71 into the shower room for her scheduled shower, the resident became agitated. STNA #200 continued the shower despite the resident's reaction. Following the incident, Resident #71 reported to Licensed Practical Nurse (LPN) #102 that STNA #200 forcefully grabbed her, undressed her, and threw her in the shower. Resident #71 also reported the incident to her son who called the facility and reported the allegations to LPN #102, requesting no male staff provide further care to his mother. LPN #102 acknowledged to the resident's son there had been an altercation between the resident and staff; however, the LPN failed to report an allegation of physical abuse to leadership staff. On 09/10/24, Resident #71 was noted to have a 25 centimeter (cm) by 20 cm bruise covering the entirety of her right forearm, one dime size bruise to the right chest, one quarter sized bruise to her right chest, a scabbed area to her right arm, and a bruise to her right inferior upper arm the size of a thumb print. The resident's injuries were consistent with the resident's report of physical abuse, and it was identified the resident had three fractures to her right wrist. STNA #200 was not immediately removed from the facility and an immediate investigation was not initiated despite reports of the allegation to leadership staff placing residents on the secured dementia unit, including Resident #71 at risk. This affected two residents (#78 and #71) of three residents reviewed for abuse. The facility census was 102. On 09/12/24 at 5:44 P.M. the Administrator (also known as the Executive Director or ED), and Regional Director of Clinical Operations (RDCO) #320 were notified Immediate Jeopardy began on 09/05/24 at approximately 3:15 P.M., when AD #400 witnessed STNA #300 grab Resident #78 by the arm and force the resident into her tilt-in- space wheelchair and inverted the chair, so her head was positioned towards the floor and her feet in the air consistent with a situation of physical abuse. The resident was tearful and crying I'm scared of you and attempting to get out of the inverted chair. Although the incident was reported to Human Resource Manager (HRM) #600, the allegation was not immediately investigated and STNA #300 continued to work at the facility, providing care to the residents on the secured dementia unit, including Resident #71. Additionally, on 09/07/24, Resident #71 alleged physical abuse involving STNA #200 when the STNA forced her to take a shower. The resident sustained multiple injuries as a result of the incident and was subsequently diagnosed with fractures to her right wrist consistent with an incident of physical abuse. Although several staff were aware of the incident, the incident was not immediately investigated and STNA #200 continued to work at the facility, providing care to the residents on the secured dementia unit, including Resident #78. The Immediate Jeopardy was removed on 09/16/24 when the facility implemented the following corrective actions: On 9/10/24 at 10:30 P.M. Registered Nurse (RN) #315 assessed Resident #71 for pain. On 09/12/24 at 7:59 A.M. Unit Manager #105 completed a skin check for Resident #71. On 09/12/24 at 10:30 A.M. Resident #71 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360) On 9/11/24 at 9:30 A.M. State tested Nursing Assistant (STNA) #200 was suspended pending investigation by the Administrator/Executive Director. On 09/11/2024 at 9:35 A.M. the Administrator/ED notified the local police department of the incident that had occurred between Resident #71 and STNA #200 on 09/07/24. On 9/11/24 at 1:00 P.M. ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 (that occurred on 09/07/24) and of the incident with Resident #78 and STNA #300 (that occurred on 09/05/24). On 09/11/2024 at 1:15 P.M. the ED notified the local police department of the incident that had occurred between Resident #78 and STNA #300 on 09/05/24. On 09/11/24 at 3:00 P.M. STNA #300 was suspended pending investigation by Executive Director. On 09/12/24 at 11:00 A.M. Resident #78 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360). On 09/12/24 at 8:06 P.M. LPN #226 reassessed Resident #78 for skin issues. On 09/13/24 at 1:48 P.M. Resident #78 had pain assessment completed by LPN #105. On 9/12/2024 beginning at 6:00 P.M. 61 residents with a Brief Interview for Mental Status Score (BIMS) score of 10 (out of a possible 15) and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse. Beginning at 7:00 P.M. skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable. All 102 residents were interviewed and/or assessed at this time. On 9/12/2024 at 4:44 P.M. the ED sent a text message to all 121 staff members, to notify them of required in-service education that was being completed by RDCO #320. The education included a quiz. Elements of the education included: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse, staff removing perpetrators from facility, reporting incident to supervisor immediately, phone numbers of department heads, including abuse coordinator, and proper steps/timelines in abuse investigation 17 employees completed the education on this day. On 09/12/24 at 430 P.M., Regional Director of Operations (RDO) #750 educated HRM #600 on the policy and procedure for appropriate pre-employment checks to be completed prior to hire. On 9/13/2024 at 10:45 A.M. RDCO #320 educated HRM #600 verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. HRM #600 was educated that if an employee reported abuse to her, she should first make sure the resident was safe and the perpetrator was out of the facility, and then report the incident to the facility Abuse Coordinator, who was the Administrator/Executive Director. On 09/13/24 at 9:30 A.M. Unit Manager #105 along with the interdisciplinary team who included the ED, ADON #100, Clinical Manager #101, Electronic Health Records Manager #751, LSW #753, Housekeeping Director #754, Maintenance Director #755, Culinary Manager #390, Activities Director #400, LPN #338, Business Office Manager #756, Mobile BOM #757, and Therapy Director #705 were educated by RDO #750. Education was in-person and included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. At 10:00 am, RDCO #320 educated Unit Manger #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints. At 1:00 pm, RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations. Elements of these policies that were emphasized include: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse On 9/13/2024 at 10:45 A.M. RDCO #320 educated the DON verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. On 09/13/24 between 1:00 P.M. and 4:45 P.M. the remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee. The facility indicated all new hires would be educated on the first day of orientation by social service staff. On 9/13/24 at 1:30 P.M. the facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71. The QAPI committee included ED, RDO #750, RDCO #320, MD #800, and the DON via telephone. The QAPI committee determined the root causes of the incidents included staff working in memory care unit without proper training in Dementia Care and Aggressive/Combative Behavior, staff needed education on the Use of Restraints in terms of tilt-and-space chairs, and staff were unaware of the Abuse Coordinator, proper reporting protocols, and proper steps/requirements of abuse investigation. On 9/14/2024 at 11:33 A.M. Resident #71 went to the hospital to have labs performed. While in the hospital, Resident #71 reported the incident of abuse to hospital staff. The hospital performed x-rays and found three fractures in Resident #71's right wrist. Resident #71 returned to facility with an order for a splint to the right wrist. An appointment was set for the resident to see an orthopedist on 09/24/24 at 8:25 A.M. On 9/16/2024 at 11:00 A.M. the DON/designees reviewed care plans for additional residents, Resident #2, #3, #7, #8, #9, #12, #17, #18, #19, #22, #24, #30, #41, #43, #44, #49, #50, #51, #54, #55, #56, #60, #62, #63, #65, #66, #69, #75, #76, #84, #85, #86, #87, #91, #96, #98, and #102 with history of catastrophic reactions. On 09/16/24 at 2:00 P.M. Resident #71's care plan was reviewed by LPN #105. The care plan was updated for the resident to have two staff members during showers, and no males were to provide care during all showers. Additionally, the residents care plan was updated related to her fracture. Changes were communicated to staff through the resident's Kardex in Point Click Care. Beginning on 09/16/24 the Administrator or designee would interview two staff and three residents once a week for four weeks to ensure that no incidents of abuse had occurred. Beginning on 09/16/24 the DON/designee would perform two random skin assessments daily for four weeks to ensure care is being provided appropriately. Beginning on 09/16/24 the DON/Designee would audit the Connections (memory care) Unit 5 days a week for four weeks. Audits would include observation of activity of daily living assistance and meal service to ensure residents were receiving proper care. Beginning on 09/16/24 the ED/designee would audit HR once a week for four weeks to ensure new hires were properly screened with BCI checks and reference checks. Audits would also ensure new hires were properly signed up for Relias for in-service training and receive proper abuse and dementia care training upon hire. Beginning on 09/16/24 the ED/designee would audit employee evaluations once a week for four weeks to ensure any issues mentioned in employee evaluations were followed with proper education or discipline by DON/designee. Beginning on 09/16/24 RDCO #320/designee would audit 24-hour reports daily for four weeks to see if any reportable incidents occurred. The RDCO/designee would also audit to ensure facility Self-Report Incidents (SRIs) were reported to the State (ODH) agency portal in a timely fashion. The results of all audits would be submitted to QAPI committee for review upon completion and quarterly thereafter. STNA #300 was terminated on 09/17/24 at 3:45 P.M. STNA #200 was terminated on 09/17/24 at 3:50 P.M. Although the Immediate Jeopardy was removed on 09/16/24, 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: 1. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including unspecified dementia, generalized anxiety disorder, hypertension, and diabetes mellitus type two. The resident resided on the secured memory care unit in the facility. Review of Resident #78's care plan, initiated on 02/02/24, revealed she had a self-care deficit requiring staff assistance with activities of daily living (ADL) related to functional decline, impaired mobility, and impaired cognition. Interventions included the resident was allowed up ad lib (out of bed/chair whenever they prefer). Review of Resident #78's quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/10/24, revealed the resident had a moderate cognitive impairment. The assessment indicated the resident did not have an impairment to her upper or lower extremities and utilized a wheelchair. The resident was not assessed to have any behaviors. Review of Resident #78's Occupational Therapy (OT) Discharge Summary, dated 08/26/24, revealed the resident met her goal to sit upright in a new custom tilt-in-space wheelchair to facilitate correct anatomical alignment for two hours without sliding or complaint of discomfort. Further review of the medical record revealed no physician order for the tilt-in-space wheelchair, any use of physical restraints and no care plan regarding the tilt-in-space wheelchair. Review of Resident #78's progress notes revealed no documentation of restraint use, allegations of abuse, or resident assessments on 09/05/24 or 09/06/24. During an interview on 09/11/24 at 10:30 A.M. with Activity Assistant (AA) #301, the AA voiced concerns that some of the staff working on the memory care unit were not treating the residents right and management would not do anything about it. She reported two of her coworkers (AD #400 and AA #310) witnessed abuse last Thursday (09/05/24). She shared STNA #300 forced Resident #78 into her tilt-in-space wheelchair and positioned her with her head to the floor and her feet in the air. AA #301 stated it was reported to the facility and they continued to allow STNA #300 to care for residents on the unit. AA #301 went on to say last Thursday (09/05/24) around 3:15 P.M. she heard STNA #300 yelling at a resident (AA reported she was unable to hear what the STNA was saying due to being in another room with residents). She stated around 3:30 P.M. she was able to respond, after she left a resident's room, while passing snacks. At that time, she witnessed Resident #78 positioned all the way back in her tilt-in-space wheelchair with her head towards the ground and her feet in the air. The resident was crying and visibly upset. She stated she went to the resident and positioned her in an upright position and gave her a snack to help her calm down. Interview on 09/11/24 at 10:41 A.M. with AD #400 revealed on 09/05/24 she was doing her rounds on the memory care unit. Between 3:15 P.M and 3:30 P.M. she was visiting with residents on the unit and heard some commotion. Resident #78 was observed to be walking around the unit, and she heard STNA #300, in a very loud voice, tell the resident to sit down. She then witnessed STNA #300 forcefully grab the resident's arm (she cannot recall which arm) and pull the resident down into the tilt-in-space wheelchair. AD #400 stated she intervened and asked STNA #300, is there anything I can do? STNA #300 then told the AD to back off. The resident then attempted to swing at STNA #300 and remove herself from the chair. STNA #300 stated, she done hit me and positioned the chair with the resident's head towards the floor and her feet in the air. The resident began to cry and stated, I'm scared of you. STNA #300 was then heard stating now you can't move. AD #400 stated she left right away and went to Human Resource Manager #600 (identified as Employee Life Cycle Manager by the facility but the employee identified herself as Human Resource Manager) and reported the incident. The HR manager advised AD #400 to write a statement and give it to LPN/Unit Manager # 105. AD #400 reported she wrote a statement and placed the statement in the DON's mailbox. She stated she then returned to the unit and observed the resident in the same position but at that time, AA #301 was walking to the resident and repositioned her in an upright position and provided her a snack. AD #400 reported the resident stated to AA #301 I'm glad you came when you did. AD #400 went on to say the next day (09/06/24) she let everyone know in morning meeting, including Administration (AD #400 was unable to recall which administrative staff were present but did state the Administrator and UM #105 were present) about the incident. Unit Manager #105 reported she should have told her right away, and that she would deal with it. AD #400 reported she was detailed and clear about what she saw when she reported the observation to HRM #600, her written statement left in the DON's mailbox, and when she reported the incident again during the morning meeting. Interview on 09/11/24 at 11:38 A.M. with HRM #600 revealed AD #400 reported to her on 09/05/24 (she was unsure of the time) that STNA #300 forcefully put Resident #78 into her tilt-in- space wheelchair and tilted it fully back so the resident could not move. HRM #600 reported she advised AD #400 to write a statement and get UM #105 involved. HRM #600 stated she did not further report the issue and did not obtain a statement from AD #400. The HRM reported she doesn't deal with abuse allegations and defers them to the management. She stated she was mostly there for the support of the staff. She confirmed she did not follow the facility abuse policy by not reporting it to the Administrator or other leadership staff. Interview on 09/11/24 at 1:13 P.M. with LPN/UM #105 revealed one day last week AA #310 came to her and mentioned that she thought Resident #78 was being restrained in her tilt-in- space wheelchair by STNA #300. UM #105 stated she checked on the resident and removed the leg rest from her tilt-in- space wheelchair. The resident was not tilted back all the way at that time. She shared she provided verbal education to STNA #300 (however, there was no documented evidence of the education) regarding how tipping the chair too far back could be considered a restraint. She stated the next day in morning meeting AD #400 reported to her that STNA #300 had restrained Resident #78 and UM #105 stated she told AD #400 that she had already taken care of it at the time of the incident (with the verbal education provided to STNA #300). UM #105 verified this was not further reported to Administration when she addressed physical restraint use with STNA #300. Review of the facility Self-Reported Incidents in the Enhanced Information Dissemination Center (portal for reporting incidents of alleged abuse) from 09/05/24 through 09/11/24 at 9:00 A.M. revealed no reporting of the incident involving STNA #300 and Resident #78. The facility had no investigation related to the incident reported to the Unit Manager #105 or HR #600. The DON was out of the office at the time of the incident and RDCO #320 was unable to locate a statement from AD #400 in the mailbox of the DON. Review of STNA #300's time clock report revealed the STNA worked 09/05/24 from 6:54 A.M. until 6:54 P.M., 09/07/24 from 6:54 A.M. until 5:46 P.M., and 09/10/ 24 from 6:53 A.M. until 6:55 P.M. Review of the staff schedule dated 09/05/24 through 09/10/24 revealed STNA #300 was scheduled to work on the secured unit. Review of a facility Self-Reported Incident (SRI), tracking number 251771 initiated following the identification of the issue by the State agency, created on 09/11/24 at 1:04 P.M. incorrectly described the incident under the incident information brief description as: Resident allegedly abused STNA. The alleged perpetrator was facility staff or other care provider, and the initial source of the allegation/suspicion was staff. The resident was identified as Resident #78 who was unable to provide meaningful information and under the question What effect did incident have on Resident? The facility answered none. The date and time of the occurrence was 09/05/24 at 3:30 P.M. in the secured dementia unit dining room. According to witness accounts, Resident #78 was walking in Memory Care Unit dining room. STNA #300 grabbed the resident, with a diagnosis of dementia and who resided on the secured dementia unit, by the arm and forced her to sit in a tilt-in- space wheelchair. The STNA was yelling at the resident to sit down and placed the tilt-in-space wheelchair with her feet in the air and her head pointing to the ground. The resident was observed to be screaming and crying for help and trying to get out of the inverted specialty wheelchair. The Activity Director approached STNA #300, offering to assist with care for the resident, but the Activity Director was met with the STNA telling the Activity Director to go away. Additionally, Activity Aide (unidentified) heard STNA yelling and when able, observed the resident positioned in her tilt-in-space wheelchair with her feet in the air and her head towards the ground. An SRI was opened (created) and the ED, DON, physician, and local police department were notified. The facility SRI investigation was completed on 09/17/24 at 3:41 P.M. and as a result of the investigation, the facility substantiated the incident of abuse. Interview on 09/12/24 1:06 P.M. with Medical Director #800 revealed he was not notified until today (09/12/24) regarding the incident of alleged abuse involving Resident #78. MD #800 stated it would be his expectation for the facility to immediately report allegations of abuse to administration, remove the STNA from the area and start an immediate investigation. Interview on 09/12/24 1:43 PM with the Administrator revealed he was unaware of the abuse allegation involving Resident #78 until it was reported to the surveyor during survey activity on 09/11/24. The Administrator stated he would have initiated an immediate investigation and taken the appropriate steps had he been aware of the incident. He denied hearing the report AD #400 made in morning meeting about the incident. 2. Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including unspecified dementia with moderate behavioral disturbance, other sequelae of cerebral infarction, dysarthria following cerebral infarction, chronic kidney disease stage three, anxiety disorder, and major depressive disorder. The resident was noted to reside on the facility's secured dementia unit. Review of Resident #71's admission MDS 3.0 Assessment, dated 07/03/2024, revealed the resident was cognitively intact. The assessment indicated the resident had a lower extremity impairment to one side and utilized a wheelchair. The resident was dependent for showering and did have one to three days of behavioral symptoms towards others including hitting, kicking, pushing, scratching, and grabbing. Review of Resident #71's care plan dated 07/08/24 revealed the resident had behaviors including yelling, cussing at other residents, refusing care, yelling out, being tearful and having loud outbursts, which required nonpharmacological interventions including redirect, reapproach, calm environment, quiet environment, comfort, active listening. Interventions included administer medications as ordered, approach, speak in calm manor, encourage the resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, and notify medical provider of increased episodes of behaviors. Review of Resident #71's nursing progress notes for 09/07/24 revealed there were no progress notes regarding any allegation of abuse or issues/incidents related to the shower the resident received on this date. Review of Resident #71's nursing progress note dated 09/09/24 at 11:39 A.M. revealed UM #105 documented This nurse manager noted an aging bruise on the resident's left forearm. When speaking with the resident she stated that I think I bumped it on my bed when I fell . Resident did have an unwitnessed fall on 08/26/24. Review of Resident #71's nursing progress note dated 09/10/2024 at 9:00 P.M. and created on 09/11/23 3:27 A.M. by Registered Nurse (RN) #315 revealed STNA (unidentified) reported that resident has a bruise on her entire right forearm. Resident was assessed by this nurse. She stated that a male aide, (STNA #200), with the blonde hair, grabbed her from behind, undressed her in front of everyone and twisted her arm. She said she grabbed his badge to check for his name and he grabbed it back. She said she fought back and screamed. According to her, this incident occurred on Saturday or Sunday between 2:00 P.M. to 4:00 P.M. She also stated that he called for a female aide, but it was only the male aide who was grabbing her arm. I was notified by an STNA (unidentified) that this resident told a similar story to another resident; manager-on-call (Assistant Director of Nursing #100) was notified; Family Member #701 updated via phone call at 10:45 P.M. Observation of Resident #71 on 09/11/23 at 11:10 A.M. revealed the resident had a large bruise with various shades of purple covering the entirety of her right forearm. Also noted was one dime size bruise to her right chest that was light red in color, one quarter sized bruise to the right chest that was light red in color, a scabbed area to her right arm, and a bruise to the right inferior upper arm the size of a thumb print which was light purple in color. The resident was seated in a wheelchair and had a contracture noted to her left hand. She presented to have minimal use of her left upper extremity. An interview with Resident #71 at the time of the observation revealed she received these injuries the past weekend when a male STNA (identified through scheduling/interview/description as STNA #200) came up to her from behind, grabbed her right arm and started taking her clothes off. The resident stated the STNA forced her into the shower while she was screaming and yelling for him to stop. The STNA then placed her under hot water and then turned it to cold water. She reported he placed shampoo on her head and face, and she was yelling, screaming, and fighting him to stop but he would not. She then reported another STNA, identified as STNA #300 told Resident #71 she paid him a hundred dollars to do this to her. The resident continued that STNA #300 is not a nice person. She gets mad and vicious. She screams at the residents. The resident reported she received all the injuries from STNA #200 forcing her into the shower. The resident stated that she called her son and told him of the incident and additionally reported the incident to staff members working the day it happened. Interview on 09/11/24 at 11:20 A.M. with Family Member #704 reported he received a phone call from his mother on Saturday (09/07/24) stating that a male STNA threw her in the shower. His mother said she was scared and wanted him to come and get her. Family Member #704 stated he then called the facility nurse (LPN #102) who was working the unit and reported what his mother had told him. He requested that male staff members no longer work with his mother. He stated LPN #102 informed him his mother got aggressive and combative and was hitting a male STNA while he was showering her. Review of STNA #200 punch details revealed the STNA worked 09/07/24 from 6:54 A.M until 7:06 P.M., on 09/08/24 from 6:53 A.M until 6:57 P.M., and 09/11/24 from 6:59 A.M. until 9:54 A.M. Review of a facility Self-Reported Incident (tracking number 251754), submitted to the State agency after the surveyor identified this abuse situation, created on 09/11/24 at 9:26 A.M. with an incorrect date and time of occurrence as 09/11/24 at 9:30 A.M., revealed Resident #71 alleged she was physically abused by STNA. The resident provided meaningful information during the interview and had bruising on her (unidentified) arm. The narrative summary of the incident revealed on 09/07/2024, a male STNA gave female (resident) a shower in facility memory care unit. During the shower, Resident #71 became combative. STNA #200 stuck his head out of the shower room to ask for assistance from other staff. STNA #300 came to assist. The resident continued to be combative and STNA #300 ceased attempting care and spoke to Resident #71 to calm her down with STNA #200 still in the room. The resident calmed down and allowed staff to complete dressing her. Once out of the shower room, the resident expressed to (unidentified) nurse that she was upset that her hair was washed, her makeup was washed off & that a male showered her. The resident began making accusations that STNA #200 forced her in the shower and stripped her clothes off. Once the SRI was created, facility staff were interviewed. Residents on the Connections Unit (where Resident #71 resided) were not interviewed due to cognition status, so skin assessments were performed. Staff and residents downstairs were also interviewed and/or assessed. Family, the ED, DON and physician were notified. The local police department was notified (Case Number #2024-12273). STNA #200 was suspended upon investigation, immediately upon submission of SRI (on 09/11/24). Review of the facility self-reported incident documentation revealed the facility substantiated the allegation of abuse but after a thorough investigation, due to the combative history of the resident, the facility could not conclude abuse occurred. However, STNA #200's employment with the facility was terminated. A telephone interview on 09/11/24 at 2:08 P.M. with LPN #102 revealed on 09/07/24 STNA #200 went to give Resident #71 a shower. The resident started hitting, kicking and punching the STNA. STNA #200 got STNA #300, and they finished showering and dressing the resident. After her shower Resident #71 was yelling that STNA #200 took her clothes off and threw her i [TRUNCATED]

Based on observation, medical record reviews, review of facility Self-Reported Incidents (SRI), facility policy review and interview, the facility failed to ensure all allegations of physical and/or emotional abuse were reported immediately to the Administrator and State Survey Agency as required. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. when Activity Director (AD) #400 witnessed State tested Nursing Assistant (STNA) #300 grab and force Resident #78 to sit in her specialty tilt-in-space wheelchair (a specialty wheelchair that offers both a tilting function and a reclining function and should not be considered an independent mobility device due to their size and weight) while yelling at the resident to sit down. STNA #300 then positioned the tilt-in-space wheelchair with the resident's feet in the air and her head pointing toward the ground. The resident was observed to be tearful and crying out I'm scared of you while attempting to get out of the inverted specialty wheelchair. The resident remained in this position until approximately 3:30 P.M. when Activity Assistant (AA) #301 responded after hearing STNA #300 yelling at the resident. The allegation was not immediately reported to the Administrator and the State Survey Agency therefore, STNA #300 continued to provide care to residents on the secure dementia unit, including Resident #78. The Immediate Jeopardy and actual physical harm continued on 09/07/24 at approximately 11:00 A.M. when STNA #200 was physically abusive to Resident #71. On 09/07/24 while STNA #200 was assisting Resident #71 into the shower room for her scheduled shower, the resident became agitated. STNA #200 continued the shower despite the resident's reaction. Following the incident, Resident #71 reported to Licensed Practical Nurse (LPN) #102 that STNA #200 forcefully grabbed her, undressed her, and threw her in the shower. Resident #71 also reported the incident to her son who called the facility and reported the allegations to LPN #102, requesting no male staff provide further care to his mother. LPN #102 acknowledged to the resident's son there had been an altercation between the resident and staff; however, the LPN failed to report an allegation of physical abuse to leadership staff. On 09/10/24, Resident #71 was noted to have a 25 centimeter (cm) by 20 cm bruise covering the entirety of her right forearm, one dime size bruise to the right chest, one quarter sized bruise to her right chest, a scabbed area to her right arm, and a bruise to her right inferior upper arm the size of a thumb print. The resident's injuries were consistent with the resident's report of physical abuse, and it was later identified the resident had three fractures to her right wrist. The allegation was not immediately reported to the Administrator and State Survey Agency therefore, STNA #200 continued to provide care to the residents on the secure dementia care including Resident #78. This affected two residents (#78 and #71) of three residents reviewed for abuse. The facility census was 102. On 09/12/24 at 5:44 P.M. the Administrator (also known as the Executive Director or ED), and Regional Director of Clinical Operations (RDCO) #320 were notified Immediate Jeopardy began on 09/05/24 at approximately 3:15 P.M., when AD #400 witnessed STNA #300 grab Resident #78 by the arm and force the resident into her tilt-in- space wheelchair and inverted the chair, so her head was positioned towards the floor and her feet in the air consistent with a situation of physical abuse. The resident was tearful and crying I'm scared of you and attempting to get out of the inverted chair. Although the incident was reported to Human Resource Manager #600, the allegation was not immediately reported to the Administrator and the State Survey Agency. STNA #300 continued to work at the facility, providing care to the residents on the secured dementia unit, including Resident #71. Additionally, on 09/07/24, Resident #71 alleged physical abuse involving STNA #200 when the STNA forced her to take a shower. The resident sustained multiple injuries as a result of the incident and was subsequently diagnosed with fractures to her right wrist consistent with an incident of physical abuse. Although several staff were aware of the incident, the incident was not immediately reported to the Administrator and the State Survey Agency. STNA #200 was not immediately removed from the facility and the STNA was permitted to continue to provide care to the residents on the secured dementia unit, including Resident #71. The Immediate Jeopardy was removed on 09/13/24 when the facility implemented the following corrective actions: On 09/11/24 at 9:26 A.M. the Administrator/Executive Director (ED) created Self-Reported Incident, tracking number 251754 regarding Resident #71's allegation of abuse. On 09/11/24 and 09/12/24 the Executive Director conducted interviews with Resident #71, STNA/Alleged perpetrator #200, Activities Aide #310, STNA #300, STNA #131, LPN#102 and RN# 315. On 09/11/24 at 9:35 A.M. the Administrator/ED notified the local police department of the incident with Resident #71 and STNA #200 that occurred on 09/07/24. The local police opened case #2024-12273. On 9/11/24 at 1:00 P.M. ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 (that occurred on 09/07/24) and the incident with Resident #78 and STNA #300 (that occurred on 09/05/24. On 09/11/24 at 1:04 P.M. Regional Director of Clinical Operations (RDCO) #320 created Self-Reported Incident, tracking number 251771 regarding the incident that occurred between Resident #78 and STNA #300 on 09/05/24. On 09/11/24 and 09/12/24 the Executive Director conducted interviews with Activities Director #400, Activities Aide #310 Activities Aide #301, STNA/Alleged Perpetrator #300, STNA #131, Unit Manger #105, HRM #600, and STNA #340. On 09/11/2024 at 1:15 P.M. the ED notified the local police department of the incident involving Resident #78 and STNA #300 that occurred on 09/05/24. The local police opened case #2024-12336. On 9/12/2024 beginning at 6:00 P.M. 61 residents with a Brief Interview for Mental Status Score (BIMS) of 10 (out of a score of a possible score of 15) and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse. Beginning at 7:00 P.M. skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable. All 102 residents were interviewed and/or assessed at this time. On 9/12/2024 at 4:44 P.M. the ED sent a text message to all 121 staff members, to notify them of required in-service education that was being completed by RDCO #320. The education included a quiz. Elements of the education included: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse, staff removing perpetrators from facility, reporting incident to supervisor immediately, phone numbers of department heads, including abuse coordinator, and proper steps/timelines in abuse investigation. Seventeen employees completed the education on this day. On 09/13/24 at 9:30 A.M. Unit Manager #105 along with the interdisciplinary team who included the ED, ADON #100, Clinical Manager #101, Electronic Health Records Manager #751, LSW #753, Housekeeping Director #754, Maintenance Director #755, Culinary Manager #390, Activities Director #400, LPN #338, Business Office Manager #756, Mobile BOM #757, and Therapy Director #705 were educated by Regional Director of Operations (RDO) #750. Education was in-person and included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. At 10:00 am, RDCO #320 educated Unit Manger #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints. At 1:00 P.M., RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations. Elements of these policies that were emphasized include: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse On 9/13/2024 at 10:45 A.M. RDCO #320 educated the DON verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. On 09/13/24 between at 1:00 P.M. and 4:45 P.M. the remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee. The facility indicated all new hires would be educated on the first day of orientation by social service staff. On 9/13/24 at 1:30 P.M. the facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71. The QAPI committee included ED, RDO #750, RDCO #320, Medical Director (MD) #800, and the Director of Nursing (DON) via telephone. The QAPI committee determined the root causes of the incidents included staff working in memory care unit without proper training in Dementia Care and Aggressive/Combative Behavior, staff needed education on the Use of Restraints in terms of tilt-and-space chairs, and staff were unaware of the Abuse Coordinator, proper reporting protocols, and proper steps/requirements of abuse investigation. Beginning on 09/16/24 RDCO #320/designee would audit 24-hour reports daily for four weeks to see if any reportable incidents occurred. The RDCO/designee would also audit to ensure facility Self-Report Incidents (SRIs) were reported to the State (ODH) agency portal in a timely fashion. On 09/17/24 the facility completed and submitted their final Self-Reported Incident information for tracking number 251771 which substantiated the incident of abuse involving Resident #78. On 09/17/24 the facility completed and submitted their final Self-Reported Incident information for tracking number 251754 which substantiated the incident of abuse involving Resident #71. Although the Immediate Jeopardy was removed on 09/13/24, 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 Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including unspecified dementia, generalized anxiety disorder, hypertension, and diabetes mellitus type two. The resident resided on the secured memory care unit in the facility. Review of Resident #78's care plan, initiated on 02/02/24, revealed she had a self-care deficit requiring staff assistance with activities of daily living (ADL) related to functional decline, impaired mobility, and impaired cognition. Interventions included the resident was allowed up ad lib (out of bed/chair whenever they prefer). Review of Resident #78's quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/10/24, revealed the resident had a moderate cognitive impairment. The assessment indicated the resident did not have an impairment to her upper or lower extremities and utilized a wheelchair. The resident was not assessed to have any behaviors. Review of Resident #78's Occupational Therapy (OT) Discharge Summary, dated 08/26/24, revealed the resident met her goal to sit upright in a new custom tilt-in-space wheelchair to facilitate correct anatomical alignment for two hours without sliding or complaint of discomfort. Further review of the medical record revealed no physician order for the tilt-in-space wheelchair, any use of physical restraints and no care plan regarding the tilt-in-space wheelchair. Review of Resident #78's progress notes revealed no documentation of restraint use, allegations of abuse, or resident assessments on 09/05/24 or 09/06/24. During an interview on 09/11/24 at 10:30 A.M. with Activity Assistant (AA) #301, the AA voiced concerns that some of the staff working on the memory care unit were not treating the residents right and management would not do anything about it. She reported two of her coworkers (AD #400 and AA #310) witnessed abuse last Thursday (09/05/24). She shared STNA #300 forced Resident #78 into her tilt-in-space wheelchair and positioned her with her head to the floor and her feet in the air. AA #301 stated it was reported to the facility and they continued to allow STNA #300 to care for residents on the unit. AA #301 went on to say last Thursday (09/05/24) around 3:15 P.M. she heard STNA #300 yelling at a resident (AA reported she was unable to hear what the STNA was saying due to being in another room with residents). She stated around 3:30 P.M. she was able to respond, after she left a resident's room, while passing snacks. At that time, she witnessed Resident #78 positioned all the way back in her tilt-in-space wheelchair with her head towards the ground and her feet in the air. The resident was crying and visibly upset. She stated she went to the resident and positioned her in an upright position and gave her a snack to help her calm down. Interview on 09/11/24 at 10:41 A.M. with AD #400 revealed on 09/05/24 she was doing her rounds on the memory care unit. Between 3:15 P.M. and 3:30 P.M. she was visiting with residents on the unit and heard some commotion. Resident #78 was observed to be walking around the unit, and she heard STNA #300, in a very loud voice, tell the resident to sit down. She then witnessed STNA #300 forcefully grab the resident's arm (she cannot recall which arm) and pull the resident down into the tilt-in-space wheelchair. AD #400 stated she intervened and asked STNA #300, is there anything I can do? STNA #300 then told the AD to back off. The resident then attempted to swing at STNA #300 and remove herself from the chair. STNA #300 stated, she done hit me and positioned the chair with the resident's head towards the floor and her feet in the air. The resident began to cry and stated, I'm scared of you. STNA #300 was then heard stating now you can't move. AD #400 stated she left right away and went to Human Resource Manager #600 (identified as Employee Life Cycle Manager by the facility but the employee identified herself as Human Resource Manager) and reported the incident. The HR manager advised AD #400 to write a statement and give it to LPN/Unit Manager #105. AD #400 reported she wrote a statement and placed the statement in the DON's mailbox. She stated she then returned to the unit and observed the resident in the same position but at that time, AA #301 was walking to the resident and repositioned her in an upright position and provided her a snack. AD #400 reported the resident stated to AA #301 I'm glad you came when you did. AD #400 went on to say the next day (09/06/24) she let everyone know in morning meeting, including Administration (AD #400 was unable to recall which administrative staff were present but did state the Administrator and UM #105 were present) about the incident. Unit Manager #105 reported she should have told her right away, and that she would deal with it. AD #400 reported she was detailed and clear about what she saw when she reported the observation to HRM #600, her written statement left in the DON's mailbox, and when she reported the incident again during the morning meeting. Interview on 09/11/24 at 11:38 A.M. with HRM #600 revealed AD #400 reported to her on 09/05/24 (she was unsure of the time) that STNA #300 forcefully put Resident #78 into her tilt-in- space wheelchair and tilted it fully back so the resident could not move. HRM #600 reported she advised AD #400 to write a statement and get UM #105 involved. HRM #600 stated she did not further report the issue and did not obtain a statement from AD #400. The HRM reported she doesn't deal with abuse allegations and defers them to the management. She stated she was mostly there for the support of the staff. She confirmed she did not follow the facility abuse policy by not reporting it to the Administrator or other leadership staff. Interview on 09/11/24 at 1:13 P.M. with LPN/UM #105 revealed one day last week AA #310 came to her and mentioned that she thought Resident #78 was being restrained in her tilt-in- space wheelchair by STNA #300. UM #105 stated she checked on the resident and removed the leg rest from her tilt-in- space wheelchair. The resident was not tilted back all the way at that time. She shared she provided verbal education to STNA #300 (however, there was no documented evidence of the education) regarding how tipping the chair too far back could be considered a restraint. She stated the next day in morning meeting AD #400 reported to her that STNA #300 had restrained Resident #78 and UM #105 stated she told AD #400 that she had already taken care of it at the time of the incident (with the verbal education provided to STNA #300). UM #105 verified this was not further reported to Administration when she addressed physical restraint use with STNA #300. Review of the facility Self-Reported Incidents in the Enhanced Information Dissemination Center (portal for reporting incidents of alleged abuse) from 09/05/24 through 09/11/24 at 9:00 A.M. revealed no reporting of the incident involving STNA #300 and Resident #78. The facility had no investigation related to the incident reported to the Unit Manager #105 or HR #600. The DON was out of the office at the time of the incident and RDCO #320 was unable to locate a statement from AD #400 in the mailbox of the DON. Review of a facility Self-Reported Incident (SRI), tracking number 251771 initiated following the identification of the issue by the State agency, created on 09/11/24 at 1:04 P.M. incorrectly described the incident under the incident information brief description as: Resident allegedly abused STNA. The alleged perpetrator was facility staff or other care provider, and the initial source of the allegation/suspicion was staff. The resident was identified as Resident #78 who was unable to provide meaningful information and under the question What effect did incident have on resident? The facility answered none. The date and time of the occurrence was 09/05/24 at 3:30 P.M. in the secured dementia unit dining room. According to witness accounts, Resident #78 was walking in Memory Care Unit dining room. STNA #300 grabbed the resident, with a diagnosis of dementia and who resided on the secured dementia unit, by the arm and forced her to sit in a tilt-in- space wheelchair. The STNA was yelling at the resident to sit down and placed the tilt-in-space wheelchair with her feet in the air and her head pointing to the ground. The resident was observed to be screaming and crying for help and trying to get out of the inverted specialty wheelchair. The Activity Director approached STNA #300, offering to assist with care for the resident, but the Activity Director was met with the STNA telling the Activity Director to go away. Additionally, Activity Aide (unidentified) heard STNA yelling and when able, observed the resident positioned in her tilt-in-space wheelchair with her feet in the air and her head towards the ground. An SRI was opened (created) and the ED, DON, physician, and local police department were notified. The facility SRI investigation was completed on 09/17/24 at 3:41 P.M. and as a result of the investigation, the facility substantiated the incident of abuse. Interview on 09/12/24 1:06 P.M. with Medical Director #800 revealed he was not notified until today (09/12/24) regarding the incident of alleged abuse involving Resident #78. MD #800 stated it would be his expectation for the facility to immediately report allegations of abuse to administration, remove the STNA from the area and start an immediate investigation. Interview on 09/12/24 1:43 P.M. with the Administrator revealed he was unaware of the abuse allegation involving Resident #78 until it was reported to the surveyor during survey activity on 09/11/24. The Administrator stated he would have initiated an immediate investigation and taken the appropriate steps had he been aware of the incident. He denied hearing the report AD #400 made in morning meeting about the incident. Review of the undated facility Ohio Abuse, Neglect, and Misappropriation policy revealed the supervisor or designee would notify the DON and Executive Director (ED) of the incident or allegation immediately. Required notification of agencies, physician, and resident representee will be completed. The ED will direct the investigation. 2. Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including unspecified dementia with moderate behavioral disturbance, other sequelae of cerebral infarction, dysarthria following cerebral infarction, chronic kidney disease stage three, anxiety disorder, and major depressive disorder. The resident was noted to reside on the facility's secured dementia unit. Review of Resident #71's admission MDS 3.0 Assessment, dated 07/03/2024, revealed the resident was cognitively intact. The assessment indicated the resident had a lower extremity impairment to one side and utilized a wheelchair. The resident was dependent for showering and did have one to three days of behavioral symptoms towards others including hitting, kicking, pushing, scratching, and grabbing. Review of Resident #71's care plan dated 07/08/24 revealed the resident had behaviors including yelling, cussing at other residents, refusing care, yelling out, being tearful and having loud outbursts, which required nonpharmacological interventions including redirect, reapproach, calm environment, quiet environment, comfort, active listening. Interventions included administer medications as ordered, approach, speak in calm manor, encourage the resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, and notify medical provider of increased episodes of behaviors. Review of Resident #71's nursing progress notes for 09/07/24 revealed there were no progress notes regarding any allegation of abuse or issues/incidents related to the shower the resident received on this date. Review of Resident #71's nursing progress note dated 09/09/24 at 11:39 A.M. revealed UM #105 documented This nurse manager noted an aging bruise on the resident's left forearm. When speaking with the resident she stated that I think I bumped it on my bed when I fell . Resident did have an unwitnessed fall on 08/26/24. Review of Resident #71's nursing progress note, dated 09/10/2024 at 9:00 P.M. and created on 09/11/23 3:27 A.M. by Registered Nurse (RN) #315, revealed STNA (unidentified) reported that resident has a bruise on her entire right forearm. Resident was assessed by this nurse. She stated that a male aide, (STNA #200)), with the blonde hair, grabbed her from behind, undressed her in front of everyone and twisted her arm. She said she grabbed his badge to check for his name and he grabbed it back. She said she fought back and screamed. According to her, this incident occurred on Saturday or Sunday between 2:00 P.M. to 4:00 P.M. She also stated that he called for a female aide, but it was only the male aide who was grabbing her arm. I was notified by an STNA (unidentified) that this resident told a similar story to another resident; manager-on-call (Assistant Director of Nursing #100) was notified; Family Member #701 updated via phone call at 10:45 P.M. Observation of Resident #71 on 09/11/23 at 11:10 A.M. revealed the resident had a large bruise with various shades of purple covering the entirety of her right forearm. Also noted was one dime size bruise to her right chest that was light red in color, one quarter sized bruise to the right chest that was light red in color, a scabbed area to her right arm, and a bruise to the right inferior upper arm the size of a thumb print which was light purple in color. The resident was seated in a wheelchair and had a contracture noted to her left hand. She presented to have minimal use of her left upper extremity. An interview with Resident #71 at the time of the observation revealed she received these injuries the past weekend when a male STNA (identified through scheduling/interview/description as STNA #200) came up to her from behind, grabbed her right arm and started taking her clothes off. The resident stated the STNA forced her into the shower while she was screaming and yelling for him to stop. The STNA then placed her under hot water and then turned it to cold water. She reported he placed shampoo on her head and face, and she was yelling, screaming, and fighting him to stop but he would not. She then reported another STNA, identified as STNA #300 told Resident #71 she paid him a hundred dollars to do this to her. The resident continued that STNA #300 is not a nice person. She gets mad and vicious. She screams at the residents. The resident reported she received all the injuries from STNA #200 forcing her into the shower. The resident stated that she called her son and told him of the incident and additionally reported the incident to staff members working the day it happened. Interview on 09/11/24 at 11:20 A.M. with Family Member #704 reported he received a phone call from his mother on Saturday (09/07/24) stating that a male STNA threw her in the shower. His mother said she was scared and wanted him to come and get her. Family Member #704 stated he then called the facility nurse (LPN #102) who was working the unit and reported what his mother had told him. He requested that male staff members no longer work with his mother. He stated LPN #102 informed him his mother got aggressive and combative and was hitting a male STNA while he was showering her. A telephone interview on 09/11/24 at 2:08 P.M. with LPN #102 revealed on 09/07/24 STNA #200 went to give Resident #71 a shower. The resident started hitting, kicking and punching the STNA. STNA #200 got STNA #300, and they finished showering and dressing the resident. After her shower Resident #71 was yelling that STNA #200 took her clothes off and threw her in the shower She was saying that a black person paid him a hundred dollars to do it. The son had called and asked about the incident and stated that his mother said a male STNA threw her in the shower and forced her to get a shower. LPN #102 went on to say the resident's son spoke with her about the encounter and stated he would prefer male staff no longer work with his mother. The nurse told the family member she would let the unit manager (UM #105) know. LPN #102 stated she meant to report the incident and allegation of abuse, but she got busy and did not report it until 09/09/24, in the morning, to Unit Manager #105. A telephone interview on 09/11/24 at 2:23 P.M. with STNA #200 reported Resident #71 was on the list for a shower on 09/07/24. He stated he got her and brought her to the shower room, when he started to undress her, she became aggressive and started hitting, screaming, biting, picked a scab off herself and wiped her blood on him. She was swinging her arm and slamming it into the wall. He continued with the shower and washed her while she was screaming and hitting him the entire time. He stated he pulled the call light and STNA #300 came and assisted with the end of the shower and getting the resident dressed. After they completed the shower, and she was dressed, she continued to be upset and was telling everyone the rest of the night that STNA #200 abused her and STNA #300 paid him to do so. STNA #200 denied STNA #300 paid him to force Resident #71 into the shower. Interview on 09/12/24 at 1:06 P.M. with Medical Director #800 revealed he was not notified until today (09/12/24) regarding the incident of alleged abuse for Resident #71. MD #600 stated it would be his expectation for the facility to immediately report the allegation, remove the STNA from the area and start and investigation. Interview on 09/12/24 at 1:43 P.M., with the Administrator confirmed the facility did not follow their abuse reporting policy resulting in a delayed investigation into the report that STNA #200 physically abused the resident and STNA #300 paid him to do so. He confirmed it would be his expectation for STNA #200 to stop care and follow the residents care plan related to behaviors when she became upset. Review of a facility Self-Reported Incident (tracking number 251754), submitted to the State agency after the surveyor identified this abuse situation, created on 09/11/24 at 9:26 A.M. with an incorrect date and time of occurrence as 09/11/24 at 9:30 A.M., revealed Resident #71 alleged she was physically abused by STNA. The resident provided meaningful information during the interview and had bruising on her (unidentified) arm. The narrative summary of the incident revealed on 09/07/2024, a male STNA gave female (resident) a shower in facility memory care unit. During the shower, Resident #71 became combative. STNA #200 stuck his head out of the shower room to ask for assistance from other staff. STNA #300 came to assist. The resident continued to be combative and STNA #300 ceased attempting care and spoke to Resident #71 to calm her down with STNA #200 still in the room. The resident calmed down and allowed staff to complete dressing her. Once out of the shower room, the resident expressed to (unidentified) nurse that she was upset that her hair was washed, her makeup was washed off & that a male showered her. The resident began making accusations that STNA #200 forced her in the shower and stripped her clothes off. Once the SRI was created, facility staff were interviewed. Residents on the Connections Unit (where Resident #71 resided) were not interviewed due to cognition status, so skin assessments were performed. Staff and residents downstairs were also interviewed and/or assessed. Family, the ED, DON and physician were notified. The local police department was notified (Case Number #2024-12273). STNA #200 was suspended upon investigation, immediately upon submission of SRI (on 09/11/24). Review of the facility self-reported incident documentation revealed the facility substantiated the allegation of abuse but after a thorough investigation, due to the combative history of the resident, the facility could not conclude abuse occurred. However, STNA #200's employment with the facility was terminated. Review of the facility undated Ohio Abuse, Neglect, and Misappropriation policy revealed the supervisor or designee would notify the DON and Executive Director (ED) of the incident or allegation immediately. Required notification of agencies, physician, and resident representee would be completed. The ED would direct the investigation. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, medical record reviews review of employee time clock punch reports, review of employee personnel files, review of facility Self-Reported Incidents (SRI), review of the facility assessment, facility policy review and interview, the facility failed to ensure all residents were free from staff to resident physical and/or emotional abuse. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. when Activity Director (AD) #400 witnessed State tested Nursing Assistant (STNA) #300 grab and force Resident #78 to sit in her specialty tilt-in-space wheelchair (a specialty wheelchair that offers both a tilting function and a reclining function and should not be considered an independent mobility device due to their size and weight) while yelling at the resident to sit down. STNA #300 then positioned the tilt-in-space wheelchair with the resident's feet in the air and her head pointing toward the ground. The resident was observed to be tearful and crying out I'm scared of you while attempting to get out of the inverted specialty wheelchair. The resident remained in this position until approximately 3:30 P.M. when Activity Assistant (AA) #301 responded after hearing STNA #300 yelling at the resident. Following the incident, STNA #300 received education from Licensed Practical Nurse (LPN)/Unit Manager #105 regarding the use of restraints but was not removed from the facility or schedule despite the allegation of abuse reported. The Immediate Jeopardy and actual physical harm continued on 09/07/24 at approximately 11:00 A.M. when STNA #200 was physically abusive to Resident #71. On 09/07/24 while STNA #200 was assisting Resident #71 into the shower room for her scheduled shower, the resident became agitated. STNA #200 continued the shower despite the resident's reaction. Following the incident, Resident #71 reported to Licensed Practical Nurse (LPN) #102 that STNA #200 forcefully grabbed her, undressed her, and threw her in the shower. Resident #71 also reported the incident to her son who called the facility and reported the allegations to LPN #102, requesting no male staff provide further care to his mother. LPN #102 acknowledged to the resident's son there had been an altercation between the resident and staff; however, the LPN failed to report an allegation of physical abuse to leadership staff. On 09/10/24, Resident #71 was noted to have a 25 centimeter (cm) by 20 cm bruise covering the entirety of her right forearm, one dime size bruise to the right chest, one quarter sized bruise to her right chest, a scabbed area to her right arm, and a bruise to her right inferior upper arm the size of a thumb print. The resident's injuries were consistent with the resident's report of physical abuse. The resident was transported to the emergency room (ER) on 09/14/24 for lab work because of the incident. While in the ER, Resident #71 reported the shower incident to hospital staff. As a result of the report, x-rays of the resident's right arm were completed, and three fractures of the resident's right wrist were identified. This affected two residents (#78 and #71) of three residents reviewed for abuse. The facility census was 102. On 09/12/24 at 5:44 P.M. the Administrator, and Regional Director of Clinical Operations (RDCO) #320 were notified Immediate Jeopardy began on 09/05/24 at approximately 3:15 P.M., when AD #400 witnessed STNA #300 grab Resident #78 by the arm and force the resident into her tilt-in-space wheelchair and inverted the chair, so her head was positioned towards the floor and her feet in the air consistent with a situation of physical abuse. The resident was tearful and crying I'm scared of you and attempting to get out of the inverted chair. Although the incident was reported to Human Resource Manager (HRM) #600, STNA #300 continued to work at the facility, providing care to the residents on the secured dementia unit, including Resident #71. Additionally, on 09/07/24, Resident #71 alleged physical abuse involving STNA #200 when the STNA forced her to take a shower. The resident sustained multiple injuries as a result of the incident and was subsequently diagnosed with fractures to her wrist consistent with an incident of physical abuse. Although several staff were aware of the incident, STNA #200 was not immediately removed from the facility and the STNA was permitted to continue to provide care to the residents on the secured dementia unit, including Resident #71. The Immediate Jeopardy was removed on 09/16/2024 when the facility implemented the following corrective actions: On 9/10/24 at 10:30 P.M. Registered Nurse (RN) #315 assessed Resident #71 for pain. On 09/12/24 at 7:59 A.M. Unit Manager #105 completed a skin check for Resident #71. On 09/12/24 at 10:30 A.M. Resident #71 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360). On 9/11/24 at 9:30 A.M. State tested Nursing Assistant (STNA) #200 was suspended pending investigation by the Administrator/Executive Director. On 09/11/2024 at 9:35 A.M. the Administrator/ED notified the local police department of the incident that had occurred between Resident #71 and STNA #200 on 09/07/24. On 9/11/24 at 1:00 P.M. ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 (that occurred on 09/07/24) and of the incident with Resident #78 and STNA #300 (that occurred on 09/05/24). On 09/11/2024 at 1:15 P.M. the ED notified the local police department of the incident that had occurred between Resident #78 and STNA #300 on 09/05/24. On 09/11/24 at 3:00 P.M. STNA #300 was suspended pending investigation by the Executive Director. On 09/12/24 at 11:00 A.M. Resident #78 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360). On 09/12/24 at 8:06 P.M. LPN #226 reassessed Resident #78 for skin issues. On 09/13/24 at 1:48 P.M. Resident #78 had pain assessment completed by LPN #105. On 9/12/2024 beginning at 6:00 P.M. 61 residents with a Brief Interview for Mental Status Score (BIMS) score of 10 (out of a possible 15) and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse. Beginning at 7:00 P.M. skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable. All 102 residents were interviewed and/or assessed at this time. On 9/12/2024 at 4:44 P.M. the Administrator/ED sent a text message to all 121 staff members, to notify them of required in-service education that was being completed by RDCO #320. The education included a quiz. Elements of the education included: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse, staff removing perpetrators from the facility, reporting an incident to a supervisor immediately, phone numbers of department heads, including abuse coordinator, and proper steps/timelines in abuse investigation. Seventeen employees completed the education on this day. On 09/12/24 at 4:30 P.M., Regional Director of Operations (RDO) #750 educated HRM #600 on the policy and procedure for appropriate pre-employment checks to be completed prior to hire. On 9/13/2024 at 10:45 A.M. RDCO #320 educated HRM #600 verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. HRM #600 was educated that if an employee reported abuse to her, she should first make sure the resident was safe and the perpetrator was out of the facility, and then report the incident to the facility Abuse Coordinator, who was the Administrator/Executive Director. On 09/13/24 at 9:30 A.M. Unit Manager #105 along with the interdisciplinary team who included the ED, ADON #100, Clinical Manager #101, Electronic Health Records Manager #751, LSW #753, Housekeeping Director #754, Maintenance Director #755, Culinary Manager #390, Activities Director #400, LPN #338, Business Office Manager #756, Mobile BOM #757, and Therapy Director #705 were educated by RDO #750. Education was in-person and included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. At 10:00 am, RDCO #320 educated Unit Manger #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints. At 1:00 P.M., RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations. Elements of these policies that were emphasized include: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse On 9/13/2024 at 10:45 A.M. RDCO #320 educated the Director of Nursing (DON) verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation. On 09/13/24 between at 1:00 P.M. and 4:45 P.M. the remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee. The facility indicated all new hires would be educated on the first day of orientation by social service staff. On 9/13/24 at 1:30 P.M. the facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71. The QAPI committee included ED, RDO #750, RDCO #320, Medical Director (MD) #800, and the DON via telephone. The QAPI committee determined the root causes of the incidents included staff working in the memory care unit without proper training in Dementia Care and Aggressive/Combative Behavior, staff needed education on the Use of Restraints in terms of tilt-and-space chairs, and staff were unaware of the facility identified Abuse Coordinator, proper reporting protocols, and proper steps/requirements of an abuse investigation. On 9/14/2024 at 11:33 A.M. Resident #71 went to the hospital to have labs performed. While in the hospital, Resident #71 reported the incident of abuse to hospital staff. The hospital performed x-rays and found three fractures in Resident #71's right wrist. Resident #71 returned to facility with an order for a splint to the right wrist. An appointment was set for the resident to see an orthopedist on 09/24/24 at 8:25 A.M. On 9/16/2024 at 11:00 A.M. the DON/designees reviewed care plans for additional residents, Resident #2, #3, #7, #8, #9, #12, #17, #18, #19, #22, #24, #30, #41, #43, #44, #49, #50, #51, #54, #55, #56, #60, #62, #63, #65, #66, #69, #75, #76, #84, #85, #86, #87, #91, #96, #98, and #102 with history of catastrophic reactions. On 09/16/24 at 2:00 P.M. Resident #71's care plan was reviewed by LPN #105. The care plan was updated for the resident to have two staff members during showers, and no males were to provide care during all showers. Additionally, the residents care plan was updated related to her fracture. Changes were communicated to staff through the resident's Kardex in Point Click Care (electronic medical record/documentation system). Beginning on 09/16/24 the Administrator or designee would interview two staff and three residents once a week for four weeks to ensure that no incidents of abuse had occurred. Beginning on 09/16/24 the DON/designee would perform two random skin assessments daily for four weeks to ensure care is being provided appropriately. Beginning on 09/16/24 the DON/Designee would audit the Connections (memory care) Unit five days a week for four weeks. Audits would include observation of activity of daily living assistance and meal service to ensure residents were receiving proper care. Beginning on 09/16/24 the ED/designee would audit Human Resources (HR) once a week for four weeks to ensure new hires were properly screened with Bureau of Criminal Investigations (BCI) (background checks) checks and reference checks. Audits would also ensure new hires were properly signed up for Relias for in-service training and receive proper abuse and dementia care training upon hire. Beginning on 09/16/24 the ED/designee would audit employee evaluations once a week for four weeks to ensure any issues mentioned in employee evaluations were followed with proper education or discipline by DON/designee. The results of all audits would be submitted to the QAPI committee for review upon completion and quarterly thereafter. STNA #300 was terminated on 09/17/24 at 3:45 P.M. STNA #200 was terminated on 09/17/24 at 3:50 P.M. Although the Immediate Jeopardy was removed on 09/16/24, 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: 1. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including unspecified dementia, generalized anxiety disorder, hypertension, and diabetes mellitus type two. The resident resided on the secured memory care unit in the facility. Review of Resident #78's care plan, initiated on 02/02/24, revealed she had a self-care deficit requiring staff assistance with activities of daily living (ADL) related to functional decline, impaired mobility, and impaired cognition. Interventions included the resident was allowed up ad lib (out of bed/chair whenever they prefer). Further review revealed Resident #78 had a care plan initiated on 04/10/2024 that indicated the resident is at risk for elopement and required a secured unit related to her diagnosis of dementia. Interventions included for staff to assess for hunger, thirst, ambulation, toileting needs, observe whereabouts every two hours and as needed due to elopement risk, provide diversionary activities as needed, redirect when appropriate, and provide structured activities at times of increased elopement risk. Review of Resident #78's Secure Care Unit Evaluation-Initial, dated 02/03/2024, revealed the resident exhibited the following: gait disturbance, cognitive impairment, lack of safety awareness. An order was in place for the secured unit and the resident's guardian was notified of the need for the secured care unit. Review of Resident #78's Wandering Observation Tool, dated 05/02/24, revealed the resident had expressed anxiety/apprehension to leave the facility, packed personal belongings, pacing with no course of action or direction, or attempted to exit doors. The assessment determined the resident was at risk for elopement or unsafe wandering. Review of Resident #78's quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/10/24, revealed the resident had a moderate cognitive impairment. The assessment indicated the resident did not have an impairment to her upper or lower extremities and utilized a wheelchair. The resident was not assessed to have any behaviors. Review of Resident #78's Occupational Therapy (OT) progress note from 08/15/24 revealed the resident can stand up from wheelchair and walk. The resident was noted to be moderately independent with mobility with functional mobility throughout hallways at a slow pace without a device with fair tolerance. On 08/23/24 a progress note revealed the resident demonstrated good wheelchair positioning in custom tilt-in-space wheelchair while provided with set up for bilateral upper extremity activities in all planes with fair activity tolerance, occasional rest breaks, and good safety to improve strength, activity tolerance, wheelchair positioning, and safely to reduce fall risk and improve self-care, mobility, and functional daily activities within her environment. Review of Resident #78's OT Discharge Summary, dated 08/26/24, revealed the resident met her goal to sit upright in a new custom tilt-in-space wheelchair to facilitate correct anatomical alignment for two hours without sliding or complaint of discomfort. Further review of the medical record revealed no physician order for the tilt-in-space wheelchair, any use of physical restraints and no care plan regarding the tilt-in-space wheelchair. Review of Resident #78's progress notes revealed no documentation of restraint use, allegations of abuse, or resident assessments on 09/05/24 or 09/06/24. During an interview on 09/11/24 at 10:30 A.M. with Activity Assistant (AA) #301, the AA voiced concerns that some of the staff working on the memory care unit were not treating the residents right and management would not do anything about it. She reported two of her coworkers (AD #400 and AA #310) witnessed abuse last Thursday (09/05/24). She shared STNA #300 forced Resident #78 into her tilt-in-space wheelchair and positioned her with her head to the floor and her feet in the air. AA #301 stated it was reported to the facility and they continued to allow STNA #300 to care for residents on the unit. AA #301 went on to say last Thursday (09/05/24) around 3:15 P.M. she heard STNA #300 yelling at a resident (AA reported she was unable to hear what the STNA was saying due to being in another room with residents). She stated around 3:30 P.M. she was able to respond after she left a resident's room while passing snacks. At that time, she witnessed Resident #78 positioned all the way back in her tilt-in-space wheelchair with her head towards the ground and her feet in the air. The resident was crying and visibly upset. She stated she went to the resident and positioned her in an upright position and gave her a snack to help her calm down. AA #301 stated she has reported issues like this in the past to management, but nothing was done. Lastly, she stated, in her opinion, staff use this wheelchair often to keep Resident #78 from walking on the unit. Interview on 09/11/24 at 10:41 A.M. with AD #400 revealed on 09/05/24 she was doing her rounds on the memory care unit. Between 3:15 P.M. and 3:30 P.M. she was visiting with residents on the unit and heard some commotion. Resident #78 was observed to be walking around the unit, and she heard STNA #300, in a very loud voice, tell the resident to sit down. She then witnessed STNA #300 forcefully grab the resident's arm (she cannot recall which arm) and pull the resident down into the tilt-in-space wheelchair. AD #400 stated she intervened and asked STNA #300, is there anything I can do? STNA #300 then told the AD to back off. The resident then attempted to swing at STNA #300 and remove herself from the chair. STNA #300 stated, she done hit me and positioned the chair with the resident's head towards the floor and her feet in the air. The resident began to cry and stated, I'm scared of you. STNA #300 was then heard stating now you can't move. AD #400 stated she left right away and went to Human Resource Manager #600 (identified as Employee Life Cycle Manager by the facility but the employee identified herself as Human Resource Manager) and reported the incident. The HRM advised AD #400 to write a statement and give it to LPN/Unit Manager # 105. AD #400 reported she wrote a statement and placed the statement in the DON's mailbox. She stated she then returned to the unit and observed the resident in the same position but at that time, AA #301 was walking to the resident and repositioned her in an upright position and provided her a snack. AD #400 reported the resident stated to AA #301 I'm glad you came when you did. AD #400 went on to say the next day (09/06/24) she let everyone know in morning meeting, including Administration (AD #400 was unable to recall which administrative staff were present but did state the Administrator and UM #105 were present) about the incident. Unit Manager #105 reported you should have told her right away, and that she would deal with it. AD #400 reported she was detailed and clear about what she saw when she reported the observation to HRM #600, her written statement left in the DON's mailbox, and when she reported the incident again during the morning meeting. Interview on 09/11/24 at 10:56 A.M. with AA #310 revealed on 09/05/24 around 3:30 P.M. she witnessed Resident #78 standing in the dining room when she heard STNA #300 come over to her and yell I told you to sit down. She continued that STNA #300 was yanking on the resident's arm (she was unable to recall which arm). AA #310 stated the resident who is a gentle soul was attempting to hit STNA #300 and crying out. AA #310 stated AD #400 went over to help with the situation and was told by STNA #300 basically to leave her alone and that she had this. AA #310 stated the resident was petrified as STNA #300 forced her into her tilt-in- space wheelchair and placed her with her head to the ground and her feet in the air. AA #310 stated she was shocked and didn't know what to do. She stated the resident was positioned in a way she could not get out of the chair. AA #310 stated STNA #300 told the resident Don't get up. She stated the resident was crying and terrified. AA #310 stated AD #400 left the floor and went straight to HRM #600 to report the incident. She went on to say STNA #300 was very loud and scary to the residents, and she wished the unit had cameras because she had never heard of so much abuse in a facility. Interview on 09/11/24 at 11:38 A.M. with HRM #600 revealed AD #400 reported to her on 09/05/24 (she was unsure of the time) that STNA #300 forcefully put Resident #78 into her tilt-in- space wheelchair and tilted it fully back so the resident could not move. HRM #600 reported she advised AD #400 to write a statement and get UM #105 involved. HRM #600 stated she did not further report the issue and did not obtain a statement from AD #400. The HRM reported she doesn't deal with abuse allegations and defers them to the management. She stated she was mostly there for the support of the staff. She confirmed she did not follow the facility abuse policy by not reporting it to the Administrator or other leadership staff. Interview on 09/11/24 at 12:47 P.M. with Therapy Manager #705 revealed Resident #78 had a custom tilt-in- space wheelchair that she utilized for positioning to help her sit up straight. She reported the resident did well with the wheelchair and while receiving therapy, the resident could get up independently from the wheelchair and walk with staff assistance. Interview on 09/11/24 at 1:13 P.M. with LPN/UM #105 revealed one day last week AA #310 came to her and mentioned that she thought Resident #78 was being restrained in her tilt-in- space wheelchair by STNA #300. UM #105 stated she checked on the resident and removed the leg rest from her tilt-in- space wheelchair. The resident was not tilted back all the way at that time. She shared she provided verbal education to STNA #300 (however, there was no documented evidence of the education) regarding how tipping the chair too far back could be considered a restraint. She stated the next day in morning meeting AD #400 reported to her that STNA #300 had restrained Resident #78 and UM #105 stated she told AD #400 that she had already taken care of it at the time of the incident (with the verbal education provided to STNA #300). UM #105 verified this was not further reported to Administration when she addressed physical restraint use with STNA #300. During a telephone interview on 09/11/24 at 2:50 P.M. STNA #300 denied the allegations but reported Unit Manager #105 did provide her verbal education to not place Resident #78 in her wheelchair with the head laid back because it could be considered a restraint. Review of STNA #300's personnel file on 09/12/24 at 9:04 A.M. with HRM #600 revealed STNA# 300 was hired on 07/26/23. There was no performance review or record of dementia care education/training despite routine assignment to the facility secure dementia unit. HRM #600 stated STNA #300 was never entered into the online training system and therefore did not receive education. HRM #600 stated the facility had attempted to contact STNA #300's references provided on the employee's application, but the facility never received calls back from the references, so the facility moved forward with hiring STNA #300. Lastly, HRM #600 denied any formal discipline in STNA #300's personnel file. Review of STNA #300's time clock punch reports revealed the STNA worked 09/05/24 from 6:54 A.M. until 6:54 P.M., 09/07/24 from 6:54 A.M. until 5:46 P.M., and 09/10/24 from 6:53 A.M. until 6:55 P.M. Review of the staff schedule dated 09/05/24 through 09/10/24 revealed STNA #300 was scheduled to work on the secured unit. Review of the facility Self-Reported Incidents in the Enhanced Information Dissemination Center (portal for reporting incidents of alleged abuse) from 09/05/24 through 09/11/24 revealed no reporting of the incident involving STNA #300 and Resident #78. The facility had no investigation related to the incident reported to the Unit Manager #105 or HR #600. The DON was out of the office at the time of the incident and UM #105 was unable to locate a statement from AD #400 in the mailbox of the DON. Interview on 09/12/24 at 1:06 P.M. with MD #800 revealed he was not notified until today (09/12/24) regarding the incident of alleged abuse involving Resident #78. MD #800 stated it would be his expectation for the facility to immediately report allegations of abuse to administration, remove the STNA from the area and start an immediate investigation. Interview on 09/12/24 at 1:43 PM with the Administrator revealed he was unaware of the abuse allegation involving Resident #78 until it was reported to the surveyor during survey activity on 09/11/24. The Administrator stated he would have initiated an immediate investigation and taken the appropriate steps had he been aware of the incident. 2. Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including unspecified dementia with moderate behavioral disturbance, other sequelae of cerebral infarction, dysarthria following cerebral infarction, chronic kidney disease stage three, anxiety disorder, and major depressive disorder. The resident was noted to reside on the facility's secured dementia unit. Review of Resident #71's admission MDS 3.0 Assessment, dated 07/03/2024, revealed the resident was cognitively intact. The assessment indicated the resident had a lower extremity impairment to one side and utilized a wheelchair. The resident was dependent for showering and did have one to three days of behavioral symptoms towards others including hitting, kicking, pushing, scratching, and grabbing. Review of Resident #71's care plan, dated 07/08/24, revealed the resident had behaviors including yelling, cussing at other residents, refusing care, yelling out, being tearful and having loud outbursts, which required nonpharmacological interventions including redirect, reapproach, calm environment, quiet environment, comfort, active listening. Interventions included administer medications as ordered, approach, speak in calm manor, encourage the resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, and notify medical provider of increased episodes of behaviors. Review of Resident #71's shower sheet skin assessment, completed by STNA #200 and dated 09/07/24, documented the resident had a shower on this date. The only skin issue noted on the shower sheet was an old scab to her left arm. The form was also signed by LPN #102. Review of Resident #71's nursing progress notes for 09/07/24 revealed there were no progress notes regarding any allegation of abuse or issues/incidents related to the shower the resident received on this date. Review of Resident #71's nursing progress note dated 09/09/24 at 11:39 A.M. revealed UM #105 documented This nurse manager noted an aging bruise on the resident's left forearm. When speaking with the resident she stated that I think I bumped it on my bed when I fell . Resident did have an unwitnessed fall on 08/26/24. Review of Resident #71's nursing progress note, dated 09/10/2024 at 9:00 P.M. and created on 09/11/23 3:27 A.M. by Registered Nurse (RN) #315, revealed STNA (unidentified) reported that resident has a bruise on her entire right forearm. Resident was assessed by this nurse. She stated that a male aide, (STNA #200), with the blonde hair, grabbed her from behind, undressed her in front of everyone and twisted her arm. She said she grabbed his badge to check for his name and he grabbed it back. She said she fought back and screamed. According to her, this incident occurred on Saturday or Sunday between 2:00 P.M. to 4:00 P.M. She also stated that he called for a female aide, but it was only the male aide who was grabbing her arm. I was notified by an STNA (unidentified) that this resident told a similar story to another resident; manager-on-call (Assistant Director of Nursing #100) was notified; Family Member #701 updated via phone call at 10:45 P.M. Observation of Resident #71 on 09/11/23 at 11:10 A.M. revealed the resident had a large bruise with various shades of purple covering the entirety of her right forearm. Also noted was one dime size bruise to her right chest that was light red in color, one quarter sized bruise to the right chest that was light red in color, a scabbed area to her right arm, and a bruise to the right inferior upper arm the size of a thumb print which was light purple in color. The resident was seated in a wheelchair and had a contracture noted to her left hand. She presented to have minimal use of her left upper extremity. An interview with Resident #71 at the time of the observation revealed she received these injuries the past weekend when a male STNA (identified through scheduling/interview/description as STNA #200) came up to her from behind, grabbed her right arm and started taking her clothes off. The resident stated the STNA forced her into the shower while she was screaming and yelling for him to stop. The STNA then placed her under hot water and then turned it to cold water. She reported he placed shampoo on her head and face, and she was yelling, screaming, and fighting him to stop but he would not. She then reported another STNA, identified as STNA #300, told Resident #71 she paid him a hundred dollars to do this to her. The resident continued that STNA #300 is not a nice person. She gets mad and vicious. She screams at the residents. The resident reported she received all the injuries from STNA #200 forcing her into the shower. The resident stated that she called her son and told him of the incident and additionally reported the incident to staff members working the day it happened. Interview on 09/11/24 at 11:20 A.M. with Family Member #704 revealed he received a phone call from his mother on Saturday (09/07/24) stating that a male STNA threw her in the shower. His mother said she was scared and wanted him to come and get her. Family Member #704 stated he then called the facility nurse (LPN #102) who was working the unit and reported what his mother had told him. He requested that male staff members no longer work with his mother. He stated [TRUNCATED]

Based on observations, interviews, facility census review, record review, facility policy review, and the Centers for Disease Control (CDC) guidance review, the facility failed to implement a comprehensive and effective infection control program to prevent the spread of COVID-19. This resulted in Immediate Jeopardy and the potential for actual harm, serious life-threatening complications, death beginning on [DATE] when the facility failed to implement effective and recommended infection control practices, including implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility when five residents (#81, #89, #98, #101 and #103), who did not have COVID-19, remained in rooms with residents (#80, #90, #97, #100 and #102), who had tested positive for COVID-19. Resident #89 and #103 subsequently tested positive for COVID-19 following potential exposure from their positive roommate. In addition, the facility failed to accurately identify residents requiring isolation for COVID-19, failed to ensure all staff were knowledgeable of the necessary precautions to take when caring for COVID-19 positive residents and failed to ensure complete and accurate information was provided to the local health department and medical director regarding resident COVID-19 status. This affected five residents (#80, #90, #97, #100 and #102) who resided in rooms with residents who were positive for COVID-19 and had the potential to affect 48 additional residents (#2, #8, #9, #11, #15, #17, #18, #19, #24, #27, #28, #36, #38, #39, #42, #43, #44, #46, #47, #48, #49, #50, #51, #58, #61, #62, #63, #65, #66, #68, #70, #71, #72, #74, #75, #76, #79, #81, #85, #86, #87, #88, #98, #101, #105, #106, #107, and #108) who were negative for COVID-19 as of [DATE]. The facility census was 111. On [DATE] at 1:02 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] when the facility failed to implement a comprehensive and effective infection control program to prevent the spread of COVID-19 resulting in a COVID-19 outbreak affecting 63 total residents and 22 total staff between [DATE] and [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: The Administrator spoke with the Infectious Disease Coordinator at the local county health department regarding the current outbreak on [DATE]. The facility indicated the Administrator would personally continue weekly calls with the local county health department until the outbreak comes to an end. On [DATE] the Administrator sent an invitation to the local county health department to request an in-service for all staff on mitigating the spread of COVID-19. The in-service on transmission-based precautions, COVID-19 signs and symptoms, and handwashing is scheduled for Thursday [DATE] at 9:00 A.M. Residents #80, #81, #89, #90, #97, #98, #100, #101, #102 and #103 were separated on [DATE]. A bed audit was performed on [DATE] by the Administrator which confirmed there were no additional COVID-19 negative residents sharing a room with COVID-19 positive residents. This audit would be submitted to Quality Assurance (QA) committee for review. On [DATE] COVID-19 precaution signage was replaced by the floor nurse on COVID-19 positive rooms. This was confirmed by the Administrator on [DATE]. On [DATE] the Director of Nursing (DON) posted a message on OnShift (an all staff messaging system) to communicate to all staff to report to the facility to receive COVID-19 policy education immediately. On [DATE] Regional Director of Clinical Operations (RDCO) #2025 educated all staff, including the DON, and the Administrator on COVID-19 policies and identification of COVID-19 positive residents. Staff unable to come into the facility were educated over the telephone on [DATE]. COVID-19 policies are now included in the new staff orientation packet that will be reviewed by the DON during orientation. The education would be submitted to QA committee for review. On [DATE] the responsible parties/residents of all COVID-19 positive residents were called by Licensed Practical Nurses (LPNs) #1189, #1153, and #2026 and updated on the facility and resident's COVID-19 statuses. On [DATE] Residents #2, #8, #9, #11, #15, #17, #18, #19, #24, #27, #28, #36, #38, #39, #42, #43, #44, #46, #47, #48, #49, #50, #51, #58, #61, #62, #63, #65, #66, #68, #70, #71, #72, #74, #75, #76, #79, #81, #85, #86, #87, #88, #98, #101, #105, #106, #107, and #108 were tested for COVID-19 by nursing staff and remained negative. Per policy, all facility negative residents would be tested every three days until the facility goes 14 days without a new positive COVID-19 test result. On [DATE] an audit was performed by the Administrator to confirm the physicians/ nurse practitioners (NPs) were notified of the test results for all COVID-19 positive residents. The notifications were appropriately made on the dates of the positive test results. The results of this audit will be submitted to QA committee for review. On [DATE] the COVID-19 infection control policies were reviewed by Registered Nurses (RNs) #2027 and #2025, and the Interdisciplinary Team (IDT). The COVID-19 infection control policy was consistent with the CDC guidelines. No changes were made to the policy. The COVID-19 infection control policy would be reviewed by the QA committee. Beginning on [DATE] the Administrator/designee would audit resident rooms daily for four weeks to ensure that COVID-19 positive residents were not in rooms with COVID-19 negative residents. The results of these audits would be submitted to QA committee for review. Beginning on [DATE] the DON/designee would notify the Medical Director whenever there was a new positive COVID-19 case in the facility. This notification would be documented on a COVID-19 outbreak checklist. When completed, this checklist would be verified by RN #2025. Checklists would be submitted to QA committee for review. The Administrator/designee will notify the local county health department via email regarding new COVID-19 positive residents and staff. The email included a spreadsheet that contained demographic information, dates of tests, symptomatic or asymptomatic, and result information (hospitalized , expired, or stable). On [DATE] a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director via telephone. Details of abatement plan were reviewed, and the Medical Director was in agreement. Beginning on [DATE] signage was posted throughout the facility for proper PPE usage and signs and symptoms of COVID-19, and staff were being constantly monitored for proper PPE usage and educated immediately if improper use was witnessed. The DON/designee was auditing staff daily on proper PPE usage. Audits have been occurring every shift since [DATE]. On [DATE] donning and doffing PPE and COVID-19 policy and procedures were added to Relias staff training quarterly. On [DATE] the DON/designee began auditing staff daily on proper PPE usage and signs and symptoms of COVID-19. Audits have been occurring every shift since the announcement of the Immediate Jeopardy, [DATE]. On [DATE] residents were given flyers by the DON/designee educating them on mitigating spread of COVID-19, signs and symptoms of COVID-19, and vaccinations. Observation of the facility signage for residents in isolation on [DATE] at 3:19 P.M. confirmed all residents on droplet precautions had the appropriate signage on the door. Interview on [DATE] at 10:44 A.M. with the DON confirmed all staff had been educated on COVID-19 requirements, COVID-19 positive residents room status and infection control. Review of the sign in sheets revealed staff received the education provided. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the list of COVID-19 positive residents provided by the facility on [DATE] revealed 44 residents and 22 employees had tested positive between [DATE] and [DATE]. No staff worked after testing positive for COVID-19. On [DATE], Residents #80, #90, and #100 tested positive for COVID-19 as a result of an outbreak testing. Resident #81 (Resident #80's roommate) and Resident #101 (Resident #100's roommate) were also administered a COVID-19 test which came back negative. Resident #89 (Resident #90's roommate) tested positive for COVID-19 on [DATE]. All four residents remained in their respective rooms. On [DATE], Residents #97 and #102 tested positive for COVID-19. Resident #98 (Resident #97's roommate) was also administered a COVID-19 test which came back negative. Resident #103 (Resident #102's roommate) tested positive for COVID-19 on [DATE]. All four residents remained in their respective rooms. Interview on [DATE] at 9:10 A.M. with Licensed Practical Nurse (LPN) #1166 revealed she was aware of two residents (#80 and #97) who were currently positive for COVID-19 sharing a room with two residents (#81 and #98) who were negative for COVID-19. Observation at the time of the interview with LPN #166 confirmed Residents #80 and #81 and Residents #97 and #98 resided in the same room. A paper was taped to the doors for Residents #80 and #81 which revealed Resident #80 was in isolation from [DATE] through [DATE]. Interview on [DATE] at 9:33 A.M. with LPN/Infection Preventionist (IP) #1153 revealed staff began testing every three days and prior to coming to work after the outbreak began, which she believed was after Thanksgiving; she was not certain of the date. Review of the COVID-19 positive employee list provided by the facility revealed IP/LPN #1153 tested positive for COVID-19 on [DATE]. LPN #1153 confirmed she had not been in the facility for seven days after she tested positive and had to be asymptomatic for three to four days with a negative test result before returning to work. At the time of the interview, she indicated she had no knowledge of residents with COVID-19 sharing a room with residents who were negative for COVID-19. Interview on [DATE] at 1:35 P.M. with the DON revealed LPN #1142 and the Administrator talked about moving COVID-19 positive residents (to different rooms in the facility for isolation) but they decided it would cause the residents too much emotional distress. She revealed the facility was aware COVID-19 positive residents were co-horting with COVID-19 negative residents and then stated they had nowhere to move either of the residents. She confirmed no formal education had been provided to staff to educate them on which residents were COVID-19 positive and which were COVID-19 negative when sharing rooms, and the residents' guardians and/or representatives were not notified of the situation. Interview on [DATE] at 1:40 P.M. with State tested Nurse's Aide (STNA) #1160 revealed she was unsure which residents on the floor were COVID-19 positive and which were COVID-19 negative. She confirmed Resident #80 and #81's room had a sign that said Resident #80 was on droplet precautions, but her roommate (Resident #81) did not have a sign, therefore she was not sure if she was on precautions as well. She confirmed she received no education on proper use of PPE when working with COVID-19 positive residents. Interview on [DATE] at 2:05 P.M. with RN #2023 revealed the local county health department had advised the facility to isolate residents if they tested positive for COVID-19. The local county health department was not aware the facility was co-horting Covid-19 positive residents with COVID-19 negative residents. RN #2023 stated, if co-horting was unavoidable, they should only be co-horting with another COVID-19 positive resident. Interview on [DATE] at 2:25 P.M. with LPN #1142 revealed not all representatives of residents were called when the facility decided not to move residents to prevent COVID-19 negative residents and COVID-19 positive residents from remaining in the same rooms. Interview on [DATE] at 2:31 PM with Medical Director (MD) #2024 revealed he was not aware of an outbreak of COVID-19 in the facility. He confirmed he would not advise having COVID-19 positive and COVID-19 negative residents residing in the same room. Interview on [DATE] at 3:54 P.M. with Resident #81's guardian revealed she was not aware the resident remained in a room with a resident who tested positive for COVID-19. She confirmed if she had known, she would have asked for one of the two residents to be moved. She added Resident #81 had COVID-19 over two years ago and had significant difficulties throughout the course of the infection. Interview on [DATE] at 9:11 A.M. with the DON revealed there had actually been 61 resident cases of COVID-19 in the facility during the time period between [DATE] and [DATE]. She confirmed the list provided on [DATE] was not accurate. During a follow up interview on [DATE] at 9:27 A.M., the DON revealed there were 63 resident and 22 staff cases of COVID-19 since the outbreak started on [DATE]. She revealed she had updated the list each day but did not update the total at the bottom of the sheet to reflect the current number. Interview on [DATE] at 2:20 P.M. with Resident #98's son revealed he was unaware of a COVID-19 outbreak in the building until his wife visited last Thursday and was told Resident #98 (his mother) was COVID-19 positive. He revealed there was a sign on the door the resident was in isolation; however, it did not identify which resident in the rooms were affected. There were two residents in the room at the time of the visit. Resident #98's son further revealed he would absolutely want to know if his mother was in a room with a resident who tested positive for COVID-19; he would prefer her not be in the room. Review of resident medical record information revealed the following: a. Resident #80 tested positive for COVID on [DATE]. Resident #81 (who was negative for COVID-19) remained in the room with Resident #80 until [DATE] when Resident #80 was moved to a different room. b. Resident #90 tested positive for COVID on [DATE]. Resident #89 (who was initially negative for COVID-19) remained in the room with Resident #90. Resident #89 subsequently tested positive for COVID-19 on [DATE]. c. Resident #97 tested positive for COVID on [DATE]. Resident #98 (who was negative for COVID-19) remained in the room with Resident #97 until [DATE] when Resident #97 was moved to a different room. d. Resident #100 tested positive for COVID on [DATE]. Resident #101 (who was negative for COVID-19) remained in the room with Resident #100 until [DATE] when Resident #100 was moved to a different room. e. Resident #102 tested positive for COVID on [DATE]. Her roommate, Resident #103 (who was initially negative for COVID-19) remained in the room with Resident #102. Resident #103 subsequently tested positive for COVID on [DATE]. Record review revealed no evidence the resident's and/or their family/responsible party were notified for any of the residents who were negative for COVID-19, but remained in a room occupied by a resident who was COVID-19 positive. Review of the facility policy titled Criteria for COVID-19 Requirements, revised [DATE], revealed the facility would follow the Centers for Disease Control (CDC) guidance for COVID-19 testing and use of PPE, as well as the state and local health department. Residents who tested positive for COVID-19 would be placed on droplet precautions in a private room, if available. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE], revealed residents with suspected or confirmed COVID-19 should be placed in a single room or if co-horting was unavoidable, should only be housed in a room with someone having the same respiratory pathogen. This deficiency represents non-compliance investigated under Complaint Number OH00148837.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record, an open medical record, the facility incident investigation, self-reported incident (SRI), the emergency department discharge summary, the facility policy and procedure on abuse and mistreatment, the local police department incident report and staff interviews, the facility failed to ensure one resident (Resident #1) was free from physical abuse. Life threatening harm and death occurred on [DATE] when Resident #2 was observed punching Resident #1 repeatedly in the face while he sat in his specialized, full body support chair in his room. This resulted in Immediate Jeopardy when Resident #1 sustained a fractured nasal bone, a fractured right orbital bone and a subdural bleed of the brain. Resident #1 subsequently died at the facility on [DATE]. The cause of death was a subdural hematoma on the right side of the head resulting from [MEDICATION NAME] force trauma. This affected one resident, Resident #1, of four residents reviewed for abuse. The facility census was 148. On [DATE] at 12:00 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] at 7:30 A.M. when Resident #2 was witnessed, by Laboratory Technician (LT) #400, assaulting Resident #1 repeatedly in the face with his closed fist. Resident #1 had nasal bleeding and swelling of the right eye. Resident #1 was sent out to the emergency department and returned the same day with a discharge [DIAGNOSES REDACTED]. Resident #1 was placed on Hospice care (end of life care) upon returning to the facility and expired five days later, on [DATE]. On [DATE] at 1:08 P.M., telephone interview with Detective #410 revealed the final cause of death for Resident #1 was a subdural hematoma, resulting from [MEDICATION NAME] force trauma to the right side of his head. Detective #410 verified Coroner #413 said this would be the official cause of death listed on the coroner's report once completed. Resident #1 remained in the facility and was under 24-hour, 1:1 observation. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] at 3:00 P.M. when the facility implemented the following corrective actions: · On [DATE] at 7:30 A.M., Resident #1 and Resident #2 were physically separated. LT #400 remained in the room and went to the doorway to call for assistance from facility staff. Licensed Practical Nurse (LPN) #418 immediately responded. · On [DATE] at 7:31 A. M., Resident #2 was placed on 1:1 supervision and placed in a private room. The 1:1 supervision will continue indefinitely pending criminal law enforcement charges. Interview on [DATE] at 3:30 P.M. with the Administrator revealed if no criminal charges were filed, Resident #1 would continue with 1:1 supervision indefinitely as this is the only way he could assure the safety of the other residents. · On [DATE] at 7:35 A.M., Resident #1 and Resident #2 were assessed for pain and injury by LPN #401 and LPN #418. Resident #1 was provided immediate treatment for [REDACTED].#1. · On [DATE] at 7:35 A.M., the physician for Resident #1 was notified of the incident by LPN #401 and the physician for Resident #2 was notified by LPN #418. The Power of Attorney and guardians for each resident were notified along with hospice services for Resident #1 at these times. · On [DATE] at 7:35 A.M., Resident #2 was assessed by Psychiatrist #402 via telecommunication. an order for [REDACTED]. · On [DATE] at approximately 7:35 A.M., LPN #403 notified the Director of Nursing (DON) of the incident. The DON immediately called the Administrator. Then at approximately 7:40 A.M., the Administrator notified Regional Director of Operations #415 and Regional Director of Clinical Operations #416 of the incident. · On [DATE] at 7:45 A.M. the facility initiated and submitted a facility SRI to the State Agency. · On [DATE] at 7:50 A.M., the local police department was notified of the incident. · On [DATE] at 7:55 A.M., the behavior history of Resident #2 was reviewed and no history of aggression towards other residents since his admission to the facility were identified. · On [DATE] at 8:45 A.M., Resident #1 was transported to the emergency department for further evaluation and treatment. · On [DATE] at 9:00 A.M., the facility implemented daily audits of all residents with behaviors to reduce potential escalation of aggression. These audits will be completed by the DON or designee. The results of the audits will be reviewed every morning during morning meeting and reported to the Quality Assurance Performance Improvement (QAPI) Committee at least monthly. · On [DATE] at 9:30 A.M. all working employees were educated on the abuse policy and procedure and all other staff were educated before the beginning of their next scheduled shift. The education of all facility staff was completed by the DON or her designee as of [DATE] at 3:00 P.M. · On [DATE] at 10:00 A.M. interviews were completed with all interviewable residents with regards to abuse concerns. No concerns were identified. · On [DATE] at 10:00 A.M. skin sweeps were conducted on all non-interviewable residents to assess for signs of abuse with no concerns identified. · On [DATE] at 1:30 P.M. Resident #2 was assessed by Nurse Practitioner (NP) #404 and all current interventions were reviewed and maintained including the assessment and anticipation of his needs, the assessment of his understanding of the situation and allowing time for the resident to express himself, involve resident in choices regarding care and activities, monitoring and documentation of any observed behaviors and attempted interventions, analysis of what escalates his feelings, assessment of and evaluation of his medications including possible side effects, providing positive feedback for good behavior, emphasize the positive aspects of compliance. Staff are to intervene before agitation escalates and guide resident away from the source of distress, and engage resident calmly in conversation. If Resident #2 becomes aggressive, staff are to calmly walk away and re-approach later. If Resident #2 becomes overly stimulated, inform the nurse to locate a quiet area for him to retreat. Psychiatric consults would be provided as indicated. · Interviews were completed on [DATE] from 2:40 P.M. through 3:35 P.M. with Licensed Social Worker (LSW) #407, LPN #408, the Assistant Director of Nursing, State tested Nursing Assistant (STNA) #450, STNA #451 and STNA #452. These staff members verified they received in-service and education related to abuse between [DATE] and [DATE]. The education provided included the knowledge of signs or symptoms displayed by residents that could lead to an abuse situation. Findings include: Review of the medical record for Resident #1 revealed a date of birth [DATE] with the most recent admitted on [DATE]. [DIAGNOSES REDACTED]. He was receiving palliative care, comfort care, through hospice services. Review of the Minimum Data Set (MDS) 3.0 comprehensive assessment, dated [DATE] revealed staff completed a brief interview for mental status (BIMS). Resident #1 scored a zero on a scale of zero to 15, with zero indicating severe cognitive impairment. The MDS section for hearing and speech revealed Resident #1 had unclear speech and was sometimes understood by others when he spoke and usually understood others when they spoke. The behavioral assessment revealed the resident would often have verbal behavioral symptoms directed toward others four to six days of the week. Resident #1 was dependent on staff for all Activities of Daily Living (ADLs). Resident #1 did not ambulate and was often in his Broda chair. Review of the care plan dated [DATE] and updated on [DATE] for Resident #1 included focus areas of social interaction and behaviors related to cognitive deficits, communication difficulty related to slurred speech, mood and anxiety behaviors related to dementia including verbal and physical outburst and constant talking to imaginary people. Review of the medical record for Resident #1 revealed no prior outbursts of yelling or crying. Resident #1 expired in the facility on [DATE] as a result of [MEDICATION NAME] force trauma to his head. Review of a nursing note for Resident #1, authored by LPN #401, dated [DATE] at 2:41 P.M., indicated at 7:30 A.M. Resident #1 was seated in his Broda chair in his room. His roommate, Resident #2, became agitated with Resident #1's verbal outburst. A physical altercation occurred. Resident #1 was immediately removed from the situation to a safe place. Notifications were made to the physician, hospice staff, and his guardian. Resident #1 was sent to the emergency department for evaluation and treatment per the request of the physician and guardian. Review of the medical record for Resident #2 revealed a date of birth of [DATE] and admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 on a scale of zero to 15 indicating the resident was cognitively intact. The MDS assessment reflected no physical or verbal outbursts directed at others or himself. Resident #2 was ambulatory and independent with ADLs. Resident #2 received mental health services along with the use of antipsychotic and antidepressant medications at the time of the incident. Review of the nursing notes and medical record for Resident #2 from [DATE] through [DATE] revealed no other incidents of physical abuse towards any other residents or staff. Review of Resident #2's care plan initiated [DATE] with the latest revision on [DATE], addressed the focus areas for the potential to demonstrate verbal or physically abusive behaviors related to mental and emotional illness and related diagnoses. Behaviors specifically identified on the care plan included: running in the facility, repeated calls for mother, sleeping, refusal of care, twitching, pacing, impulsive decisions and leaving to find a quiet place. Review of the facility SRI dated [DATE] revealed at 7:50 A.M. an investigation was started related to resident to resident physical abuse between Resident #1 and Resident #2. The investigation indicated the abuse was reported to the Administrator by the DON on [DATE] at 7:40 A.M. Resident #2 had struck Resident #1 in his face while in their shared room on [DATE] at approximately 7:30 A.M. The residents were separated and assessments for pain and injury were completed. First aid was administered to Resident #1 for a bloody nose and he was later transferred to the hospital for further evaluation. Resident #2 was placed under continuous 1:1 staff supervision. Physicians and guardians for each resident were notified. Review of the discharge form from the emergency room titled, Discharge instructions, dated [DATE], for Resident #1 revealed he was now listed as having a Do Not Resuscitate (DNR), an order for [REDACTED].#1 sustained a 2.5 millimeter (mm) right subdural hematoma, right-sided orbital fracture and a nasal bone fracture. Review of a nursing note for Resident #2 dated [DATE] at 10:45 A.M., authored by the DON, provided a summary of the incident from [DATE] at 7:30 A.M. The DON indicated LPN #403 notified her via telephone on the handwritten witness statement, dated [DATE] at 7:30 A.M. The DON indicated she was informed Resident #2 had a physical altercation with his roommate. Resident #2 was separated from Resident #1. Resident #2 denied any pain and no skin issues were noted. Psychologist (PSY) #402, was notified and medications were adjusted for Resident #2. A urinalysis and laboratory blood test for Resident #2 were ordered. Resident #2 was immediately placed on continuous 1:1 staff supervision. Resident #2 apologized for the incident. The primary care provider and responsible party were notified. Review of the email statement dated [DATE], obtained from LT #400, revealed she was leaving the room of another resident after completing a blood draw. She said she was walking in the hall and noticed in a room, a man standing over another patient and he was repeatedly punching him. She said hey and Resident #2 stopped. She proceeded to obtain assistance from the nursing staff and found Resident #1 beaten up and bleeding all down his face. His right eye was swollen, and a bruise was forming. When asked what happened, Resident #2 said Resident #1 was laughing and would not shut up. Review of the written witness statement from LPN #403, dated [DATE] indicated at 7:30 A.M., during her medication pass, she was informed by LT #400, that a resident was hitting another resident. She entered the resident room and found Resident #1 sitting in his Broda chair, bleeding from his nose and mouth. LPN #403 asked Resident #2 what happened and Resident #2 stated his roommate was laughing at him. Review of the police report titled, Ohio Uniform Incident Report, #,[DATE], dated [DATE], listed Resident #1, as the victim of the offenses of assault. LPN #403 had notified the police department of the alleged assault via telephone on [DATE] at 7:50 A.M. Detective #410 responded to the call. Review of the mortician document dated [DATE] revealed Resident #1's body was released to the County Coroner's office. Review of the document received from Detective #412, titled, Narrative Supplement, dated [DATE] revealed on [DATE] she had contacted the coroner's office related to the completion date of the autopsy for Resident #1. Later the same day, Detective #412 was contacted by County Coroner #413 and indicated the autopsy on Resident #1 was complete and the preliminary cause of death was a subdural hematoma on the right side of Resident #1's head and the preliminary manner of death was homicide. On [DATE] at 2:00 P.M., interview with the Administrator and DON verified Resident #2 had struck and assaulted Resident #1 in the face/head on [DATE]. Both staff denied any known history of abusive behavior from Resident #2 prior to this incident. An interview was completed with Resident #2 on [DATE] at 4:20 P.M. Resident #2 stated he hit Resident #1 in the face a couple of times because, I thought he was laughing at me. Interview completed on [DATE] at 5:04 P.M. with the Medical Director verified the incident and stated NP #404 had been to the facility to assess Resident #2 after the incident on [DATE]. The Medical Director was not aware of any past problems of aggression related to Resident #2. The county coroner's office was contacted on [DATE] at 5:08 P.M. and the coroner's report was not complete and not available at the time of the investigation. Interview completed on [DATE] at 5:10 P.M. with the physician for Resident #1, Physician #405, stated he had not been aware of Resident #1 having been physically abused by any resident or staff member in the past. Interview on [DATE] at 5:15 P.M. with Physician #406, the primary care physician for Resident #2, revealed he had not been aware of any prior episodes of aggression. He said Resident #2 was very nice when he had visited him. Interview completed on [DATE] at 5:20 P.M. with NP #404 revealed the Medical Director and she were notified promptly of the incident between Resident #1 and Resident #2. NP #404 stated she assessed Resident #2 on the morning of [DATE]. She said he had no prior aggressive behaviors. Interview completed via telephone on [DATE] at 8:40 A.M. with the Administrator revealed he had no knowledge of Resident #2 requesting any room changes or reporting any problems with his roommate. The behaviors on [DATE] were out of the ordinary and he had no idea what triggered Resident #2 to hit his roommate. A second interview was completed with Resident #2 on [DATE] at 8:45 A.M. Resident #2 stated they (Resident #1 and Resident #2) had been roommates for several years. He said nothing out of the ordinary had happened. He said Resident #1 would not shut up. When asked if Resident #1 was laughing at him Resident #2 stated, It wasn ' t that. He said Resident #1 was yelling and would not shut up. He yells all the time. Resident #2 stated he had never asked for a room change or notified the staff of any concerns or problems with Resident #1. Interview was completed via telephone on [DATE] at 8:50 A.M. with Assistant Director of Nursing (ADON) #409. She stated nothing out of the ordinary happened on the morning of the incident. Resident #1 was his usual self and she had no knowledge of outbursts of laughter or yelling as that would have not been normal or baseline behavior for Resident #1 as he was pleasant. She said Resident #2 had never asked for a room change to her knowledge. Interview completed via telephone on [DATE] at 9:26 A.M. with Detective #410 in charge of the case indicated no specifics could be discussed as it was an open case. A summary of the incident was obtained verifying the assault allegation on the victim, Resident #1. An interview was completed via telephone on [DATE] at 9:35 A.M. with LT #400, who witnessed the incident involving Resident #1 and Resident #2 on [DATE]. LT #400 stated she was walking down the hallway and saw Resident #2 standing over Resident #1 and hitting him in the face. LT #400 said hey and the resident stopped as LT #400 secured help. She stated Resident #2 hit Resident #1 at least three times in the face. Resident #2 had blood on his left hand. She did not hear any laughing or yelling out before witnessing the assault. She was just walking by the room and the door was open. LT #400 stated, Resident #2 went and laid back in his bed and stated, he was laughing and would not shut up. Interview completed via telephone on [DATE] at 10:02 A.M. with LPN #401, the unit nurse manager, revealed Resident #2 was brought down to her unit for assessment and monitoring. She completed the assessment and the police department arrived shortly thereafter. LPN #401 stated Resident #2 had no prior behavioral outburst prior to the incident. Interview via telephone was completed on [DATE] at 2:00 P.M. with the Administrator and the timeline of events and corrective actions listed above were verified. On [DATE] at 10:30 A.M. the coroner's office was contacted, and the call was received by Administrative Secretary (AS) #411 who stated Coroner #413 oversaw the case and was not in the office the week of the survey. She could not verify the cause of death and stated it would be four to six weeks before the toxicology results were received back, and a final report was generated. No other information was provided. Interview on [DATE] at 10:39 A.M. with the lead detective for the case, Detective #412, revealed she did not have a final coroner's report but verified the preliminary report from Coroner #413 stated the cause of death for Resident #1 was a subdural hematoma to the right side of the head. Review of the facility's policy and standard procedure for Abuse, Neglect and Misappropriation, last revised [DATE], revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Page four of the policy, under the section titled Policy, indicated it was the policy of the facility to prevent the abuse, mistreatment or neglect of residents. This deficiency substantiates Complaint Number OH 265.

Based on observation, record review and interview, the facility failed to ensure the administration of an [MEDICATION NAME] medication prior to a dressing change for Resident #230. This resulted in actual harm when Resident #230 experienced increased pain during the observed dressing change. The facility also failed to ensure post [MEDICAL TREATMENT] assessments were completed for Resident #67. This affected one resident (Resident #230) of six residents receiving wound care and one resident (Resident #67) of two residents who received [MEDICAL TREATMENT]. The facility census was 138. Findings include: 1. Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was receiving [MEDICAL CONDITION] therapy five days a week. He was also on palliative care, and required a daily dressing change to a buttocks pressure wound described on 11/11/15 as suspected deep tissue injury with dark purple discoloration to left inner buttock measuring 8.0 centimeters (cm) in length by 4.5 cm width with an area to the center of discoloration measuring 2.5 cm by 1.0 cm. He had a physician's orders [REDACTED]. Observation of the dressing change was completed on 11/17/15 at 12:43 P.M. with Licensed Practical Nurse (LPN) #10, assisted by State tested Nursing Assistant (STNA) #11. As the resident was gently rolled to his right side, he began to grimace and moan. During the dressing change procedure, he exhibited significant pain both verbally and non-verbally with large eyes, grimacing and multiple vocalizations. The nurse apologized, and finished the procedure at 12:58 P.M. When questioned if the resident was pre-medicated with pain medication, she stated that she did not provide this. The visiting family member indicated at 1:05 P.M. that the resident was usually comfortable when left undisturbed, but has pain when they move him. Review of the palliative care nursing documentation dated 11/10/15 indicated, patient will not be truthful with nursing staff and doctor regarding pain, sleep and nutrition. Ordered [MEDICATION NAME] pain medications included [MEDICATION NAME] 5 milligrams (mg) every 4 hours as needed, [MEDICATION NAME] 10-325 mg every 6 hrs as needed, and [MEDICATION NAME] ([MEDICATION NAME]) 5mg/5ml every 4 hours as needed. The most recent administration of any of these medications was for [MEDICATION NAME] on 11/17/15 at 5:05 A.M., over seven hours prior to this procedure. LPN #11 and the Director of Nursing both confirmed on 11/17/15 at 11:54 P.M. that this resident should have been pre-medicated for anticipated pain needs prior to the dressing change procedure that was observed to be completed above. 2. Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #67's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive impairment. Review of Resident #67's physician orders [REDACTED].M. and an order dated 08/11/15 for Return [MEDICAL TREATMENT] Evaluations to be completed in the afternoon every Tuesday, Thursday and Saturday. Review of Resident #67's medical record revealed the facility Return [MEDICAL TREATMENT] Evaluations from 10/01/15 to 11/17/15 were not completed on 10/01/15, 10/03/15, 10/06/15, 10/13/15, 10/15/15, 10/17/15, 10/20/15, 10/22/15, 10/24/15, 10/27/15, 10/29/15, 10/31/15, 11/03/15, 11/05/15, 11/10/15, 11/12/15 and 11/14/15. Observation on 11/17/15 at 2:52 P.M. revealed Resident #67 was in his room watching television. Interview with Resident #67 immediately following the observation revealed the resident received [MEDICAL TREATMENT] three times per week. Interview on 11/17/15 at 3:41 P.M. with the Director of Nursing (DON) verified seventeen of twenty-one Return [MEDICAL TREATMENT] Evaluations were not completed as required per the physician order.

Based on record review and staff interview, the facility failed to ensure Resident #79 received adequate supervision to prevent a fall with injury. This resulted in actual harm when Resident #79 experienced a fall resulting in a hip fracture in the proximity of a hazardous renovation area within the facility. This affected one resident (Resident #79) of three residents reviewed for accidents. The facility census was 138. Findings include: Review of Resident #79's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes, dated 08/17/15 revealed the resident suffered a fall landing on the left hip and 911 was called for transport to the local hospital. An additional nurse's note, dated 08/18/15 revealed the facility was informed by the hospital the resident was admitted with a [DIAGNOSES REDACTED]. Review of the fall investigation indicated on 08/18/15 the resident was ambulating in the unit dining room, grabbed and went under caution tape in area under renovation. The resident then tripped over the construction materials falling landing on her left hip. On 11/18/15 at 11:40 A.M., interview with the Administrator and Director of Nursing verified that Resident #79 entered an area under renovation, fell and sustained a fracture to the left hip. They further stated a construction worker was installing a temporary wall to prevent residents from wandering into the construction zone, but the area during construction of the temporary wall was not being monitored by staff.