Every finding on record at Harmony Court Rehab and Nursing

Based on observation, resident interview, and staff interview, the facility failed to provide a safe, functional and sanitary environment. This affected one (Residents #78) and had the potential to affect all of the residents in rooms 302, 304, 317, and 325. The facility census was 96 residents. Findings include: 1. Interview on 06/01/26 at 11:59 A.M with Resident #78 on confirmed the resident had a leak in his ceiling. Staff had placed containers in the resident's room to catch the water that leaked in while it was raining the previous week but no one has come to repair the leak. Interview on 06/03/26 at 12:00 P.M. with Assistant Director of Nursing (ADON) #385 confirmed Resident #78 did have a leak in his ceiling during the previous week's heavy rain. Interview on 06/03/26 at 3:36 P.M. with Clinical Director (CD) #607 and the Administrator confirmed they were unaware of the leak in Resident #78's room. CD #607 stated the roof needed some work and the facility needed to fix the leak in Resident #78's room. 2. Observation on 06/01/26 at 12:15 P.M. revealed the walls in room [ROOM NUMBER] were dirty and scuffed. The wall in room [ROOM NUMBER] was missing a bathroom mirror and the wall had gouges in it. Observation of the bathrooms in rooms [ROOM NUMBERS] revealed the linoleum was coming up causing a trip hazard. Interview on 06/01/26 at 12:20 P.M. with Certified Nursing Assistant (CNA) #781 verified the dirty walls, the missing mirror, the gouges in the walls, and the loose linoleum flooring of resident rooms. Interview n 06/03/26 at 1:37 P.M. with CD #607 on 06/03/26 at 1:37 P.M. confirmed there were several resident rooms that needed new linoleum on the bathroom floors and also many rooms that needed to be repainted. This deficiency represents noncompliance investigated under Complaint Number 3027775 and Complaint Number 3022262 and Complaint Number 3017462.

:THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, staff interview, review of facility Self-Reported Incidents (SRI), review of the facility investigation, review of the local weather report, and review of the facility policy, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy when Resident #70 left the facility without staff knowledge, was missing approximately three hours and was found approximately 0.8 miles from the facility by a facility staff member before returning to the facility. This affected one (Resident #70) of three residents reviewed for risk of elopement. The facility identified 26 residents at risk for elopement. The facility census was 101. On 04/02/26 at 1:05 P.M. the Administrator, Director of Nursing (DON), and Director of Clinical Operations (DCO) were notified Immediate Jeopardy began on 10/11/25 at 8:55 P.M. when Resident #70's wife called the facility and reported to Licensed Practical Nurse (LPN) #281 that Resident #70 was not in the facility. He had called his wife from his personal cell phone stating he was at a bus stop. LPN #281 transferred Resident #70's wife's call to Registered Nurse (RN) #282 who was working the 400 Unit, a secured memory care unit. RN #282 did not answer the phone. LPN #281 did not take any further action to report or search for the missing resident. On 10/11/25 at 9:20 P.M., Resident #70's wife called back and asked LPN #281 if the staff had located the resident. LPN #281 then physically went to the 400 Unit to inform RN #282 Resident #70 was reportedly not in the facility. Certified Nursing Assistant (CNA) #280 and RN #282 realized Resident #70 was not on the secure memory care unit and began searching for him throughout the facility. At 9:45 P.M. CNA #280 reported to the night shift supervisor, LPN #219, that Resident #70 was missing. Staff began searching for Resident #70 outside the perimeter of the building and were unable to locate the resident. At 10:05 P.M. LPN #219 searched the neighborhood in his private vehicle and returned to the facility at 10:21 P.M. unable to locate Resident #70. At 10:38 P.M., RN #282 notified the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator that Resident #70 was missing. No one from the facility notified local police to assist in the search for Resident #70. At 10:50 P.M., RN #282 searched the neighborhood in his private vehicle and at 11:03 P.M. returned to the facility with Resident #70, who was found 0.8 miles away from the facility at a bus stop on the other side of a four-lane road. At 11:30 P.M. the Administrator checked the Unit 400 egress door which was functioning properly, but the secondary screamer alarm was buzzing softly and not sounding loudly enough to alert staff when a resident exited the door. The Immediate Jeopardy was removed on 10/12/25 and continued at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) until it was subsequently corrected on 10/26/25 when the facility implemented the following corrective actions: On 10/11/25 at 11:03 P.M., RN #282 returned to the facility with Resident #70. RN #282 and the ADON assessed Resident #70, who was at his baseline with no injuries noted. Resident #70 was placed on one-on-one supervision immediately upon his return to the facility and remained on one-on-one supervision for the next 72 hours. On 10/11/25 at 11:05 P.M., RN #282 notified Resident #70's wife and the Medical Director (MD) that Resident #70 was located and returned to the facility. On 10/11/25 at 11:15 P.M., the DON and ADON completed a full facility head count with no missing residents. On 10/11/25 at 11:30 P.M., the Administrator changed the battery to the Unit 400 egress door so the secondary screamer alarm to the door would sound loudly if anyone tried to exit the door. The Administrator also checked the other secured doors, and all were functioning properly. The Administrator also checked Unit 400 windows and found no windows had been broken and all windows on the unit remained secure. On 10/12/25 beginning at 12:30 A.M., the DON and ADON begin immediate education with the staff present in the facility to reeducate them on the Elopement Wandering Management Protocols/Missing Person policy and the Resident Abuse, Neglect, Misappropriation of Resident Property and Injury of Unknown Origin policy. Education also included responding immediately regarding a report of a missing resident and the importance of not leaving the secured units unattended. Education continued for current staff and was completed on 10/12/25 unless they were either on vacation, paid time off (PTO), or sick leave. Current staff were notified via the OnShift scheduling messaging system that prior to the start of their next scheduled shift they had to contact the Administrator, the DON, or the ADON before accepting an assignment. Education continued for all new employees during orientation and as needed. The DON and the ADON also gathered staff statements regarding the incident. The training was completed with the staff working the 7:00 P.M. to 7:00 A.M. shift by 1:00 A.M. on 10/12/25. The weekend RN Supervisor #283 continued to educate staff on both shifts on 10/12/25 and all training was finished at approximately 7:30 P.M. on 10/12/25. On 10/12/25 at 10:30 A.M., the Maintenance Director changed the codes on all secured units and egress doors. On 10/12/25, the Administrator and the ADON terminated employment for RN #282 and for CNA #280. Both employees were terminated for falsification of records and for giving misleading information during an investigation. Initially, RN #282 told administration Resident #70 had been found outside the building when the resident was found 0.8 miles away from the facility. On 10/12/25, the DON reported RN #282 to the to the Ohio Board of Nursing for falsification of records. On 10/12/25, the DON reported CNA #280 to the Ohio Nurse Aide Registry for falsification of records. On 10/12/25, the DON interviewed Resident #70 about the elopement and the resident said he watched the enemy flow of the enemy and then used them for cover, waited for the right time, grabbed his jacket, and then slipped into the night. On 10/12/25, at 10:30 A.M., the DON completed updated elopement assessments/evaluations for all current residents on secured units (the 100 Unit, the 200 Unit, the 400 Unit) The also DON reviewed elopement binders for all units and updated them as needed. On 10/12/25, the Maintenance Director/Designee began auditing all secured doors and alarms five times per week for four weeks, then weekly for four weeks and then monthly ongoing. Review of the audit reports revealed audits were conducted on the following dates: Week One-10/12/25, 10/13/25, 10/14/25, 10/15/25, 10/16/25, 10/17/25, Week Two-10/20/25, 10/21/25, 10/22/25, 10/23/25, 10/24/25, Week Three-10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, Week Four-11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, Month One-11/20/25, 11/26/25, Month Two-12/3/25, 12/9/25, 12/16/25, 12/22/25, 12/30/25, Month Three 1/1/26, Month Four- 2/4/26, Month Five- 03/03/25. On 10/13/25, the Administrator began questioning five randomly selected staff members regarding elopement and missing person protocols. This was completed once weekly for four weeks. Review of the documentation revealed the performance monitoring was conducted on the following dates: Week One-10/13/25, 10/14/25, 10/15/25, 10/16/25, 10/17/25, Week Two-10/20/25, 10/21/25, 10/22/25, 10/23/25, 10/24/25, Week Three-10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, Week Four-11/03/25. On 10/13/25 at 3:00 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with participation of the Administrator, the DON, the Medical Director and a member of the Governing Body (the DCO) to review and discuss the incident involving Resident #70 and a plan of action. On 10/13/25, the Administrator and the DON completed a root cause analysis of Resident #70's elopement and determined that a delayed response by staff in identifying the residents' absence and notifying the appropriate individuals resulted in an extended duration of the resident being missing. The prompt return of the residents could have been achieved through quicker identification and notification. It was also found that the Unit 400 egress secondary screamer alarm buzzed softly until the battery was replaced, which would have allowed a person to exit the unit without alerting staff. Beginning on 10/16/25, ongoing monitoring and education elopement drills were conducted at varying times weekly for four weeks and then quarterly thereafter. Review of the audit reports revealed elopement drills were conducted on the following dates and times: 10/16/25 at 3:58 PM P.M., 10/17/25 at 3:20 P.M., 10/31/25 at 2:59 P.M., 11/5/25 at 9:00 A.M., 02/10/26 st 2:20 P.M. There were no negative findings during any of the drills. The facility will continue with quarterly elopement drills. By 10/19/25, the Maintenance Director installed an additional camera for the 400 unit. Observation on 04/06/26 revealed a camera at the entrance to unit 400 pointing down the hallway to the egress door. By 10/19/25, the facility purchased three additional cordless phones to aid staff with rapid communication in the event of an elopement. On 04/02/26, review of the medical records for two additional Residents #9 and Resident #57 reviewed for elopement, revealed no concerns. On 04/06/26, random observations of Resident #70, Residents #9, and Resident #57, revealed elopement interventions were in place and residents were not actively exit-seeking. On 04/01/26 and 04/02/26 between 8:00 A.M. and 3:30 P.M., staff interviews were conducted with CNAs #272, #133, LPNs #225, #237, and MA #241, which confirmed staff were knowledgeable about the procedures to follow if a resident eloped from the facility and the need to reassess residents for elopement risk if they had a change in condition such as increased wandering behaviors and/or exit-seeking behaviors. Interview on 04/06/26 at 10:00 A.M. with the DCO and the Administrator confirmed the facility has had no further elopements since Resident #70's elopement on 10/11/25. Findings include: Record review revealed Resident #70 was admitted on [DATE] with diagnoses including dementia, hypertension, major depressive disorder, and diabetes mellitus type two. Review of the admission baseline care plan for Resident #70 dated 10/06/25 revealed the resident was assessed as being at risk for elopement and should reside in a secured unit due to cognitive impairment and wandering tendencies. Review of the nurse progress note for Resident #70 dated 10/12/25 at 2:23 A.M. per RN #282 revealed on 10/11/25 at 11:00 P.M., Resident #70 was discovered missing during a routine check. Resident #70 was found outside the door and escorted inside. Resident #70 reported to the nurse he had been out looking for his car. A head-to-toe assessment of Resident #70 revealed the resident had no injuries, was alert and oriented to person and place which was the resident's baseline, and vital signs were within normal limits. Resident #70 was placed on one-on-one supervision. The nurse notified management, the resident's wife, and the resident's medical provider with no new orders noted. During an interview on 04/01/26 at 5:26 P.M., the ADON stated she received a call from RN #282 on 10/11/25 at approximately 10:00 P.M. reporting Resident #70 was missing from the facility. The ADON stated she told RN #282 to check all the rooms then called the DON and the Administrator to notify them of the missing resident. While the ADON was in transit to facility, RN #282 called and reported Resident #70 had been found right outside the door to the unit. The ADON arrived shortly before 11:00 P.M. and went immediately to the 400 Unit, but neither Resident #70 nor RN #282 were on the unit. The ADON then opened the egress door to the 400 unit using the code, but the screamer alarm on the door buzzed softly and was not loud enough to alert staff. RN #282 and Resident #70 then arrived on the unit. The ADON and RN #282 assessed Resident #70 for injuries. He was not injured. The ADON asked RN #282 to go outside with her to show her the exact location where the RN had found Resident #70. RN #282 indicated Resident #70 was at a bus stop adjacent to the Captain D's restaurant across Reading Road which was a four-lane road, 0.8 miles from the facility. The Administrator arrived and checked the camera footage from the facility camera in the 400 unit which revealed staff began searching for Resident #70 two hours prior to any call to management. Review of the camera footage also revealed RN #282 and CNA #280 had left the unit unattended during the time Resident #70 exited the building. The ADON verified RN #282 and CNA #280 were the only staff assigned to the 400 unit at the time of Resident #70's elopement. RN #282 and CNA #280 were on a different unit at the time of the elopement. The ADON confirmed the facility had a policy to never leave a secured unit unattended. The ADON confirmed RN #282 changed his version of the events surrounding Resident #70's elopement multiple times. During an interview on 04/01/25 at 4:50 P.M., the DON stated the ADON notified her by phone of Resident #70's elopement on 10/11/25 at approximately 11:00 P.M. The DON stated she then notified the Administrator and the DCO by phone of the elopement. The DON stated when she arrived at facility on 10/11/25, Resident #70 was back in the unit, had been assessed and placed on one-on-one supervision. RN #282 then reported to the DON that Resident #70 had been found outside, across a field, off the property about 0.8 miles from the facility and on the other side of a four-lane road at a bus stop near Captain D's restaurant on Reading Road. The DON stated multiple staff interviews confirmed they had heard no alarms sounding at any time while Resident #70 was missing. During a second interview on 04/02/26 at 11:37 A.M., the DON stated she expected staff to contact her and the Administrator immediately when a resident was missing from the facility. The DON stated when staff contacted her on 10/11/25 at 10:00 P.M. to report Resident #70 as missing they did not share the resident's wife had reported him missing at 8:55 P.M. The DON further stated calling the police for assistance did not occur to her at the time, because the ADON lived less than 20 minutes from facility and would arrive soon to manage the situation. The DON verified the staff failed to follow the missing persons policy by failing to immediately call a code E designating an elopement and failed to immediately notify management, the resident's physician and the local authorities. During an interview on 04/02/25 at 9:47 A.M., the Administrator stated when RN #282 found Resident #70 on 10/11/25, the resident was dressed appropriately for the weather and was wearing a red shirt, pants, shoes with socks and had a jacket with him. During an interview on 04/02/26 at 9:49 A.M. by telephone, LPN #237 stated she had worked on the 100 unit on 10/11/25 from 7:00 P.M. to 7:00 A.M. LPN #237 stated when she returned from lunch around 10:00 P.M. staff told her Resident #70 was missing and she went to the 400 unit to see if she could help. LPN #237 then went out the back door with CNA#280 and RN 282 to look for Resident #70 outside the building, but they could not find him. During an interview on 04/06/26 at 1:40 P.M., the DCO stated the DON notified him of Resident #70's elopement on 10/11/25 at approximately 11:00 P.M. The DCO verified he actively participated in the ad hoc QAPI meeting the facility held on 10/13/25 where they reviewed and discussed the incident involving Resident #70 and developed a plan of action. Review of the online weather report dated 10/11/25 at 9:00 P.M from Weather Underground revealed in Cincinnati, Ohio the air temperature during the time Resident #70 was missing from the facility was 56 degrees Fahrenheit (F) with no precipitation and a wind speed of approximately five miles per hour. Review of the facility incident investigation report for Resident #70 dated 10/13/25 revealed the resident was last seen in the facility on the unit on 10/11/25 at 8:00 P.M. and was reported missing by the resident's wife at 8:55 P.M. The investigation determined Resident #70 likely exited the facility when the unit was unattended by staff via 400-unit egress door around 8:30 P.M. The screamer feature to the 400-unit door did not sound loudly because the battery needed to be replaced. Staff found Resident #70 out of the facility off the facility grounds and returned the resident back to facility unharmed at 11:03 P.M. Review of the facility SRI regarding Resident #70's elopement initiated 10/11/25 and completed 10/17/25 revealed the facility substantiated an allegation of neglect of the resident per RN #282 and CNA #280. Review of the facility policy titled Missing Person Policy dated July 2020 revealed the facility staff should take the following actions immediately upon discovery of a missing resident: the supervisor will notify all staff of the missing resident by paging code E for elopement, staff will complete a thorough search of the facility, report the missing resident to the Administrator, the DON, the physician, and the resident's representative/family, notify the police department, provide the police department with a picture of the resident, medication list, history of resident and possible locations/areas he may have gone to in the past, and description of what the resident is wearing, etc., notify local hospitals, continue to search the interior and exterior grounds of facility and as other areas as designated by the administrative staff, document the proper sequence of events thoroughly in the resident record. This deficiency represents non-compliance investigated under Complaint Number 2648926 and Complaint Number 1348234.

Based on medical record review, observation, staff interview, review of pharmacy guidelines, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected five Residents (#26, #55, #85, #86 and #99) of the 24 residents with medications stored in the unit-100 medication cart. The facility census was 101 residents. Findings include: 1.Review of the medical record for Resident #26 revealed an admission date of 09/12/24 with diagnoses of diabetes mellitus type two and chronic kidney disease. Review of the physician's orders for Resident #26 revealed an order dated 09/04/25 for Degludec insulin 10 units at bedtime. Review of the Medication Administration Record (MAR) for Resident #26 dated March 2026 revealed the resident received Degludec insulin at bedtime on every day of the month. 2. Review of the medical record for Resident #55 revealed an admission date of 05/04/23 with diagnoses of diabetes mellitus type two and schizoaffective disorder. Review of physician's orders for Resident #55 revealed an order dated 12/17/25 for Novolog insulin per sliding scale four times per day. Review of MAR for Resident #55 dated March 2026 revealed the resident received insulin 87 times during the month. 3. Review of the medical record for Resident #85 revealed an admission date of 08/01/14 with diagnoses of diabetes mellitus type two and paranoid schizophrenia. Review of the physician's orders for Resident #85 revealed an order dated 04/10/25 for Lispro insulin five units at meals. Review of the MAR for Resident #85 dated March 2026 revealed the resident received insulin at meals on every day of the month. 4. Review of the medical record for Resident #86 revealed an admission date of 08/01/24 with diagnoses of diabetes mellitus type two and schizoaffective disorder. Review of the physician's orders for Resident #86 revealed an order dated 02/17/26 for Novolog insulin per sliding scale four times per day and an order for Glargine insulin 25 units every 12 hours. Review of the MAR for Resident #86 dated March 2026 revealed the resident received Novolog insulin per sliding scale 114 times during the month and Glargine insulin 31 times during the month. 5. Review of the medical record for Resident #99 revealed an admission date of 02/02/26 with diagnoses of diabetes mellitus type two and hypertension. Review of the physician's orders for Resident #99 revealed an order dated 02/03/26 for insulin Aspart seven units with meals and insulin Glargine 32 units at bedtime. Review of the MAR for Resident #99 dated March 2026 revealed the resident received insulin Aspart 93 time during the month and insulin Glargine insulin 31 times during the month. Observation on 04/01/26 at 8:42 A.M. of the 100-nursing unit medication cart with Licensed Practical Nurse #225 revealed Resident #26's Degludac insulin was opened on 02/04/26. Resident #55's Novolog insulin was opened on 02/25/26. Resident #85's Lispro insulin was not dated. Resident #86's Novolog and Lantus insulins were both opened on 02/20/26. Resident #99's Aspart and Glargine insulins were not dated. Interview on 04/01/26 at 8:44 A.M. with LPN #225 verified all insulin products were to be dated when removed from the refrigerator and placed in the medication cart, and that insulins have an expiration date of 28 to 30 days from the date placed on the medication cart. LPN #225 confirmed the insulins for Residents #26, #55, #85, #86, and #99 were either expired or not properly dated and should have been discarded. Interview on 04/01/26 at 8:52 A.M. with the Director of Nursing (DON) verified all insulin products were to be dated when removed from refrigerated storage and placed in the medication cart, and that insulins had an expiration date of 28 to 30 days from the date placed on the medication cart. Review of the Insulin Stability Chart provided by the facility's pharmacy revealed Degludec insulin expired 56 days after opening, Novolog (Aspart) insulin expired 28 days after opening, Lispro (Humalog) insulin 28 days after opening, and Lantus (Glargine) insulin 28 days after opening. Review of the facility policy titled Storage of Medications dated 2018 revealed medications should be stored according to the recommendations of the manufacturer or the supplier. The nurse shall place a date opened sticker on the medication and enter the date opened and date of expiration. No expired medication should be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide nail care for dependent residents. This affected two (Residents #21 and #82) of three residents reviewed for activities of daily living (ADL) care. The facility census was 101 residents. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 02/25/25 with diagnoses including end-stage renal disease (ESRD) hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 03/04/26 revealed the resident had moderate cognitive impairment and required staff assistance with ADLs. Review of the care plan for Resident #21 dated 02/25/25 revealed the resident had an ADL deficit. Interventions included staff were to assist the resident with personal hygiene. Observation on 03/31/26 at 9:27 A.M. revealed Resident #21's fingernails were long and jagged with an unknown brown substance underneath the nails. Interview on 03/31/26 with Resident #21 confirmed he would like his fingernails to be cut and cleaned. Interview on 03/31/26 at 9:27 A.M. with Certified Nursing Assistant (CNA) #344 verified Resident #21's fingernails needed nailcare. 2. Review of the medical record for Resident #82 revealed an admission date of 11/13/16 with diagnoses including paranoid schizophrenia, bipolar disorder, hypertension and chronic obstructive pulmonary disease. Review of the MDS assessment for Resident #82 dated 03/19/26 revealed the resident had moderate cognitive impairment and required staff assistance with ADLs. Review of the care plan for Resident #82 dated 07/22/16 revealed the resident had an ADL deficit. Interventions included staff were to assist the resident with personal hygiene. Observation on 03/30/26 at 10:54 A.M. revealed Resident #82's fingernails were long and jagged with an unknown brown substance underneath the nails. Interview on 03/30/26 at 10:54 A.M. with Resident #82 confirmed he would like his fingernails to be cut and cleaned. Interview on 03/31/26 at 9:27 A.M. with CNA #267 verified Resident #82's fingernails needed nailcare. Review of the facility policy titled Personal Care Needs dated 2024 revealed the facility promoted a healthy environment and prevented infection by meeting the personal care needs of the residents. Personal care and ADL support would be provided according to the resident plan of care. Personal care and support included nail care. This deficiency represents noncompliance investigated under Complaint Number 2706077.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene while delivering meal trays to residents. This affected three (Residents #21, #51, #54) and had the potential to affect the 99 facility-identified residents who received meals prepared in the facility kitchen. The facility census was 101 residents. Findings include: Observation on 03/31/26 from 9:31 A.M. to 9:38 A.M. revealed Certified Nursing Assistant (CNA) #267 delivered breakfast meal trays in the 100-nursing unit dining room to Residents #21, #51 and #54 and failed to sanitize hands before and after passing the meal trays to the residents. CNA #267 opened Resident #21's milk carton and did not sanitize her hands before and after assisting the resident. Interview on 03/31/26 at 9:38 A.M. with CNA #267 verified she should have sanitized her hands before and after passing a meal tray to each resident. Interview on 04/03/26 at 11:25 A.M. with Infection Control Preventionist #310 verified staff are to sanitize hands before and after delivering a resident meal tray. Review of the facility policy titled Hand Hygiene dated February 2026 revealed the facility considered hand hygiene the primary means to prevent the spread of infection. Staff should practice hand hygiene before and after assisting a resident with meals or passing trays to another resident.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to provide residents with a dignified dining experience. This affected three (Residents #21, #51 and #54) but had the potential to all affect the 99 facility-identified residents who received meals from the kitchen. The facility census was 101 residents. Findings include:1. Review of the medical record for Resident #21 revealed an admission date of 02/25/25 with diagnoses including end-stage renal disease (ESRD) hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 03/04/26 revealed the resident had moderate cognitive impairment and required set up assistance for eating. 2. Review of the medical record for Resident #51 revealed an admission date of 05/16/24 with diagnoses including dementia and major depressive disorder. Review of the MDS assessment for Resident #51 dated 02/09/26 revealed the resident had moderate cognitive impairment and required supervision for eating. 3. Review of the medical record for Resident #54 revealed an admission date of 11/30/19 with diagnoses including hypertensive heart disease with heart failure, bipolar disorder, and diabetes mellitus type two. Review of the MDS assessment for Resident #54 dated 01/06/26 revealed the resident had moderate cognitive impairment and required supervision for eating. Observation on 03/31/26 at 9:25 A.M. of the nursing 100 Unit dining room revealed Certified Nursing Assistant (CNA) # 267 delivered meal trays to residents which had plastic cutlery. Interview on 03/31/26 at 9:29 A.M. with CNA #267 confirmed the facility frequently provided plastic cutlery with resident meals when either the dishwasher wasn't working or there were not enough metal utensils available for all the residents. Interviews on 03/31/26 between 9:30 A.M. and 9:37 A.M. with Residents #21, #51 and #54 who were all provided with plastic cutlery with their breakfast tray confirmed the residents preferred to use metal utensils with their meals. Resident #54 stated it was difficult to cut through some foods with a plastic knife. Interview on 03/31/26 at 9:41 A.M. with Dietary Supervisor (DS) #292 verified plastic utensils were utilized because the facility did not have an adequate supply of metal utensils.

Based on medical record review, observation, and staff interview, the facility failed to ensure call lights were kept within resident reach. This affected one (Resident #94) of three residents reviewed for call lights. The facility census was 101 residents. Findings include:Review of the medical record for Resident #94 revealed an admission date of 09/09/24 with diagnoses including disorganized schizophrenia, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 03/05/26 revealed the resident had severe cognitive impairment and required set-up assistance with oral hygiene, supervision for toileting, bathing, dressing and personal hygiene, and was independent for eating, bed mobility and transfers. Observation on 03/30/26 at 11:09 A.M. of Resident #94 revealed the resident was lying in bed and the call light cord was lying on the floor out of the resident's reach. The call light cord was too short to reach from the wall to the resident's bed. Interview on 03/30/36 at 11:10 A.M. with Certified Nursing Assistant (CNA) #344 verified Resident #94 did not have access to the call light cord because the call light cord was not long enough to reach the resident's bed.

Based on medical record review, observation, and staff interview, the facility failed ensure resident rooms were clean and sanitary. This affected one (Resident #94) of three residents reviewed for physical environment. The facility census was 101 residents.Findings include: Review of the medical record for Resident #94 revealed an admission date of 09/09/24 with diagnoses including disorganized schizophrenia, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 03/05/26 revealed the resident had severe cognitive impairment and required set-up assistance with oral hygiene, supervision for toileting, bathing, dressing and personal hygiene, and was independent for eating, bed mobility and transfers. Observation on 03/30/26 at 11:09 A.M. of Resident #94's room revealed there were spiderwebs above the entire width of the resident's sliding glass door which was approximately six feet wide. Interview on 03/30/36 at 11:10 A.M. with Certified Nursing Assistant (CNA) #344 verified there were spiderwebs above Resident #94's sliding glass door. This deficiency represents noncompliance investigated under Complaint Number 2563479 and Complaint Number 1348234.

Based on medical record review, staff interview, review of Self-Report Incidents (SRI) and facility policy review, the facility failed to implement their abuse policy when an allegation of sexual abuse was reported. This affected two Residents (#01 and #12) out of the three residents reviewed for abuse. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of physician orders for Resident #01 dated 08/16/23, revealed resident was ordered to be housed in the secured unit for safety of self and others related to major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). Review of the Nurse Practitioner (NP) progress notes for Resident #01 recorded as a late entry for 01/28/26 at 5:42 P.M. and authored by NP #501on 02/09/26 at 10:48 A.M. revealed Resident #01 was assessed at the bedside for high-risk sexual behavior. The resident resides in locked men's unit and per nursing staff the resident had inappropriate behaviors like this incident involving another resident who was discharged . The resident was alert and oriented. Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The nurse notified Resident #12's guardian regarding Resident #01 inappropriately touching Resident #12. Resident #01 was to be put in a private room and start 15-minute checks. Resident #01 was ordered medroxyprogesterone (for high-risk sexual behavior) daily. Review of the nurse progress note for Resident #01 dated 01/28/26 at 7:10 P.M. and authored by Licensed Practical Nurse (LPN) #256, revealed Certified Nursing Assistant (CNA) #222 reported that Resident #01 was observed with hand contact to Resident #12's genital area while they were seated in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12. All parties including Guardian were notified. Review of the physician order for Resident #01 dated 01/28/26 revealed the resident was ordered medroxyprogesterone acetate (for high-risk sexual behaviors) five milligram (mg) daily.Review of the care plans for Resident #01 created on 01/29/26, revealed he had a behavioral care plan for sexually inappropriate behaviors with other residents.Review of Interdisciplinary Team (IDT) note for Resident #01 dated 02/04/26 at 12:42 P.M., revealed Resident #01 was observed engaging in appropriate physical contact with Resident #12. Resident #01 placed his hand on another resident's perineal rea. The residents were immediately separated and Resident #01 was moved to a private room. Resident #01 was seen by psychiatric provider and started on medications. Further review of the medical record for Resident #01 revealed no documented evidence Resident #01 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #12. 2) Review of the medical record for Resident #12 revealed he was admitted to the facility on [DATE]. Diagnoses included insomnia, dementia, essential primary hypertension, major depressive disorder, and DM. The resident was housed in the secured MCU.Review of the care plan for Resident #12 dated 10/07/25 revealed the resident had impaired cognition related to dementia, had short and long-term memory impairment and required assistance with decision making.Review of the MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition. Review of the Nurse Practitioner (NP) progress notes for Resident #12 recorded as a late entry for 01/28/26 at 5:48 P.M. and authored by NP #501 on 02/09/26 at 10:54 A.M., revealed Resident #12 was the receiver of another resident's (Resident #01) inappropriate behavior. Resident #12 was witnessed by two therapists being ejaculated by Resident #01 and Resident #12 did not appear to understand what happened. The assessment / diagnoses revealed Resident #12 was the receiver of another resident's high risk sexual behavior and did not understand what happened. The plan was to notify Resident #12's guardian, keep the two residents separated and start 15-minute checks. The physician and psychiatric NP were notified. Review of the nurse progress notes for Resident #12 dated 01/28/26 at 7:12 P.M. and authored by LPN #256, revealed CNA (#222) reported that Resident #01 was observed with hand contact to Resident #12's genital area in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12 All parties including Guardian were notified. Further review of the medical record for Resident #12 revealed no documented evidence that Resident #12 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #01. Interview on 02/09/26 at 7:37 A.M., CNA #222 stated she was the CNA on duty at the time of the incident between Resident #01 and Resident #12 on 01/28/26. CNA #222 stated she observed OTA #171 and PT #189 standing in the hallway looking into the living room area with an alarmed look on their face. The therapists stated Resident #01 had his hand on the private area of Resident #12 and was caressing it through his pants. STNA #222 stated she called Assistant Director of Nursing (ADON) #258 and reported the incident. Interview on 02/09/26 at 12:25 P.M., Occupational Therapy Assistant (OTA) #177 stated she walked toward the television room in the men's secured unit with Physical Therapist (PT) #189 when she observed Resident #01 seated to the left of Resident #12 on the couch. OTA #177 stated she observed Resident #01's hand around Resident #12's penis squeezing and rubbing it. OTA #177 stated she reported it to CNA #222. OTA #177 stated she was asked to write a statement today. Interview on 02/09/26 at 12:30 P.M., PT #189 stated on 01/28/26 she was standing in the hall with OTA #177 and observed Resident #01 on the couch sitting next to Resident #12. PT #189 stated she observed Resident #01 had his hand on the genital area of Resident #12. PT #189 stated she was asked to write a statement today. Interview on 02/09/26 at 12:49 P.M., LPN #256 stated on 01/28/26 CNA #222 reported to him that Resident #01 had his hand on Resident #12's private area and was rubbing it. LPN #256 stated two therapists (OTA #171 and PT #189) witnessed the incident. Interview on 02/09/26 at 1:15 P.M., Resident #50 (spouse and emergency contact of Resident #12) stated she was notified of the incident between Resident #01 and Resident #12 on 01/28/26. Resident #50 stated she received a call from LPN #256, and he notified her that Resident #01 was observed with his hand on Resident #12's penis and was rubbing it. Resident #50 stated she was told by LPN #256 that both Residents had their clothes on. Interview on 02/09/26 at 1:48 P.M., the Administrator stated he did not consider the incident with Resident #01 and Resident #12 to be sexual abuse. The Administrator stated both residents had their clothes on, so it was not reportable. The Administrator verified Resident #01 had a history of being sexually inappropriate. The Administrator verified Resident #01 was cognitively intact and Resident #12 was severely cognitively impaired and unable to consent to someone touching him inappropriately. The Administrator verified the facility should have implemented their abuse policy, reported the incident to the state agency and completed a thorough investigation. Subsequent interview on 02/09/26 at 5:00 P.M. the Administrator verified the facility did not implement their abuse policy. The Administrator stated he did not report the incident because nothing happened to Resident #12 because the resident was fully clothed. The surveyor reviewed NP #500's documentation with the Administrator from 01/28/26, which noted Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The Administrator stated NP #501's note was not accurate information because NP #501 was not at the facility and did not know the details of the incident.Interview on 02/10/26 at 8:35 A.M., NP #501 stated she was at the facility on 01/28/26 when she received a call from ADON #258 related to an incident that occurred in the men's secure unit. NP #501 indicated that ADON #258 stated Resident #01 was observed by staff attempting to ejaculate Resident #12. NP #501 stated she went to the men's unit and assessed Residents #01 and #12. NP #501 stated the men were separated and both were fully clothed. NP #500 stated she was told by the staff that Resident #01 had his hand around Resident #12's penis and was rubbing it up and down. NP #500 stated the staff reported Resident #12 was confused and unsure of what was going on. NP #500 stated she called Medical Director (MD) #501 and was advised on the next steps to take. MD #501 directed NP #500 to have staff contact both guardians and Resident #01 was given order for medication related to his inappropriate sexual behavior. NP #500 stated she contacted the Director of Nursing (DON) who instructed her to relay the orders to the unit managers, then the DON left the facility. NP #500 stated she was told by the staff Resident #01 had this behavior with another Resident in the past; however, this resident had been discharged . NP #500 stated after she learned of Resident #01's previous behaviors, she questioned why the resident was in the room with a resident who was severely impaired. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, injury of unknown origin dated August 2024 revealed the Administrator had a responsibility for implementation of the abuse/neglect program. Any reports of abuse will be promptly and thoroughly investigated. Additionally, the facility will immediately report such allegations to the Administrator/designee and to the Department of Health and social services. The policy indicated sexual abuse was the non-consensual sexual contact of any type with a resident and this included but not limited to, unwanted intimate touching of any kind especially of breasts or perineal area. The policy stated if there is an allegation that a resident did not consent to engage in sexual activity with another resident or may not have the capacity to consent, the facility would respond to it as an alleged violation of sexual abuse. The facility would provide for the immediate safety of the residents upon identification of suspected abuse. Means of protection include but are not limited to; provide one-on-one monitoring as appropriate and implement discharge process immediately if the resident is in danger to self or others.This deficiency represents non-compliance investigated under Complaint Number 2737505.

Based on medical record review, interview, and facility policy review. The facility failed to investigate an allegation of abuse. This affected two Residents (#01, #12) out of three residents (#01, #03, #12) reviewed. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of physician orders for Resident #01 dated 08/16/23, revealed resident was ordered to be housed in the secured unit for safety of self and others related to major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). Review of the Nurse Practitioner (NP) progress notes for Resident #01 recorded as a late entry for 01/28/26 at 5:42 P.M. and authored by NP #501on 02/09/26 at 10:48 A.M. revealed Resident #01 was assessed at the bedside for high-risk sexual behavior. The resident resides in locked men's unit and per nursing staff the resident had inappropriate behaviors like this incident involving another resident who was discharged . The resident was alert and oriented. Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The nurse notified Resident #12's guardian regarding Resident #01 inappropriately touching Resident #12. Resident #01 was to be put in a private room and start 15-minute checks. Resident #01 was ordered medroxyprogesterone (for high-risk sexual behavior) daily. Review of the nurse progress note for Resident #01 dated 01/28/26 at 7:10 P.M. and authored by Licensed Practical Nurse (LPN) #256, revealed Certified Nursing Assistant (CNA) #222 reported that Resident #01 was observed with hand contact to Resident #12's genital area while they were seated in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12. All parties including Guardian were notified. Review of the physician order for Resident #01 dated 01/28/26 revealed the resident was ordered medroxyprogesterone acetate (for high-risk sexual behaviors) five milligram (mg) daily.Review of the care plans for Resident #01 created on 01/29/26, revealed he had a behavioral care plan for sexually inappropriate behaviors with other residents.Review of Interdisciplinary Team (IDT) note for Resident #01 dated 02/04/26 at 12:42 P.M., revealed Resident #01 was observed engaging in appropriate physical contact with Resident #12. Resident #01 placed his hand on another resident's perineal rea. The residents were immediately separated and Resident #01 was moved to a private room. Resident #01 was seen by psychiatric provider and started on medications. Further review of the medical record for Resident #01 revealed no documented evidence Resident #01 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #12. 2) Review of the medical record for Resident #12 revealed he was admitted to the facility on [DATE]. Diagnoses included insomnia, dementia, essential primary hypertension, major depressive disorder, and DM. The resident was housed in the secured MCU.Review of the care plan for Resident #12 dated 10/07/25 revealed the resident had impaired cognition related to dementia, had short and long-term memory impairment and required assistance with decision making.Review of the MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition. Review of the Nurse Practitioner (NP) progress notes for Resident #12 recorded as a late entry for 01/28/26 at 5:48 P.M. and authored by NP #501 on 02/09/26 at 10:54 A.M., revealed Resident #12 was the receiver of another resident's (Resident #01) inappropriate behavior. Resident #12 was witnessed by two therapists being ejaculated by Resident #01 and Resident #12 did not appear to understand what happened. The assessment / diagnoses revealed Resident #12 was the receiver of another resident's high risk sexual behavior and did not understand what happened. The plan was to notify Resident #12's guardian, keep the two residents separated and start 15-minute checks. The physician and psychiatric NP were notified. Review of the nurse progress notes for Resident #12 dated 01/28/26 at 7:12 P.M. and authored by LPN #256, revealed CNA (#222) reported that Resident #01 was observed with hand contact to Resident #12's genital area in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12 All parties including Guardian were notified. Further review of the medical record for Resident #12 revealed no documented evidence that Resident #12 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #01. Interview on 02/09/26 at 7:37 A.M., CNA #222 stated she was the CNA on duty at the time of the incident between Resident #01 and Resident #12 on 01/28/26. CNA #222 stated she observed OTA #171 and PT #189 standing in the hallway looking into the living room area with an alarmed look on their face. The therapists stated Resident #01 had his hand on the private area of Resident #12 and was caressing it through his pants. STNA #222 stated she called Assistant Director of Nursing (ADON) #258 and reported the incident. Interview on 02/09/26 at 12:25 P.M., Occupational Therapy Assistant (OTA) #177 stated she walked toward the television room in the men's secured unit with Physical Therapist (PT) #189 when she observed Resident #01 seated to the left of Resident #12 on the couch. OTA #177 stated she observed Resident #01's hand around Resident #12's penis squeezing and rubbing it. OTA #177 stated she reported it to CNA #222. OTA #177 stated she was asked to write a statement today. Interview on 02/09/26 at 12:30 P.M., PT #189 stated on 01/28/26 she was standing in the hall with OTA #177 and observed Resident #01 on the couch sitting next to Resident #12. PT #189 stated she observed Resident #01 had his hand on the genital area of Resident #12. PT #189 stated she was asked to write a statement today. Interview on 02/09/26 at 12:49 P.M., LPN #256 stated on 01/28/26 CNA #222 reported to him that Resident #01 had his hand on Resident #12's private area and was rubbing it. LPN #256 stated two therapists (OTA #171 and PT #189) witnessed the incident. Interview on 02/09/26 at 1:15 P.M., Resident #50 (spouse and emergency contact of Resident #12) stated she was notified of the incident between Resident #01 and Resident #12 on 01/28/26. Resident #50 stated she received a call from LPN #256, and he notified her that Resident #01 was observed with his hand on Resident #12's penis and was rubbing it. Resident #50 stated she was told by LPN #256 that both Residents had their clothes on. Interview on 02/09/26 at 1:48 P.M., the Administrator stated he did not consider the incident to be sexual abuse. The Administrator stated it was not reportable because nothing happened and both residents had their clothes on. The Administrator verified Resident #01 had a history of being sexually inappropriate. The Administrator verified Resident #01 was cognitively intact and Resident #12 was severely cognitively impaired and unable to consent to someone touching him inappropriately. The Administrator verified the incident should have been thoroughly investigated.Subsequent interview on 02/09/26 at 5:00 P.M. the Administrator verified the facility did not complete a thorough investigation related to the incident that occurred on 01/28/26 between Resident #01 and Resident #12. The Administrator reported he did not report the incident because nothing happened to Resident #12 because the resident was fully clothed. The surveyor reviewed NP #500's documentation from 01/28/26,which noted Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The Administrator stated NP #501's note was not accurate information because NP #501 was not at the facility and did not know the details of the incident.Interview on 02/10/26 at 8:35 A.M. NP #501 stated she was at the facility on 01/28/26 when she received a call from ADON #258 related to an incident that occurred in the men's secure unit. NP #501 indicated that ADON #258 stated Resident #01 was observed by staff attempting to ejaculate Resident #12. NP #501 stated she went to the men's unit and assessed Residents #01 and #12. NP #501 stated the men were separated and both were fully clothed. NP #500 stated she was told by the staff that Resident #01 had his hand around Resident #12's penis and was rubbing it up and down. NP #500 stated the staff reported Resident #12 was confused and unsure of what was going on. NP #500 stated she called Medical Director (MD) #501 and was advised on the next steps to take. MD #501 directed NP #500 to have staff contact both guardians and Resident #01 was given order for medication related to his inappropriate sexual behavior. NP #500 stated she contacted the Director of Nursing (DON) who instructed her to relay the orders to the unit managers, then the DON left the facility. NP #500 stated she was told by the staff Resident #01 had this behavior with another Resident in the past; however, this resident had been discharged . NP #500 stated after she learned of Resident #01's previous behaviors, she questioned why the resident was in the room with a resident who was severely impaired. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, injury of unknown origin dated August 2024 revealed the Administrator had a responsibility for implementation of the abuse/neglect program. Any reports of abuse will be promptly and thoroughly investigated. Additionally, the facility will immediately report such allegations to the Administrator/designee and to the Department of Health and social services. The policy indicated sexual abuse was the non-consensual sexual contact of any type with a resident and this included but not limited to, unwanted intimate touching of any kind especially of breasts or perineal area. The policy stated if there is an allegation that a resident did not consent to engage in sexual activity with another resident or may not have the capacity to consent, the facility would respond to it as an alleged violation of sexual abuse. The facility would provide for the immediate safety of the residents upon identification of suspected abuse. Means of protection include but are not limited to; provide one-on-one monitoring as appropriate and implement discharge process immediately if the resident is in danger to self or others.This deficiency represents non-compliance investigated under Complaint Number 2737505.

Based on medical record review and staff interview the facility failed to ensure physician visits were signed and dated in a timely manner. This affected two Residents (#01, #12) out of two residents reviewed. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). Review of the Nurse Practitioner (NP) progress note for Resident #01 recorded as a late entry for 01/28/26 at 5:42 P.M. and authored and signed by NP #501 on 02/09/26 at 10:48 A.M. revealed Resident #01 was assessed at the bedside for high-risk sexual behavior. Review of the NP progress note for Resident #01 recorded as a late entry for 02/03/26 at 5:38 P.M. and authored and signed by NP #501 on 02/07/26 at 5:42 P.M. revealed a provider visit related to his diabetes and morbid obesity.2) Review of the medical record for Resident #12 revealed he was admitted to the facility on [DATE]. Diagnoses included insomnia, dementia, essential primary hypertension, major depressive disorder, and DM. The resident was housed in the secured MCU.Review of the MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition. Review of the NP progress note for Resident #12 recorded as a late entry for 01/28/26 at 5:48 P.M. and authored and signed by NP #501 on 02/09/26 at 10:54 A.M., revealed Resident #12 was the receiver of another resident's (Resident #01) inappropriate behavior. Review of the NP progress note for Resident #12 recorded as a late entry for 01/31/26 at 6:46 A.M. and authored and signed by NP #502 on 02/02/26 at 6:46 A.M., revealed Resident #12 was seen for rash.Interview on 02/10/26 at 8:35 A.M., NP #501 verified she created and signed the late entry progress notes from 01/28/26 involving Residents #01 and #12 on 02/09/26. NP #501 verified the other provider visits were not being created and signed on the days the residents were being seen. NP #501 stated she was behind on her documentation because of the workload.

Based on medical record review, staff interview, review of Self-Report Incidents (SRI) and facility policy review, the facility failed to report an allegation of sexual abuse. This affected two Residents (#01 and #12) out of the three residents reviewed for abuse. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of physician orders for Resident #01 dated 08/16/23, revealed resident was ordered to be housed in the secured unit for safety of self and others related to major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). Review of the Nurse Practitioner (NP) progress notes for Resident #01 recorded as a late entry for 01/28/26 at 5:42 P.M. and authored by NP #501on 02/09/26 at 10:48 A.M. revealed Resident #01 was assessed at the bedside for high-risk sexual behavior. The resident resides in locked men's unit and per nursing staff the resident had inappropriate behaviors like this incident involving another resident who was discharged . The resident was alert and oriented. Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The nurse notified Resident #12's guardian regarding Resident #01 inappropriately touching Resident #12. Resident #01 was to be put in a private room and start 15-minute checks. Resident #01 was ordered medroxyprogesterone (for high-risk sexual behavior) daily. Review of the nurse progress note for Resident #01 dated 01/28/26 at 7:10 P.M. and authored by Licensed Practical Nurse (LPN) #256, revealed Certified Nursing Assistant (CNA) #222 reported that Resident #01 was observed with hand contact to Resident #12's genital area while they were seated in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12. All parties including Guardian were notified. Review of the physician order for Resident #01 dated 01/28/26 revealed the resident was ordered medroxyprogesterone acetate (for high-risk sexual behaviors) five milligram (mg) daily.Review of the care plans for Resident #01 created on 01/29/26, revealed he had a behavioral care plan for sexually inappropriate behaviors with other residents.Review of Interdisciplinary Team (IDT) note for Resident #01 dated 02/04/26 at 12:42 P.M., revealed Resident #01 was observed engaging in appropriate physical contact with Resident #12. Resident #01 placed his hand on another resident's perineal rea. The residents were immediately separated and Resident #01 was moved to a private room. Resident #01 was seen by psychiatric provider and started on medications. Further review of the medical record for Resident #01 revealed no documented evidence Resident #01 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #12. 2) Review of the medical record for Resident #12 revealed he was admitted to the facility on [DATE]. Diagnoses included insomnia, dementia, essential primary hypertension, major depressive disorder, and DM. The resident was housed in the secured MCU.Review of the care plan for Resident #12 dated 10/07/25 revealed the resident had impaired cognition related to dementia, had short and long-term memory impairment and required assistance with decision making.Review of the MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition. Review of the Nurse Practitioner (NP) progress notes for Resident #12 recorded as a late entry for 01/28/26 at 5:48 P.M. and authored by NP #501 on 02/09/26 at 10:54 A.M., revealed Resident #12 was the receiver of another resident's (Resident #01) inappropriate behavior. Resident #12 was witnessed by two therapists being ejaculated by Resident #01 and Resident #12 did not appear to understand what happened. The assessment / diagnoses revealed Resident #12 was the receiver of another resident's high risk sexual behavior and did not understand what happened. The plan was to notify Resident #12's guardian, keep the two residents separated and start 15-minute checks. The physician and psychiatric NP were notified. Review of the nurse progress notes for Resident #12 dated 01/28/26 at 7:12 P.M. and authored by LPN #256, revealed CNA (#222) reported that Resident #01 was observed with hand contact to Resident #12's genital area in the common area. The staff intervened and Resident #01 was redirected and guided away from Resident #12 All parties including Guardian were notified. Further review of the medical record for Resident #12 revealed no documented evidence that Resident #12 was evaluated by psychiatric services after the incident on 01/28/26 involving Resident #01. Interview on 02/09/26 at 7:37 A.M., CNA #222 stated she was the CNA on duty at the time of the incident between Resident #01 and Resident #12 on 01/28/26. CNA #222 stated she observed OTA #171 and PT #189 standing in the hallway looking into the living room area with an alarmed look on their face. The therapists stated Resident #01 had his hand on the private area of Resident #12 and was caressing it through his pants. STNA #222 stated she called Assistant Director of Nursing (ADON) #258 and reported the incident. Interview on 02/09/26 at 12:25 P.M., Occupational Therapy Assistant (OTA) #177 stated she walked toward the television room in the men's secured unit with Physical Therapist (PT) #189 when she observed Resident #01 seated to the left of Resident #12 on the couch. OTA #177 stated she observed Resident #01's hand around Resident #12's penis squeezing and rubbing it. OTA #177 stated she reported it to CNA #222. OTA #177 stated she was asked to write a statement today. Interview on 02/09/26 at 12:30 P.M., PT #189 stated on 01/28/26 she was standing in the hall with OTA #177 and observed Resident #01 on the couch sitting next to Resident #12. PT #189 stated she observed Resident #01 had his hand on the genital area of Resident #12. PT #189 stated she was asked to write a statement today. Interview on 02/09/26 at 12:49 P.M., LPN #256 stated on 01/28/26 CNA #222 reported to him that Resident #01 had his hand on Resident #12's private area and was rubbing it. LPN #256 stated two therapists (OTA #171 and PT #189) witnessed the incident. Interview on 02/09/26 at 1:15 P.M., Resident #50 (spouse and emergency contact of Resident #12) stated she was notified of the incident between Resident #01 and Resident #12 on 01/28/26. Resident #50 stated she received a call from LPN #256, and he notified her that Resident #01 was observed with his hand on Resident #12's penis and was rubbing it. Resident #50 stated she was told by LPN #256 that both Residents had their clothes on. Interview on 02/09/26 at 1:48 P.M., the Administrator verified the facility failed to report the incident that occurred on 01/28/26 between Resident #01 and Resident #12. The Administrator stated he did not consider the incident to be sexual abuse. The Administrator stated it was not reportable because nothing happened and both residents had their clothes on. The Administrator stated the facility implemented a care plan on 01/29/26 related to Resident #01 being sexually inappropriate with another resident on 01/28/26. The Administrator verified Resident #01 had a history of being sexually inappropriate. The Administrator verified Resident #01 was cognitively intact and Resident #12 was severely cognitively impaired and unable to consent to someone touching him inappropriately. The Administrator verified the incident should have been reported the state agency via SRI and should have been thoroughly investigated.Subsequent interview on 02/09/26 at 5:00 P.M. the Administrator verified the facility did not complete a thorough investigation related to the incident that occurred on 01/28/26 between Resident #01 and Resident #12. The Administrator reported he did not report the incident because nothing happened to Resident #12 because the resident was fully clothed. The surveyor reviewed NP #500's documentation from 01/28/26, which noted Resident #01 was witnessed in the common area by two therapists, attempting to ejaculate another resident (Resident #12) who had severe dementia. The Administrator stated NP #501's note was not accurate information because NP #501 was not at the facility and did not know the details of the incident.Interview on 02/10/26 at 8:35 A.M. NP #501 stated she was at the facility on 01/28/26 when she received a call from ADON #258 related to an incident that occurred in the men's secure unit. NP #501 indicated that ADON #258 stated Resident #01 was observed by staff attempting to ejaculate Resident #12. NP #501 stated she went to the men's unit and assessed Residents #01 and #12. NP #501 stated the men were separated and both were fully clothed. NP #500 stated she was told by the staff that Resident #01 had his hand around Resident #12's penis and was rubbing it up and down. NP #500 stated the staff reported Resident #12 was confused and unsure of what was going on. NP #500 stated she called Medical Director (MD) #501 and was advised on the next steps to take. MD #501 directed NP #500 to have staff contact both guardians and Resident #01 was given order for medication related to his inappropriate sexual behavior. NP #500 stated she contacted the Director of Nursing (DON) who instructed her to relay the orders to the unit managers, then the DON left the facility. NP #500 stated she was told by the staff Resident #01 had this behavior with another Resident in the past; however, this resident had been discharged . NP #500 stated after she learned of Resident #01's previous behaviors, she questioned why the resident was in the room with a resident who was severely impaired. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, injury of unknown origin dated August 2024 revealed the Administrator had a responsibility for implementation of the abuse/neglect program. Any reports of abuse will be promptly and thoroughly investigated. Additionally, the facility will immediately report such allegations to the Administrator/designee and to the Department of Health and social services. The policy indicated sexual abuse was the non-consensual sexual contact of any type with a resident and this included but not limited to, unwanted intimate touching of any kind especially of breasts or perineal area. The policy stated if there is an allegation that a resident did not consent to engage in sexual activity with another resident or may not have the capacity to consent, the facility would respond to it as an alleged violation of sexual abuse. The facility would provide for the immediate safety of the residents upon identification of suspected abuse. Means of protection include but are not limited to; provide one-on-one monitoring as appropriate and implement discharge process immediately if the resident is in danger to self or others.This deficiency represents non-compliance investigated under Complaint Number 2737505.

Based on observation, staff interviews and Centers for Disease Control and Prevention guidelines the facility failed to ensure proper infection control measures were followed during medication administration. This had the potential to affect one Resident (#14) of four reviewed. The facility census was 107.Findings include:Review of medical record for Resident #14 revealed admission date of 12/13/17. The resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hemiplegia, bipolar disorder and depression. The annual Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition and he required supervision with eating, bed mobility, toileting hygiene and transfers.Observation on 10/29/25 at 9:58 A.M. of the medication pass with Registered Nurse (RN) #100 for Resident #14 revealed RN #100 unlocked the medication cart and removed the medication card from the drawer of the cart. He was observed punching the medication into his ungloved hand and then placed it into a medication cup. This same action was observed for a second medication. Interview on 10/29/25 at 10:03 A.M., RN #100 acknowledged he should not punch medication into his ungloved hand, and it should be transferred directly into the medication cup.Observation at 10/29/25 at 10:05 A.M. revealed RN#100 placed the medication card over the medication cup. When he punched the medication, the pill missed the cup and landed directly onto the cart. Using his ungloved fingers, RN #100 picked up the medication and placed it into the medication cup. Interview on 10/29/25 at 10:09 A.M. with RN #100 verified he picked up medication from the top of the medication cart and placed it into the medicine cup.Review of the Centers for Disease Control and Prevention website: https://www.cdc.gov/infection-control/hcp/core-practices/index.html revealed Standard Precautions are the basic practices that apply to all patient care and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. These precautions are recommended for medication safety. This deficiency represents non-compliance investigated under Complaint Number 2591479.

Based on observation, staff interview, and review the facility policy, the facility failed to ensure proper storage of medication. This had the ability to affect all 25 residents on the hall. The facility census was 107.Findings include:Observation on 10/29/25 at 10:09 A.M. of the medication pass revealed RN#100 prepared medication for Resident #14 removed the medication cup from the cart, turned in the opposite direction, walked approximately five feet down the hall and entered Resident #14's room. The unattended medication cart was left unlocked in the hall for approximately four minutes.Interview on 10/29/25 at 10:09 A.M. with RN #100 acknowledged the medication cart should not be left unlocked if unattended. RN #100 verified he he did not lock the medication cart and left it unsecured in the hallway. Review of the facility policy, Medication storage in the facility dated 11/11 revealed medications should be stored safety and securely.

Based on medical record reviews, observations and staff interviews the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 27 opportunities observed which resulted in an 11.11 percent (%) error rate. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.Findings include:Review of the medical record for Resident #15 revealed admission date of 5/30/25. The resident was admitted with diagnoses including schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), major depressive disorder and syndrome of inappropriate secretion of anti-diuretic hormone.The quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required supervision with eating, bed mobility, toileting hygiene and transfers.Review of the medical record for Resident #15 revealed a physician order dated 08/19/25 for Fluphenazine Hydrochloride (schizoaffective disorder) 10 milligram (mg) give two tablets by mouth two times a day. A second order dated 05/31/25 for Bumetanide (diuretic) on mg by mouth daily and a third order dated 05/31/25 for Aspirin (blood thinner) 81 mg chewable tablet by mouth daily.Observation on 10/29/25 at 10:19 A.M. of the medication pass with Registered Nurse (RN) #100 for Resident #15 revealed he prepared Fluphenazine (antipsychotic) one 10 milligram (mg) tablet (tab), Hydroxyzine Pamoate (antihistamine) 25 mg, Metoprolol (high blood pressure) 25 mg tab, Lamotrigine (Bipolar disorder) 25 mg, Trihexyphenidyl (Tremors) five mg tab, Turmeric (supplement)500 mg capsule, Stress formula vitamin one tab, Sennosides (constipation) 8.6 mg tab, Lorazepam (anxiety) one, one mg tablet and Geodon (antipsychotic) 20 mg tablet and placed them into a medication cup.Observation on 10/29/25 at 10:29 A.M. revealed RN #100 took the medication cup to the table where Resident #15 was seated. Resident #15 looked in the medication cup and asked where her Bumex (diuretic) and aspirin were. RN #100 returned to the medication cart and opened the electronic medical record for Resident #15. After reviewing the medications, he opened the medication drawer and removed the card for Bumex one mg tablet and opened a bottle of Aspirin 81 mg enteric coated and put one pill into the medication cup. He then delivered the additional two pills to Resident #15. Interview on 10/29/25 at 10:27 A.M., RN #100 verified he had only given one tablet of Fluphenazine instead of two and had given an enteric coated 81 mg Aspirin instead of the chewable tablet as ordered. RN #100 acknowledged he did not prepare the Bumex and Aspirin for administration until after Resident #15 informed him it was not present in the medication cup.This deficiency represents non-compliance investigated under Complaint Number 2591479.

Based on observation, record review, and staff interview, the facility failed to ensure medications were given as prescribed. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.Findings include:Review of the medical record for Resident #15 revealed an admission date of 5/30/25. The resident was admitted with diagnoses including schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), major depressive disorder and syndrome of inappropriate secretion of anti-diuretic hormone.The quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required supervision with eating, bed mobility, toileting hygiene and transfers.Observation on 10/29/25 at 10:19 A.M. of the medication pass with Registered Nurse (RN) #100 for Resident #15 revealed he prepared Fluphenazine (antipsychotic) one 10 milligram (mg) tablet (tab), Hydroxyzine Pamoate (antihistamine) 25 mg, Metoprolol (high blood pressure) 25 mg tab, Lamotrigine (Bipolar disorder) 25 mg, Trihexyphenidyl (Tremors) five mg tab, Turmeric (supplement) 500 mg capsule, Stress formula vitamin one tab, Sennosides (constipation) 8.6 mg tab, Lorazepam (anxiety) one, one mg tablet and Geodon (antipsychotic) 20 mg tablet and placed them into a medication cup.Observation on 10/29/25 at 10:29 A.M. revealed RN #100 took the medication cup to the table where Resident #15 was seated. Resident #15 looked in the medication cup and asked where her Bumex (diuretic) and Aspirin (salicylate) were. RN #100 returned to the medication cart and opened the electronic medical record for Resident #15. After reviewing the medications, he opened the medication drawer and removed the card for Bumex one mg tablet and placed it into a medication cup, he then opened a bottle of Aspirin 81 mg, enteric coated and added it into the medication cup. He then delivered the additional two pills to Resident #15. Review of the physician orders for Resident #15 revealed an order for Fluphenazine 10 mg tablet, give two tablets, two times daily with a start date of 08/19/25. Further review revealed an order for Aspirin 81mg chewable tablet with a start date of 05/31/25 and an order for Bumex one mg by mouth daily with a start date of 05/31/25.Interview on 10/29/25 at 10:27 A.M., RN #100 verified he had only given one tablet of Fluphenazine instead of two and had given an 81 mg, enteric coated Aspirin instead of the chewable tablet as ordered. RN #100 acknowledged he did not prepare Bumex and Aspirin for administration until Resident #15 informed him it was not present in the medication cup.This deficiency represents non-compliance investigated under Complaint Number 2591479.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to prevent resident elopements. This affected one (Resident #45) of three residents reviewed for elopements. The facility census was 112 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 11/20/23 with diagnoses including atherosclerotic heart disease, Alzheimer's disease, psychotic disorder with delusions and hallucinations, and Parkinson's disease. Review of the elopement risk assessment for Resident #45 dated 01/23/25 revealed the resident was at risk for elopement due to a history of wandering with a pattern, goal-directed wandering, and wandering that might affect the resident's safety and the privacy of others. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 03/28/25 revealed the resident was moderately cognitively impaired, was independently mobile with a walker, and required supervision with activities of daily living (ADLs). Review of the care plan for Resident #45 updated 04/28/25 revealed the resident was at risk for elopement related to disorientation, voicing the desire to leave, and piling his belongings on his walker seat. Interventions included the following: attempt to redirect the resident from wandering with diversional activities, encourage structured activities and calls and visits from family, Review of a progress note for Resident #45 dated 05/01/25 revealed a nurse from another unit notified the nurse the resident had gotten out the back door. The nurse went to the back door where the door alarm was sounding and found the resident sitting on his walker. The nurse directed Resident #45 back into the building and placed the resident on one-on-one supervision. Review of the elopement risk assessment for Resident #45 dated 05/01/25 revealed the resident was at risk for elopement due to prior elopements, a history of wandering with a pattern, goal-directed wandering, and wandering that might affect the resident's safety and the privacy of others. Review of the facility SRI dated 05/01/25 revealed Resident #45 exited an alarmed door on the secured unit without staff knowledge. When Resident #45 exited the facility, the door alarm sounded but it was not sufficiently loud enough for the two aides working the unit to hear. The aides on the unit were notified of Resident #45's elopement when an aide from another unit came over to tell them the police had called the facility advising there was a resident outside. Interview on 05/13/25 at 3:15 P.M. with Certified Nursing Assistant (CNA) #151 confirmed she and another aide were on the unit and the nurse was not present when Resident #45 eloped from the facility on 05/01/25. CNA #151 confirmed both she and the other aide were in the nursing station and did not hear the door alarm sounding when Resident #45 exited the building. CNA #151 confirmed staff from another unit told them the police had called the facility stating Resident #45 was outside. CNA #151 confirmed she had not been aware Resident #45 was an elopement risk, or she would have provided closer supervision. Observation on 05/13/25 at 5:25 P.M. revealed the door alarm to the secured unit from which Resident #45 eloped did not sound loudly when activated and could not be heard from the nurses' station. Interview on 05/14/25 at 9:20 A.M. with Maintenance Director (MD) #385 confirmed he knew a resident had eloped on 05/01/25 but he had received no requests to make the alarm louder. Interview on 05/14/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #241 confirmed she was not working on Resident #45's unit when the resident eloped. LPN #241 further confirmed she was working another unit when she received a call from the police that there was a resident outside the building. LPN #241 then went to Resident #45's unit to notify the aides who had not been able to hear the door alarm when the resident exited. Interview on 05/14/25 at 11:03 A.M. with the Administrator and Assistant Director of Nursing (ADON) #357 confirmed Resident #45 was at risk for elopement and eloped from an alarmed door on the secured unit without staff knowledge in the morning of 05/01/25. At the time of Resident #45's elopement the two aides working the unit did not hear the alarm as it didn't sound loudly enough to be heard from the nurses' station where the two aides were sitting. The nurse for the unit had not arrived to work. The Administrator and ADON #357 confirmed the staff was not aware Resident #45 had eloped until the police observed the resident outside and called the facility. Review of the facility policy titled Elopement Prevention and Management Unsafe Wandering and Exit Seeking Behavior revised May 2024 revealed elopement from the facility was defined as when a cognitively impaired resident left the physical structure of the facility unattended and without staff knowledge. Residents would be assessed for elopement risk and interventions would be developed to meet their individualized needs based on the assessment. The facility would ensure door alarm and wander control system were in proper working order. This deficiency represents noncompliance investigated under Complaint Number OH00165418.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse by the staff. This affected one (Resident #104) of three residents reviewed for abuse. The facility census was 112 residents. Findings include: Review of the medical record for Resident #104 revealed an admission date of 02/13/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, bipolar disorder, post-traumatic stress disorder, and aphasia. Review of the facility SRI for Resident #104 initiated 04/19/25 revealed the facility substantiated an allegation of abuse per Licensed Practical Nurse (LPN) #500 towards Resident #104. On 04/19/25 at approximately 5:30 P.M. Resident #104 and another nurse witnessed LPN #500 using profane language and speaking in a verbally abusive manner towards the resident. The facility reported LPN #500's actions to the Ohio Board of Nursing (OBN) and terminated the nurse. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 04/24/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Interview on 05/14/25 at 11:03 A.M. with the Administrator and Assistant Director of Nursing (ADON) #357 confirmed the facility investigated an allegation of verbal abuse per LPN #500 towards Resident #104. Interview confirmed the facility substantiated verbal abuse had occurred, and they terminated LPN #500 and reported the nurse to the OBN. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin dated August 2024 revealed the facility had a zero-tolerance policy for resident abuse which included verbal abuse. This deficiency represents noncompliance investigated under Complaint Number OH00165135.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to provision of care for residents on enhanced barrier precautions (EBP.) This affected two (Residents #11 and #13) of three residents reviewed. The facility census was 107 residents. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including hypotension, gastrotomy, colostomy, obesity, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 12/07/24 revealed the resident had mild cognitive deficits and required substantial to total dependence with activities of daily living (ADLs.) Review of care plan for Resident #13 dated 09/23/24 revealed the resident required EBP related to an indwelling medical device (colostomy) regardless of multi drug resistant organisms (MDROs). Interventions included staff should don gowns and gloves prior to and during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact interactions included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs/toileting, and device care or use. Observation of incontinence care for Resident #13 on 12/31/24 at 10:00 A.M. per Certified Nursing Assistant (CNA) #33 revealed the aide did not don a gown prior to proving incontinence care to the resident. Interview on 12/31/24 at 10:05 A.M. with CNA #33 confirmed that she did not don a gown prior to providing incontinence care for Resident #13. 2. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including bipolar disorder, schizophrenia, and psychotic disorder. Review of the MDS assessment for Resident #11 dated 10/19/24 revealed the resident had no cognitive deficits and was independent with ADLs. Review of the care for Resident #11 plan dated 06/11/23 revealed the resident required EBP related to a left ankle wound. Interventions included staff should don gowns and gloves prior to and during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact interactions included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs/toileting, and device care or use. Observation of wound care for Resident #11 on 12/31/24 at 10:16 A.M. per Licensed Practical Nurse (LPN) #32 revealed the nurse did not don a gown prior to providing wound care for the resident. Interview on 12/31/24 at 10:25 A.M. with LPN #32 confirmed that she did not don a gown prior to providing wound care for Resident #11. Review of the facility policy titled Enhanced Barrier Precautions dated 03/22/24 revealed EBP were indicated for residents with indwelling medical devices and wounds even if the resident was not known to be infected or colonized with an infection. EBP measures included staff should don gowns and gloves during high contact resident care activities.

Based on review of facility Self-Reported Incident Reviews (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations of misappropriation were reported in a timely manner to the Ohio Department of Health (ODH). This affected one (Residents #12) of 12 residents reviewed for misappropriation. The facility census was 110 residents. Findings include: Review of the facility SRI initiated 09/30/24 revealed the facility substantiated an allegation of misappropriation of Resident #12's narcotic medication, oxycodone per Registered Nurse (RN) #175. The facility substantiated misappropriation had occurred and RN #175 was terminated. Interview on 10/30/24 at 9:00 A.M. with the Director of Nursing (DON) confirmed she received a text from Licensed Practical Nurse (LPN) #225 on Friday 09/27/24 at 6:45 P.M. with a photograph of a Resident #12's controlled substance record with Registered Nurse (RN) #175's initials signing out doses of medication but on some of the lines Resident #19's name was written in the margin. The DON confirmed she attempted to call LPN #225 who sent her the image, but the nurse did not respond. The DON further confirmed the photograph was suspicious and she had concerns RN #175 had possibly misappropriated resident medication, because RN #175 had written Resident #19's name on Resident #12's record. The DON confirmed she did not follow up on the possible misappropriation concerns until Monday, 09/30/24 when the DON notified the Administrator, who opened the SRI on 09/30/24, and the facility began their investigation. The DON confirmed she did not report the suspicious information she received on 09/27/24 to her supervisor until 09/30/24. Interview on 10/30/24 at 10:00 A.M. with the Administrator confirmed the DON notified him on 09/30/24 of concerns regarding misappropriation per RN #175 which she had learned of on 09/27/24, and the facility did report the allegation to ODH till 09/30/24. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin dated 08/01/22 revealed the facility would report allegations of misappropriation to the state agency, ODH, within 24 hours. The policy definition of misappropriation included missing prescription medications or diversion of a resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. This deficiency represents noncompliance investigated under Complaint Number OH00159179 and Complaint Number OH00158434.

Based on medical record review, staff interview, review of hospital records, review of hospice notes, review of a transportation report, observations, and review of facility policy, the facility failed to ensure one resident (Resident #87) did not experience neglect. This resulted in Immediate Jeopardy and the potential for serious harm, injury, and/or negative health outcomes when on 12/03/23 Resident #87, whose left hand was discolored and painful, did not receive an x-ray as ordered, was not medicated for pain, and was not assessed by a physician or appropriately assessed by a nurse. She was not seen by a physician, and the primary care physician was not made aware of her condition. There was no documentation that Resident #87's radial pulse or capillary refill was assessed for appropriate blood flow to her left hand. X-rays were ordered on 12/03/23 but not completed until 12/07/23. Pain medication was ordered on 12/03/23 but not given until 12/06/23. The hospice physician ordered Resident #87 to be sent to the emergency room (ER) on 12/07/23 at 2:30 P.M. for evaluation, but she was not transported until 5:30 P.M. when she went by non-emergent transport. After being assessed in the emergency room , Resident #87 was diagnosed having left limb ischemia and dry gangrene, and her hand may not be salvageable. This affected one (Resident #87) of three residents identified by the facility as having a significant change in condition. The facility census was 108. On 12/14/23 at 1:09 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations #16 were notified Immediate Jeopardy began on 12/03/23 when Resident #87 was observed with a discolored left hand, which became swollen, more painful and darkened in color. Upon assessment at the hospital on 12/07/23 Resident #87's hand was found to be painful and cold, with no left radial pulse detected. Her left hand was flaccid. Resident #87 had a hemoglobin level of 4.5 requiring a transfusion of three units of packed red blood cells. After being assessed in the emergency room , Resident #87 was diagnosed having left limb ischemia and dry gangrene, and her hand may not be salvageable. The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective actions: On 12/07/23 at 5:30 P.M., Resident #87 was sent to the hospital by non-emergency transport. On 12/13/23, the DON began immediate education with all nurses to educate on the following and to be completed by 12/15/23: a. Facility protocol of Episodic and Narrative Documentation and physician and responsible party notification. b. Physician Orders and timely implementation and follow-up. c. Pain Management Protocols d. Any nurse who was not scheduled or who could not be educated will receive education prior to working their next scheduled assignment. On 12/14/23 at 1:10 P.M., the facility reviewed the 24-hour summary report up to 5:00 P.M. for current residents to verify that any other residents who had/may have had a change of condition that appropriate documentation, notification, and follow-up occurred. Two residents were identified with a change of condition and appropriate documentation and notification had occurred. On 12/14/23, the DON had phone conversations with our other contracted Hospices to make them aware of our expectations of communication of injuries of unknown origin, communication of new orders, and physician notification. On 12/14/23, the Licensed Nursing Home Administrator (LNHA) began immediate education for all current staff on the facility protocols for Abuse, Neglect, Misappropriation, and Injury of Unknown Origin. This will be completed by 12/15/23. Any staff member who was unable to be educated will be educated prior to their next scheduled assignment. On 12/14/23, the Medical Director was notified of the Immediate Jeopardy once the facility was notified. On 12/15/23, the facility will conduct ongoing monitoring for condition change and documentation during the daily clinical morning meeting by reading the 24-hour summary report in the Electronic Health Record (EHR) Monday through Friday, and the 72-hour report on Mondays for Friday through Sunday to verify appropriate assessment/documentation and notification has occurred and will follow up as indicated. The DON/Designee will complete a condition change audit tool daily Monday through Friday to verify that condition change protocols, notification and documentation have been followed. On 12/15/23, the LNHA will query five random staff members daily Monday through Friday weekly times four weeks, and then three times per week for four weeks, and then weekly for two weeks. Results will be reviewed at the Quality Assurance and performance Improvement meetings. On 12/18/23 from 3:15 P.M. to 3:32 P.M., interviews conducted with Licensed Practical Nurse (LPN) #93, LPN #106, State tested Nursing Assistant (STNA) #10, and STNA #38 verified they had received in-servicing as specified in the corrective action plan. Although the Immediate Jeopardy was removed on 12/15/23, the facility remains out of compliance at a Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance, protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred to the hospital on 12/07/23 at 5:30 P.M. Review of Resident #87's care plan dated 03/21/23 revealed Resident #87 had the potential for pain with a goal to be free of pain/discomfort. One of the interventions was to evaluate for non-verbal indicators of pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment and at that time she was assessed as not having pain. She was noted as being under hospice care. Review of a progress note dated 12/03/23 at 8:00 A.M., written by LPN #120, documented the aide advised me about (the) res (resident's) left hand being discolored. It noted the nurse called hospice and told the nurse who answered about Resident #87's hand. She asked if the resident had any pain medication ordered. The nurse charted that she looked up her Medication Administration Record (MAR) and saw that she did not. The nurse (Hospice Nurse #171) stated she would call the doctor and would give her a call back. A couple hours later Hospice Nurse #171 came to the facility and looked at Resident #87. She said she had called the doctor and was waiting for them to call her back to see what pain medicine he could prescribe. She stated she would call the facility when she had an order. The note documented Hospice Nurse #171 did not call back during the shift. The progress note revealed the nurse let the following nurse know that they were waiting for a return call from hospice to see what they suggested. Review of the hospice note dated 12/03/23 revealed Hospice Nurse #171 was in on 12/03/23 at 11:30 A.M. to 12:05 P.M. The pain medication order on the hospice file at that time was Acetaminophen 500 milligrams (mg) to give two tablets every morning as needed for pain that started on 06/21/23. The Acetaminophen order was not on the facility's MAR or in the resident's electronic record. The note said the visit was completed at that time and Resident #87 was in bed complaining of left hand pain. The facility staff reported that she had blue and purple fingers. The physician was notified, and hospice staff were awaiting directions. Review of the hospice case note dated 12/03/23 at 8:55 P.M. documented a return call was received from Hospice Physician #172. Hospice Nurse #171 reported to the physician that Resident #87's hand was discolored at the fingertips. Resident #87 was able to move her fingers at that time and complained of discomfort and some swelling. Hospice Physician #172 gave orders for Tylenol 325 mg every six hours as needed and Norco 5/325 mg every four to six hours as needed. The physician was requesting an anteroposterior (AP) and lateral x-ray of her hand. The orders were called to the facility. Hospice Physician #172 would sign and send the orders for medication to the pharmacy. The orders were called and faxed to the facility. Review of the hospice case note dated 12/04/23 at 9:10 A.M. revealed a call was made to the facility by Hospice Nurse #171 to receive the results of the X-ray per request of Hospice Physician #172. The floor nurse stated the results were still pending. The nurse reported the pain intervention was effective. Review of a progress note dated 12/04/23 at 3:39 P.M. written by LPN #118 documented Resident #87's left hand was swollen, and the fingers were discolored (dark bruising). It further documented hospice was notified, awaiting a return call. The note indicated she was told verbally that Hospice came out the day before (12/03/23) for an evaluation and there were no new orders. Review of a nursing progress note dated 12/04/23 at 11:56 P.M. revealed Resident #87 refused her evening medication. Review of the narcotic count sheet for Norco 5-325 mg revealed it was signed as being received by the facility on 12/04/23. Review of a change of condition note dated 12/05/23 at 5:00 P.M. revealed Resident #87's condition had gotten worse. Her weight had dropped from 72 pounds on 11/03/23 to 60 pounds on 12/02/23. She had increased confusion and decreased mobility. She had edema, but the location was not documented. She had discoloration to her left hand, and her intensity of pain was rated a nine on a zero to ten scale. She had called for Hospice Nurse #171 to come out and reevaluate her on 12/05/23 at 3:00 P.M. Resident #87's responsible party was notified of her decline and change to her left hand. Review of the hospice note dated 12/05/23 at 9:15 P.M. revealed that a call was made to Resident #87's responsible party due to his concern that she was refusing medication. He was advised the facility reported the patient was taking Norco on the previous day and that she had relief. Review of the MAR revealed on 12/05/23 night shift, Resident #87 had a pain rating score of six with no pain medication given. Review of a progress note dated 12/06/23 at 8:55 A.M. by LPN #93 revealed a call was placed to the hospice nurse requesting her to come and reevaluate Resident #87. Review of the hospice visit note dated 12/06/23 at 10:15 A.M. revealed Resident #87 was in her room with her hand elevated on a pillow. Her hand had previously been assessed with plus one edema (a 2 millimeter indentation that rebounds immediately), now non-pitting. Resident #87's hand was still hurting to touch. She said she just needed some sleep and was tired. The facility reported she was not eating at all except small snacks left in her room. The staff reported the X-ray was completed but are still awaiting results of the X-ray. It stated, Patient has decreased range of motion still able to move fingers, just painful. Review of the MAR revealed on 12/06/23 at 4:49 P.M., Resident #87 was given Norco 5-325 mg after she reported her pain was rated a seven. Review of Resident #87's order recap report revealed the order for a two-view X-ray of the hand was ordered on 12/07/23. During an observation on 12/07/23 at 10:54 A.M., Resident #87 was sitting in a reclining wheelchair in the dining room. Her hand appeared to have a dark bruise on her thumb and fingertips. During an interview at this time, Resident #87 stated she hit her hand on a door. When asked if it hurt, she said It hurts so bad! A nearby nurse said she had given Resident #87 pain medication that was ordered after her injury. Review of the progress note dated 12/07/23 at 11:50 A.M. by LPN #92 revealed Resident #87 had swelling to her left hand with discolored fingers (bluish black colored). Hospice was informed over the past weekend. Resident #87 had complaints of pain and the as needed Norco pain medication was given. The pain subsided for about an hour, but the pain came back, and Resident #87 wasn't due for more pain medication until 2:46 P.M. Her pain was rated a four out of ten but did not interfere with her activities of daily living at that time. A call was made to the hospice provider and the nurse would come out that day to re-evaluate Resident #87's hand. Review of the MAR revealed Resident #87 was medicated for pain on 12/07/23 at 8:44 A.M. after rating her pain a four. Review of the hospice skilled nursing visit note dated 12/07/23 at 1:10 P.M. revealed Resident #87 was present in a chair. Her fingers were more swollen than the previous visit with a slight change in color. Orders were given to the facility on Sunday evening (12/03/23), and no results and no orders were put in by the facility nurse. The DON ordered an X-ray at that time. She informed Hospice Physician #172 and he stated he did not want to wait for results and to send her to the hospital. The orders to send her to the hospital were given directly to the DON at that time. The DON demonstrated understanding. The responsible party was present and acknowledged understanding also. Review of the transport record revealed she was picked up on 12/07/23 at 5:30 P.M. by non-emergent transport. Review of Resident #87's two-view X-ray to her left hand dated 12/07/23 revealed the findings that the hand demonstrated slightly decreased bony ossification. There was no evidence of acute fracture, or dislocation. Diffuse arthritic changes were noted throughout the hands and digits. No significant soft tissue swelling was identified and there was no evidence of osteomyelitis. Review of the hospital records for Resident #87 revealed on 12/07/23 at 11:00 P.M. results from a computed tomography-angio of the upper extremity with and without hypoattenuation revealed she had severe 90 percent atherosclerotic stenosis of the left subclavian artery shortly after its origin with mural thrombus. It showed patent left axillary, brachial, and radial arteries. The left ulnar artery was patent at its origin and no longer visualized along the proximal to mid forearm. A vascular surgery consultation was recommended. Review of the medical intensive care unit history and physical, dated 12/08/23 at 1:22 A.M., documented the resident was admitted on [DATE] at 8:57 P.M. Her left hand was painful and cold. Her blood pressure was in the 120s/40s and she was tachycardic. Her hemoglobin was 4.6 (normal level for females 11.6 to 15 per Mayo Clinic). She had no left radial pulse detected. She was admitted to the Surgical Intensive Care Unit (SICU) for anemia in setting of limb ischemia. She had left limb ischemia and dry gangrene. Review of the SICU flow sheet dated 12/08/23 at 5:17 A.M. revealed she had complaints of pain at a level of eight in her left hand. Her hand was black at the fingertips and the patient was unable to perform fine motor skills. She had to be given as needed Haldol one time so staff could safely and effectively provide treatments. She had mitt restraints in place. Review of the hospital Vascular Surgery Daily Progress note dated 12/08/23 at 7:01 A.M. revealed her pulses were palpable at the left brachial only and absent in the radial and ulnar. Her left hand was flaccid. They could not perform surgery with her hemoglobin of 4.5 and her hand may not be salvageable. During an interview on 12/11/23 at 2:30 P.M., the DON said the resident went to the hospital on 12/07/23. She spoke to Resident #87's responsible party who said he was going to meet her at the hospital. Non-emergency transport was called to take her and drop her off. She said the facility sent the X-ray results, face sheet, and orders. She stated the hospice nurse was out to see her on 12/04/23 at around 1:00 P.M. to 2:00 P.M. The hospice nurse told the responsible party and the nurse that there was nothing they could do. There were no new orders from hospice at that time. The DON said she went through the hospice notes finding there was an order for an X-ray. She spoke with the hospice nurse and she said she spoke with a nurse about the X-ray order. She was unable to provide the name of the nurse, but said it was requested from the day shift nurse. The DON saw that an order for an X-ray was not obtained until 12/03/23 at 8:30 P.M. She said the facility did not get the order and requested the resident be seen again on Tuesday and asked for the hospice notes. When she found the order, she called to have it done on 12/07/23. The results were that she did not have any fractures. During an interview on 12/11/23 at 4:36 P.M., LPN #120 stated she worked day shift on 12/03/23 and the aide told her she should look at Resident #87's hand. She stated Resident #87's hand was discolored, and when LPN #120 touched her hand, Resident #87 was in pain. She stated she called the physician and he said she had to contact hospice. She said she called the hospice provider and spoke with the nurse telling her that Resident #87's left hand fingers were discolored. Hospice Nurse #171 asked if Resident #87 had any as needed pain medication. LPN #120 looked at her orders and there were no orders for as needed pain medication. Hospice Nurse #171 said she would have to contact the doctor to see what they could do about it. About one and a half to two hours later, Hospice Nurse #171 came out to see Resident #87. She revealed Hospice Nurse #171 said yes it does look bad and told her she was waiting for the doctor to call back to see what she could prescribe. She believed Hospice Nurse #171 came out on 12/03/23 about 1:00 P.M. She said Resident #87 stayed in her room and did not want to come out. She stated Hospice Nurse #171 did not call back with a pain medication order during the shift. LPN #120 said she did not call the physician again but felt she should have. She revealed Resident #87 did not complain of pain anymore that shift. She said Hospice Nurse #171 did not say they were ordering an X-ray. She also stated the bruising was not reported to management, and she was not aware of the proper procedure regarding a bruise. During an interview on 12/13/23 at 12:57 P.M., LPN #119 stated she worked on the 200 unit that night and stated Resident #87 complained of pain when her left hand was touched or if she moved it. She said Resident #87's hand was turning blue. She was not aware of Hospice Nurse #171's visit and thought they were still waiting for her. She stated she did not receive a call for an order for an X-ray or pain medication. She stated when the State tested Nursing Assistant (STNA) tried to move her hand she said it hurt. She said she tried to call hospice and did not get an answer. She said Resident #87 could move her arm, wiggle fingers, and had a pulse. She stated Resident #87 did not get any pain medicine but did not complain if her hand was not touched. She said Resident #87 slept through the night. She passed on to day shift that she did not hear from hospice. She said the supervisor was Registered Nurse (RN) #157. During an interview on 12/13/23 at 1:24 P.M., RN #157 said he was not aware of any concerns regarding Resident #87's left hand and did not receive a call from hospice. During an interview on 12/13/23 at 12:37 P.M., LPN #118 stated Resident #87's responsible party came in and got her. He said she was really complaining about her hand. She said the night shift nurse said they were not going to do an X-ray. She said she talked to LPN #93 and was told they were not going to do anything due to her being on hospice. She said she tried to contact the hospice by trying several numbers (due to one of the numbers not being a good contact number). The hospice staff did not know what to do and said they would send someone out. She revealed Resident #87 was in pain at that time. She said she looked to see if there was anything ordered for pain. She revealed they were supposed to get a prescription for her for pain medications, so she looked for a prescription and did not find one. She said Resident #87 was able to wiggle her fingers very little due to pain and Resident #87 told her she slammed it in the door. She stated the complaint of pain was after lunch. LPN #118 did not remember checking her wrist for a pulse. She said she did not hear from the hospice nurse and was taught that all orders were to go through hospice. During an interview on 12/13/23 at 12:28 P.M., LPN #88 stated she was told Hospice Nurse #171 had been called and she came to evaluate her. She said she did not send her out. She said she did not remember if Resident #87 complained of pain or not. She said one finger was discolored and swollen. She thought there was pain medication in the cart but did not administer any. She was not aware of any order for an X-ray. She did not remember Resident #87 having any changes out of the ordinary. She believed she checked her pulse but was not sure and the resident could move her hand and arm. During a telephone interview on 12/13/23 at 11:36 A.M., LPN #128 said the resident did not have pain medication on the MAR, but she did not remember her having pain. She revealed she did not check Resident #87's pulse, but her hand looked contracted with her fingers turning in. She said Resident #87 was moving the arm, but her fingers were discolored. The behavior that she observed was Resident #87 being agitated and refusing her medication. She said Resident #87 did not cry out in pain, she just wanted ice chips. During an interview on 12/13/23 at 10:22 A.M., LPN #92 said she worked on the 200 unit caring for Resident #87 often. She said Resident #87 was right-handed and was able to feed herself. She noticed the resident was declining to come to the dining room around the end of November. Resident #87 could use both hands but her appetite was poor. She said she did not see Resident #87's bruised hand until 12/05/23. She did a change of condition assessment on 12/05/23, taking her vitals but she did not check for a pulse in her left hand. She had said Resident #87 had edema, pain, and discoloration in her left hand. She revealed she called hospice on 12/05 and talked to Resident #87's responsible party. She was letting him know that Resident #87's appetite was poor, she had weight loss, and swelling in her hand. She stated she called hospice out to reevaluate her, and the on-call nurse said Hospice Nurse #171 would call her back or come out. She stated she did not get a call back on 12/05/23, so she called hospice again on 12/06/23. She revealed Resident #87 could use both hands at that time. She said Resident #87 said her left hand hurt but she did not recall the pain rating. She believed Resident #87 had Norco for pain. She said the prescription was not put on the MAR until 12/06/23. She said the hospice on call was not sure when, but the doctor had sent over the prescription for Norco. She revealed the orders were usually electronically sent directly to the pharmacy. She said Resident #87 did not have any pain medication from 12/03/23 to 12/05/23, but she did not think the hand looked worse. During an interview on 12/13/23 at 11:52 A.M., Hospice Nurse RN #171 said on Sunday 12/03/23 she came to see Resident #87. She said Resident #87's index and ring finger were a purplish color around the nail bed like a bruise. She had slight edema and complained of severe pain, wincing, and screaming when touched. She said Resident #87 did not have any pain medication ordered on file. She said usually Resident #87 did not like taking pain medications and would not take them. She revealed that evening (12/03/23) she received orders for Norco and Tylenol. There was also an order for an X-ray of the left hand that evening. She said she called the facility, and the orders were given to a nurse, but she didn't know her name. She said they do not call the pharmacy with orders. They use an application called Arcopia which goes straight to the pharmacy. Their physician signs for the narcotic and she was able to see this was done on the computer. She said she was in constant contact with the doctor. She revealed it would have been the night shift nurse that she talked to. She said at that time Resident #87 had a pulse in that hand and good capillary refill. She was able to flex her fingers, and she could lift her left arm. She called the next day (12/04/23) for the results of the x-ray and the facility staff nurse said they were waiting for the results. The nurse said they put in the orders, and she also said a pain pill was given and was effective. She did not see her 12/04/23, but on 12/05/23 Resident #87's responsible party told her the hand was about to fall off. He said the nursing home did not get in touch with him on Sunday. He was surprised and angry he was not informed. The responsible party was to come on Saturday, but she asked if he wanted to meet her on Wednesday. She said she came and saw Resident #87 on Wednesday 12/06/23 in the early morning. She said Resident #87 was asleep, not appearing to be in pain. She said Resident 87's left hand was not severely different than Sunday. She stated she did not see a change and was told the X-ray had not gotten back. She talked to third shift staff briefly, and there were no complaints. They said she slept all night. She stated she checked Resident #87's pulse and her capillary refill and vitals were within normal limits. On 12/07/23, facility staff called the responsible party and then called her saying her hand was black and falling off. She said she came to the facility and met with Resident #87's responsible party. She said Resident #87's left hand was not black but darker and more swollen. She said there was a pulse, and she was able to move arm, wrist, and elbow. Hospice Nurse #171 said Resident #87 appeared to be in pain when she came in. She revealed the DON pulled her aside and asked what happened on Sunday, telling her there was no documentation. She asked why she did not come in to facilitate the X-ray, but hospice would usually give orders for the facility to schedule the X-ray. She talked to the social worker and responsible party, who was saying the resident never talked to him about the resident. A facility nurse reported to Resident #87's responsible party that she was mottling, and he was beginning to get family together. She said Resident #87 was not mottling. She stated she called Hospice Physician #172 from the facility to ask if he wanted to wait for X-ray or send her to the hospital to make sure there was no deep vein thrombosis. His orders were to send her to the hospital on 12/07/23 at 2:30 P.M. She called the hospital at 8:30 P.M. to 9:00 P.M. The responsible party called and told her he had just left the hospital at about 8:45 P.M. She said the DON was calling report. She stated Resident #87 was admitted to the Intensive Care Unit (ICU) and she was taken off hospice service when admitted . During an interview on 12/13/23 at 3:01 P.M., Hospice Physician #172 stated on 12/03/23 Hospice Nurse #171 sent him a picture of Resident #87's left hand saying her hand was smashed in a door. The note said she could move her fingers, and the original treatment was to apply ice at first every 20 minutes and use Naproxen or Ibuprofen for pain. He ordered Norco due to Resident #87 not keeping the ice on. He said he also ordered an X-ray for her hand. Her pain level was rated 10. He sent a verbal order which the system notified him to sign. He stated he would sign for narcotics immediately, and the electronic prescription went to the pharmacy. He would later sign all other verbal orders, including the X-ray order, on Tuesdays. He received another call from Hospice Nurse #171 on 12/04/23 at 9:37 A.M. but did not recall the conversation. He said there was a picture sent to him by Hospice Nurse #171 on Thursday at 2:23 P.M. He said Resident #87's left hand looked swollen but wrinkled, not stretched, slightly curled fingers, showing her index finger having a darker color and a whitish nail bed. He compared the pictures from 12/03/23 and 12/07/23. He said Resident #87's left hand looked worse and due to not having anything else to go by, he ordered her be sent to the emergency room for evaluation on 12/07/23 at 2:23 P.M. During an interview on 12/14/23 at 11:00 A.M., the DON said Resident #87 went into the hospital where she was found to have a blockage on 12/07/23. She said the hospital tried to get in touch with her responsible party for options, but when they got in touch with him, he refused to have a stent placed to improve circulation to the arm. She said after two days, once the fingers developed dry gangrene they were talking about palliative care. She said Resident #87 was in the emergency room waiting area for several hours prior to being seen. She said Resident #87 was scheduled to return on 12/08/23, but the responsible party wanted more options done before sending her back. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin, revised on 08/01/22 stated the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. This deficiency represents non-compliance found during the investigation of Complaint Number OH00148957.

Based on medical record review, staff and physician interview, review of personnel files, review of the facility menus and review of facility policy, the facility failed to ensure a resident on a mechanically altered diet was provided food in the correct texture assessed to meet their individual needs. This resulted in Immediate Jeopardy for one (#99) resident who experienced serious life-threatening harm when staff served Resident #99 the incorrect texture of food items during a meal, the resident subsequently choked requiring staff and Emergency Medical Service (EMS) intervention to perform the [MEDICATION NAME] maneuver in an effort to remove the food bolus from the residents airway, the resident's condition deteriorated and the resident passed away at the facility. This affected one (#99) of seven residents reviewed for choking and/or mechanical altered diets. The facility identified six (#27, #43, #47, #63, #68, #91) current residents with a dysphagia [DIAGNOSES REDACTED]. The facility census was 98. On [DATE] at 4:09 P.M., the Administrator, Director of Nursing (DON), the Regional Director of Clinical Operations, and Registered Nurse (RN) #10 were notified Immediate Jeopardy began on [DATE] at approximately 4:30 P.M. when Resident #99 who was edentulous, had a [DIAGNOSES REDACTED]. The nurse performed the [MEDICATION NAME] maneuver which resulted in the resident expelling a piece of meat. EMS was called and took over rescue efforts and retrieved a large piece of meat from Resident #99's airway. Resident #99 was pronounced dead by EMS personnel on [DATE] at approximately 4:45 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 4:45 P.M., the nurse on duty performed the [MEDICATION NAME] maneuver on Resident #99 and staff summoned EMS personnel. EMS personnel took over Resident #99's care. At 4:45 P.M., Resident #99 was pronounced dead at the facility. · On [DATE], the DON and Dietary Supervisor (DS) #60 did an audit of the printed meal tray ticket for every resident in the facility to ensure the correct diet orders were noted. The audit was 100 percent in compliance. · On [DATE], following Resident #99's choking incident, State tested Nursing Assistant (STNA) #40 and Cook #50 were removed from the schedule. On [DATE], STNA #40 and Cook #50 were terminated. · On [DATE] beginning at 6:00 P.M., the DON educated all nurses and STNAs regarding ensuring residents were served the correct diet based upon their tray ticket. The education was completed on [DATE] at 7:00 P.M. · On [DATE], DS #60 educated all dietary staff on ensuring trays were sent out from the kitchen with a tray ticket with the resident's name and correct diet. · On [DATE], Registered Dietitian (RD) #90 completed an audit of various meals to ensure the resident received the correct diet which matches the diet listed on the tray ticket. The audit was in 100 percent compliance. · On [DATE], the Quality Assurance Performance Improvement (QAPI) Committee met to review and investigate the incident regarding Resident #99. The committee performed a root cause analysis and determined staff made errors and did not follow proper procedure when the kitchen staff sent out a tray for the resident without a tray ticket which would have indicated the correct diet for Resident #99. · On [DATE], the governing body of the facility met to review the choking incident. · On [DATE], the Administrator implemented audits of meal delivery. The audits will be completed five times weekly for four weeks and then weekly for one month. The QAPI Committee will meet monthly and the results of the audits will be reviewed with the committee. The QAPI Committee will determine the need for further monitoring. · On [DATE] between 3:00 P.M. and 3:10 P.M., interviews with Licensed Practical Nurse (LPN) #20 and Cook #80 confirmed they received education on [DATE] regarding the meal delivery process and ensuring residents receive the correct physician ordered diets. · On [DATE] at 8:00 A.M., observation of the breakfast meal revealed Resident #19, #78, and #50 received the correct diets as ordered by the physician and each resident's tray had a ticket which indicated the resident's name and the correct diet. · On [DATE], six (#27, #43, #47, #63, #68, #91) current residents with a dysphagia [DIAGNOSES REDACTED]. The medical record reviews revealed current physician orders for mechanically altered diets were accurate and no concerns were identified. · On [DATE] between 11:52 A.M. and 12:14 P.M., observations revealed Resident #27, #43 and #63 were served mechanical soft diets as ordered by the physician. Further observations of the resident's meal tickets revealed the correct diet was listed. · On [DATE] between 11:45 A.M. and 11:53 A.M., interviews with LPN #110, STNA #120, and STNA #130 confirmed they had received education on [DATE] from the DON regarding ensuring residents received the correct diet and to check the meal ticket prior to serving the resident. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #99 revealed the resident was admitted to the facility on [DATE]. Resident #99 passed away at the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #99's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired, required supervision and set up for eating and was edentulous. Review of the care plan for Resident #99 dated [DATE] revealed resident had an alteration in nutrition related to dysphagia and poor dentition. Interventions included the following: encourage compliance with diet guidelines, monitor for signs and symptoms of dysphagia, monitor diet tolerance, supervision and assistance with meals and snacks as needed. Review of the [DATE] physician orders for Resident #99 revealed an order for [REDACTED]. Review of the nurses progress notes for Resident #99 dated [DATE] timed at 6:49 P.M. revealed the resident was eating dinner with supervision in the fine dining room and became non-responsive and turned blue while eating the meal. Further review of the note revealed the nurse performed the [MEDICATION NAME] maneuver on Resident #99 and was able to remove a small piece of meat, nine-one-one (911) was called immediately, and EMS personnel arrived and took over rescue efforts. EMS personnel removed another piece of meat from the resident's airway and provided oxygen to the resident and monitored her noting she continued to be non-responsive but had a faint pulse. EMS personnel pronounced Resident #99's death at the facility. Resident #99's guardian and attending physician were notified and an order was given to release the resident's body to the funeral home. Review of nurses progress notes for Resident #99 dated [DATE] timed at 7:00 P.M. revealed the resident's body was released to the funeral home. Review of Resident #99's MDS dated [DATE] revealed the resident passed away in the facility. Interview on [DATE] at 11:00 A.M. with the DON confirmed Resident #99 had a physician's order for a mechanical soft diet but received a regular diet for dinner on [DATE]. The DON confirmed the entrée for dinner on [DATE] was smoked sausage, and Resident #99 received a whole intact sausage on her dinner tray instead of ground sausage. The DON confirmed Resident #99 was edentulous and had a [DIAGNOSES REDACTED].M., Resident #99 turned blue and became non-responsive. The DON stated Registered Nurse (RN) #100 performed the [MEDICATION NAME] maneuver on Resident #99 and was able to remove a small piece of meat, 911 was called immediately, and EMS personnel arrived and took over rescue efforts. The DON stated EMS personnel were able to remove another piece of meat from Resident #99's airway, EMS personnel provided oxygen to the resident and monitored her noting she continued to be non-responsive but had a faint pulse. EMS personnel pronounced Resident #99's death at 4:45 P.M., and the appropriate notifications were made to the resident's guardian and attending physician. The DON stated an order was given to release the resident's body to the funeral home. The DON stated RN #100 is currently on leave and not available for an interview but the DON further confirmed she was in the facility at the time of the choking incident and assisted with Resident #99's care. Interview on [DATE] at 12:00 P.M. with Physician #70 confirmed the coroner's office would be completing Resident #99's death certificate but stated the choking incident which occurred on [DATE] was a factor in the resident's death. Interview on [DATE] at 1:17 P.M. with the Administrator confirmed Cook #50 and STNA #40 were terminated on [DATE] due to not following facility policy. The Administrator further confirmed the facility's investigation of the incident determined the root cause of Resident #99's choking incident and subsequent death was due to facility staff not providing Resident #99 with the correct physician ordered mechanical soft textured diet at the dinner meal on [DATE]. On [DATE] at 10:00 A.M., a request was made to obtain Resident #99's EMS squad run report from [DATE]. Review of the personnel file for former STNA #40 revealed a date of hire of [DATE] and a termination date of [DATE] due to failing to comply with facility policies. Further review of the file reveals STNA #40 was terminated [DATE] for serving a resident a meal tray without a ticket indicating the resident's correct diet. Further review of the termination notice revealed the STNA gave the resident a regular diet tray, but the resident who was supposed to be on a mechanical soft diet, choked during the meal and expired as a result. Review of the personnel file for former Cook #50 revealed a date of hire of [DATE] and a termination date of [DATE] due to failing to comply with facility policies. Further review of the file revealed Cook #50 was terminated on [DATE] for providing a meal tray for a resident without obtaining a written ticket which indicated the resident's correct diet. Further review of the termination notice revealed the resident was provided a regular diet tray but was supposed to be on a mechanical soft diet, and the resident choked on the meal and expired as a result. Review of the facility menu for the dinner meal on [DATE] revealed the entrée was smoked sausage. Review of facility's undated policy titled Standard House Diets revealed the facility would ensure appropriate modified texture diets would be available to residents to ensure meal trays were prepared and served accurately. Further review of the policy revealed a mechanical soft diet would be prepared to accommodate residents with difficulty chewing to include ground meats. This deficiency substantiates Complaint Number OH 810.

Based on medical record review, observation, interviews, review of a written statement, review of a police report, review of the National Weather Service report, and facility policy review, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident, who had a legal guardian, and was assessed as being at risk for elopement. This resulted in Immediate Jeopardy when one resident (#103) was placed at risk for serious harm and injury when the resident eloped from the facility, without staff knowledge and was missing for approximately 26 hours. The resident was found by local police approximately 3.5 miles away from the facility. This affected one (#103) of three residents reviewed for risk of elopement. The facility identified 22 residents who resided on the same secured unit. The facility census was 110. On 11/15/18 at 3:40 P.M., the Administrator, the Director of Nursing (DON), and Director of Clinical Operations #01 were notified Immediate Jeopardy began on 10/26/18 at 5:00 P.M., when Resident #103 was not provided adequate supervision and eloped from the facility. Resident #103 was assessed at risk for wandering and elopement. Resident #103 had a history of [REDACTED]. On 10/26/18 at 5:00 P.M., State tested Nurse Aide (STNA) #08 delivered Resident #103's dinner tray to his room and noticed the resident was missing. The patio door in the resident's room was ajar, approximately two to three inches and the bottom of the frame was bent. Resident #103 was found on 10/27/18 at 7:30 P.M., at a friend's house approximately three and a half miles away from the facility. The Immediate Jeopardy was removed on 11/14/18 when the facility implemented the following corrective actions: · On 10/26/18 at 9:00 P.M. to 10/27/18 at 5:00 P.M., Registered Nurse (RN) #14 and RN #15 called the police 11 times attempting to get updates. · On 10/26/18 at 9:30 P.M., the Administrator completed an audit of all door alarms in the building. The door alarms were all functioning properly. · On 10/26/18 at 10:00 P.M., the DON and Assistant Director of Nursing (ADON) #06 completed an audit of all residents using the wander risk scale. · On 10/26/18 at 10:00 P.M., the Administrator and State tested Nurse Aide (STNA) #10 completed an audit of all the sliding glass doors and windows in the building. There were no concerns found. · On 10/26/18 at 11:30 P.M., Maintenance Director #11 and Maintenance Aide #12 took additional measures to repair and secure Resident #103's exterior sliding glass door. Two pieces of galvanized pipe were installed into the lower and upper sliding tracks of the door, thereby preventing the door from being opened. Screws were also inserted in the side of the door frame extending into the sliding door. · On 10/27/18 at 7:30 P.M., Resident #103 was located by the local police, but refused to come back to the facility. The DON called Psychiatrist #100 and Medical Director #101 to attempt to get the resident directly admitted to the hospital, but neither Psychiatrist #100 or Medical Director #101 were able to get Resident #103 directly admitted to the hospital. The local police informed the DON that Resident #103 was transported to the hospital due to him having a [MEDICAL CONDITION]. · On 10/28/18 at 10:00 A.M., the DON initiated staff education regarding locked doors and codes. Specifically, to ensure staff are checking to ensure residents aren't following staff off a locked unit and to ensure staff don't give the door codes to anyone. Education of all employees was completed on 11/14/18 by the DON. · On 10/28/18 at 2:15 P.M., Resident #103 returned to the facility from the hospital and was placed on one-to-one (1:1) supervision. · On 11/03/18 at 7:00 A.M., Resident #103 was taken off 1:1 supervision and 15-minute checks were initiated. Resident #103 was taken off the 15 minutes checks on 11/08/18 at 6:15 P.M. · On 11/14/18 at 6:00 P.M., RN #13 implemented an audit tool to monitor education on locked doors and codes. The audits will be completed three times per week for four weeks, then bi-weekly for a month. The Administrator also implemented audits for inspection of sliding glass doors, windows and secured doors. The audits will be competed three time per week for four weeks, once a week for four weeks and then every two weeks for a month. · On 11/14/18, medical record reviews and observations of two additional residents (#92 and #108) identified at risk for elopement, noted appropriate interventions were in place in accordance with the facility's corrective actions taken. · On 11/14/18, interviews with STNA's #03, #04 and #07 and interview with Licensed Practical Nurse (LPN) #05 revealed they had been recently in-serviced and were knowledgeable to ensure a resident does not follow them off the unit and to not give out the door codes to anyone. They were also knowledgeable of the elopement policy and procedures. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident 103's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #103's wandering risk scale dated 07/18/18 revealed the resident was at risk of wandering. Review of Resident #103's care plan initiated on 07/26/18 revealed the resident was at risk for elopement due to poor safety awareness, ambulation, dementia and exit seeking. Interventions included encouraging resident to participate in activities, attempting to allow resident to verbalize feelings, encouraging resident to remain inside the facility unless accompanied by a responsible person, redirect resident when he wanders from the facility or attempts to go outside, use friendly persuasion to bring resident inside the facility when he wanders outside, assess for injuries upon return of resident if he successfully elopes and notify the resident's family, physician, the police and the Administrator if resident is unable to be located. Review of the resident quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Further review of the MDS revealed Resident #103 wandered daily and had physical behaviors, verbal behaviors, and rejection of care. Review of Resident #103's progress notes dated 10/26/18 at 5:00 P.M. revealed at 4:00 P.M., Resident #103 was walking down the hallway. At 5:00 P.M., staff delivered the dinner tray to the resident's room. The resident was not in his room and the patio sliding door, in the resident's room, was observed to be bent at the bottom of the frame. The door was ajar approximately two to three inches but was not able to be opened any further. After searching the room, the elopement protocol was initiated, a search was conducted, the Administrator, the DON, Medical Director (MD) #01, police departments, guardian, and local hospitals were notified. Review of the progress notes dated 10/27/18 at 9:27 P.M. revealed the police called and informed the facility Resident #103 was found at approximately 7:30 P.M. at a friend's house, in no distress. The police were made aware Resident #103's guardian wished for the resident to return to the facility. Resident #103 refused to come back to the facility and reported he would beat up the staff if he came back. The DON recommended to the police the resident be sent to the hospital. The police reported they could not take Resident #103 to the hospital unless he was guaranteed to be a direct admission. The facility contacted Psychiatrist #103, but the psychiatrist could not guarantee the resident would be a direct admission. The DON reported the facility could not admit the resident if he was threatening to hurt staff. The DON contacted Physician #01 and the physician recommend the resident not return to the facility due to him refusing his medications in the past and threatening to beat up staff if he returned to the facility. The facility later received a call from the police indicating the resident was transported to the hospital due to having a [MEDICAL CONDITION]. Review of Psychiatrist #103's progress note dated 11/01/18 revealed the resident indicated he used cocaine at his friend's house after he eloped from the facility. Interview with the Administrator on 11/13/18 at 9:00 A.M. revealed the facility was unsure how Resident #103 got out of the facility. The Administrator felt he probably followed someone off the unit. The Administrator reported Resident #103 was found at a friend's house. The Administrator reported the facility identified a possible location of where Resident #103 might have been, so the police went to that location, but Resident #103 refused to return to the facility. The Administrator reported the police left Resident #103 at his friend's house and Emergency Medical Services (EMS) was later dispatched to Resident #103's friend's house due to the resident having a [MEDICAL CONDITION]. Resident #103 was transported to the hospital by EMS and was later transferred back to the facility. The Administrator reported Resident #103's friend resided nearby but was unsure how the resident got to his friend's house. Interview with Social Services Director (SSD) #02 on 11/13/18 at 9:35 A.M. revealed she was unaware of how Resident #103 eloped from the facility. SSD #02 stated Resident #103 told her staff member, who was his relative, to let him out of the facility. SSD #02 reported Resident #103's sliding glass door was tampered with, but SSD #02 was unsure if Resident #103 could have fit though the sliding glass door as the opening was very small. Interview with LPN #01 on 11/14/18 at 8:00 A.M. revealed he was on duty on 10/26/18 when Resident #103 eloped from the facility. LPN #01 reported staff went into Resident #103's room to give him his dinner tray and they noticed he was missing. LPN #01 stated Resident #103's sliding glass door appeared to be tampered with as the metal was bent causing a slight opening. LPN #01 stated he was unsure if Resident #103 could have fit through the opening due to the opening being so small. LPN #01 reported staff immediately searched the building and initiated the elopement protocol. The police were also called as a part of the emergency process. Interview with Resident #103 on 11/14/18 at 10:50 A.M. revealed he left the facility alone and went to his friend's house a few weeks ago. Resident #103 stated a nurse let him out of the facility, but he refused to say which nurse let him out. Resident #103 reported he took a bus to his friend's house after he was let out of the facility. Resident #103 stated the police came to his friend's house and brought him back to the facility. Resident #103 denied having any medical event or hospital stay prior to coming back to the facility. Observation of Resident #103 on 11/14/18 at 11:00 A.M. revealed the resident ambulating in the hallway independently and communicating with staff. Interview with the Administrator, DON and Director of Clinical Operations #01 on 11/14/18 at 12:27 P.M. revealed the Administrator was notified on 10/26/18 at 6:04 P.M. that Resident #103 had eloped from the facility. The Administrator reported the police had already been called prior to him being notified. The Administrator reported staff searched the building and grounds and two staff members drove around the neighborhood when Resident #103 was discovered missing from the locked unit. The Administrator stated it was raining on the night Resident #103 eloped. The Administrator reported the facility did not have working video cameras. The Administrator stated the DON initiated education to staff regarding making sure the secured doors close behind them. The DON reported an audit of residents at risk for elopement using the wandering risk scale was competed on 10/26/18. The Administrator reported the facility had reinforced Resident #103's glass door from the outside prior to the resident eloping. The Administrator also stated the facility changed all the secure codes after the incident on 10/26/18. The Administrator stated the facility did not give the secure codes out to visitors. The Administrator stated the facility obtained statements from staff members that worked on 10/26/18 and none of the staff had any knowledge of how Resident #103 got out of the facility. The DON reported Resident #103 was placed on one-on-one checks upon his return to the facility on [DATE]. Interview with Director of Clinical Operations #01 on 11/14/18 at 3:00 P.M. revealed staff check on residents every two hours or more often, as a standard of practice. Telephone interview with STNA #08 on 11/15/18 at 4:01 P.M. revealed STNA #08 reported she had worked on 10/26/18 when Resident #103 eloped but she did not remember what happened due to her caring for another resident at the time of the elopement. Review of STNA #08's undated statement revealed STNA #08 identified Resident #103 was missing on 10/26/18 at dinner time and she notified LPN #01 that the resident was missing. Review of the National Weather Service history report revealed the local weather temperature on the evening of 10/26/18 was a high of 50 and a low of 45 degrees Fahrenheit on the night of 10/26/18. Review of the local Police Report dated 10/28/18 revealed Resident #103's guardian contacted the police and reported the resident had eloped from the facility. The police were able to locate Resident #103 at a friend's residence. Resident #103 told the police he was leaving for California and he would tear up the nursing home if the police brought him back to the facility. Resident #103 reported he was kidnapped and placed in the nursing home. He also reported the nursing home staff were poisoning his food. Resident #103 was taken to the hospital. Review of the facility's Emergency Preparedness Manual dated 10/18/01 revealed elopement risk assessments would be provided to ensure the safety of residents. The manual also reported elopement risk assessments would be completed quarterly, upon a change in condition and following an elopement. The resident's care plan also needs to manage or eliminate the risk for elopement. Elopement attempts will be documented in the resident's record. Review of the facility's Elopement Precautions policy dated 06/13/07 revealed elopement is defined as an unsupervised exit from the facility. The resident will be placed on elopement precautions per the decision of the interdisciplinary team and this will be addressed in the resident's plan of care. The resident on elopement precautions is not to leave the facility without accompaniment of a staff member or family member. Code systems will be used on all doors as indicated to alert staff of a resident's departure. Review of the facility's Missing Person policy dated 06/05/18 revealed the supervisor will notify all staff of a missing person by calling a code and thoroughly searching the building. The missing person will also be reported to the Director of Nursing (DON), Administrator, the missing person's physician and to the missing person's responsible party. An elopement fact sheet will be completed, and law enforcement will be notified of the missing person. An incident report will also be completed, and the interdisciplinary team will review and update the resident's plan of care. The Director of Operations will be notified of resident's missing more than 24 hours and the Ohio Department of Health (ODH) will be notified by completing a Self-Reported Incident. This deficiency substantiates Control Number OH 931.

Based on record reviews, staff and resident interviews, the facility failed to ensure one residents' transfer with a mechanical Hoyer lift was performed in a supervised and safe manner. Harm occurred when the resident hit her head on the bed rail during the transfer and suffered a laceration to the back of her head that required staples. Two nurse aides performed this transfer when three staff members were required for transfers in accordance with the fall assessment. This was determined to be an avoidable fall. This affected one resident (#90) of three sampled residents with falls. The census was 116. Findings include: Review of the Care Area Risk assessment dated [DATE] revealed the resident had no history of falls. The plan of care initiated 02/10/11 with a goal date of 08/31/11 revealed the resident was at risk for falls/injury related to poor eyesight, poor decisions for safety, cardiac medications, incontinence, uncontrollable movements, seizure and confusion. This plan of care was initiated on 02/10/11. Interventions included assist with all transfers. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] revealed severe impairment of cognitive patterns. This MDS stated the resident was dependent on two plus staff for bed mobility and transfers. She required extensive assistance of three staff for toilet use and personal hygiene. She had limitation of range of motion on the right side of her lower extremity. The MDS revealed the resident had no falls since admission or the prior assessment. Review of physician orders [REDACTED]. Review of the Kardex stated the resident required three staff for transfers using the mechanical Hoyer lift. Nursing notes dated 06/20/11 at 6:55 A.M. reported that nurse aides had reported to the nurse that Resident #90 had slid from the Hoyer lift and had hit her head on the bed frame. Upon entering the room, the SR was lying on floor next to bed with her feet towards the closet and head towards the bed. Her head was on a pillow and moderate bleeding was noted. The resident was assessed for range of motion and level of consciousness. Her vital signs were blood pressure 154/94, pulse of 77 beats per minute and respirations were 18 per minute. Neurological checks were within normal limits. The physician was called and the resident was assisted to bed with the Hoyer lift and four staff's assistance. The back of the resident's head was assessed with [REDACTED]. A pressure dressing was applied and the resident remained awake and alert. A return call from the physician instructed staff to send the resident to the hospital for evaluation. The nursing notes indicated the family was notified. On 06/20/11 at 7:10 A.M. nursing notes documented the neurological checks and were within normal limits. Resident #90 was alert, oriented, and talking without a change in level of consciousness or increased bleeding from the back of her head. Nursing notes dated 06/20/11 at 7:30 A.M. documented the resident had remained awake and alert and complained of a headache without dizziness. The neurological checks were within normal limits. On 07/20/11 at 7:50 PM the ambulance transported the resident to the hospital. Nursing notes dated 06/21/11 at 4:00 A.M. documented the resident returned from the hospital with staples for the laceration to the back of her head. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing #4 (ADON #4) affirmed Resident #90 had fallen from the Hoyer lift during a transfer on 06/20/11. They said the two nurse aides had not applied the Hoyer pad to the Hoyer lift correctly. As a result, the resident slipped through the pad. They said one of the two nurse aides was experienced and the other nurse aide was relatively new to the facility. This conclusion was made after the two staff re-enacted the transfer for the DON. Interview with Registered Nurse #5 (RN #5) on 07/07/11 at 1:50 P.M. revealed she was in her office when the nurse aide had notified her the resident had slid out of the Hoyer lift. She said the nurse aides had told her that as they were transferring the resident from the wheelchair to the bed, she hit her head on the bed rail. After that, the nurse aides slowly lowered the resident to the floor. RN #5 said she put a pressure dressing on the resident and she was sent to the hospital for treatment. She said the Kardex was confusing as the top of the Kardex stated two staff were required for the transfer and the bottom of the Kardex had identified three staff were required for the transfer. RN #5 said she asked the two nurse aides to demonstrate how the transfer was performed. She said the staff should have used the larger Hoyer pad for this transfer. Also, the staff should have crisscrossed the straps at the bottom. RN #5 said three nurse aides were required for this transfer for increased safety precautions and because the resident had leg and knee pain. During interview on 07/07/11 at 2:10 PM an interview with Nurse Aide #10 (NA #10) revealed he was trying to transfer Resident #90 from the wheelchair to the bed. He was using the Hoyer lift and a Hoyer pad was under the resident in the wheelchair. The SR hit her head during the transfer and she was slowly lowered to the ground. He said that it was a mystery as to how she had fallen. NA #10 said that he had used the Hoyer lift for five years. The Administrator stated during interview on 07/07/11 at 2:50 P.M. she had reviewed fall documentation back through 2009 and since that time there had been no injuries related to Hoyer transfers. She stated there was no documentation the facility had oriented the nurse aide to the Hoyer lift. It was an expectation that he was a state tested nurse aide and if he did not know how to operate a piece of equipment he should have asked for assistance. Interview with Nurse Aide #12 (NA #12) on 07/07/11 at 4:25 P.M. revealed the resident slipped from the Hoyer pad as he was trying to transfer her from the wheelchair. NA #12 said this was his first day of work as he just completed orientation. He said he had become a nurse aide in March 2011 and he had never used the Hoyer lift before 06/20/11. NA #12 said he had seen Hoyer lifts in textbooks but had never used one. He said he had asked Nurse Aide #10 if he knew how to use the Hoyer lift and he told him that he did. NA #12 stated that he did not know how many staff were required to transfer Resident #90 with the Hoyer lift. Resident #90 was interviewed on 07/08/11 at 9:50 A.M. and stated that approximately two to three weeks ago, she was being lifted out of the wheelchair onto the bed. She said the nurse aides had lifted her up and she did not know what she had hit her head on. The resident stated she felt okay now and her staples had been removed from the back of her head. This citation substantiates Complaint Number OH 288.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, review of a self-reported incident (SRI) investigation including witness statements, clinical record review, staff interview and review of the facility ' s abuse policy the facility failed to ensure cognitively impaired Resident #132 was free from physical abuse from Licensed Practical Nurse #103. This resulted in Immediate Jeopardy for one (Resident #132) of seven sampled residents and had the likelihood to affect 19 cognitively-impaired residents (#20, #27, #30, #48, #74B, #76, #77B, #78B, #79B, #80B, #81B, #82B, #83B, #86B, #87B, #89B, #90B, #91B, #92B & #96) residing on the 300 B dementia unit receiving care from LPN #103 from 01/24/10 to 03/30/10. On 05/05/10 at 2:30 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 01/24/10 during the 7:00 P.M. to 7:00 A.M. shift when State tested Nurse Aides (STNA) #67 and #25 witnessed LPN #103 hit cognitively impaired Resident #132 twice in the chest, grab her shirt and push her twice into the metal pipes running up the bathroom wall behind the commode. The Immediate Jeopardy was removed on 03/30/10 when LPN #103 and STNAs #67 and #25 were suspended from work pending termination. The deficiency remained at a Severity Level 2 (no actual harm with potential for more that minimal harm that is not immediate jeopardy) until it was corrected on 04/06/10 when the facility implemented the following corrective actions: - STNAs #67 and #25 remained suspended from 03/30/10 until termination on 04/29/10. - LPN #103 remained suspended from 03/30/10 until termination on 04/29/10. On 03/30/10, the local police department was notified of the abuse allegation. -On 03/30/10, the DON completed head to toe assessments on all residents on the 300 B unit. No suspicious injuries indicating abuse were found. -From 03/30/10 through 04/06/10, all staff received in-service training about abuse, neglect and mistreatment of [REDACTED]. -Beginning on 04/01/10 and on-going, Performance Improvement monitoring was initiated three times a week. This monitoring included interviews of randomly selected staff regarding the facility ' s abuse policy and procedures including asking for examples of abuse, management of residents with behaviors, immediate reporting of abuse, protection of residents and any possibility of disciplinary action when abuse is reported. -On 04/14/10, the Administrator met with the residents attending a Resident Council meeting and discussed the reported abuse allegation. - On 04/20/10 through 04/23/10, during the facility's annual survey, observations of staff to resident interactions did not identify any mistreatment, neglect or abuse on Unit 300B or throughout the facility. - On 05/04/10, three supervisory staff, five STNA ' s and one LPN currently working on the 300B dementia unit were interviewed regarding identification and immediate reporting of witnessed or alleged abuse, protection of residents from abuse, increased stress and indicators of increased risk of resident abuse and the supervisor's role and responsibility in acting upon any allegations of abuse. All supervisory staff and direct care staff provided appropriate responses. -On 05/05/10, five state tested nurse aides and one Licensed Practical Nurse working on other units of the facility were interviewed regarding the abuse protocol and procedures. All six employees were knowledgeable on the abuse protocol with special emphasis on timely reporting of abuse. Findings include: Review of Resident #132 ' s clinical record revealed an Accumulative [DIAGNOSES REDACTED]. The initial comprehensive minimum data set (MDS) assessment dated [DATE] identified Resident #132 had long and short term memory problems and never or rarely made decisions. The MDS identified Resident #132 demonstrated less than daily verbally abusive behaviors and was resistive to care. Both of these behaviors were easily altered. The MDS documented Resident #132 ambulated independently, was continent of bowel and bladder and needed oversight supervision with toileting. A care plan for cognition, combative behaviors, and non-compliance with care dated 12/08/09 included the following interventions: approach calmly and be aware of sudden belligerence, remove from anger inducing situation immediately, aid in avoiding stressful situations, re-approach an, if unable to calm, have another staff member approach as needed and observe interactions with others to prevent physical outbursts. The Mood and Behavior Episodic charting dated 01/24/10 at 10:20 A.M. documented Resident #132 attempted to hit another resident (her roommate), was throwing objects, and becoming aggressive with other residents living on her unit. The nurse ' s notes dated 01/24/10 at 2:30 P.M. documented Resident #132 was transferred to Unit 300B (the female dementia unit) and had no signs and symptoms of distress noted at the time of the transfer. The next nurse ' s note dated 01/25/10 at 3:30 A.M. written by LPN #103 stated an anxiolytic medication ([MEDICATION NAME]) was administered due to the resident slapping staff. Interview with the DON and Administrator on 05/07/10 at 8:10 A.M. affirmed Resident #132 was moved to the 300B unit due to an altercation with the roommate. Review of a SRI dated 04/05/10 revealed the Administrator and DON conducted an investigation into an allegation of physical abuse of Resident #132. The allegation of physical abuse was made by STNAs #67 who witnessed the incident. The SRI did not include the date of the alleged abuse and documented LPN #103 grabbed Resident #132 by the shirt and hit her hard in the chest two times. Review of a QA/RM (witness) statement dated 03/30/10 by STNA #67 revealed Resident #132 was being toileted (no date) in the bathroom by STNAs #67 and #25. As LPN #103 came into the bathroom, she saw Resident #132 was patting STNA #67 on the buttock. LPN #103 grabbed Resident #132 by the shirt, yelled at her, hit her hard on the chest twice and pushed her back against the back of the commode. STNA #67 further documented that " there is no excuse for me (STNA #67) turning a blind eye to any situation of abuse. " The QA/RM statement did not have any documentation regarding notifying administrative staff of the physical abuse nor protecting the resident from further abuse. During a telephone interview with STNA #67 on 05/05/10 at 9:30 A.M., she affirmed the QA/RM statement regarding the incident. She further stated on 01/24/10, LPN #103 assessed Resident #132 at the beginning of the 7:00 P.M. to 7:00 A.M. shift. She (STNA #67) was assisting STNA #25 with toileting Resident #132. STNA #25 left the room to get an incontinence brief, when LPN #103 came into the room to take the resident's blood pressure while she sat on the commode. As she (STNA #67) reached across the resident to get toilet paper, Resident #132 patted her on the buttocks. She stated the resident did not hurt her and never tried to hit LPN #103. STNA #67 continued to say LPN #103 grabbed the resident by the shirt, hit her hard in the chest two times, and then pushed the resident twice on the metal plumbing pipes behind the toilet. As LPN #103 was pushing Resident #132 into the plumbing pipes, STNA #25 entered the room and witnessed the incident. STNA #67 heard STNA #25 tell LPN #103 to stop or she would have to report her if she did it again. STNA #67 stated she documented bruises on the resident's back but it was no longer in the documentation book. She also acknowledged she did not report the incident and should have reported immediately but could not give a reason why she didn ' t. Review of the QA/RM statement dated 03/31/10 and signed by STNA #25 revealed she (STNA #25) had not seen or heard of anyone doing anything wrong to a resident. However, during a telephone interview with STNA #25 on 05/05/10 at 9:00 A.M., STNA #25 reiterated and affirmed the 01/24/10 incident involving Resident #132 as stated by STNA #67. She stated she was aware of the facility's abuse prevention policy and knew she should have reported the incident to the nursing supervisor. When queried why she did not, she insisted she had reported it to LPN #84 the next day, but nothing happened. During an interview with LPN #84 on 05/05/10 at 10:02 A.M., she denied having received any reports of an allegation of abuse by STNA #25. During interview with the Administrator on 05/06/10 at 8:40 A.M., she verified she was not aware of the abusive incident involving Resident #132 and LPN #103 until 03/30/10, two months after it happened, as neither STNA #67 or #25 reported the incident. She stated both STNAs or any individual with knowledge of the incident should have reported it at the time of the incident. Resident #132 was observed on 05/04/10 at 8:00 A.M. and on 05/05/10 at 10:30 A.M. The resident was in a wheelchair in a common area, awake, but nonverbal. She was sitting with her head down, not responding to any verbal interactions and her eyes half closed. The Assistant Director of Nursing confirmed the resident was extremely demented without recollection of the incident. The facility ' s abuse policy titled Allegations of Resident Mistreatment, Abuse, Neglect, Injuries of Unknown Source, or Misappropriation of Property Investigations - Policy and Procedure revised 11/18/09 was reviewed. The Procedure for Investigation section stated that if an employee witnesses or suspects an incident of resident mistreatment, abuse (including verbal), neglect, and/or misappropriation, they must report it directly to a nursing supervisor or administrative personnel immediately. The timeliness of reports is of the utmost importance; therefore employees are not to make their report on any type of voicemail system. 2. Residents #20, #27, #30, #48, #74B, #76, #77B, #78B, #79B, #80B, #81B, #82B, #83B, #86B, #87B, #89B, #90B, #91B, #92B & #96 resided on the 300B unit from 01/24/10 through 03/30/10. These residents received care and services from LPN #103 during this time frame. Each of these residents had a [DIAGNOSES REDACTED]. This citation substantiates allegations in complaint control #OH 245.

Based on observation, record review, and staff interview the facility failed to provide residents with pressure sores the necessary care, treatment, pressure relief, repositioning, and incontinence care to promote healing and prevent new pressure sores from developing. This affected one (#93) of two residents reviewed on stage II for stage IV pressure sores. Findings include: The face sheet for Resident #93 identified [DIAGNOSES REDACTED]. The current minimum (MDS) data set [DATE] stated the resident had short term memory impairment, poor decision making ability, required extensive physical assistance with all activities of daily living, standing balance deficits, range of motion limitations of the arm and foot, frequent bladder incontinence, [MEDICAL CONDITION], unsteady gait, and one stage IV pressure sore. An activity of daily living/mobility/ urinary quarterly progress note dated 04/02/10 stated the resident required staff assistance for all activities of daily living, used the toilet, had weakness, and limited range of motion. The resident's monthly vital signs and weight record stated on 03/10/10 her weight was 173 and on 04/09/10 her weight was 164 a nine pound weight loss in one month. On 03/26/10 at 8:00 A.M. a nursing note documented while the resident was having her brief changed a discoloration was noted to the left heel. The discoloration was pink/red and lined in black on the right side. At 8:30 A.M. a nursing note documented the resident's skin was assessed. On the left heel, a dark area was noted. The area was not open. A small superficial open area was noted on the inner aspect of the buttocks. The pressure sore on the resident's left heel was described as a stage IV 7.2 by 14.1 centimeters in diameter and deep tissue injury. A physician's orders [REDACTED]. A second order was obtained to cleanse area to the buttocks then spray with Peleverus spray, gently pat dry, and apply Peleverus ointment. The treatment to the buttocks was to be done each shift. A weekly skin assessment dated [DATE] stated the pressure sore on the resident's buttock was healed. On 04/12/10, an active skin condition/causative factor evaluation documented the pressure sore on the resident's left heel was 7 by 13.8 centimeters in diameter, round/oval in shape, attached edges, deep tissue injury, stage IV, and hard, with the edges beginning to lift. The resident's April 2010 physician orders [REDACTED]. Care planned interventions included turning and repositioning the resident every two hours, monitor for lack of response to treatments, and off load the heels off the bed with pillows. There were no changes or new interventions added to the care plan since it was initiated on 06/22/09. Review of the resident's labatory blood tests revealed on 04/14/10 the resident's [MEDICATION NAME] was low at 2.9 (normal 3.5 to 5), hemoglobin was low at 8.7 (normal 12 to 16), and hematocrit was low at 28.3 (normal 37 to 47). The dietary progress note dated 04/21/10 did not identify the abnormal laboratory values which could potentially delay and prevent wound healing. When reviewed on 04/22/10, dietary progress notes dated 03/26/10 did not identify the stage IV pressure sore on the resident's left heel or the stage II pressure sore on the buttocks. Subsequent dietary progress notes dated 03/29, 04/01, 04/09, and 04/21/10 did not document a nutritional assessment being done related to the presence of the two pressure sores. The dietary progress note dated 04/09/10 identified the resident's weight was 164 pounds with a 5.2 percent weight loss in the past month. This note documented the resident's oral intake was fair to good at times. A recommendation was made for eight ounces of milk with meals for additional calories and increased calcium. On 04/21/10 at 8:55 A.M. the resident was observed sitting in the dining room in a wheelchair without any pressure relief devices on her feet or heels. The resident was wearing socks and both of her feet were resting on the floor. On 04/22/10 at 6:50 A.M. the resident was observed lying in bed on her back. The resident's feet are bare. There was no dressing on the left heel. The resident's thighs were resting on a thin pillow; her heels were resting directly on the mattress. Nurse Aide #117 was summoned to the resident's room. When she got to the room, she lifted the resident's left heel from the mattress. The entire bottom and back of the left heel was observed covered with hard black eschar. The tissue at the back of the heel was pulling away from the black eschar at the edges. Nurse aide #117 left the resident's room leaving her left heel resting directly on the bed. From 6:50 A.M., after Nurse Aide #117 left the room, to 8:25 A.M. no staff were observed entering this resident's room. The resident remained in bed on her back and her heels resting on the mattress. Intermittent observations of Resident #93 at 8:56 A.M., 9:05 A. M. , and 9:15 A.M. revealed Resident #93 remained in bed lying on her back from 6:50 A.M. until 9:15 A.M. and did not have her position changed, was not checked for incontinence and did not have her heels off loaded from the mattress. Continued observations on 04/22/10 revealed at 9:26 A.M. STNA's # 24 and #1117 prepared the resident for her breakfast tray. The STNAs pulled the resident up in bed, raised the head of the bed and put a bedside table in front of her. They put her dentures in and put her glasses on. When the STNa's pulled the resident up in bed, the resident's incontinence brief was visibly wet with urine but the STNA's did not removed the wet brief or provide incontinence care. The resident's breakfast tray arrived at 9:36 A.M. The STNA's set up the breakfast tray and left the room at 9:40 A.M.. At 10:01 A.M., the resident was observed sitting upright in the bed still wearing the wet incontinence brief with her breakfast tray in front of her. At 11:18 A.M. Nurse Aides #117 and #23 entered the resident's room and stated they were going to take the resident to the shower. The nurse aides uncovered the resident and removed a urine saturated incontinence brief. The blue pad and the bed pad under the resident were also saturated with urine. When the resident was turned to the right side, two unidentified stage II pressure sores were observed. One pressure sore was on the coccyx and one on the right inner buttock. The buttock pressure sores had yellow slough tissue in the center and wa surrounded by red tissue. The resident was then turned onto her back Nurse Aide #117 stated she was assigned to care for Resident #93 that day. Nurse aide #117 stated she started working at 7:00 A.M. and had not repositioned, turned, changed, or provided incontinence care for Resident #93 since she started working. Nurse aide #117 stated the only thing she had done for this resident was pull her up in bed, give her glasses and teeth to her, and set up her breakfast tray. On 04/22/10 at 2:11 P.M. the treatment to the newly identified pressure sores was observed. Nurse aide #9 pulled down the resident's brief and Registered Nurse (RN) #152 provided treatment to both the pressure sores. RN #152 stated the pressure sores were new and she was not aware of the pressure sores until they were brought to the attention of the Director of Nursing on that date. RN #152 also provided the treatment to the pressure sore on the resident's left heel after completing the right lower buttock and coccyx treatment. RN #152 was interviewed and asked about pressure relief for the resident's heels when she is up in a chair. RN #152 stated she had never thought about putting pressure relief on the resident's feet. She stated she was not aware the resident did not have foot rest and pads for pressure relief. The observations made on 04/21/10 of the resident sitting with her feet on the floor and no pressure relief was shared with RN #152 at this time. She stated , "I did not think about that." On 04/22/10 RN #152 documented the pressure sore on the resident's coccyx as 2.5 by 2.5 centimeters in diameter with 0.5 centimeters depth, with redden surrounding tissue and a moist wound bed. The pressure sore on the resident's right inner and lower buttock was measured at 3 by 4 centimeters in diameter with an irregular shape, reddened edges and a moist wound bed.