Every finding on record at Hudson Elms Nursing Center

Based on observation, record review, and interview, the facility failed to provide privacy during an insulin injection for Resident #37. This affected one (Resident #37) resident of seven residents observed for medication administration. The facility census was 46. Findings include:Review of Resident #37's medical record revealed an admission date of 02/24/26 with diagnoses including diabetes mellitus and diabetic nephropathy. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment and required set up or clean up assistance with eating and oral hygiene. Resident #37 required supervision with toileting hygiene, partial to moderate assistance with showers, and was independent with bed mobility. Review of Resident #37's physician orders dated August 2026 revealed an order for Lantus 40 units subcutaneously at bedtime for diabetes, and Novolog Flex pen insulin 25 units subcutaneously before meals. Observation on 08/11/26 at 1:30 P.M. of medication administration by Licensed Practical Nurse (LPN) #839 revealed LPN #839 lifted Resident #37's shirt exposing his abdomen and gave an insulin injection into the resident's exposed abdomen while the resident was sitting at the receptionist desk in the common area hallway with another resident's family members present and in plain view of the resident while he was receiving the injection. At no time did LPN #839 offer to take Resident #37 back to his room or to a more private location before giving his injection. LPN #839 also did not ask Resident #37 if it was ok to receive the insulin in the common area. An interview on 08/11/26 at 1:35 P.M. with LPN #839 confirmed she gave Resident #37 the insulin injection while he was sitting at the reception desk. LPN #839 stated she should not have given him the injection at the reception desk but should have taken him back to his room for privacy.

Based on observation, interview, record review and facility policy review, the facility failed to ensure proper infection control practices were followed during medication administration. This affected three (Residents #25, #35, and #46) of seven residents observed for medication administration. The facility census was 46. Findings include:Review of Resident #25's medical record revealed an admission date of 08/10/18 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), paranoid schizophrenia, schizo-affective disorder and hypertension.Review of Resident #25's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #25's physician orders dated August 2026 revealed orders for Gabapentin 600 milligrams (mg), and meloxicam 7.5 mg. 2. Review of Resident #35's medical record revealed an admission date of 09/05/25 with diagnoses including dementia, schizoaffective disorder, and major depressive disorder (MDD). Review of Resident #35's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #35's physician orders dated August 2026 revealed orders for Bentil 10 mg, Risperdal one mg, and Tylenol 650 mg. 3. Review of Resident #46's medical record revealed an admission date of 05/15/26 with diagnoses including COPD and dementia. Review of Resident #46's quarterly MDS 3.0 assessment dated [DATE] revealed intact cognition. Review of Resident #46's physician orders dated August 2026 revealed orders for Gabapentin 800 mg and Norco 7.5 mg/325 mg.Observation was conducted on 08/11/26 at 11:10 A.M. of Licensed Practical Nurse (LPN) #839 during medication administration for Resident #25, Resident #35 and Resident #46. Resident #25 received Gabapentin 600 milligrams (mg), and meloxicam 7.5 mg, Resident #35 received Bentil 10 mg, Risperdal one mg, and Tylenol 650 mg and Resident #46 received Gabapentin 800 mg and Norco 7.5 mg/325 mg during the observation. For each of the three residents, LPN #839 touched each pill she dispensed for each of the residents with her bare hand between removing the pill from the pill packaging and placing each pill into the medication cups. At the time of the observation, LPN #839 confirmed she was not wearing gloves, did not perform hand hygiene and she touched each medication directly with her bare hands prior to placing the pills into the medication cups for Resident #25, #35 and #46. Review of the facility policy titled Administering Medications, dated April 2019, revealed staff followed facility infection control procedures such as handwashing, antiseptic technique, gloves, etc.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure an insulin pen was dated upon opening for Resident #37. This affected one (Resident #37) of seven residents observed for medication administration. The facility identified seven residents (#1, #5, #10, #11, #13, #33 and #37) with physician orders for insulin. The facility census was 46.Findings include: Record review for Resident #37 revealed an admission date of 02/24/26 with diagnoses including diabetes mellitus, and diabetic nephropathy. Review of the care plan for Resident #37, date initiated 02/25/26, revealed Resident #37 had diabetes mellitus requiring insulin therapy. Intervention included giving medication as ordered by the physician. Review of physician orders for Resident #37 revealed an order dated 04/14/26 for Novolog Flexpen 100 units per milliliter (units/ml) solution pen injector and an order dated 04/03/26 for Lantus SoloStar Subcutaneous Pen-Injector 100 units/ml (insulin Glargine). Observation on 08/11/26 at 1:30 P.M. of medication administration by Licensed Practical Nurse (LPN) #839 revealed LPN #839 prepared the Novolog insulin pen by first wasting two units of the insulin and then proceeded to give Resident #37 the insulin injection per physician order. Observation of the insulin pen revealed the insulin pen was not labeled with the date of when it was opened. An interview on 08/11/26 at 1:35 P.M. with LPN #839 verified the Novolog insulin pen should have been labeled with the date of when it was opened and it was not. Review of the Novolog single-patient use Flexpen manufacturer's instructions, revised 02/2023, revealed the Novolog Flexpen should be thrown away after 28 days, even if it still has insulin left in it. Review of the facility policy titled Insulin Pen, dated 2026. revealed insulin pens contain multiple doses but are used for a single resident only. Insulin pens must be clearly labeled with the resident's name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to ensure Licensed Practical Nurse (LPN) #853 had a valid and active license. This had the potential to affect all 43 residents residing in the facility.Findings include:Review of the State licensure database for LPN's revealed LPN #853 did not have an active license. His nursing license was suspended.Email correspondence on 05/05/26 at 2:46 P.M. from the Chief of Compliance Ohio Board of Nursing (OBN) verified LPN #853 did not have an active license. LPN #853 license was noted to have been suspended on 11/20/25 and remains suspended since that date.Review of LPN #853's time punches revealed he worked 33 days on a suspended nursing license. 11/25/25, 12/01/25, 12/12/25, 12/13/25, 12/19/25, 12/27/25, 12/28/25, 12/31/25, 01/02/26, 01/10/26, 01/11/26, 01/12/26, 01/15/26, 01/22/26, 01/24/26, 01/25/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/15/26, 02/16/26, 02/17/26, 02/20/26, 02/22/26, 02/25/26, 03/02/26, 03/05/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26 and 03/12/26.Interview with the Administrator and the Regional Director of Clinical Services on 05/06/26 at 2:10 P.M. revealed LPN #853 did not notify anyone his nursing license was suspended. It was not known he had a suspended license. Once they knew, they notified OBN and corrected the issue. Interview with LPN #853 was attempted twice and the phone number was no longer valid. The deficient practice was corrected on 03/16/26 when the facility implemented the following corrective actions for affected residents:-On 03/16/26 the DON/Designee notified the Medical Director and OBN of the incident.-On 03/16/26 the DON/Designee completed head-to-toe assessments for all residents to ensure no injuries of unknown origin were identified. -On 03/16/26 Social Services/Designee completed psychosocial assessments for all residents to ensure residents remained at their baseline mental status.-On 03/16/26 Human Resources/Designee completed licensure verification for all nursing staff to ensure all staff had unincumbered licensure.-On 03/16/26 the Administrator/Designee reviewed the facility's hiring process/procedure including verification of licensure for nurses upon hire and annually thereafter. No revisions were needed.-On 03/16/26 the Administrator/Designee educated the Human Resource Manager on the process/procedure used to verify licensure for nurses. -On 03/16/26 the DON/Designee educated all nurses on the OBN licensure requirements for nurses and the facility's process/procedure for licensure verification. -Beginning 03/16/26 Human Resources/Designee will monitor new hires and verify nurses have a current/valid license upon hire and per the facility's protocol. The Human Resources/Designee will audit three new nurse hires a week, for four weeks and randomly thereafter to ensure compliance. -On 03/16/26 an Ad Hoc QAPI was held with the IDT and Medical Director to discuss the incident and the plan to correct.

Based on record reviews and interviews, the facility failed to implement a quality assurance plan to ensure resident pharmacy recommendations were acted upon timely. This finding had the potential to affect all 43 residents in the facility. Findings include:Review of Resident #2, #4, #5, and #40's medical record revealed ongoing recommendations from pharmacy starting in July 2025 to make modifications to their medication administration regimen without timely response and justification of declination of the recommendations from Physician #854.Telephone interview on 05/05/26 at 1:52 P.M. with Consultant Pharmacist #857 she had come to the building to talk to Physician #854 about the usage of narcotics for residents with no clear indication of use at some point in the Fall of 2025 and the physician had asked her who made the rules for narcotics. She stated Physician #854 wanted to know who to talk to about administering narcotics and was told Centers for Medicare and Medicaid (CMS) guidelines. Telephone interview on 05/06/26 at 10:29 A.M. with Physician #863 revealed she was aware Physician #854 was over prescribing narcotics to residents and she counseled the physician on several occasions. Physician #863 indicated she had urged the facility on multiple occasions to discontinue association with Physician #854 and the facility refused. Physician #863 indicated Physician #854 would assess her residents and order narcotics for these residents and then bill for visit when the resident was not his to assess. Physician #863 revealed she parted with the facility in 02/2026.Review of the QAPI Policy and Procedure dated 2026 revealed to ensure continuous evaluation of the Facility's systems with the objectives of ensuring that care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available; preventing deviation from care processes, to the extent possible; identifying issues and concerns with the facility's systems, as well as identifying opportunities for improvement; and developing and implementing plans to correct and/or improve identified areas.Review of the QAPI report dated 05/06/26 authored by the Administrator revealed gradual dose reductions (GDR) and pharmacy recommendations were not being completed timely and accurately. There was no evidence the facility implemented a QAPI plan prior to 05/06/26.Interviews on 05/12/26 at 3:18 P.M. with the Administrator, Registered Nurse (RN) Regional Director of Clinical Services #860, Regional Director of Operations #862 and Regional MDS #855 revealed the QA meets quarterly to discuss resident care which included the Medical Director. The QAPIs were implemented during the survey for narcotics at the lowest effective dose and GDR and pharmacy recommendations to be addressed timely.

Based on observation, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean sanitary manner and that food was stored and labeled properly. This had the potential to affect 43 out of 43 residents who ate meals in the facility's kitchen. The facility census was 43.Findings include:1.Interview and observation on 05/04/26 at 9:40 A.M. with Kitchen Director (KD) #875 during kitchen initial tour revealed the following:-A container of Pork and Beans dated 04/28/26. -An unlabeled potato salad container-Unlabeled pitched of orange Kool-Aid-Unlabeled pitched of purple Kool-Aid-Container of pork dated but unlabeled-The wall behind the bread shelf storage was dirty with various dried splatters-Various crumbs and debris on tray line shelving's-The standing fridge by KD #875 office was dirty with various crumbs and splatters-Multiple vents in the kitchen had visible dust build-upKD #875 confirmed observations at the time and revealed the facility keeps leftovers for 2 days.2. Further interview and observation on 05/06/26 at 1:50 P.M. with Regional Kitchen Director (RKD)#865 revealed the area behind the ice machine had built up dirt on the floor and trash including tape and a Styrofoam cup. Multiple moldy strawberry containers in the walk-in refrigerator. RKD #865 said the strawberries were delivered last night. He threw away the entire carton of strawberries. There was a hole in the wall behind the 3-part sink that RKD #865 revealed was from a pipe bursting. 3. Observation and interview on 05/07/26 at 10:35 A.M. with RKD #865 revealed a very strong odor by the dishwasher area. RKD #865 revealed the wall between the beverage area and the dishwasher area was rotting and moldy. He said the facility had contacted a company to replace the wall and this was causing the fruit flies and the strong odor.Review of facility policy titled, Food Safety and Sanitation, not dated revealed the following under food storage, when a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Left overs are used within 72 hours (or discarded).Review of facility policy titled, Food Safety-Director of Dining Services' Responsibilities, not dated revealed sanitary conditions will be maintained in the food storage, preparation and serving areas.

Based on observation, interviews and facility policy, the facility failed to ensure the kitchen walk-in freezer was in functional working conditions. This had the potential to affect 43 out of 43 residents who ate meals in the facility's kitchen. The facility census was 43.Findings include:Interview and observation on 05/04/26 at 9:40 A.M. with Kitchen Director (KD) #875 during initial tour of kitchen revealed the large walk-in freezer was broken. There were two standing freezers in the beverage area where facility was storing frozen items.Interview and observation on 05/07/26 at 10:35 A.M. with KD #875, Regional Kitchen Director #865 and Registered Dietitian #871 revealed the freezer had been broken for a few months. When asked to see the substitution log, KD #865 revealed that he is substituting a lot of food items due to not having a freezer. He said they were supposed to have pork for dinner that night, but he had to substitute the pork because he did not have a freezer to store the pork in. Regional Kitchen Director #865 said he would get pork for dinner tonight. He said facility had received 9 quotes for the freezer repair. Interview and observation on 05/07/26 at 04:55 P.M. with KD #875 and Regional Kitchen Director #865 revealed dinner was ham and cheese sandwiches. When asked about not serving the pork KD #875 revealed he did not have a freezer to store the pork and that the residents do not like pork.

Based on observation, interviews and facility policy, the facility failed to maintain an effective pest control management system in the kitchen. This had the potential to affect 43 out of 43 residents who ate meals in the facility's kitchen. The facility census was 43. Findings include:Interview and observation on 05/04/26 at 9:40 A.M. with Kitchen Director (KD) #875 during kitchen initial tour revealed the beverage area had multiple fruit flies flying around the covered trash can. When trash can lid was lifted numerous fruit flies flew out of the trash can. By the dishwashing area uncovered trash can with no bag and a piece of bread in the can with fruit flies.Observation and interview on 05/06/26 at 4:47 P.M. with KD #875 and Regional Kitchen Director (RKD) #865 of dinner tray line revealed numerous fruit flies around the brownies that were on the tray line and being served to residents. Confirmed observation with both KD #875 and RKD #865.Interview on 05/07/26 at 9:11 A.M. with Registered Dietitian #871 revealed she had observed fruit flies in the kitchen ceiling, in the ceiling lights and behind the wallpaper by the dishwasher area. She said facility had repeatedly flushed the drains but was not sure what they were flushing them with. Observation and interview on 05/07/26 at 10:35 A.M. with Registered Dietitian #871 of the kitchen. Interview with KD #875 revealed staff flushed the drains weekly with an enzyme cleaner. The dishwasher area had a bad smell and Regional Kitchen Director #865 revealed the wall between the beverage area and the dishwasher area was rotting and moldy. He said this was the cause of the strong odor and the fruit fly issue. Facility had contacted a contracting company to replace the wall but RKD #865 did not provide any further information regarding repairs.Review of Orkin Service Report dated 03/23/26 revealed drains were foamed to help break down organic material that caused drain and phorid fly activity. Food debris and buildup was present in the floor drains, in the track of the pull-down door that the flies were congregating in, and in the garbage disposal. Recommended facility regularly deep cleaned to remove conducive conditions. The garbage disposal most likely needed servicing and clean out. Fly activity will continue until cleanliness levels are maintained.Review of facility policy titled, Pest Control, not dated revealed routine pest control procedures will be in place. If pests are seen in the kitchen, the director of food and nutrition services or designee shall be informed, describing where the pest was seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department.

Based on observation and interview, the facility failed to ensure a clean, sanitary and homelike environment. This finding affected 16 residents who smoke (Residents #2, #4, #7, #9, #13, #14, #17, #23, #24, #31, #35, #36, #37, #39, #40 and #56) and had the potential to affect all 43 residents at the facility. The facility census was 43.Findings include:1. Interview and observation on 05/11/26 at 3:48 P.M. with Registered Nurse Travel Director of Nursing #861 in Resident #5 and Resident #2 room of paint peeling off above the floor board by the window. Observation of Resident #10 revealed a white wooden cover under the window that was being held up with black duct tape. Interview and observation on 05/11/26 at 3:49 P.M. with Resident #11 in room revealed four 1/2-inch by 1/2-inch holes in the wall with crumbling dry wall exposed to be below the window and above the heat register. Resident #11 said the holes were from a shelf that was removed 3 years ago and that were never fixed. Interview and observations on 05/11/26 at 4:08 P.M. with the Director of Maintenance (DM) #877 and Regional Traveling Administrator (RTA) #876 revealed the following concerns during facility tour: -In Resident #10 room part of the privacy curtain track was missing above bed 2. -In the central bathroom on the 100 Hall there were 2 broken wall tiles near the bottom of the wall by the shower. -Confirmed observation of holes in the wall in Resident #11 room. -Resident #44 room had a large area where popcorn ceiling was peeled off. -Resident #26 room had a 1 foot (ft) by 1 ft water stain on the ceiling. -The wall between room [ROOM NUMBER] and #205 had dried liquid stains on it by the floor vent. Multiple areas in the hallway had dried stains on the wall and dust along the handrailing's. -The wall to the right of the central bath on the 200 Hall revealed a large area with paint peeling and dry wall exposed due to a previous item being removed from wall. -Resident #21 room had multiple dry wall patches that had not been painted over. -In the dining room there were three chairs with the arm rest unbolted to the chair arm and two chairs missing arm rest. Review of facility policy titled, Homelike Environment, with a revised date of February 2021 revealed, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 2. Observations of the resident smoke break on 05/04/26 at 11:22 A.M. revealed cigarette butts on ground greater than 25 butts observed during smoke break on 05/04/26 at 11:20 a.m. revealed Residents #2, #4, #7, #9, #13, #14, #17, #23, #24, #31, #35, #36, #37, #39, #40 and #56 were observed in the smoking area. Approximately 25 cigarette butts were located on the ground and in the rocks of the smoking area. Interview on 05/04/25 at 11:22 A.M. with Activities Director (AD) #832 confirmed the resident smoking area had a large number of cigarette butts on the ground and was not maintained in a clean manner. Review of the Smoker list revealed 23 residents currently reside in the facility who smoke including Residents #2, #4, #6, #9, #13, #14, #16, #17, #18, #23, #24, #29, #31, #32, #33, #35, #36, #37, #38, #39, #43, #44 and #56. The facility census was 43. Review of the Resident Smoking Policy and Procedure dated 2025 revealed to accommodate the individual needs and preferences of residents while still protecting the safety and health of individuals residing in the facility, the facility will maintain an environment that remains as free from accident hazards as possible and the facility will ensure that each resident receives adequate supervision and assistance to prevent accidents. The Facility will also provide accommodation for individual needs and preferences without endangering the health or safety of any resident in the Facility. This deficiency represents non-compliance investigated under Complaint Number 2708314, 2721208, and 2682116.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were acted upon timely and the recommendations reflected a valid reason a gradual dose reduction (GDR) was not attempted. This finding affected four (Residents #2, #4, #5 and #40) of 11 records reviewed for unnecessary medications. The facility census was 43.Findings include:1. Review of Resident #2 medical record revealed an admission date of 01/09/26 with diagnoses including schizoaffective disorder, anxiety, major depressive disorder and insomnia.Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #2's physician orders revealed an order dated 02/11/26 (discontinued 04/13/26) for Ambien oral tablet 10 milligrams (mg) give one tablet by mouth every 24 hours as needed for sleep.Review of Resident #2's Consultant Pharmacist's Report dated 02/20/26 revealed resident was ordered Zolpidem (Ambien) 10 mg one tablet by mouth at bedtime as needed for sleep without a stop date. Pharmacist recommendation was to discontinue the medication or add a stop date to the current as needed order.Review of Resident #2's Consultant Pharmacist Report dated 03/22/26 revealed the resident had an order for Zolpidem 10 mg one tablet by mouth as needed for sleep without a stop date (started 02/11/26). Please consider either discontinuation or add a duration for use to the current order. The recommendation was addressed by the physician on 04/13/26 and the physician agreed to the recommendation. Resident #2's medical record revealed the first recommendation dated 02/20/26 and second recommendation dated 03/22/26 for the Ambien were not acted upon until 04/13/26.Interview on 05/11/26 at1:51 P.M. with Director of Nursing (DON) confirming above findings.2. Review of Resident #5 medical record revealed an admission date of 05/08/23 with diagnosis that included dementia, schizophrenia, intellectual disabilities, hallucinations and delusional disorder.Review of Resident #5's Quarterly MDS 3.0 assessment dated [DATE] revealed resident exhibited severe cognitive impairment.Review of Resident #5's physician orders revealed an order dated 02/07/25 for Trazodone (antidepressant medication) oral tablet 150 mg with instructions to give 75 mg by mouth take half tab at bedtime for insomnia; an order dated 09/11/25 for Paxil (antidepressant medication) Oral Tablet 10 mg one tablet by mouth one time a day (discontinued date of 04/11/26); and an order dated 04/11/26 for Paxil 10 mg tablet orally one time a day for mood.Review of Resident 5's physician orders revealed an order dated 02/21/25 for Potassium 10 mg one tablet by mouth one time a day for hypokalemia.Review of Resident #5's Pharmacist Recommendation to Provider form dated 07/27/25 and 09/19/25 revealed the resident was ordered Potassium oral tablet with instructions to give 10 mg by mouth one time a day for hypokalemia. Pharmacist's recommendation was to correct the dose to give potassium 10 milliequivalent (mEq) one tablet by mouth once daily. There was no evidence that the pharmacy recommendation was acted upon.Review of Resident #5's Pharmacist Recommendation to Provider form dated 03/22/26 revealed the resident was ordered two or more antidepressants at this time, for different indications, without a recent documented GDR (gradual dose reduction) attempt in the past 6 months. Resident was ordered Paroxetine (Paxil) 10 mg one tablet by mouth once a daily for one tablet by mouth once daily for sexually acting out. Resident was ordered Trazodone 75 mg tablet at bedtime for insomnia. Pharmacist's recommendation was to consider a GDR of one or both of these agents, at this time. Perhaps decreasing Trazodone 50 mg and/or trial without paroxetine, while concurrently monitoring for response or reemergence of symptoms. Otherwise, must indicate rationale for use of two or more psychotropics from same therapeutic class for this resident. The physician response dated 04/15/26 revealed other was marked and will review.Interview on 05/11/2026 at 1:51 P.M. with the DON confirmed the pharmacy recommendations for Potassium were not acted upon and never changed. DON confirmed that the order for Paroxetine was discontinued and reordered for the same dose and Trazodone was not adjusted either without justification to decline pharmacy recommendations.3. Review of Resident #4's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including paraplegia, anxiety disorder and major depressive disorder.Review of Resident #4's Annual MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #4's physician orders revealed an order dated 09/23/25 for Oxycodone 5 mg give one tablet every six hours as needed for moderate pain; and an order dated 09/23/25 for Oxycodone oral tablet 5 mg give 2 tablets every six hours as needed for pain.Review of Resident #4's Pharmacist Recommendation to Prescriber form dated 11/19/25 revealed the resident had multiple analgesic orders without a clear indication or sequence for administration including Oxycodone 10 mg one tablet by mouth every six hours as needed for body pain; Oxycodone 5 mg one tablet by mouth every six hours as needed for moderate pain; and Oxycodone 5 mg two tablets by mouth every six hours as needed for pain. The form was signed on 12/03/25 by Physician #854 to discontinue both orders for Oxycodone 10 mg and retain the Oxycodone 5 mg as needed orders. (The physician response was 14 days.)Telephone interview on 05/05/26 at 1:52 P.M. with Consultant Pharmacist #857 revealed that Physician #854 ordered Oxycodone narcotics without clear indication of use and he had multiple orders for pain medications. Interview on 05/05/26 at 4:45 P.M. with Regional MDS #855 confirmed Resident #4's pharmacy recommendation dated 11/19/25 to retain the Oxycodone as needed 5 mg and the order had two orders on the same physician order including Oxycodone 5 mg one tablet every six hours as needed for moderate pain and oxycodone 5 mg two tablets every six hours as needed for pain. The two tablets every six hours as needed for pain were not discontinued as indicated on the pharmacy recommendation.4. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia and Alzheimer's disease.Review of Resident #40's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #40's physician orders revealed an order dated 02/07/26 (discontinued 03/13/26) for oxycodone 10 mg by mouth three times a day for pain due at 7:00 A.M., 2:00 P.M. and 7:00 P.M.Review of Resident #40's MARS from 02/01/26 to 02/28/26 revealed the resident's medications were administered as ordered and no as needed pain medications were administered.Review of Resident #40's Pharmacist Recommendation to Prescriber form dated 02/19/26 revealed the order for oxycodone was recently increased the oxycodone 5 mg three times a day to oxycodone 10 mg three times a day on 02/07/26. Physician #854 signed the form on 02/27/26 and disagreed with the recommendation but no clinical justification for refusing the GDR was documented on the recommendation.Review of Resident #40's physician orders revealed an order dated 03/12/26 (discontinued 03/27/26) for Dilaudid 4 mg (hydromorphone) give one tablet by mouth three times a day for pain due at 7:00 A.M., 2:00 P.M. and 7:00 P.M.; and an order dated 03/27/26 (discontinued 04/14/26) for Dilaudid 4 mg give one tablet by mouth four times a day for pain due at 7:00 A.M., 11:00 A.M., 3:00 P.M. and 7:00 P.M.Review of Resident #40's Pharmacist Recommendation to Provider form dated 03/22/26 revealed the resident was receiving duplicate opioid therapy with both Dilaudid narcotic pain medication 4 mg three times a day and oxycodone 5 mg twice daily with 10 mg at bedtime. The medications had similar actions and as a result, both may not be necessary. Please discontinue the Dilaudid and adjust the dose of oxycodone for continued pain management. The physician response dated 04/15/26 revealed the oxycodone was discontinued and to continue the Dilaudid. The form was signed on 04/15/26 by the physician which stated the oxycodone was discontinued and continue the Dilaudid. The recommendation did not have a clinical justification for continuing the Dilaudid instead of the oxycodone and the recommendation was not addressed until 23 days after the recommendation was made.Review of Resident #40's MARS from 03/01/26 to 03/31/26 revealed the medications were administered as ordered and one dose of as needed narcotic pain medications was administered and from 04/01/26 to 04/30/26 revealed the medications were administered as ordered. No as needed narcotic pain medications were administered.Interview on 05/04/26 at 5:38 P.M. with the MD revealed Resident #40's family members felt the resident was more confused and on a lot of narcotics. The MD felt the resident was on egregious amounts of hydromorphone narcotic and started weaning the resident.Telephone interview on 05/05/26 at 1:52 P.M. with Consultant Pharmacist #857 confirmed she requested Physician #854 to decrease Resident #40's narcotics on 02/19/26 and again on 03/22/26 and the physician denied the recommendation. She stated she had come to the building to talk to Physician #854 about the usage of narcotics for residents with no clear indication of use at some point in the Fall of 2025 and the physician had asked her who made the rules for narcotics. She stated Physician #854 wanted to know who to talk to about administering narcotics and was told Centers for Medicare and Medicaid (CMS) guidelines. Telephone interview on 05/06/26 at 10:29 A.M. with Physician #863 revealed she was aware Physician #854 was over prescribing narcotics to residents and she counseled the physician on several occasions. Physician #863 indicated she had urged the facility on multiple occasions to discontinue association with Physician #854 and the facility refused. Physician #863 indicated Physician #854 would assess her residents and order narcotics for these residents and then bill for visit when the resident was not his to assess. Physician #863 revealed she parted with the facility in 02/2026.Review of the Unnecessary Medication Policy dated 2025 revealed it was the facility's policy that each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs.This deficiency represents non-compliance investigated under Complaint Number 2992828.

Based on records review and interviews, the facility failed to ensure Residents #2, #5, #6, #21, #27 and #31 Pre-admission Screening and Resident Review (PASRR) forms accurately reflected the resident's psychiatric diagnoses. This finding affected six (Residents #2, #5, #6, #21, #27 and #31) of seven residents reviewed for PASRR requirements. The facility census was 43.Findings include:1. Review of Resident #31's medical record revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, borderline personality disorder, major depressive disorder recurrent, suicidal ideations and personal history of suicidal behavior. Review Resident #31's discharge (DC)-return anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 required modified independence for cognitive skills for daily decision making. Review of Resident #31's PASRR Identification Screen dated 03/19/26 revealed she did not have any indications of serious mental illness and/or developmental disability effective 03/18/26. Review of Resident #31's PASRR Identification Screen was not updated to reflect the resident's admission diagnosis of personality disorder, bipolar disorder and major depressive disorder. Interview on 05/06/26 at 3:30 P.M. with Social Service Designee (SSD) #839 confirmed Resident #31's PASRR was not updated to reflect the serious diagnosed mental issues. 2. Review of Resident #6's medical record revealed an admission date of 03/26/24 and continues to reside in the facility. Diagnoses included schizoaffective disorder bipolar type, vascular dementia, altered mental status and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #6's Annual MDS 3.0 assessment dated [DATE] revealed he was cognitively intact. Review of Resident #6's PASRR Identification Screen dated 03/26/24 revealed no indications of serious mental illness and/or developmental disability effective date: 03/26/24. Review of Resident #6's PASRR Identification screen was not updated to reflect the resident's admission diagnosis of Schizoaffective disorder bipolar type. Interview on 05/06/26 at 3:30 P.M. with SSD #839 confirmed Resident #6's PASRR was not updated to reflect the serious diagnosed mental issues. 3. Review of Resident #27's medical record revealed the resident was admitted on [DATE] and discharged on 05/05/26 with diagnoses including major depressive disorder, generalized anxiety disorder and bipolar disorder (all listed as 02/26/26). Review of Resident #27's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #27's PASRR Identification Screen dated 03/11/26 revealed a diagnosis of mood disorder. Review of Resident #27's PASRR Identification Screen was not updated to reflect the resident's admission diagnosis of major depressive disorder. Interview on 05/06/26 at 3:25 P.M. with SSD #839 confirmed Resident #27's PASRR was not updated to reflect the accurate diagnosis of major depressive disorder. 4. Review of Resident #2's medical record revealed an admission date of 01/09/26 with diagnosis of malignant neoplasm of prostate, schizoaffective disorder, anxiety, major depressive disorder, insomnia, secondary malignant neoplasm of lung, pain, acute cystitis without hematuria, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, essential hypertension, epilepsy, metabolic encephalopathy, chronic viral hepatitis C, and cerebral infarction due to unspecified occlusion. Review of PASRR Result Notice dated 11/08/24 revealed No indications of serious mental illness and/or developmental disability. Resident #2's PASRR did not reflect the resident's diagnosis of schizoaffective disorder, anxiety and major depressive disorder. Interview on 05/06/26 at 12:20 P.M. with SSD #839 revealed she had worked at the facility for about a month and had been trying to go through residents PASSR's to make sure they were accurate. SSD #839 confirmed Resident #2's PASRR was not accurate. 5. Review of Resident #5's medical record revealed an admission date of 03/08/23 with diagnosis that included dementia, peripheral vascular disease, schizophrenia, intellectual disabilities, hallucinations, delusional disorder, essential hypertension, hyperlipidemia, and insomnia. Review of Resident #5's MDS quarterly assessment dated [DATE] revealed BIMS score was unable to be completed due to resident's non-verbal status and inability to answer questions. Review of PASRR completed on 04/24/23 revealed resident was marked under Section E: Indications of Serious Mental Illness question 1) Does the individual have a diagnosis (es) of any of the mental disorders listed below? was marked as No. Resident #5's PASRR did not reflect the resident's diagnosis of schizophrenia and delusional disorder. Interview on 05/06/26 at 12:20 P.M. with SSD #839 revealed she had worked at the facility for about a month and had been trying to go through residents PASSR's to make sure they were accurate. SSD #839 confirmed Resident #5's PASRR was not accurate. 6. Review of Resident #21's medical record revealed an admission date of 04/02/26 with diagnosis that included dysphagia, bipolar disorder, depression, anxiety, chronic systolic heart failure, edema, obesity, cerebrovascular disease, hemiplegia, DM 2, essential hypertension, paroxysmal atrial fibrillation, schizoaffective disorder, neuroleptic parkinsonism, chronic kidney disease and anemia. Review of PASRR completed on 04/02/26 revealed Section E: Indications of Serious Mental Illness question 1) Does the individual have a diagnosis (es) of any of the mental disorders listed below? was marked as No. Resident #21's PASRR did not reflect the resident's diagnosis of bipolar disorder and schizoaffective disorder. Interview on 05/06/26 at 12:20 P.M. with SSD #839 revealed she had worked at the facility for about a month and had been trying to go through residents PASSR's to make sure they were accurate. SSD #839 confirmed Resident #21's PASRR was not accurate. Review of the undated PASRR Statutes form provided by the facility revealed such assessments shall be coordinated with any State-required preadmission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. In addition, a nursing facility shall notify the State mental health authority or State mental retardation or developmental disability authority, as applicable, promptly after a significant change in the physical or mental condition of a resident who was mentally ill or mentally retarded.

Based on record review and interview, the facility failed to ensure residents were provided education on COVID-19 vaccinations and the vaccinations were offered and/or administered as ordered. This finding affected four (Residents #2, #3, #23 and #31) of five residents reviewed for immunizations. The facility census was 43.Findings include:1.Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, generalized anxiety disorder and major depressive disorder.Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #2's electronic health record (EHR) revealed the COVID-19 vaccination was not listed as given. Interview on 05/11/26 at 12:09 P.M. with Registered Nurse (RN) Travel Director of Nursing (DON) #861 confirmed Residents #2's medical records did not have the evidence the resident was educated on COVID-19 vaccine use, consents for COVID-19 vaccines were obtained and evidence vaccines were offered and/or administered.2. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the border of the tongue, alcohol abuse and adult failure to thrive.Review of Resident #3's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #3's immunization tab in the EHR revealed the COVID-19 vaccination was not listed as given. Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #3's medical records did not have the evidence the resident was educated on COVID-19 vaccine use, consents for COVID-19 vaccines were obtained and evidence vaccines were offered and/or administered.3. Review of Resident #23's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, diabetes and dependence on renal dialysis.Review of Resident #23's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #23's immunization tab in the EHR revealed the COVID-19 vaccination was not listed as given. Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #23's medical records did not have the evidence the resident was educated on COVID-19 vaccine use, consents for COVID-19 vaccines were obtained and evidence vaccines were offered and/or administered.4. Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left lower limb, bipolar disorder and heart failure.Review of Resident #31's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's immunization tab in the EHR revealed the COVID-19 vaccination was not listed as given. Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #31's medical records did not have the evidence the resident was educated on COVID-19 vaccine use, consents for COVID-19 vaccines were obtained and evidence vaccines were offered and/or administered.Review of the Coronavirus (COVID-19) Policy revised 05/10/23 revealed for the protection of the residents and staff which was the top priority. The facility had developed a proactive plan designed to minimize the impact of COVID-19 within the facility.

Based on record review and interview, the facility failed to ensure residents were provided education on influenza and pneumococcal vaccinations and the vaccinations were offered and/or administered as ordered. This finding affected four (Residents #2, #3, #23 and #31) of five residents reviewed for immunizations. The facility census was 43.Findings include:1.Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, generalized anxiety disorder and major depressive disorder.Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #2's electronic health record (EHR) revealed immunizations including influenza and pneumococcal vaccines were not listed as given.Interview on 05/11/26 at 12:09 P.M. with Registered Nurse (RN) Travel Director of Nursing (DON) #861 confirmed Residents #2's medical record did not have evidence the resident was educated on vaccine use, consent for vaccines was obtained and vaccines were offered and/or administered as required.2. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the border of the tongue, alcohol abuse and adult failure to thrive.Review of Resident #3's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #3's immunization tab in the EHR revealed pneumococcal and influenza vaccines were not listed as given.Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #3's medical record did not have evidence the resident was educated on vaccine use, consent for vaccines was obtained and vaccines were offered and/or administered as required.3. Review of Resident #23's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, diabetes and dependence on renal dialysis.Review of Resident #23's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #23's immunization tab in the EHR revealed pneumococcal and influenza vaccines were not listed as given.Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #23's medical record did not have evidence the resident was educated on vaccine use, consent for vaccines was obtained and vaccines were offered and/or administered as required.4. Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left lower limb, bipolar disorder and heart failure.Review of Resident #31's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's immunization tab in the EHR revealed pneumococcal and influenza vaccines were not listed as given.Interview on 05/11/26 at 12:09 P.M. with RN Travel DON #861 confirmed Residents #31's medical record did not have evidence the resident was educated on vaccine use, consent for vaccines was obtained and vaccines were offered and/or administered as required.Review of the Influenza Vaccine policy revised 03/2022 revealed all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents or residents' legal representatives.Review of the Pneumococcal Vaccine policy revised 10/2023 revealed all residents were offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.

Based on record review and interview, the facility failed to ensure Resident #31 was provided timely incontinence care. This finding affected one resident (#31) of three residents reviewed for incontinence care. The facility census was 43. Findings include:Record review of Resident #43 revealed he was admitted on [DATE] with diagnoses included cerebral infarction, heart failure, acute respiratory failure with hypoxia, tobacco use, alcohol abuse, hypertension, chronic obstructive pulmonary disease with acute exacerbation, generalized anxiety disorder, shortness of breath, asthma and personal history of pulmonary embolism.Record review of Resident #43's care plan dated 03/05/26 revealed he was resistive to care related to refusing to shower, refusing to change clothes, refusing incontinence care, refusing wound care and refusing to sleep in his bed. Interventions were to allow the resident to make decisions about treatment regime to provide a sense of control, encourage as much participation/interaction by the resident as possible curing care activities, give clear explanation of all care activities prior to and as they occur during each contact and praise the resident when behavior is appropriate. Provide consistency in care to promote comfort with activities of daily living skills (ADLs). Maintain consistency in timing of ADLs, care givers and routine as much as possible and provide resident with opportunities for choice during care provision. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 required partial to moderate assist for toileting hygiene and substantial to maximum assist from staff for shower/bathing self. He was not on a urinary or bowel toileting program and was occasionally incontinent of urine and bowel.Review of a nursing note dated 05/03/26 at 11:38 P.M. revealed an aide made this nurse aware Resident #43 fell out of his wheelchair and onto the floor. Vital signs were taken. No pain was noted but having difficulty breathing while being on the floor. He urinated on himself and it was blood and urine mixed. 911 was called because this nurse and staff were not able to get him off the floor. Resident #43 would be transported to the hospital.Review of Resident #43's medical record revealed no evidence Resident #43 refused to get cleaned up after being incontinent when he fell on the floor or interventions implemented due to refusing ADL care.Review of Resident #43's Prehospital Care Report Summary dated 05/03/26 at 5:00 A.M. revealed the resident was lying on the floor supine and pants were saturated with urine, feces, and blood. The resident did not know how long he had been on the floor. One nurse stated the resident had been on the floor for two minutes, another nurse stated the resident had been on the floor for ten minutes. By the condition of the resident's clothes, EMS estimated the resident had been lying on the floor for a longer period of time.Review of a confidential concern submitted to the State Agency revealed on 05/03/26 Resident #43 arrived at the hospital with a saturated depends with concerns of possible neglect at the nursing home.Interview with Licensed Practical Nurse (LPN) #878 on 05/12/26 at 1:55 P.M. revealed Resident #43 was found on the floor and he had urinated on himself. She stated he refused toileting and hygiene care therefore did present at the hospital incontinent of urine. He did not wear briefs; he used the urinal or commode for bowel and bladder needs.This deficiency represents non-compliance investigated under Complaint Number 3004505 and 2721208.

Based on record reviews and interviews, the facility failed to ensure individualized interventions were developed and implemented to prevent resident-to-resident physical abuse between Resident #2 and Resident #24. This finding affected two (Residents #2 and #24) of three residents reviewed for abuse. The facility census was 43.Findings include: Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder and essential hypertension.Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #24's medical record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, bipolar disorder and alcohol dependence.Review of Resident #24's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of facility submitted physical abuse Self-Reported Incident (SRI) form, tracking #271735 dated 03/04/26 revealed Resident #24 struck Resident #2 because he felt as though he cut him in line. The residents were immediately separated, and Resident #24 was placed on 15-minute checks for increased monitoring. Skin assessments were conducted for both residents with no injuries. Resident #24 was his own person but Resident #2's guardian and the physician were made aware. The following interventions were completed post-altercation including separating both residents immediately, placing Resident #24 on fifteen-minute checks, notifying the Medical Director of the altercation, obtaining skin assessments for Residents #2 and #24, obtaining staff statements, obtaining resident questionnaires with no negative findings and abuse education with facility staff. The SRI was unsubstantiated for physical abuse. Review of Resident #2's witness statement dated 03/04/26 revealed the resident was in the smoke line first but left the line. The resident had then attempted to cut the line and one of the other residents became upset and told him not to cut in line. The resident then proceeded to tell Resident #24 to be quiet and that he would punch him. Resident #24 punched first.Review of Resident #24's witness statement dated 03/04/26 revealed the resident hit Resident #2 because the resident threatened to hit him.Review of Resident #2 and Resident #24's medical record revealed no additional individualized interventions were implemented other than 15 minute checks ending on 03/07/26 to prevent physical abuse between the residents. Review of the facility submitted physical abuse SRI tracking #273847 dated 04/27/26 revealed Resident #24 struck Resident #2 in the face because he felt that he was going too slow down the hallway. The residents were immediately separated and no injuries were noted. The interventions completed post-altercation included separating both residents, placing both residents on fifteen-minute checks, completing neurological checks, notifying the Medical Director and the emergency contacts, completing skin assessments, obtaining staff statements and resident questionnaires and completing staff abuse education. The SRI was unsubstantiated for physical abuse.Review of Resident #24's witness statement dated 04/28/26 revealed the resident was on the way to a smoke break and Resident #2 blocked the hallway. Resident #24 asked Resident #2 to move and the resident replied negatively. Resident #2 hit Resident #24 in the face near the resident's eye with a closed fist and broke the resident's glasses.Interview on 05/07/26 at 12:16 P.M. with Registered Nurse (RN) Travel Director of Nursing (DON) #861 and the Administrator confirmed the facility was aware the two separate resident-to-resident altercations occurred between Residents #2 and #24. The Administrator stated she felt the residents in the facility had behaviors and 15-minute checks were completed following both altercations. The Administrator also indicated the facility staff tried to keep the two residents separated and one resident was moved to another hall following the second altercation. Interview on 05/07/26 at 12:16 P.M. with the Administrator and Travel DON #861 revealed the staff were aware the resident-to-resident incidents occurred and the facility did initiate the 15-minute checks post incident to ensure resident safety. The Administrator revealed one incident occurred in the hall and another in the smoking area. She stated a new policy was implemented for the smoking area to ensure resident safety.Review of the Abuse and Neglect Clinical Protocol policy revised 03/2018 revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.This deficiency represents non-compliance investigated under Complaint Number 2990964.

Based on record review and interview, the facility failed to ensure Resident #48 was provided a notification in writing the reason for the discharge to the hospital in a language the resident understands and a bed hold policy indicating the bed hold days remaining and the process for returning to the facility. This finding affected one (Resident #48) of two residents reviewed for hospitalization. The facility census was 43.Findings include:Review of Resident #48's closed medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including unspecified dementia, hyperlipidemia and essential hypertension. Resident #48 did not return to the facility.Review of Resident #48's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #48's progress note dated 02/24/26 at 5:24 A.M. revealed during morning care, the resident had an episode of coffee ground emesis. The emesis was reported to the physician, and orders were obtained to send the resident to the hospital.Review of Resident #48's medical record did not reveal evidence the resident and/or representative were provided a notice for the reason for the discharge to the hospital in a language the resident understands or a bed hold policy with rates and bed hold days.Interview on 05/12/26 at 3:30 P.M. with Social Service Designee (SSD) #839 confirmed Resident #48's medical record did not have evidence the resident was provided with the reason for discharge to the hospital in a language the resident understands or the bed hold policy listing the rate and bed hold days.Review of the Resident Transfer and Discharge Policy and Procedure dated 2026 revealed once residents were admitted , the residents have a right to remain in the facility. Discharging a resident was a violation of this right unless the facility demonstrated that the conditions that allow for transfer or discharge were met.

Based on observation, record review and interview, the facility failed to ensure residents were served meals to meet their individual needs. This finding affected two residents (Residents #24 and #35) of four residents reviewed for food. The facility census was 43.Findings include:1. Review of Resident #24's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, bipolar disorder and alcohol dependence.Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #24's physician orders revealed an order dated 04/26/24 for a regular diet, regular texture with a regular consistency and double portions for meals.Review of Resident #24's meal ticket dated 05/06/26 revealed the resident wanted juice and hot cereal with no pasta and double portions for all meals.Interview on 05/04/26 at 12:13 P.M. with Resident #24 revealed he did not routinely get double portions even though it was on the meal ticket.Observation on 05/06/26 at 12:20 P.M. revealed Resident #24's lunch meal tray consisted of an Italian sausage link, scalloped potatoes and lima beans. The meal tray did not have double portions.A second interview on 05/06/26 at 12:22 P.M. with Resident #24 revealed he never received double portions.Interview on 05/06/26 at 12:25 P.M. with the Director of Nursing (DON) confirmed Resident #24 did not receive double portions for the lunch meal.2. Review of Resident #35's medical record revealed the resident was admitted on [DATE] with diagnoses including bipolar disorder, essential hypertension and diabetes.Review of Resident #35's MDS 3.0 assessment dated [DATE] revealed the resident's memory was okay.Review of Resident #35's physician orders revealed an order dated 03/30/26 for a regular diet, regular texture with thin liquids consistency and double portions.Observation on 05/04/26 at 12:13 P.M. with Resident #35 revealed the facility did not provide double portions and the food was a big thing.Observation on 05/04/26 at 12:45 P.M. revealed Resident #35's lunch meal tray consisted of a hamburger, potato salad, peas/carrots and pudding. The resident did not receive double portions as indicated on the meal ticket.Interview on 05/04/26 at 12:50 P.M. with Certified Nursing Assistant (CNA) #848 confirmed Resident #35 did not receive double portions per the meal ticket.Review of Resident #35's lunch meal ticket dated 05/06/26 revealed the resident did not want fish, hot dogs or kielbasa. The lunch ticket listed double portions.Observation on 05/06/26 at 12:40 P.M. revealed Resident #35's lunch meal tray consisted of one piece of Italian sausage link, scalloped potatoes and lima beans. The resident's meal tray did not have double portions.Interview on 05/06/26 at 12:45 P.M. with the DON confirmed the above findings.Review of the Food and Nutrition Services policy revised 10/2017 revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, record review and interview, the facility failed to maintain proper infection control practices during wound care for Resident #31. This affected one resident (Resident #31) of one resident observed for wound care. The census was 43.Findings include:Record review revealed Resident #31 was admitted to the facility 03/19/26 with diagnoses including but not limited to acquired absence of left leg below-knee amputation (BKA).Record review revealed Resident #31 had an order to cleanse the left stump with soap and water, pat dry, apply Santyl and an abdominal pad and cover with kerlix. Observation of the wound care and dressing change with the Director of Nursing (DON) on 05/06/26 at 1:31 P.M. revealed the bedside table was visibly dirty and not cleaned/wiped down with an antiseptic cloth prior to the DON putting two paper towels from Resident #31's bathroom on it, as a barrier. The DON stated she forgot her marker and scissors so started removing the old dressing by removing what tape she could get ahold of with gloves on, from the top of the dressing closest to resident's knee, then pulled the rest of it off Resident #31's stump. The old dressing was then put in the trash can. The DON then grabbed the wound cleaner, sprayed the wound and started cleaning the wound with four-by-four gauze without removing the old gloves and washing her hands. The gauze used to clean the surgical site was thrown away along with the gloves. DON washed her hands and applied new gloves, but the gloves that were applied were lying half on the barrier paper while the fingers were off the barrier resting on a dirty remote-control device. DON confirmed the observation after the dressing change.Review of the facility policy, Wound Care, dated 10/2010 revealed the facility would gather equipment necessary ie: scissors and a writing utensil. Staff would pull gloves over dressing and discard and staff would ensure all clean items were on a clean field. This deficiency represents non-compliance investigated under Complaint Number 2721208.

Based on observations, interviews and facility policy the facility failed to ensure residents call lights were in working order. This affected three residents (Residents #6, #9, and #41) of 56 residents reviewed for call light function. The facility census was 43. Findings include: Interview on 05/06/26 at 3:02 P.M. with Resident Council members Resident #16, Resident #11 and Resident #36 revealed call light response times at night are very long and response times are sometimes over two hours.Interview on 05/07/26 at 3:45 P.M. with Resident #41 revealed he needed a new call light and his had not worked for three weeks. The bedside call cord was pulled revealing the bedside station light was activated but the corridor dome light outside the room did not light up. Interview and observation on 05/07/26 at 3:48 P.M. with Resident #6 revealed the resident tested bedside call cord revealed the bedside station light was activated but the corridor dome light outside the room did not light up and the light was missing the cover. Interview on 05/07/26 at 3:55 P.M. with Director of Clinical Services #860 confirmed the above observations.Interview on 05/11/26 at 4:22 P.M. with Resident #9 revealed he did not have a functioning call light. Interview with Regional Traveling Administrator (RTA) #876 at the time who said he would have maintenance get resident a bedside call cord.Review of facility policy titled, Answering the Call Light with a revised date of March 2021 under General Guidelines revealed be sure that the call light is plugged in and functioning at all times and report all defective call lights to the nurse supervisor promptly.

Based on record review and interview, the facility failed to ensure scheduled narcotics for pain were administered as ordered and quarterly pain assessments were completed for residents on narcotic pain medications. This finding affected three (Residents #10, #31 and #40) of eleven residents reviewed for unnecessary medications. The facility census was 43.Findings include:1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and essential hypertension.Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #10's quarterly pain assessments (admit date [DATE]) revealed a pain assessment dated [DATE]. The resident's record did not have a pain assessment for 02/2026.Review of Resident #10's pain care plans revised 04/06/26 revealed to administer analgesia as per orders, anticipate the resident's need for pain relief, identify and record previous pain history, monitor/document for probably cause of each pain episode, monitor/document side effects of pain medication/ and monitor/record/report to nurse any signs or symptoms of non-verbal pain. Interview on 05/06/26 at 12:10 P.M. with Regional Director of Clinical Services #860 confirmed Resident #10 was missing the quarterly pain assessment for 02/2026.Review of the Pain policy dated 2001 revealed the nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The assessment and recognition of pain included reviewing known diagnoses and conditions that commonly cause pain, including a review for any treatments the resident is currently receiving for pain, including complementary and non-pharmacological treatments. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and provider will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. The staff and provider will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.2. Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified complications of an amputation stump, chronic obstructive pulmonary disease and bipolar disorder.Review of Resident #31's admission MDS dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's physician orders revealed an order dated 03/27/26 (discontinued 04/06/26) for Lidocaine external gel 4% apply to skin topically one time a day for pain; an order dated 04/11/26 to document pain every shift; an order dated 03/26/26 for Gabapentin 300 mg one tablet by mouth three times a day for pain; an order dated 04/10/26 for Hydrocodone-Acetaminophen 7.5-325 mg give one tablet every six hours as needed for pain; an order dated 04/06/26 (discontinued 04/10/26) for Oxycodone 5 mg one tablet by mouth every six hours as needed for pain; an order dated 04/11/26 for Acetaminophen 325 mg give one tablet every six hours as needed for pain; and an order dated 04/14/26 for Hydrocodone-Acetaminophen 7.5-325 mg give one tablet every 8 hours as needed for pain related to cellulitis of the left lower limb.Review of Resident #31's progress note dated 05/06/26 at 1:30 A.M. revealed the resident requested the midnight narcotic for pain and the medication as not available due to reorder. The facility was waiting for the delivery from the pharmacy. The resident became visibly upset, throwing items from the bedside table and pushing the tablet across the room. The resident then lowered herself to the floor and was observed lying on the floor yelling into the hallway. The nurse and two aides approached the resident and initially aided return to bed and the resident refused. The Director of Nursing (DON) was notified and the physician was notified.Review of Resident #31's MARS and TARS from 04/01/26 to 05/07/26 revealed the scheduled Hydrocodone-Acetaminophen 7.5-325 mg tablets were due every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. The MARS confirmed Resident #31 did not receive the scheduled narcotics on 05/06/26 at 12:00 A.M., 6:00 A.M. and 12:00 P.M.Interview on 05/11/26 at 7:10 A.M. with Registered Nurse (RN) Regional Director of Clinical Services #860 confirmed the nurses could pull narcotics from the pyxis and she was not sure why Resident #31 did not receive her narcotic pain medications for three doses on 05/06/26.Interview on 05/11/26 at 7:35 A.M. with Director of Nursing (DON) revealed the staff had to have an authorization to pull narcotics before they could remove Resident #31's scheduled narcotics from the pyxis medication system and she had ordered the narcotic pain medications the next day when she found out the resident did not have more narcotics for resident use.3. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia and Alzheimer's disease.Review of Resident #40's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #40's Quarterly pain assessments revealed an assessment dated [DATE]. The resident was missing quarterly pain assessments for 05/2025,11/2025 and 02/2026.Review of Resident #40's pain care plan dated 07/22/24 revealed interventions including administering analgesics as ordered; anticipate the resident's need for pain relief and respond immediately; monitor/document for probably cause of each pain episode, monitor/document side effects of pain/ monitor/record/report to nurse any signs or symptoms of non-verbal pain. Interview on 05/06/26 at 12:10 P.M. with Regional Director of Clinical Services #860 confirmed Resident #40 was missing the quarterly pain assessments for three of the four quarters.Review of the Pain policy dated 2001 revealed the nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The assessment and recognition of pain included reviewing known diagnoses and conditions that commonly cause pain, including a review for any treatments the resident is currently receiving for pain, including complementary and non-pharmacological treatments. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and provider will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. The staff and provider will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.This deficiency represents non-compliance investigated under Complaint Number 2721208.

Based on review of open and closed medical records, review of hospital records, review of the facility investigation, review of the hazardous chemical policy, review of in-service education, review of Material Safety Data Sheets (MSDS), review of facility self-reported incidents, observations of the housekeeping cart, interviews with staff, interviews with residents, and review of an emergency medical services report, the facility failed to properly store hazardous chemicals when a reasonable risk to resident safety was present. This resulted in Immediate Jeopardy and Actual Harm with subsequent death on 06/12/25 when Resident #55, who was known to have a history of depression and prior suicide attempts, consumed liquid from a bottle of mild acid disinfectant (Drano) bowl cleaner that had been left in the resident's bathroom unsecured by Housekeeper #800. Resident #55 was identified to have intentionally ingested an unknown quantity of the chemical, resulting in the resident's hospitalization and subsequent death due to complications from the ingestion of the chemical/liquid. Additionally, a concern that did not rise to Immediate Jeopardy occurred on 07/10/25 at 9:02 A.M. when observation of the housekeeping cart revealed only one-half of the housekeeping cart was locked where cleaning supplies were stored. The cleaning supplies were accessible from the opposite side of the cart, which had a keyhole but no key to secure it. Contained in the cart were two marked bottles of mild acid disinfectant bowl cleaner and a marked bottle of window cleaner. This affected one resident (#55) reviewed for potential self-harm and had the potential to affect all 41 residents residing in the facility. The facility census was 41.On 07/09/25 at 1:18 P.M., Corporate Nurse #560, Regional Nurse #570, the Administrator, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/12/25 at approximately 11:30 P.M. when Resident #55 was found by Certified Nursing Assistant (CNA) #251 to have had an emesis. CNA #251 reported the resident's emesis to Licensed Practical Nurse (LPN) #265 who immediately assessed Resident #55. LPN #265 noted the emesis appeared blue in color and a smell of mint. LPN# 265 asked the resident if she consumed mouthwash. Resident #55 stated she had ingested Drano. LPN #265 asked her where she got it from, and the resident pointed to a bottle of cleaning solution in a white drawstring bag on her bedside table. LPN #265 contacted the physician, called nine-one-one (911), and stayed with Resident #55 until Emergency Medical Services (EMS) arrived at 11:40 P.M. Resident #55 was hospitalized and passed away at the hospital on [DATE] due to complications as a result of the ingestion of the chemical liquid. The Immediate Jeopardy was removed on 07/11/25 when the facility implemented the following corrective actions: On 06/12/25 at 11:30 P.M., CNA #251 informed LPN #265 Resident #55 had an emesis. LPN #265 went to Resident #55's room and observed blue-colored emesis on the bed and around Resident #55's mouth. Resident #55 told LPN #265 she drank Drano and showed the bottle to her. LPN #265 asked the resident where she got the bottle of cleaning solution from, and the resident pointed to her bedside table where the bottle was in a white drawstring bag. On 06/12/25 at 11:40 P.M., EMS arrived at the facility to transport Resident #55 to a local hospital. On 06/13/25 at 8:30 A.M., Social Service Director (SSD) #209, Housekeeping Director #207, Activity Director #246, Minimum Data Set (MDS) Nurse #206, Staffing Coordinator (SC) #237 and admission Director (AD) #227 began performing room searches looking for any chemicals or other poisonous substances in residents' rooms using the facility's floor plan as guide. On 06/13/25 at approximately 9:00 A.M., the Administrator interviewed the resident's roommate, Resident #59, regarding the incident. Resident #59 stated I heard her talking about wanting to die. The resident denied reporting this to anyone and did not observe the resident drink the toilet bowl cleaner.On 06/13/25 at approximately 9:00 A.M., a statement was taken from Housekeeper #800, who had been assigned to clean Resident #55's room. Housekeeper #800 admitted to leaving the chemical in an unsecured area in the resident's room and was terminated effective 06/13/25. On 06/13/25 beginning at 9:00 A.M., MDS Nurse #206 and Assistant Director of Nursing (ADON) #203 began reviewing progress notes for all residents, specifically looking for anything out of the ordinary or related to suicidal ideations or behaviors, between the dates of 05/13/25 and ending on 06/13/25.On 06/13/25 at approximately 9:30 A.M., SSD #209 identified three like residents (#10, #17, and #39) based on their diagnoses and history of suicidal ideations. SSD #209 completed face-to-face interviews with Residents #10, #17, and #39 on their psycho-social well-being and history of trauma, with no concerns identified. Beginning on 06/13/25 at 9:30 A.M., SSD #209 completed psycho-social and trauma assessments on all residents. On 06/13/25 at 9:57 A.M., upon facility room searches, the following were found in the resident's rooms: Resident #2 had Snuggle Fabric Softener, Resident #3 had Dawn Power Wash, Resident #17 had Lysol Spray, Resident #29 had Febreze, and Resident #22 had Lysol Spray. MD #525 and MD #515 were notified and placed orders for the five residents to have laboratory testing completed. The residents were educated, and the items were immediately removed from resident rooms. This process was overseen by the Administrator. On 06/13/25 at or around 1:18 P.M., the Administrator educated all facility staff, both in person and via phone, of the facility policy regarding chemical ingestion and safe storage of chemicals. The DON educated facility staff on recognizing and reporting suicidal behavior. On 06/13/25 at approximately 2:00 P.M., all facility residents had a head-to-toe assessment completed, including vital signs and pain assessments. These assessments were completed by MDS Nurse #206. On 06/13/25 at approximately 3:00 P.M., resident room rounds were completed by the Housekeeping Director #207, SC #237, AD #227, MDS Nurse #206, SSD #209 and Activity Director #246 to ensure no chemicals were left out throughout the day. On 06/13/25 at approximately 4:00 P.M., the facility's floor map and census report were compared to ensure both morning and afternoon room searches had occurred for all residents. All room searches were noted as completed once in the morning and once in the afternoon. This process was overseen by the Administrator. On 06/13/25 at 5:00 P.M., an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with MD #525 and the Interdisciplinary Team (IDT) to discuss the incident. The safety committee would continue to monitor the safety plan and would evaluate the plan at each QAPI meeting monthly and as necessary. Beginning on 06/13/25, ongoing facility round audits specific to chemical storage were implemented three times a week for three weeks, then once five times weekly indefinitely. Each department head is assigned rooms to check off to ensure compliance. If any concerns were to be identified, they would be immediately reported to the DON or Administrator and would be addressed immediately. On 06/13/25, a sign was posted by the visitor sign-in sheet and at the nurse's station by the leave of absence book notifying visitors to check with the Administrator before bringing in any items. These signs were placed by the Administrator. On 06/13/25, the facility implemented a plan for the DON or designee to identify residents with a diagnosis of suicidal ideation (SI) on an ongoing basis. These residents would be reviewed monthly at the facility QAPI meetings. On 06/13/25, the facility implemented a plan that on admission, any new admission identified to have a history of suicidal ideations would be identified by noting the history of suicidal ideations under the special instructions tab in the electronic medical record. These residents would have every one-hour safety checks completed for 72-hours post-admission which would be completed by the assigned nurse. An order would be placed to assess the resident for suicidal ideations on an ongoing basis and care plans would be updated to reflect the history of suicidal ideations. This would be completed by the DON or designee. On 07/10/25 at 9:02 A.M., the housekeeping cart that only locked on one side was removed from use and placed into a service hallway. An additional lock was placed on the cart on 07/10/25 at 11:18 A.M. by Housekeeping Director #207 which prevented access without a key or code. The housekeeping cart was then returned to service. On 07/10/25 at approximately 5:00 P.M., education was provided to all facility staff on suicide prevention precautions. Training included education for three specific residents (#10, #17 and #39) noted by the facility as in house residents who had a history of suicidal ideations. This training was provided by the DON or designee and was completed on 07/11/25. Although the Immediate Jeopardy was removed on 07/11/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, paranoid personality disorder , mild cognitive impairment, insomnia and schizoid personality disorder. A diagnosis of delusion disorder was added 05/15/25 and diagnoses of suicidal ideations and post-traumatic stress disorder (PTSD) were added on 06/13/25. Review of the prior-to-admission hospital record for Resident #55 revealed an emergency room Provider Note dated 12/19/24 and timed at 12:10 P.M. which revealed Resident #55 was admitted from an assisted living facility with complaints of a fall and facial injuries. Resident #55 stated she was trying to reach her rollator walker (an assistive device with a seat) when she fell forward hitting her face. Resident #55 stated she did not feel safe going back to the assisted living facility. Resident #55 had stopped taking her medication for a month because she was concerned the facility was poisoning her. The note referenced, per Resident #55's son, that the resident had a history of suicide attempts in the past including a gunshot wound to the face. The hospital records included additional psychiatric history which revealed the resident had additional prior suicide attempts including in the 1980's when she attempted to overdose on pills, and in the 1990's when she attempted to kill herself by drinking anti-freeze. Resident #55 sustained a self-inflicted gunshot wound (GSW) to the face in 2011 and attempted to overdose on Tylenol (an over-the-counter mild pain reliever) in 2013. Review of a Suicide Risk flowsheet dated 12/23/24, contained in outside hospital records, noted Resident #55 was high risk for suicide. Review of a hospitalist progress note dated 12/24/24 revealed Resident #55's current diagnoses included right eye blindness, permanent facial deformity from self-inflicted GSW, depression, suicidal ideations and attempts, and paranoid personality disorder. Review of the hospital After Visit Summary (AVS) dated 12/26/24 revealed the reason for the visit was listed as dizziness and fall and referenced a diagnosis of a stroke. The AVS included Suicidal Thoughts Instructions which included the National Suicide Hotline number. The summary also revealed a 1:1 sitter was removed on 12/21/24 and Resident #55 was not suicidal at that time. The resident was discharged from the local hospital to the nursing facility on 12/26/24.Review of the care plan dated 12/27/24 for Resident #55 revealed multiple goals related to suicidal ideations which included the resident would be kept safe until transfer to a psychiatric facility, the resident would no longer have suicidal ideations, and the resident would remain free from self-inflicted injury. Interventions included but were not limited to, removing all items which resident could harm self with and explain to the resident and family that frequent monitoring would be done and why. This care plan was not visible in Resident #55's electronic medical record at the time of the record review on 07/08/25 at 2:32 P.M.; but was provided to the surveyor on 07/09/25 at 1:12 P.M. Review of Resident #55's Baseline Care Plan screen in the electronic medical record revealed three baseline care plan assessments. The assessments dated 01/13/25 and 01/16/25 were listed as in progress and an additional assessment dated [DATE] was listed as incomplete. There was no evidence a baseline care plan for Resident #55 had been completed after her admission to the facility on [DATE]. Review of the progress notes revealed results of the Patient Health Questionnaire 2-9 (PHQ-2-9) (a more detailed screening to identify individuals who may be at risk for depression) dated 03/26/25 and timed at 8:39 A.M. which indicated Resident #55 answered yes to the statement Thoughts that you would be better off dead, or of hurting yourself in some way with a frequency of 7-11 days. The overall score was 18. A score of 15-19 indicated moderately severe depression. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #55 was cognitively impaired. The assessment noted the resident had inattention and disorganized thinking. In additional, the assessment included Resident #55 required substantial (staff) assistance for toileting. Review of Resident #55's Treatment Administration Record (TAR) dated May 2025 revealed behavior monitoring was in place for behaviors including calling 911 and accusations for poisoning. The TAR was marked 16 times for affirming behaviors occurring. There was no evidence facility staff had assessed or tracked Resident #55's mood, checked her room, or completed more frequent monitoring related to the identification of self-harm or suicidal ideation. Review of Resident #55's TAR dated June 2025 revealed behavior monitoring was in place for behaviors including calling 911 and accusations for poisoning. The TAR was marked eight times for affirming behaviors occurring. There was no evidence facility staff had assessed or tracked Resident #55's mood, checked her room, or completed more frequent monitoring related to the identification of self-harm or suicidal ideation. Review of a progress note dated 06/10/25 at 2:07 P.M. revealed Resident #55's son had reported that Resident #55's sister passed away and he was going to inform her later that day.Review of an incident report dated 06/12/25 and timed at 11:34 P.M. revealed LPN #265 stated a staff member notified her Resident #55 was vomiting. Upon entering the room, a blue liquid substance was noted on resident's bed, pillow and mouth. The note included Resident #55 admitted to drinking Drano. LPN #265 asked where the bottle was and she pointed to the bedside table. The nurse grabbed the black bottle and called the physician and 911. The incident report noted the resident's son and the DON were both notified of the resident's change in condition.Review of Emergency Medical Services (EMS) run report dated 06/12/25 and timed 11:40 P.M. revealed EMS were dispatched by 911 for a resident who ingested a cleaning product. Resident #55 was lying in bed with blue colored vomit surrounding her. Staff reported she was acting appropriately one hour prior. Staff found a bottle of cleaning product next to the resident, half full. The cleaning product was secured and taken with crew. The report noted Resident #55 was confused and unable to answer questions. Staff reported her baseline was alert and oriented with erratic behavior. Resident #55 was loaded into ambulance and vitals signs were taken. Resident #55 was noted to be tachycardic (elevated heart rate) and hypertensive (elevated blood pressure). Poison control was contacted and advised they should protect her airway and check for burns. No airway burns were noted. Resident #55 vomited copious amounts and was suctioned. A nasopharyngeal airway (a flexible tube inserted into the nasal passage to maintain an open airway) was placed in right nostril. Oxygen was administered at six liters per minute. Intravenous (IV) access was established and Narcan was administered via IV. Resident #55's airway was suctioned frequently due to her being unable to expel the vomit adequately. Resident #55's lung sounds were reassessed with slight crackles (popping or crackling sounds heard during breathing, usually upon inhalation, caused by the opening of small airways and alveoli that have been collapsed by fluid, exudate, or lack of aeration) heard in the lower lobes bilaterally. The report noted that a handoff report was given to the emergency room doctor and transfer of care was made. Arrival to hospital was on 06/13/25 at 12:17 A.M. Review of the hospital records for Resident #55 revealed an admitting history and physical dated 06/13/25at 4:40 A.M., listed the chief complaint as intentional ingestion of acid and attempt to self-harm. Past medical history included paranoid psychosis, schizoaffective disorder and bipolar (disorder). The record indicated Resident #55 had a history of self-harm including medication ingestion as well as an attempt with a firearm. The hospital record indicated Resident #55 reported she felt like she was being abused at the nursing facility and became overwhelmed and reportedly intentionally ingested half a bottle of drain cleaner. The records noted Resident #55 had a hoarse, gurgling voice with significant secretions, but was able to nod yes to pain. The records noted Resident #55 was yellow slipped (used for mentally ill patients subject to involuntary hospitalization who are not medically cleared for psychiatric care) in the emergency department and not allowed to leave against medical advice (AMA). Review of the facility's investigation revealed the facility began to investigate the incident on 06/13/25. As part of the investigation, all resident progress notes were audited and reviewed for the past 30 days. As a result of this audit, the facility discovered a progress note dated 06/07/25 in Resident #55's record accusing a nurse of being a murderer and abuser. The facility initiated a Self-Reported Incident (SRI) on 06/13/25 upon learning of the note. Review of a facility SRI tracking number 261593 revealed it was initiated on 06/13/25 but listed a discovery date of 06/07/25. The SRI indicated Resident #55 had accused Registered Nurse (RN) #217 as being a murderer and an abuser. The SRI listed Resident #55 was unable to be interviewed as she was at the hospital at the time the allegation was identified. The facility investigation included a witness statement from Housekeeper #800. The statement dated 06/13/25 and authored by Housekeeper #800 revealed he went into Resident #55's room and started cleaning. The resident came in the room to use the bathroom at approximately 10:30 A.M. The statement included, he thought he got everything out of the room, but forgot a cleaning product in Resident #55's bathroom. Housekeeper #800 noted he got sidetracked by his manager to get his physical done. Housekeeper #800 reiterated he got sidetracked and stated he was sorry and was new to the facility. Review of a witness statement dated 06/13/25 taken by the Administrator from Resident #39 revealed she heard Resident #55 talking about wanting to die. Resident #39 stated she did not report it and she did not see Resident #55 with the toilet bowl cleaner.Review of a witness statement dated 06/13/25 taken by the DON from CNA #251 revealed she entered Resident #55's room and noticed Resident #55 had an episode of emesis. She stated she went to get the nurse right away and the nurse began assessing the resident. Review of a witness statement dated 06/13/25 taken by the DON from LPN #265 revealed a CNA made her aware Resident #55 had an episode of emesis. LPN #265 observed emesis on bed and pillow. The emesis appeared blue in color. She stated it smelled like mint. She asked Resident #55 if she drank mouthwash and asked what happened. Resident #55 stated she drank Drano. LPN #265 asked here where she got it from and the resident pointed to her bedside table which had a bottle cleaning solution in a white draw string bag. The statement referenced that Resident #55 denied pain, was alert and oriented to person, place and time and able to answer questions. LPN #265 called the physician and 911. She stayed with the resident until EMS arrived. Review of a hospitalist progress note dated 06/29/25 at 11:49 A.M. revealed Resident #55 received a gastrointestinal (GI) consultation and had an urgent esophagogastroduodenoscopy (EGD) [a a procedure used to examine the lining of the esophagus, stomach, and duodenum]. Resident #55 was identified to have grade 2a (indicating superficial ulcerations, erosions, friability, blisters, exudates, hemorrhages, or whitish membranes) esophagitis (inflammation or irritation of the esophagus, the tube that carries food from your throat to your stomach) with no bleeding. The consultation note referenced the resident had significant gastritis with possible necrosis (dead tissue) versus retained dark gastric contents. The report ordered to continue nothing by mouth and advised against placement of a gastrostomy tube (a feeding tube placed directly into the stomach) or a jejunostomy tube (a feeding tube placed directly into the jejunum part of the small intestine) given the resident's high risk for perforation. Total Parenteral Nutrition (TPN) [a method of feeding that delivers essential nutrients directly into a patient's bloodstream via a catheter inserted into a vein, bypassing the digestive system] was started. The note indicated the anticipated healing time after a caustic ingestion injury was between six to eight weeks and the resident would then need to be re-evaluated by the GI provider. Interview on 07/07/25 at 12:24 P.M. with LPN #203 revealed Resident #55 was currently in the hospital after ingesting toilet bowl cleaner which was left in the bathroom by a housekeeper. The LPN revealed Resident #55 had been placed on hospice as she was not able to have surgery for placement of a feeding tube. LPN #203 stated Resident #55 had a history of suicide attempts and mentioned she had shot herself in the face around ten to 15 years ago.Interview on 07/07/25 at 4:00 P.M. with LPN #217 revealed Resident #55 would make accusations the doctor was poisoning her. LPN #217 denied knowledge of Resident #55 making any suicidal statements. Interview on 07/07/25 at 4:10 P.M. with the Administrator and Regional Nurse #570 revealed it was Housekeeper #800's first day working on his own (without a trainer) when he left the cleaning solution in Resident #55's bathroom when the resident had come in to use the bathroom. They stated the housekeeper forgot to return to Resident #55's room to retrieve it. The Administrator denied knowledge of Resident #55 expressing suicidal ideations to her since she met her a few months ago. Interview on 07/08/25 at 2:32 P.M. with SSD #209 revealed she was aware of Resident #55's past suicide attempts and suicidal ideations prior to 06/12/25. She stated the resident believed things such as that she was going to be poisoned or that she did not have a bowel movement in 12 weeks. Resident #55 did not like to be challenged with her thoughts. SSD #209 stated Resident #55 would always say, I'm going to die soon. Continued interview and record review with SSD #209 revealed she started at the facility in October 2024 and Resident #55 was admitted in December 2024. SSD #209 revealed there was no social service assessment or what she referred to as her 72-hour note upon admission. She stated the son wanted Resident #55 to be followed by psychiatric services; however, the resident would refuse to sign even after she promised she would sign consent if the son visited. At the time of review of the care plan with SSD #209 revealed no evidence of a care plan regarding mood or behaviors specifically history of suicide attempts. A care plan was provided on 07/09/25.Interview on 07/08/25 at 3:30 P.M. with MDS Nurse #206 revealed she started at the facility at the end of February 2025. She stated she did most of the care plans though other departments may do some. MDS Nurse #206 stated she was not aware of Resident #55's history of suicide attempts prior to the 06/12/25 incident. A subsequent interview on 07/09/25 at 11:34 A.M. with LPN #217 revealed Resident #55 used a rollator walker, but could have walked without it. She often toileted herself. LPN #217 revealed she was aware of Resident #55's history of suicidal ideations. Interview on 07/09/25 at 11:43 A.M. with CNA #263 revealed Housekeeper #800 was still in training on 06/12/25. Telephone interview on 07/09/25 at 12:52 P.M. with MD #525 revealed he was unaware of any issues with Resident #55 except for her accusing others of poisoning her. She consistently refused certain medications and psychiatric services. MD #525 stated she did not have any specific recommendations for the facility in managing suicidal ideation behaviors as it had never come to that point until the incident.During an interview on 07/09/25 at 1:12 P.M. with Corporate Nurse #560, Regional Nurse #570, the Administrator, and the DON the Corporate Nurse presented a care plan dated 12/27/24 which included notations about Resident #55's suicidal ideations and interventions. The care plan was not visible to the surveyor during review or to SSD #209 when attempting to review it earlier in the investigation. Regional Nurse #570 stated sometimes you can't see everything. The surveyor questioned how the staff could care for residents (including Resident #55) if they did not have access to necessary information. Regional Nurse #570 stated it may be an information technology (IT) issue. Regional Nurse #570 then stated Resident #55 did not voice suicidal ideation but also stated the son told the facility it was inevitable. The surveyor questioned whether or not Resident #55 needed more care, such as one-on-one care or more frequent checks, if suicide/attempts were considered inevitable, despite Resident #55 not voicing suicidal ideations. There was no response. It was also acknowledged in this interview there was no evidence in the corrective action file provided as of this time of like-residents being identified as part of any abatement plan.Interview and review of records on 07/09/25 at 2:45 P.M. with CNA #219 revealed Resident #55 did not need a lot of care as she would come out of her room when she wanted to. CNA #219 was not aware of Resident #55's history of suicidal ideations/attempts. She was not aware of any current residents with suicidal ideations. She reviewed Resident #55's tasks in the electronic medical record (EMR). It was blank under the section special instructions. CNA #219 showed the surveyor two other residents who had special instructions which included visitors needing a password to speak to resident and that resident was not allowed to receive calls from certain people. CNA #219 stated this was where she would look for anything out of the norm. CNA #219 stated they mainly learned (of resident needs) through word of mouth. Interview on 07/09/25 at 3:50 P.M. with LPN #217 stated she did not know about the care plan interventions for Resident #55. She stated the facility was a behavioral place, not a nursing home, and needed to be treated like that. Interview on 07/09/25 at 3:57 P.M. with Resident #39 revealed she did not recall anything about Resident #55 making comments about wanting to die. Review of Resident #39's medical record revealed she was cognitively impaired. Interview on 07/09/25 at 4:01 P.M. with LPN #241 revealed anything special about a resident would be on the TAR or given through verbal report. She stated she did not routinely care for Resident #55 but knew Resident #55 refused medications regularly. Interview on 07/09/25 at 4:10 P.M. with LPN #265 revealed she was aware of Resident #55's history of suicidal ideations and attempts. She stated she knew Resident #55 from when she resided in the facility Assisted Living. LPN #265 stated she was the nurse assigned to care for Resident #55 on 06/12/25 and denied the resident making any comments about suicidal ideations. She described it as a normal day of activities for Resident #55. She stated she did not check on Resident #55 any more or less than other residents, but stated she did scan rooms as she was up and down the hallways throughout her shift. The LPN stated there was nothing unusual in the resident's room. LPN #265 stated the CNA came to get her after Resident #55 had an emesis. When she walked into the room she noticed it smelled like mouthwash. The emesis was a blue color which was on the bed. She asked the resident if she drank mouthwash with the resident responding she drank drano. There was a bag in her bottom drawer of the nightstand with a black bottle in it. She was uncertain how much Resident #55 drank but stated there was at least half of the cleaning solution left in the container. She stated she called 911 and the the physician. She stayed with the resident until EMS transported her to the hospital. LPN #265 was not aware of other residents with history of suicidal ideations.Observation on 07/09/25 at 4:35 P.M. with Housekeeping Director #207 revealed a bottle of the cleaner Resident #55 drank. It was labeled mild acid disinfectant bowl cleaner and was in a one-quart bottle. The precautionary statement included it was hazardous to humans and domestic animals . It had instructions on it if swallowed which included calling poison control, sipping water if able, to not induce vomiting unless instructed by poison control, and to not give anything by mouth to an unconscious individual. Housekeeping Director #207 stated she believed at the time of the incident with Resident #55 on 06/12/25, the bottle was less than half full. She stated the housekeeper was terminated. Housekeepers were to have two bottles on their cart of the toilet bowl cleaner and one bottle of window cleaner. She stated the housekeeping carts were to be locked. Housekeeping Director #207 revealed she was not aware of Resident #55's history of suicidal ideations but stated she wished she had known. She stated they did rounds after the incident to look for chemicals, saying the checklist form already listed to check for chemicals on the front side. She stated she had a meeting with her team and reviewed the checklist again with them having them sign a new one.Interview on 07/09/25 at 4:50 P.M. with the Administrator revealed she agreed the correct or full care plan not being visible for staff reference was a concern. When asked about Resident #55's interventions on the care plan regarding more frequent checks and removing items from her room revealed she could not provide evidence of these interventions being completed. Interview on 07/09/25 at 5:45 P.M. with Regional Nurse #570 revealed the facility's initial abatement plan provided to the surveyor indicated there were no like residents with a history of suicidal ideations who were reviewed and assessed on 06/13/25. However, Regional Nurse #570 provided the names of three residents (#10, #17 and #39) who were identified as like residents based on their diagnosis of suicidal ideations. The facility provided evidence that these three residents had psychosocial assessments and post-traumatic stress assessment, and care plan reviews following surveyor request. Regional Nurse #570 stated these three residents' assessments were contained in a separate file and she stated she thought she had previously provided these to the surveyor. Interview on 07/10/25 at 8:15 A.M. with CNA #205 revealed she was not aware of any residents with history of suicidal ideations, nor was she familiar enough with Resident #55's history. She stated she received education on chemical storage on 06/13/25 but not other like residents. A subsequent interview and observation on 07/10/25 at 8:49 A.M. with CNA #219 revealed she did [TRUNCATED]

Based on record review, interview, and facility self-reported incident (SRI) review, the facility failed to develop and implement effective, comprehensive, and individualized dementia/behavioral health care plans to address the total care needs of all residents and to prevent a resident-to-resident altercation resulting in resident injury. This affected two residents (#31 and #35) of three residents reviewed for abuse. The facility census was 34. Actual harm occurred on 02/13/24 when Resident #35 sustained a head injury, which included bleeding from the head with two bumps (one to the forehead and one behind the ear) as a result of a resident-to-resident altercation that occurred after he wandered into Resident #31's room. Resident #35 was subsequently transferred to the emergency room where he required staples to the area. Findings Include: Record review revealed Resident #35 was admitted to the facility on [DATE] and discharged on [DATE]. Medical diagnoses included unspecified dementia severe with agitation, restlessness and agitation, dysphagia, insomnia, and depression. Review of a nursing note dated 02/07/24 4:00 P.M. revealed resident was alert to self only. Review of a nursing note dated 02/08/24 at 7:23 A.M. revealed Resident #35 had been up walking the unit all night and required multiple redirection attempts. The note indicated Resident #35 attempted to go into other resident rooms without permission. Record review revealed no additional interventions were implemented at this time to address the resident's wandering behaviors. Review of Resident #35's care plan initiated 02/09/24 revealed no comprehensive or individualized interventions were in place to address Resident #35's wandering or behavioral health needs related to wandering, safety and/or dementia. Review of a nursing note dated 02/13/24 at 1:56 A.M. revealed Resident #35 continued to enter other resident rooms and was unable to be redirected. Record review revealed no additional interventions were implemented at this time to address the resident's wandering behaviors. Review of a nursing note dated 02/13/24 at 8:09 A.M. revealed Resident #35 was bleeding from the head with two bumps, one on the forehead and the other behind the head. Resident #35 was sent to the Emergency Department at 7:00 A.M. via Emergency Medical Services (EMS). Review of hospital discharge paperwork for Resident #35 dated 02/13/24 revealed the resident had a laceration to his head that required repair with staples. Review of the nursing note dated 02/14/24 at 2:25 P.M. revealed Resident #35 continued to pace into other resident rooms. Staple to head was intact, no swelling or redness noted to area was noted at that time. Review of Admission Minimum Data Set (MDS) assessment dated [DATE] revealed assessment was in progress. Review of the medical record revealed Resident #35 was discharged to another long-term care facility with a locked dementia unit on 02/19/24. Review of medical record for Resident #31 revealed an admitted [DATE], medical diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, schizoaffective disorder, depression, and lack of coordination. Review of care plan dated 12/31/23 for Resident #31 revealed the resident required psychotropic medications related to behavior management. The care plan for Resident #31 did not indicate the resident had a history of physical aggression that required interventions. Review of progress note dated 02/13/24 9:06 A.M. revealed Resident #31 was involved in an incident involving another resident and was placed on one on one (staff supervision) for safety. Review of progress note dated 02/13/24 11:41 A.M. revealed Resident #31 was assessed for psychosocial needs due to resident-to-resident altercation. All needs had been assessed and met, no physical, mental, or emotional concerns at this time. Resident continued to be monitored at time of progress note. Review of admission Minimum Data Set (MDS) 3.0 assessment for Resident #31 revealed the resident was cognitively intact. Interview on 02/20/24 at 12:30 P.M. with Licensed Practical Nurse (LPN) #316 revealed Resident #35 had wandered the unit since he was admitted to the facility. Interview on 02/20/24 at 4:15 P.M. with State tested Nursing Assistant (STNA) #308 revealed Resident #35 wandered on the unit and in and out of other resident rooms. Resident #35 would take things that were not his. STNA #308 stated staff tried to keep eyes on him and redirect if possible but most times he was not able to be redirected. STNA #308 stated Resident #35 needed to be at a facility that was designed for residents who wander and voiced frustration over the resident's placement at the facility. Review of a facility Self-Reported Incident (SRI), tracking number 244129 dated 02/13/24 revealed the facility reported an incident of physical abuse involving Resident #35 and Resident #31. The facility investigation was still in progress as of 02/20/24. Review of a facility witness statement dated 02/13/24 from Registered Nurse (RN) #338 revealed the RN was in another resident room around 6:25 A.M. RN #338 heard someone ask Resident #35 what was wrong. When RN #338 exited the resident room that he was in he saw blood drops on the floor. RN #338 met up with Resident #35 at the nurse's station where he saw Resident #35 bleeding. RN #338 followed the blood drops that were on the floor which led to Resident #31's room. RN #338 interviewed Resident #31 and asked why Resident #35 was bleeding and Resident #31 showed no concerns and said he did not know. Review of a facility witness statement dated 02/13/24 from STNA #315 revealed she was at the nurse's station charting and at 6:28 A.M. she heard someone state that Resident #35 was bleeding. STNA #315 saw Resident #35 walking towards the nurse's station with blood dripping from his head. Review of a facility witness statement from STNA #300 dated 02/13/24 revealed she had last seen Resident #35 around 6:20 A.M. as he was walking and wandering the halls continuously as he did not sleep. Review of witness statement from Resident #31 revealed that after 3:00 A.M. Resident #35 came into Resident #31's room and started taking his reacher and hit Resident #31 on the left side of the head and neck. Resident #31 then took the reacher from him and hit him (Resident #35) on top of his head. Interview on 02/20/24 at 3:08 P.M. with the Director of Nursing (DON) confirmed Resident #35 showed behavioral signs of wandering following admission. The DON revealed she felt Resident #35's plan of care did address the resident's wandering/behavioral health needs by staff keeping a close eye on him. However, based on the investigation completed, the facility failed to develop and implement a comprehensive, individualized and effective plan of care for all residents (including Resident #35 and #31) to address behaviors including wandering and to prevent resident-to-resident altercations. There was no evidence the facility had measures in place to proactively prevent the situations identified affecting the resident's total care needs; the facility plan was simply reactive to Resident #35's wandering behaviors and not preventative. This deficiency represents non-compliance investigated under Master Complaint Number OH00151262 and Self-Reported Incident Control Number OH00151103.

Based on record review, review of pharmacy delivery sheets, review of facility policy and interviews with family and staff, the facility failed to provide Resident #3 effective pain management, including the administration of narcotic analgesic medication as ordered to prevent unrelieved pain. Actual harm occurred on 05/05/23 when physician ordered narcotic medications for pain including Oxycodone tablets and Fentanyl patches were not available to administer to Resident #3, and Resident #3 rated his pain level a nine on a scale of one to 10 with 10 being the most severe pain. On 05/07/23 at 8:46 P.M. Resident #3 stated he was ready to flip out and complained of pain, anxiety, and restlessness. These pain medications were not available from 05/05/23 through 05/08/23. This affected one resident (#3) of three residents reviewed for pain. The facility census was 27. Findings included: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including progressive multifocal leukoencephalopathy, human immunodeficiency virus, ulcerative colitis, psychosis, and infectious gastroenteritis. Review of the plan of care dated 09/27/22 revealed Resident #3 was on pain medication therapy related to ulcerative colitis. Interventions included administering pain medications as ordered by physician, monitor/document side effects and effectiveness every shift, ask physician to review medication if side effects persist, and monitor risks of falls. Review of the modification to the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/26/23, revealed Resident #3 had impaired cognition, required total assistance from one staff member for toilet use and personal hygiene, total assist from two staff members for transfers, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for dressing and eating. The MDS assessment revealed the resident received scheduled and as needed pain medication. Review of the May 2023 physician's orders revealed Resident #3 had an order (dated 11/30/22) for Oxycodone 10 milligrams (mg) three times a day for pain, an order (dated 02/09/23) for Fentanyl patch 12 micrograms an hour transdermal patch every 72 hours and an order (dated 10/12/22) for Morphine Sulfate 10 mg/ml every two hours as needed. Review of a pain assessment dated [DATE] revealed Resident #3 had vocal complaints of pain, facial expressions, and protective body movements or postures. Review of medication delivery sheets dated 04/25/23 revealed Resident #3 received a narcotic count card of 30 tablets of Oxycodone 10 mg and a narcotic count card of 21 tablets of Oxycodone 10 mg. Review of the facility shift-to-shift added and removed count sheets revealed Resident #3 received two cards/51 tablets of Oxycodone on 04/25/23. Review of the Controlled Drug Receipt record dated 04/25/23 revealed Resident #3 had 30 tablets of Oxycodone 10 mg. Further review revealed the last 10 mg tablet dose of this medication was administered to Resident #3 on 05/05/23 at 3:20 P.M. by Licensed Practical Nurse (LPN)# 503. Review of the May 2023 Medication Administration Record (MAR) indicated on 05/05/23 at 7:00 P.M. LPN #501 had administered a dose of Oxycodone 10 mg to Resident #3, however, there was no Oxycodone left in his narcotic count card to give him at that time and no record of a dose of Oxycodone being signed out by LPN #501. Further review of the MAR revealed the resident had not received any Oxycodone from 05/05/23 at 7:00 P.M. until 05/08/23 at 7:00 P.M. Record review revealed the Oxycodone medication was scheduled to be administered at 7:00 A.M., 2:00 P.M. and 7:00 P.M. everyday. Resident #3 was to receive a Fentanyl 12 micrograms patch on 05/07/23 at 8:09 A.M., however it was not available to be administered. The resident was administered a dose of as needed (PRN) Morphine 10 mg on 05/08/23 at 12:58 P.M. Review of the May 2023 MAR revealed on 05/06/23 at 7:00 A.M. the resident's Oxycodone was not available. The resident rated his pain a five out of 10. Record review revealed no new interventions or pain management interventions were implemented at this time. Review of the May 2023 MAR revealed on 05/06/23 at 2:00 P.M. the resident's Oxycodone was not available and there was no pain level documented. Review of the May 2023 MAR revealed on 05/06/23 at 7:00 P.M. the resident's Oxycodone was not available, and no pain level was documented. Review of the May 2023 MAR revealed on 05/07/23 at 7:00 A.M. the resident's Oxycodone was not available and there was no pain level documented. Review of the May 2023 MAR revealed on 05/07/23 at 8:09 A.M. the resident's Fentanyl patch was not available and there was no pain level documented. Review of the nursing note dated 05/07/23 at 8:18 A.M. revealed the nurse spoke with the pharmacy technician to follow up on Resident #3 Oxycodone order delivery and to request an authorization to pull (the medications). The pharmacy technician stated he would have a pharmacist return the call with an update. Review of the May 2023 MAR revealed on 05/07/23 at 2:00 P.M. the resident's Oxycodone was not available and there was no pain level documented. Review of the May 2023 MAR revealed on 05/07/23 at 7:00 P.M. the resident's Oxycodone was not available. Review of the medication administration note dated 05/07/23 at 8:50 P.M. revealed Resident #3's Oxycodone was not available. Review of the Narc EDK Pull Sheet revealed on 05/07/23 at 10:00 P.M. two Oxycodone 5 mg and one 12 microgram Fentanyl patch were pulled for Resident #3. However, there was no documentation on the MAR, no narcotic count sheet or nurse's note indicating these medications were actually administered to Resident #3. A call was placed to the nurse who signed the medication out however no contact was made with her. Review of the nurse's notes dated 05/08/23 at 4:10 A.M. revealed the nurse called the pharmacy at 8:46 P.M. on 05/07/23 due to Resident #3 not having Oxycodone or Fentanyl patches available. Resident #3 stated he felt like he was ready to flip out and he complained of pain, anxiety, and restlessness. The nurse attempted to administer Morphine for which he had an order for, but the medication was also unavailable. The note indicated the nurse left a message on the pharmacy's after-hours phone number. The pharmacy called back at 9:25 P.M. and stated they would need another prescription because the resident should not have been out of the medication. The nurse called the physician who instructed the nurse to have the pharmacy call him for a verbal order. The pharmacy called back at 12:52 A.M. with authorization to pull a Fentanyl 12 mcg patch and two Oxycodone 5 mg to make a 10 mg dose. Review of the May 2023 MAR revealed on 05/08/23 at 7:00 A.M. the resident's Oxycodone was not available and there was not a pain level documented. Review of the May 2023 MAR revealed on 05/08/23 at 12:58 P.M. Resident #3 was administered Morphine 20 mg for a pain level rated a nine out of 10. Morphine was documented as effective. Review of the May 2023 MAR revealed on 05/08/23 at 2:00 P.M. Resident #3's Oxycodone was not available, and he had a pain level rated a nine out of 10. There was no documentation of any other pain management interventions considered or implemented at that time. Review of a pain assessment dated [DATE] at 4:04 P.M. revealed Resident #3 had vocal complaints of pain, facial expressions, and protective body movements or postures. However, there was no documentation that any pain interventions were implemented. Review of the pharmacy-controlled medication packing slip dated 05/08/23 revealed Resident #3 received seven tablets of Oxycodone 10 mg. Review of the pharmacy-controlled medication packing slip dated 05/09/32 revealed Resident #3 received two Fentanyl 12 mcg patches. On 05/15/23 at 1:10 P.M. during an interview with Regional Director of Clinical Services (DCS) #600, the DCS revealed because of this incident, the facility completed and submitted a self-reported incident (SRI) to the State agency related to misappropriation. The DCS revealed the SRI was a collaborative effort between the Director of Nursing, the Administrator, and himself. He indicated the facility did not know when a card of Oxycodone for Resident #3 went missing, however it was brought to their attention when the nurse called pharmacy indicating they were out of his Oxycodone and the pharmacy indicated that was impossible because they had just sent two cards on 04/25/23. The DCS verified the cards were missing but stated they were unable to identify what had happened to them. On 05/15/23 at 1:12 P.M. an interview with the Director of Nursing (DON) revealed the pharmacy delivery sheet was electronically signed by LPN #500 was when the medication was received from the driver and the other handwritten one from LPN #501 was when she put them away. She stated LPN #500 who worked 7:00 A.M. to 7:00 P.M. on 04/25/23 received the narcotic medication from the pharmacy and placed them in the medication room without reconciling them and placing them in the narcotic drawer in the medication cart then LPN #501 worked from 7:00 P.M. on 04/05/23 to 7:00 A.M. on 04/26/23 and did not reconcile the narcotic until sometime on 04/26/23. She verified this medication where not properly managed and reconciled per facility procedure. The DON revealed a card of 21 Oxycodone tablets was the card they could not find for Resident #3. On 05/15/23 at 1:15 PM an interview with the Administrator revealed the facility believed LPN #501 was responsible for the missing medications. A police report was filed, and they had the pharmacy do an in-house audit of all narcotics. On 05/15/23 at 2:30 P.M. an interview with Family Member #700 revealed Resident #3 was out of his pain medication from 05/06/23 to 05/08/23 then again on 05/11/23. She stated she was not told about it at first. She stated she felt like they were trying to hide it from her. She stated her husband came and sat with Resident #3 on 05/06/23 and he called her and told her Resident #3's pain medication was not available. So, when she came in later that night, she asked about it, she found out they were missing and that was why they could not give the medication to him. She stated she asked the nurses several times why they had not gotten a prescription or at least pulled from the house medication kit but was never given an answer. She stated they were not telling her anything as to why he did not have his Fentanyl. She stated the Morphine did not help with the resident's pain because it wore off too quick and he got no relief with it. She stated it was now going to take days to get his pain back under control. She stated they run out of his medication all the time and she does not understand how or why it keeps happening. On 05/15/23 at 4:15 P.M. an interview with Regional Director of Clinical Services #600 verified they did not have a count sheet and there was no documentation on the medication administration record for the medication pulled from the facility's emergency kit on 05/07/23. On 05/16/23 at 9:20 A.M. an interview with LPN #503 revealed she had worked on 05/05/23 and had given Resident #3 a dose of Oxycodone at around 3:00 P.M. and she realized he did not have another card, so she called the pharmacy. The pharmacy indicated to her his medication was ordered too soon and he should still have another card. She stated she could not find the card. She stated the count had been correct that morning. On 05/16/23 at 10:28 A.M. an interview with Physician #703 revealed nursing staff had called him during the evening, but he was not sure of the day to inform him Resident #3 was out of his Oxycodone and Fentanyl patches. He stated he had only been called once about the resident being out of his medication and he addressed it as soon as he was made aware. He stated the facility had a lot of agency nurses on the weekends and they were not as thorough as the facility staff. He stated Resident #3's pain was all over his body due to his HIV and leukoencephalopathy diagnoses. He stated he had been made aware of an incident of misappropriation that had happened at the facility. On 05/16/23 at 11:05 A.M. an interview with Agency LPN # 507 revealed she only worked at the facility occasionally. She stated she worked from 7:00 P.M. to 7:00 A.M. on 05/06/23. She stated she was told in the report that the pharmacy had been notified that Resident #3's pain medications were out, and they were going to drop ship them. She stated she called the pharmacy in the early A.M. on 05/07/23 to find out why they had not been delivered and the pharmacy technician stated they would have someone call her back, but no one ever called her back before she left. She stated she never called the doctor regarding this. On 05/16/23 at 12:40 P.M. during an interview with LPN #505, the LPN stated you could just tell Resident #3 was in pain, he stated to her he hurt all over and just wanted to be laid down. She stated she gave him the Morphine at his mother's request (at 12:58 P.M.) because she stated he needed to have something for his pain. She stated they needed a new prescription, or they were out of it in the emergency kit. She could not remember but there was a reason they had not received his medication from the pharmacy. She stated the Morphine did help a little bit but only for a brief period of time. She stated on 05/08/23 she did not try to give him anything at 2:00 P.M. because she was told by the DON his medication was on order and should be delivered soon. She stated he did have a pain level of nine at 2:00 P.M. but she had not given him anything else for pain nor did she call the physician. She stated they got seven tablets that evening, so he had some available for his 7:00 P.M. dose. She also verified they had run out of his medication again on 05/11/23 at 7:00 A.M. because they only sent seven tables on 05/08/23. On 05/16/23 at 1:26 P.M. an interview with Agency LPN #508 revealed she had gotten report from the midnight nurse on 05/06/23 and was told Resident #3 did not have any Oxycodone left but pharmacy had been notified and would drop ship She stated they never delivered on her shift, she ever called them or notified the physician. On 05/16/23 at 2:10 P.M. an interview with Regional Director of Clinical Services #600 verified there were no pain assessments documented on 05/06/23 at 2:00 P.M., on 05/07/23 at 2:00 P.M. or on 05/08/23 at 2:00 P.M. for a pain level of nine out of 10, there were no pain interventions documented as being completed and the physician was not notified Resident #3 was having pain and his medication had not been delivered. Review of the facility policy titled, Administering Medications, dated 04/19 revealed medication were to be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00142545.

Based on record review and interview the facility failed to ensure Resident #312, who had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when nursing staff failed to check and routinely monitor Resident #312's blood sugars and administer insulin (for diabetes) as ordered by the physician from 05/18/21 (admission) through 07/17/21 resulting in episodes of [CONDITION(S)] (very elevated blood sugars) and elevation of her hemoglobin A1c (HbA1c), a laboratory test which revealed the average blood sugar levels for a two to three month period. Resident #312 was noted to have increased pain requiring the use of as needed pain medication as a result of the increased blood sugars. This affected one resident (#312) of three residents reviewed for diabetic care, testing and management. Findings include: Review of the medical record for Resident #312 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medications ordered by the physician on admission for Resident #312 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were to administer Novolog insulin as follows for the sliding scale: for a blood sugar of 151 to 200 give two units, for a blood sugar of 201 to 250 give four units, for a blood sugar of 251 to 300 give six units, for a blood sugar of 301 to 350 give eight units, for a blood sugar of 351 to 400 give 10 units, and for a blood sugar reading of greater than 400 or less than 60, the physician was to be called. Review of the current plan of care, dated 05/25/21 revealed Resident #312 was at risk for complications related to type two diabetes mellitus. Interventions included for staff to administer diabetes medications as ordered by the physician and to monitor and document for side effects and effectiveness. Staff were also to monitor and document/report any symptoms of [CONDITION(S)], including frequent urination, weight loss, fatigue, muscle cramps, and abdominal pain. Review of the quarterly Minimum Data Set assessment, dated 06/24/21 revealed Resident #312 was alert, oriented and had intact cognition. Review of the Medication Administration Records (MARs) for May and June 2021 revealed [MEDICATION(S)] insulin 20 units subcutaneously at bedtime was administered as ordered by any nurse from 05/19/21 through 05/31/21 or from 06/01/21 through 06/30/21. These same MARs also revealed the Novolog insulin per sliding scale, before meals and at bedtime, was not administered by any nurse for any of the times during the day from 05/19/21 through 05/31/21 or from 06/01/21 through 06/30/21. Review of the MAR for July 2021 revealed [MEDICATION(S)] insulin 20 units subcutaneously at bedtime was not administered by a nurse from 07/01/21 through 07/16/21. The blood sugar checks four times a day and corresponding Novolog insulin per sliding scale before meals and at bedtime were not completed from 07/01/21 through 07/17/21. Review of the nursing progress note, dated 07/13/21 at 3:25 P.M. and completed by Registered Nurse (RN) #114, revealed Resident #312 requested her HbA1c level to be checked. The Certified Nurse Practitioner (CNP) was notified and new orders were received for a complete metabolic panel, complete blood count, lipid panel, HbA1c, [CONDITION(S)] stimulating hormone and a vitamin D level in the morning, 07/14/21. Review of the lab results reported on 07/15/21 revealed Resident #312's HbA1c was very elevated at 10.9, with normal levels being 4.1 to 6.1. Resident #312's blood glucose level was 454 (with a normal fasting range being 65 to 99 and a normal non-fasting range being 65 to 125). According to Mayoclinic.org, the higher the HbA1c, the poorer blood sugar control is and the higher the risk for diabetic complications. Symptoms of high blood glucose, or [CONDITION(S)], include excessive thirst, increased hunger, frequent urination, fatigue and blurry vision. More severe symptoms can include nausea, vomiting, fruity breath, rapid breathing and loss of consciousness. Review of the nursing progress note, dated 07/17/21 at 10:47 P.M. and completed by Licensed Practical Nurse (LPN) #112 revealed Resident #312 said she did not feel to well and requested her blood sugar to be checked. LPN #112 tested Resident #312's blood and the glucometer (blood sugar testing meter) read HI, meaning the blood sugar results were higher than the glucometer could measure. The CNP was notified of the findings and new orders were received to administer a one time dose of 20 units of Novolog insulin subcutaneously and to recheck the blood sugar in 20 minutes. The CNP also ordered insulin to be given according to a sliding scale at bedtime. However, Resident #312 had already been ordered insulin to be given according to the sliding scale before meals and at bedtime on admission to the facility, this had not been previously completed. Review of the MAR for July 2021 revealed the first dose of [MEDICATION(S)] insulin was documented as being administered on 07/17/21 at 8:00 P.M. The nursing progress note, dated 07/18/21 at 5:39 A.M. and completed by LPN #112 revealed a blood sugar of 88. Resident #312 said she was feeling much better. The July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., when six units of insulin was given for a recorded blood sugar of 266. On 07/18/21 at 11:00 A.M. Resident #312's blood sugar was elevated at 461. Interview on 07/20/21 at 12:15 P.M. with Resident #312 revealed, They just started checking my blood sugar and giving me insulin last Sunday. I have been diabetic and receiving insulin since 2002. I didn't know if I needed it anymore because they weren't giving it to me, I thought they would know. I thought I had a kidney or bladder infection because I had constant pain in my sides and lower back, and I had been feeling so jittery and flakey. I have been telling them I want my labs done but they never listen or do anything. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #312 received acetaminophen 650 mg on 07/10/21, 07/11/21, 07/14/21, 07/15/21, and 07/16/21. Resident #312 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #312 received [MEDICATION(S)] 50 mg on 07/01/21, 07/02/21, 07/03/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/09/21, 07/11/21, 07/14/21, 07/15/21, and 07/16/21 for pain. There was no documentation found to indicate the location of Resident #312's pain when she requested these as needed pain medications. There was also a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #312's record was reviewed on 07/20/21 at 1:00 P.M. with the DON who confirmed Resident #312's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the [MEDICATION(S)] and Novolog insulins were not given as ordered by the physician and the blood sugar testing was not completed as ordered for the months of May, June and part of July 2021. The DON verified the medications and blood sugar testing were started on 07/18/21. The DON verified if the admitting nurse entered medication orders in the system under routine instead of standard, the medications would not show up on the MAR for the nurse to administer the medication. The DON revealed she had added the concern in February 2021 to the Quality Assurance (QA) agenda and the plan was to monitor physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the facility used multiple agency nurses and confirmed not all nurses knew how to enter the medications correctly into the computer and electronic medication record. The DON said their QA audit was initiated 02/25/21 and ended 03/07/21 per their plan. The DON confirmed she was aware of the risks but she did not have time to continue to audit the orders. Interview on 07/20/21 at 2:00 P.M. with Certified Nurse Practitioner (CNP) #113 revealed she cared for Resident #312 at a previous facility before she was admitted to this nursing facility. CNP #113 confirmed Resident #312 was to continue her insulin orders upon admission. She verified Resident #312's previous HbA1c from July 2020 had been 7.5 and without her ordered diabetic medications her HbA1c was elevated at 10.9 on the 07/15/21 lab results. Review of facility policy titled, Administering Medication, dated April 2019, revealed medications were to be administered in a safe and timely manner and as prescribed. This deficiency substantiates Complaint Number OH 939.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's infection control policies and procedures, review of the facility's Coronavirus (Covid-19) timeline, observations, medical record review, and staff interview, the facility failed to isolate residents who tested positive for Covid-19 from the general population, implement appropriate isolation and quarantine procedures, and ensure proper use of personal protective equipment (PPE) to prevent the spread of Covid-19 within the facility. This resulted in Immediate Jeopardy on 10/16/20 when the facility identified two residents (Residents #13 and #14) who tested positive for Covid-19 and failed to separate the Covid-19 positive residents, quarantined residents and non-Covid-19 positive residents; did not provide dedicated staff to provide care to the residents who tested positive for Covid-19 virus or ensure staff properly donned and doffed PPE when moving from Covid-19 positive residents to quarantined residents or the general population residents. The lack of effective infection control practices placed all 36 residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failure to control the spread of Covid-19. The facility census was 36. The administrator in-training was notified on 10/20/20 at 2:08 P.M. that Immediate Jeopardy began on 10/16/20 when two residents tested positive for Covid-19 (Residents #13 and #14) and the facility failed to separate the Covid-19 positive residents, quarantined residents and non- Covid-19 positive residents; did not provide dedicated staff to provide care to the residents who tested positive for Covid-19 virus or ensure staff properly donned and doffed PPE when moving from Covid-19 positive residents to quarantined residents or the general population residents. The Immediate Jeopardy was removed on 10/21/20 at 3:00 P.M. when the facility implemented the following correction actions: · On 10/20/20 at 4:30 P.M., residents that tested positive for Covid-19 were placed in a designated Covid-19 unit within the facility with a physical barrier separating this unit from residents who have not tested positive for Covid-19 and from those who were quarantined for possible exposure to Covid-19. · On 10/20/20 at 11:00 P.M., all facility residents were tested for Covid-19 by the Director of Nursing using point of care (POC) testing. No new residents were positive for Covid-19. · On 10/20/20 at 11:41 P.M., all residents were assessed by Licensed Practical Nurse (LPN) #40, LPN #41, and Registered Nurse (RN) #46 for signs and symptoms of Covid-19 including a head to toe assessment. Symptoms assessed were the presence of a cough, shortness of breath, malaise and vital signs. No residents exhibited signs or symptoms of Covid-19. · On 10/21/20 at 7:00 A.M., designated staff was assigned to care for the residents who tested positive for Covid-19 and resided on the designated Covid-19 unit. The dedicated staff will continue to provide care to the Covid-19 positive residents until all residents have a negative Covid-19 test and the residents have been asymptomatic for Covid-19 for 10 days. · On 10/21/20 at 3:00 P.M., all facility staff were tested for Covid-19 by the DON using POC testing. Any employee not tested by would not be permitted to work until they have been tested and have negative results. · On 10/21/20 at 3:00 P.M., all facility employees were educated by the Administrator Regional Director of Operations, Licensed Social Worker, Human Resources Director, and the Regional Registered Nurse. The education included ensuring residents who tested positive for Covid-19 were placed in the designated Covid-19 unit separating them from residents who had not tested positive for Covid-19 and from those who were quarantined for possible exposure to Covid-19; designated employees to care for residents who tested positive for Covid-19; planning and delivering care for the residents from the healthiest to the sickest, and proper donning and doffing of PPE. Any employee not educated would not be permitted to work until they were educated. Said employees would be verbally educated via phone and documented by DON, Administrator Regional Director of Operations, Licensed Social Worker, or the Regional Registered Nurse. · All agency staff assigned to provide care to residents in the facility will be oriented to the facility and floor plan and informed of the designated Covid-19 positive unit, location of the residents quarantined and location of the non-positive Covid-19 residents. The agency staff will be educated on the same information as the facility staff at the beginning of their shift prior to performing their assigned duties or interacting with the residents by the DON, Administrator Regional Director of Operations, the Regional Registered Nurse or Charge Nurse. · Facility residents will be tested using POC by the DON on an on-going basis every three to seven days until no new cases are identified for a 14-day period. · The DON or Administrator Regional Director of Operations will monitor to ensure residents who have tested positive for Covid-19 are placed in the designated Covid-19 unit; a designated employee(s) provides care for residents who have tested positive for Covid-19 and who reside on the designated Covid-19 unit; employees deliver care for the residents from healthiest to the sickest; when exiting the room of a resident on quarantine, the employee properly doffs his/her PPE and dons new/clean PPE prior to entering the room of another resident on quarantine or another resident in the general population on a daily basis until there are no residents who have tested positive for Covid-19 for two consecutive weeks. · The Quality Assurance team including the Medical Director, Administrator, Assistant Director of Nursing (ADON), DON, Minimum Data Set (MDS) Registered Nurse, Interdisciplinary Team and all department managerial staff will review Covid-19 precautions initiated in the facility and appropriate monitoring practices to ensure ongoing compliance with federal and State requirements to ensure infection control practices to prevent the spread of Covid-19 in the facility at least monthly. · On 10/27/20 from 12:00 P.M. to 12:30 P.M. interviews with staff representing all shifts (LPN # 41, STNA #42, Agency STNA #56, and STNA #49 ) confirmed they received re-education on the facility ' s infection control policies and procedures. The staff were knowledgeable regarding infection control policies and procedures to prevent the spread of Covid-19 virus. Although the Immediate Jeopardy was removed on 10/21/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20 revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). An initial tour of the facility on 10/19/20 from 10:45 A.M. to 11:10 A.M. indicated the 100 hall had two residents (Resident #13, Resident #14) isolated with droplet isolation precautions for a positive Covid-19 [MEDICAL CONDITION] infection, eight residents (Resident #12, Resident #26, Resident #17, Resident #2, Resident #21, Resident #5, Resident #6, Resident #31) in quarantine with droplet isolation precautions for Covid-19 due to possible exposure and five residents (Resident #3, Resident #34, Resident #16, Resident #23, Resident #35) who had tested negative for Covid-19 [MEDICAL CONDITION] infection. Outside the resident rooms were signs which indicated the two residents with a positive Covid-19 [MEDICAL CONDITION] infection and residents in quarantine with droplet isolation precautions. There was no physical barrier to separate the five negative residents from the residents in isolation precautions. A review of the facility documentation of the Covid-19 resident testing completed on 10/16/20 indicated Resident #13 and Resident #14 had tested positive for Covid-19 virus. A review of Resident #13's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's physician order [REDACTED].#13 in droplet isolation precautions for 14 days (due to the COVID positive test). A review of Resident #14's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14's physician order [REDACTED]. Observations on 10/20/20 from 8:30 A.M. to 9:00 A.M. revealed LPN #41 administering medications to the residents on the 100 Hall. LPN #41 administered medications to Resident #17 who was quarantined with isolation precautions and then proceeded to administer medications to Resident #23 who was not quarantined or on isolation precautions. LPN #41 exited Resident #17's room and did not remove her outer surgical mask and don a new/unused surgical mask prior to entering Resident #23's room. LPN #41 did not wear eye protection or an isolation gown when in the room of Resident #17 who was in quarantine. LPN #41 continued to administer medications without moving from residents who tested negative for Covid-19 [MEDICAL CONDITION] infection to the residents quarantined to the residents who had a positive Covid-19 test (from the healthiest to the sickest) wearing the same surgical masks. An interview with LPN #41 on 10/20/20 at 9:25 A.M. indicated she started from one end of the 100 Hall to the other end of the 100 Hall when administering medications and confirmed she did not don a gown or eye protection prior to entering the residents quarantined in droplet isolation. LPN #41 indicated she did not discard the surgical mask covering the N95/KN95 surgical respirator and don a new/clean surgical mask covering the N95/K95 respirator prior to entering other residents ' rooms on the 100 Hall including the residents who tested negative for Covid-19. An observation of staff serving the lunch meal to the residents on the 100 Hall on 10/20/20 from 12:15 P.M. to 12:45 P.M. revealed the staff started at the one end of the hall and served the residents their lunch and continued moving down the 100 Hall from room to room in numerical order until reaching the end of the 100 Hall. STNA #42 entered multiple resident rooms (Resident #17, Resident #35, Resident #21, Resident #6) with isolation precautions who were quarantined for possible exposure to Covid-19 without donning a gown. STNA #42 did not discard her surgical mask covering the N95/KN95 surgical mask or goggles upon exiting the quarantined residents' rooms in droplet isolation precautions prior to entering other resident's rooms and serving the residents their meal who were quarantined and had tested non-positive for Covid-19. An interview with STNA #42 on 10/20/20 at 1:45 P.M. indicated she did not plan her care on the 100 Hall to assist with bathing the residents according to the healthiest to sickest. STNA #42 indicated she assisted the residents on the 100 Hall according to when the resident was ready for assistance and did not consider the resident ' s Covid-19 isolation/quarantine status when deciding which resident to assist next with their direct care needs. STNA #42 indicated she did not wear a gown when caring for the residents in isolation precautions who were quarantined due to possible exposure to Covid-19. STNA #42 indicated she did not change her outer surgical mask covering the N95/KN95 mask when exiting the room of a resident quarantined and on droplet isolation precautions due to possible exposure to Covid-19 A phone interview with Medical Director of the facility and Medical Director of Summit County (county the facility is in) on 10/20/20 at 11:26 A.M. and 11:35 A.M. respectively indicated they were informed by the facility of two residents who had tested positive in the facility on 10/16/20 on 10/20/20. Both Medical Directors indicated they advised the facility to follow the current State/Federal/CDC guidelines for the prevention and spread of Covid-19 in the facility. An interview with the Corporate Administrator on 10/20/20 at 1:30 P.M. indicated Resident #16 and Resident #23 tested positive for Covid-19 [MEDICAL CONDITION] infection on 10/16/20. The Corporate Administrator indicated she attempted to reach the Local Health Department on 10/16/20 and eventually spoke to the Medical Director of the local county earlier in the day on 10/20/20. The Medical Director for the local county informed the Corporate Administrator to follow the current State/Federal/CDC guidelines to prevent the spread of the Covid-19 virus to other residents in the facility. The Corporate Administrator indicated all staff in the facility were in-serviced on the appropriate use of PPE for care of the residents in isolation precautions on 10/16/20. On 10/21/20 at 5:55 A.M., an interview with Agency LPN #43 indicated she was unaware the facility had residents who tested positive for Covid-19 until she entered the facility. LPN #43 indicated she did not wear a gown when entering the residents' rooms who were quarantined with droplet isolation precautions when providing care or change her outer surgical mask covering her N95 respirator mask upon exiting the residents' rooms who were quarantined for Covid-19 in droplet isolation precautions. An interview with the Administrator Director of Operations on 10/21/20 at 10:15 A.M. revealed the DON was responsible for the infection control program in the facility. The Administrator Director of Operations indicated the DON was not a certified Infection Control Preventionist and indicated the facility did not have an Infection Control Preventionist to provide the duties as indicated in their emergency planning. A review of the facility staff in-service dated 10/16/20 for Current COVID testing protocols, notification, Covid-19 monitoring, quarantine, working clean to dirty revealed the facility was notified of a resident who was out to the hospital had tested positive for Covid-19 and two residents who resided in the facility had tested positive on 10/16/20. All staff and other residents had tested negative for the Covid-19 virus. There would be a designated Covid-19 unit and current Covid-19 positive residents would be isolated together. All current residents quarantined with droplet isolation precautions would continue with current Covid-19 precautions and monitoring. Residents would continue to be monitored for signs/symptoms of Covid-19 including malaise, vomiting, temperature, body aches, cough, shortness of breath, diarrhea, or any symptoms abnormal for the specific resident. Staff would continue to use proper PPE, universal precautions, hand washing and doffing PPE for Covid-19 positive residents and residents quarantined with droplet isolation precautions. All employees would discard the surgical mask covering the N95/KN95 respirator mask after each interaction with the positive tested Covid-19 residents and the quarantined residents in droplet isolation precautions. Staff would work from clean to dirty meaning care of the non-quarantined residents first and then residents who were quarantined and the Covid-19 positive residents would be cared for last. Review of National Institute for Occupational Safety and Health (NIOSH) Pandemic Planning, titled Recommended Guidance for Extended Use and Limited Re-Use of N95 Filtering Facepiece Respirators in Healthcare Settings, revealed discard N95 respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions. A review of the current CDC N95 guidance when there is no shortage of N95 mask indicated disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. The current CDC website for nursing home response indicated if the facility is experiencing a shortage of masks and can detail their efforts to obtain supplies they would then go into a reuse model. A review of the Interim infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID Pandemic) Infection Control Guidance dated 06/25/20 indicated to identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify health care personnel (HCP) who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, healthcare personnel (HCP) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (monitor closely, avoid placing unexposed residents into a shared space with them). Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 in Nursing Homes dated 04/30/20 indicated to: Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents are infected). · Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. · Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. · Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. · Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended personal protective equipment (PPE). Review of the facility's Infection Control Guidelines for all Nursing Procedures revised 08/2012 indicated general guidelines for Standard Precautions, Transmission-Based precautions and hand hygiene. The guidelines also indicated to wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted.

Based on record review and interview the facility failed to ensure Resident #4 and Resident #23 were free from abuse. Actual Harm occurred when Resident #4 and Resident #23 sustained injuries (bruising, pain) after being hit with a closed fist in the face by Resident #7. This affected two out of three residents investigated with allegations of physical abuse. The facility census was 36. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's clinical record indicated a plan of care to address his activity of daily living (ADL) needs revised on 09/03/19. The plan of care indicated Resident #4 had an ADL self care performance deficit related to limited mobility, pain, impaired balance, muscle weakness, and abnormality of gait (shuffled gait). Interventions on the plan of care indicated to provide a cane for ambulation and provide physical and occupational therapy services as ordered by the physician. Review of a nursing progress note dated 9/23/20 indicated Resident #4 alleged that another resident made contact with a closed hand to his nose causing him to fall and hit his head. Both residents were immediately separated. Neurological checks were initiated with vital signs within normal limits. Resident #4 was informed that if he felt uncomfortable with another resident to immediately notify the staff. Review of Resident #4's quarterly Minimum Data Set ((MDS) dated [DATE] indicated he needed supervision or touching assistance when ambulating 150 feet in the corridor or similar space and ambulating on an uneven/sloping surfaces. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #7's MDS assessment dated [DATE] indicated Resident #7 exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), rejection of care on one to three days during the review period. The MDS assessment indicated a care plan should be initiated to address the behavioral symptoms. Resident #7's MDS assessment dated [DATE] indicated an escalation of physical behavior directed toward others on four to six days during the review period. Resident #7 had no plan of care initiated to address his aggressive behaviors. A review of a Self Reported Incident (SRI) dated 09/23/20 indicated an allegation of physical abuse. On 09/23/20 at approximately 7:00 P.M. Resident #4 alleged Resident #7 made contact to his nose using a closed hand. Resident #7 was self propelling in a wheelchair and attempted to enter Resident #4's room. Resident #4 redirected Resident #7 out of his room and Resident #7 made contact with his nose. Staff separated the two residents and completed a head to toe assessment of Resident #4 with no injury found. Resident #7 was sent to the hospital for an evaluation and returned with no additional orders. Resident #7 was placed on one-on-one supervision upon return to the facility. The facility investigation completed on 09/23/20 indicated witness statements from Licensed Practical Nurse (LPN) #41 and State tested Nurse Aide (STNA) #49. LPN #41 indicated she heard yelling and went to investigate the cause. Resident #4 informed her that Resident #7 had punched him in the nose. Resident #4 indicated Resident #7 was staring at him when he passed by his room. Resident #4 asked him to stop staring and Resident #7 stood up out of his wheelchair and punched Resident #4 in the nose. The residents were separated and one-on-one supervision was initiated for Resident #7. STNA #49 indicated she heard Resident #4 yelling loudly while walking down the hallway towards the nursing station. Resident #4 informed her that Resident #7 had punched him in the nose. An interview with Resident #7 on 10/19/20 at 1:50 P.M. indicated he hit someone a while ago because the resident swung at him first. Resident #7 was unable to remember the exact details of the incident but did indicate the incident occurred in the facility with another resident. An interview with LPN #43 on 10/21/20 at 5:55 A.M. indicated the she was instructed to provide one-on-one supervision for Resident #7. LPN #43 indicated STNA #44 and herself were the only two staff working the overnight shift and it was impossible to provide the supervision needed for Resident #7 due to the staffing level. An interview with Resident #4 on 10/21/20 at 10:15 A.M. indicated a few weeks ago Resident #7 was independently propelling himself up and down the hallway. When Resident #7 passed his room he would stop and stare at Resident #4. Resident #4 indicated he felt uncomfortable with the way Resident #7 was staring at him and asked him to stop staring at him. Resident #7 stood up from his wheelchair and walked in his room and punched him in the middle of his forehead and knocked him off his chair and on to the floor. Resident #4 indicated he yelled for help and was very upset. Resident #4 indicated he filed a police report and was sent to the hospital. Resident #4 indicated he was evaluated at the hospital and a computerized tomography ( (CT) radiographic diagnostic test) of his head which was negative for bleeding or other abnormality. Resident #4 indicated he then returned to the facility and tried to stay away from Resident #7 and in his room most of the time. 2. Resident # 23 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #23's clinical record indicated a nursing progress note dated 09/28/20. The nursing progress not indicated Resident #23 was observed by an STNA in the middle of the 100 hallway sitting in her wheelchair blocking the hallway refusing to let a resident in room [ROOM NUMBER]-2 pass by in a wheelchair. Resident #23 was screaming at other residents stating no you can't get by and to go the other way. At this time the Resident Resident #7 propelled up to Resident #23 and punched her in the face without speaking a word. Staff immediately separated the residents and assisted each resident to safety. A skin assessment completed on Resident #23 noting swelling to nasal area as well as black and blue discoloration to nasal area, no other skin issues noted. Neurological checks were initiated and the DON was notified. The Medical Director was notified with an order to send Resident #23 to the hospital for an evaluation to rule out fractures. Resident #23's brother was notified and Emergency Medical Services (EMS) were called. The police and EMS arrived but Resident #23 refused to go to hospital for further evaluation. Resident #23 refused an ice pack application and Resident #23's brother was notified of Resident #23's refusal. The DON was aware and Medical Director indicated he would see Resident #23 on the next visit to the facility. A review of the SRI dated 09/29/20 indicated Resident #7 was self propelling himself down the hallway to return to his room where he resided. Another resident (Resident #23) was sitting in the middle of the same hallway and yelled at Resident #7 not to come down the hallway. Resident #7 became upset with the other resident (Resident #23) yelling at him and he hit her with a closed hand to her face. Both residents were immediately separated and assessed by the nurse for injury. Head to toe assessment was completed and at that time no apparent injuries were noted. Later that evening Resident #23 developed bruising to her eyes. The nurse on duty told her that she needed to go to the hospital for further evaluation due to the bruising and she declined. She initially declined ice to her face and then later allowed ice to be applied to her face. A police report was made. Social Service spoke to her on 09/29/20 and neurological checks were initiated by nursing with no visual or verbal signs of pain. The Nurse Practitioner and Resident #23's brother and his guardian were made aware of the incident. Resident #7 had a head to toe assessment completed with no apparent injury noted. He was immediately placed on one-on-one supervision. Resident #7 was sent to the hospital for an evaluation and was immediately sent back with no new orders. A review of the facility investigation indicated a written statement from STNA #56. STNA #56's statement indicated she witnessed the altercation between Resident #7 and Resident #23. STNA #56 indicated Resident #7 hit resident #23 in the face after Resident #7 yelled at him to change direction and go the other way. As Resident #7 passed Resident #23 in the hallway, Resident #7 hit Resident #23 in the face. An interview with Resident #7 on 10/19/20 at 1:50 P.M. indicated no memory of an incident with Resident #23. Resident #7 indicated he had recently hit Resident #4 but was unable to remember details of an altercation with Resident #23. An interview with Resident #23 on 10/19/20 at 1:55 P.M. indicated she had no memory of the incident with Resident #7. During the interview an observation revealed a quarter sized bruise beneath each of Resident #23's eyes. When asked how she sustained the bruises Resident #23 refused to discuss the incident. Resident #23 refused to answer additional questions and ended the interview. An interview on 10/19/20 at 2:10 P.M. with RN # 46 and RN #47 indicated Resident #7 had aggressive behaviors and had punched/hit multiple residents and staff. Both staff indicated Resident #7 entered other resident rooms uninvited and physically attacked them. Both RNs indicated Resident #7 needed one-on-one supervision which they were unable to provide due to the staffing level in the facility. Both staff indicated Resident #7 needed placement in an appropriate facility to manage his aggression and provide appropriate supervision to protect the other residents. The staff indicated many of the residents were unable to protect themselves and were vulnerable and the staff were unable to protect them from Resident #7's impulsive aggressive behaviors. The RNs indicated Resident #7 had recently punched Resident #23 and Resident #23 sustained a nose bleed and two black eyes during the incident. An interview with STNA #45 on 10/19/20 at 1:15 P.M. indicated Resident #7 punched her on the side of her face when she attempted to redirect him. STNA #45 indicated Resident #7 had punched many staff and residents since his admission to the facility approximately one month ago. An interview with STNA #48 on 10/20/20 at 4:45 A.M. indicated Resident #7 had punched her in the face when she attempted to redirect him from removing items from the medication cart. STNA #48 reported the incident to the DON. STNA #48 indicated she suffered a nose bleed, headache and bruised face. STNA #48 indicated Resident #7 did not belong with the general population of residents in the facility. STNA #48 indicated the residents were afraid of him and tried to stay in their room and away from Resident #7 when he was propelling himself independently in the facility. STNA #48 indicated the staff were unable to provide close supervision of Resident #7 to ensure the other residents were safe. An interview with Resident #33 on 10/20/20 at 5:45 A.M. indicated he was afraid of Resident #7 and tried to stay out of his way. Resident #33 indicated he had personally witnessed Resident #7 punch other residents and staff in the facility for no apparent reason. An interview with LPN #40 on 10/20/20 at 7:50 A.M. indicated she was aware Resident #7 had punched staff including the DON, STNA #45, Resident #7, and Resident #23 recently in the facility. LPN #40 indicated she observed bruising under Resident #23's eyes and was informed Resident #23 sustained the bruises during an altercation with Resident #7. LPN #40 indicated the staff were unable to provide one-on-one supervision when Resident #7 was out of his room to protect the other residents from his impulsive physical behaviors. A review of the facility policy and procedure Resident's Right To Freedom From Abuse, Neglect, And Exploitation (undated) indicated the facility's residents had the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in the policy. This includes, but was not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applied to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility (Associates). The facility Abuse Prevention Program dated 12/2016 indicated the policy was the residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Abuse was defined as the willful infliction of injury-, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This deficiency substantiates Complaint Number OH 490.

Based on record review, interview, review of the facility investigation and review of the facility abuse policy and procedure, the facility failed to implement their abuse policy and procedure related to a thorough investigation, protection and reporting an allegation of sexual abuse. This resulted in Immediate Jeopardy when Resident #150 was observed in Resident #201's bed, on top of the resident in a prone position with his pants down and his erect penis on Resident #201's incontinence brief with his hand on her inner thigh and was returned to his room without increased supervision. This failure had the potential for serious harm to occur to Resident #201 and three additional cognitively impaired female residents, Residents #9, #12 and #28. Facility census was 36. On 02/23/18 at 10:25 A.M. the Director of Nursing (DON) was notified Immediate Jeopardy began on 01/25/18 at 1:00 A.M. when Resident #150 was found on top of Resident #201 in a prone position with his pants down and his erect penis on Resident #201's incontinence brief with his hand on her thigh and the facility failed to implement their abuse policy and procedure related to reporting, thorough investigation, and protection. The Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M. when the facility implemented the following corrective actions: · On 02/14/18 all residents were interviewed by the Regional Vice President of Operations, Administrator, Business Office Manager (BOM) #412, Assistant Director of Nursing (ADON) #411, Licensed Social Worker (LSW) #408 and LSW #413 to determine if anyone had touched them without consent or had unwelcomed sexual contact. All residents reported no concerns. · On 02/14/18 Resident #150 was transferred to another facility. · On 02/14/18 The DON and ADON #411 started education for all staff members on abuse, neglect, misappropriation, and exploitation policies and procedures including the investigation and reporting of abuse. The Administrator indicated education would be provided to staff prior to their returning to work. · On 02/14/18 the facility initiated auditing by the Administrator or designee to include interviewing four residents per week for four weeks asking if anyone touched them sexually without consent or if they had any unwelcomed sexual contact. The Administrator or designee would tour the facility including all resident areas five times per week for four weeks to observe cognitively impaired residents to ensure they were free from signs or symptoms of abuse. The Administrator and/or designee would also interview at least one direct care staff member per week for four weeks to review observations and ensure freedom from abuse for all residents. The results of the audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) program. · Interviews on 02/15/18 from 4:15 P.M. to 4:25 P.M. with Registered Nurse (RN) #405, State tested Nursing Assistant (STNA) #404, Licensed Practical Nurse (LPN) #414, STNA #417, STNA #418, LSW #408, LSW #413 and Housekeeping Supervisor #416 confirmed the identified staff were educated on the facility abuse policy. Although the Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Interview on 02/14/18 at 10:42 A.M. with Resident #201's roommate, Resident #151, revealed she was concerned about an incident that occurred approximately two weeks ago that she felt should be investigated. Resident #151 said a male resident from across the hall came into her room during the night and tried to (expletive) her roommate. Resident #151 said Resident #150 was in between Resident #201's legs with his pants down and Resident #201's legs were spread and the resident was touching Resident #201's vaginal area. Review of Resident #201's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #201's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem and required extensive one person assist with bed mobility, dressing, eating, toilet use, personal hygiene and was a two-person extensive assist for transfers. Resident #201 was not care planned for sexual behaviors and there was no evidence in the medical record regarding a sexual encounter between Resident #150 and Resident #201. An attempt to interview Resident #201 on 02/14/18 at 11:36 A.M. was unsuccessful. Resident #201 did not respond to questions. She made eye contact but did not shake her head in response or use gestures. Resident #201 was seated in a specialized wheelchair with head support. Her hands were in her lap and she made no attempt to lift or move her arms or hands. Interview on 02/14/18 at 11:49 A.M. with Registered Nurse (RN) #403 revealed she reported sexual contact between Resident #150 and Resident #201 to the administrator. RN #403 indicated the administrator directed her to write a statement and wait to document in Resident #201's record until the facility determined if the sexual encounter was consensual. RN #403 said she observed Resident #201's incontinence brief was intact when she completed her assessment of the resident and there was no evidence of trauma. RN #401 indicated the physician and family had not been notified of the sexual contact. Interview on 02/15/18 at 8:28 A.M. with the Regional Vice President of Operations, Director of Nursing (DON) and administrator confirmed Resident #150 was found on top of Resident #201 in a prone position with his pants down and his erect penis on Resident #201 on 01/25/18. The facility determined the sexual encounter between Resident #150 and Resident #201 was consensual approximately five hours later when Resident #201 was interviewed by the DON. The Regional Vice President of Operations and the DON confirmed it had been reported by the state tested nurse aide (STNA), who found the residents, Resident #201 shook her head 'no' when asked if she wanted Resident #150's sexual advances. The Regional Vice President of Operations stated part of the puzzle was the STNA went into a darkened room and determined something was going on that was negative and startled the residents. It would not be unheard of that the resident was embarrassed and a shake of her head indicating 'no' could be perceived as something different. When the DON interviewed the resident approximately five hours after the incident, Resident #201 shook her head 'no' when asked if a man came into her room and bothered her, did anyone touch her private parts when she did not want touched, and if she was afraid of any man in the facility. The allegation of sexual abuse was not reported to the State agency, physician, family or other officials because they determined the sexual encounter was consensual. The DON and Regional Vice President of Operations confirmed Resident #150 was allowed to return to his room without increased supervision and, although they felt the sexual encounter was consensual, Resident #150 was moved to another hall the next day due to the perception of some of the staff and residents related to the incident. Resident #150 was discharged from the facility on 02/14/18 due to his desire to live in the city to which he was transferred. Interview on 02/15/18 at 9:42 A.M. with Resident #201's attending physician, Physician #409 revealed Resident #201 did not have the cognition to consent to a sexual relationship. The resident suffered a severe [MEDICAL CONDITION] and although she had made progress since the injury she lacked the capacity to consent. Physician #409 indicated he visited Resident #201 every month and he last evaluated her in (MONTH) (YEAR). Physician #409 indicated he was not notified of the sexual contact between Resident #150 and Resident #201 and if he had been notified the protocol would have been for staff to send the resident to the emergency room for evaluation. Review of the facility investigation revealed statements from RN #403, Licensed Practical Nurse #600, STNA #402, STNA #404, STNA #406, STNA #407, Resident #201 and Resident #150. There was not a statement from Resident #201's roommate or any other resident. Review of the facility Abuse policy dated (MONTH) 2008 indicated it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. The policy indicated the facility must immediately report all such allegations to the Administrator and the Administrator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. Reporting incidents of alleged or suspected abuse by other than staff members, were to be reported immediately to the police and facility security. In allegations of sexual abuse every effort would be made to preserve evidence on both the resident and the perpetrator, the resident and perpetrator wound not be bathed or cleaned, no oral care would be provided, both resident and perpetrator would be evaluated in emergency room , linens bagged and provided as evidence, if applicable, and police to be notified.

Based on record review, interview, review of the facility investigation and review of the facility abuse policy and procedure, the facility failed to immediately report an allegation of sexual abuse to the State agency and other officials in accordance with State law. This resulted in Immediate Jeopardy when Resident #150 was observed in Resident #201's bed, on top of the resident in a prone position with his pants down and his erect penis on Resident #201's incontinence brief with his hand on her inner thigh, and after receiving the report of the incident the administrator failed to complete the required reporting. This failure had the potential for serious harm to occur to Resident #201 and three additional cognitively impaired female residents, Residents #9, #12 and #28. Facility census was 36. On 02/23/18 at 10:25 A.M. the Director of Nursing (DON) was notified Immediate Jeopardy began on 01/25/18 at 1:00 A.M. when Resident #150 was found on top of Resident #201 in a prone position with his pants down and his erect penis on Resident #201's incontinence brief with his hand on her thigh and the facility did not immediately report to the State agency and other officials in accordance with State laws. The Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M. when the facility implemented the following corrective actions: · On 02/14/18 all residents were interviewed by the Regional Vice President of Operations, Administrator, Business Office Manager (BOM) #412, Assistant Director of Nursing (ADON) #411, Licensed Social Worker (LSW) #408 and LSW #413 to determine if anyone had touched them without consent or had unwelcome sexual contact. All residents reported no concerns. · On 02/14/18 Resident #150 was transferred to another facility. · On 02/14/18 The DON and ADON #411 started education for all staff members on abuse, neglect, misappropriation, and exploitation policies and procedures including the investigation and reporting of abuse. The Administrator indicated education would be provided to staff prior to their returning to work. · On 02/14/18 the facility initiated auditing by the Administrator or designee to include interviewing four residents per week for four weeks asking if anyone touched them sexually without consent or if they had any unwelcome sexual contact. The Administrator or designee would tour the facility including all resident areas five times per week for four weeks to observe cognitively impaired residents to ensure they were free from signs or symptoms of abuse. The Administrator and/or designee would also interview at least one direct care staff member per week for four weeks to review observations and ensure freedom from abuse for all residents. The results of the audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) program. · Interviews on 02/15/18 from 4:15 P.M. to 4:25 P.M. with Registered Nurse (RN) #405, State tested Nursing Assistant (STNA) #404, Licensed Practical Nurse (LPN) #414, STNA #417, STNA #418, LSW #408, LSW #413 and Housekeeping Supervisor #416 confirmed the identified staff were educated on the facility abuse policy. Although the Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Interview on 02/14/18 at 10:42 A.M. with Resident #201's roommate, Resident #151, revealed she was concerned about an incident that occurred approximately two weeks ago that she felt should be investigated. Resident #151 said a male resident from across the hall came into her room during the night and tried to (expletive) her roommate. Resident #151 said Resident #150 was in between Resident #201's legs with his pants down and Resident #201's legs were spread and the resident was touching Resident #201's vaginal area. Review of Resident #201's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #201's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem and required extensive one person assist with bed mobility, dressing, eating, toilet use, personal hygiene and was a two-person extensive assist for transfers. Resident #201 was not care planned for sexual behaviors and there was no evidence in the medical record regarding a sexual encounter between Resident #150 and Resident #201. An attempt to interview Resident #201 on 02/14/18 at 11:36 A.M. was unsuccessful. Resident #201 did not respond to questions. She made eye contact but did not shake her head in response or use gestures. Resident #201 was seated in a specialized wheelchair with head support. Her hands were in her lap and she made no attempt to lift or move her arms or hands. Interview on 02/14/18 at 11:49 A.M. with Registered Nurse (RN) #403 revealed she reported sexual contact between Resident #150 and Resident #201 to the administrator. RN #403 indicated the administrator directed her to write a statement and wait to document in Resident #201's record until the facility determined if the sexual encounter was consensual. RN #403 said she observed Resident #201's incontinence brief was intact when she completed her assessment of the resident and there was no evidence of trauma. RN #401 indicated the physician and family had not been notified of the sexual contact. Interview on 02/15/18 at 8:28 A.M. with the Regional Vice President of Operations, Director of Nursing (DON) and administrator confirmed Resident #150 was found on top of Resident #201 in a prone position with his pants down and his erect penis on Resident #201 on 01/25/18. The facility determined the sexual encounter between Resident #150 and Resident #201 was consensual approximately five hours later when Resident #201 was interviewed by the DON. The Regional Vice President of Operations and the DON confirmed it had been reported by the state tested nurse aide (STNA), who found the residents, Resident #201 shook her head 'no' when asked if she wanted Resident #150's sexual advances. The Regional Vice President of Operations stated part of the puzzle was the STNA went into a darkened room and determined something was going on that was negative and startled the residents. It would not be unheard of that the resident was embarrassed and a shake of her head indicating 'no' could be perceived as something different. When the DON interviewed the resident approximately five hours after the incident, Resident #201 shook her head 'no' when asked if a man came into her room and bothered her, did anyone touch her private parts when she did not want touched, and if she was afraid of any man in the facility. The allegation of sexual abuse was not reported to the State agency, physician, family or other officials because they determined the sexual encounter was consensual. Interview on 02/15/18 at 9:42 A.M. with Resident #201's attending physician, Physician #409 revealed Resident #201 did not have the cognition to consent to a sexual relationship. The resident suffered a severe [MEDICAL CONDITION] and although she had made progress since the injury she lacked the capacity to consent. Physician #409 indicated he visited Resident #201 every month and he last evaluated her in (MONTH) (YEAR). Physician #409 indicated he was not notified of the sexual contact between Resident #150 and Resident #201. Review of the facility Abuse policy dated (MONTH) 2008 indicated it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. The policy indicated the facility must immediately report all such allegations to the Administrator and the Administrator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy.

Based on medical record review, staff, resident and attending physician interview, review of staff statements, and review of the facility's abuse policy, the facility failed to protect one cognitively impaired resident (Resident #201) from sexual abuse. This resulted in Immediate Jeopardy and the potential for serious harm when Resident #150 was observed in Resident #201's bed, on top of the resident in a prone position with his pants down and his erect penis on Resident #201's incontinence brief with his hand on her inner thigh. This affected Resident #201, and had the potential to affect three additional cognitively impaired female residents (Residents #9, #12 and #28) who resided in the facility. The facility census was 36. In addition, the facility failed to ensure Residents #17 and #33 were free of physical abuse from Resident #19 which had the potential for more than minimal harm that did not rise to the level of Immediate Jeopardy. This affected two of three residents reviewed for abuse. On 02/14/18 at 2:50 P.M. the Administrator, Regional Vice President of Operations, Director of Nursing (DON) and Assistant Director of Nursing (ADON) #411 were notified Immediate Jeopardy began on 01/25/18 at 1:00 A.M. when Resident #150 was found on top of Resident #201 in a prone position with his pants down and his erect penis on Resident #201's incontinence brief and his hand on her inner thigh. The Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M. when the facility implemented the following corrective actions: · On 02/14/18 all residents were interviewed by the Regional Vice President of Operations, Administrator, Business Office Manager (BOM) #412, ADON #411, Licensed Social Worker (LSW) #408 and LSW #413 to determine if anyone had touched them without consent or had unwelcomed sexual contact. All residents reported no concerns. · On 02/14/18 Resident #150 was transferred to another facility. · On 02/14/18 The DON and ADON #411 started education for all staff members on abuse, neglect, misappropriation, and exploitation policies and procedures including the investigation and reporting of abuse. The Administrator indicated education would be provided to staff prior to their returning to work. · On 02/14/18 the facility initiated auditing by the Administrator or designee to include interviewing four residents per week for four weeks asking if anyone touched them sexually without consent or if they had any unwelcomed sexual contact. The Administrator or designee would tour the facility including all resident areas five times per week for four weeks to observe cognitively impaired residents to ensure they were free from signs or symptoms of abuse. The Administrator and/or designee would also interview at least one direct care staff member per week for four weeks to review observations and ensure freedom from abuse for all residents. The results of the audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) program. · Interviews on 02/15/18 from 4:15 P.M. to 4:25 P.M. with Registered Nurse (RN) #405, State tested Nursing Assistant (STNA) #404, Licensed Practical Nurse (LPN) #414, STNA #417, STNA #418, LSW #408, LSW #413 and Housekeeping Supervisor #416 confirmed the identified staff were educated on the facility abuse policy. Although the Immediate Jeopardy was removed on 02/15/18 at 4:10 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Interview on 02/14/18 at 10:42 A.M. with Resident #151, Resident #201's roommate, revealed she was concerned about an incident that occurred approximately two weeks ago that she felt should be investigated. Resident #151 said a male resident from across the hall came into her room during the night and tried to (expletive) her roommate. Resident #151 said Resident #150 was in between Resident #201's legs with his pants down and Resident #201's legs were spread apart and the resident was touching Resident #201's vaginal area. Review of Resident #201's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #201's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem and required extensive one person assist with bed mobility, dressing, eating, toilet use, personal hygiene and was a two-person extensive assist for transfers. Resident #201 was not care planned for sexual behaviors. There was no evidence in the medical record regarding a sexual encounter between Resident #150 and Resident #201. Review of a physician progress notes [REDACTED].#201 was alert and oriented to self and uncertain about place or time. The resident made eye contact but it was hard to test the resident's cognition. The note indicated Resident #201 had a [DIAGNOSES REDACTED]. Review of a physician progress notes [REDACTED].#201 was alert, pleasant with no signs or symptoms of mania, hypomania, delusions, hallucinations, paranoia or depression. The note indicated Resident #201 had dementia secondary to head trauma with a status [REDACTED]. Review of Resident #201's Speech Therapy Evaluation for the certification period of 01/31/18 to 03/01/18 revealed the resident's cognitive-communicative skills were impaired. Review of Resident #150's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #150's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition for decisions of daily living. Resident #150 was not care planned for sexual behaviors and there was no evidence in the medical record regarding a sexual encounter between Resident #150 and Resident #201. Review of a witness statement dated 01/18/18 authored by STNA #404 revealed it was lunch time and the STNA had just finished feeding Resident #201 in the dining room and was getting ready to take the resident back to the front common area. As Resident #201 was transported, Resident #150 put his hand on Resident #201's thigh. Resident #201 kind of moved Resident #150's hand away and STNA #404 instructed Resident #150 not to do that. Resident #150 said okay, okay I'm sorry I won't do it again. Review of a witness statement dated 01/25/18, authored by STNA #402, revealed Resident #150 was observed in Resident #201's bed on top of Resident #201 (no time provided). Resident #150 was in a missionary style sexual position with his pants down and his erect penis on Resident #201's yellow brief. Resident #150's left hand was placed on Resident #201's inner thigh going into the resident's incontinence brief. Resident #201's roommate (Resident#151) was awakened by the incident and observed Resident #150 on top of Resident #201. Resident #150 pulled up his pants, returned to his wheelchair and wheeled out of room. Resident #201 was asked if she gave permission for the sexual contact with Resident #150 and she shook her head no. The witness statement indicated the nurse notified the administrator of the incident immediately. Review of a witness statement dated 01/25/18, authored by RN #403 who worked the 7:00 P.M. to 7:00 A.M. shift, revealed a STNA called for the nurse to come to Resident #201's room and called out he is on top of her (no time provided). RN #403 entered Resident #201's room and observed Resident #150 sitting on the side of the resident's bed with his incontinence brief down. The STNA reported she observed Resident #150 on top of Resident #201 trying to open her legs and moving up and down over the top of her incontinence brief. Resident #201's incontinence brief was closed and no marks were observed during the head to toe assessment. The STNA asked Resident #201 if she wanted Resident #150 in her room and Resident #201 shook her head no. The ADON and Administrator were notified and a message was left for the DON. An attempt to interview Resident #201 on 02/14/18 at 11:36 A.M. was unsuccessful. Resident #201 did not respond to questions. She made eye contact but did not shake her head in response or use gestures. Resident #201 was seated in a specialized wheelchair with head support. Her hands were in her lap and she made no attempt to lift or move her arms or hands. Interview on 02/14/18 at 11:49 A.M. with RN #403 revealed she reported the sexual contact between Resident #150 and Resident #201 to the administrator. RN #403 indicated the administrator directed her to write a statement and wait to document in Resident #201's record until the facility determined if the sexual encounter was consensual. RN #403 said she observed Resident #201's incontinence brief was intact when she completed her assessment of the resident and there was no evidence of trauma. RN #401 indicated the physician and family had not been notified of the sexual contact. Interview on 02/14/18 at 12:00 P.M. with Resident #150 revealed he was alert and oriented. He confirmed he went into Resident #201's room but denied getting into bed with the resident or touching the resident in an inappropriate manner. Interview on 02/15/18 at 8:14 A.M. with LSW #408 verified Resident #201 had severe cognitive impairment according to the facility comprehensive assessment which she herself had completed. LSW #408 said she had not talked to Resident #201 or Resident #150 about sexuality prior to or after the sexual contact on 01/25/18. LSW #48 did not think Resident #201 had the cognitive ability to consent to a sexual relationship but she had not completed an evaluation of the resident's capacity to consent. LSW #48 was not aware of the residents having a consensual sexual relationship prior to the incident; however, she had observed Resident #201 holding hands with several male residents while seated in the common areas watching television. Interview on 02/15/18 at 8:28 A.M. with the Regional Vice President of Operations, DON and administrator revealed the facility determined the sexual encounter between Resident #150 and Resident #201 was consensual. Regional Vice President of Operations stated part of the puzzle was the STNA went into a darkened room and determined something was going on that was negative and startled the residents. It would not be unheard of that the resident was embarrassed and a shake of her head indicating 'no' could be perceived as something different. When the DON interviewed the resident approximately five hours after the incident, Resident #201 shook her head 'no' when asked if she had unwanted sexual contact. Interview on 02/15/18 at 9:42 A.M. with Resident #201's attending physician, Physician #409 revealed Resident #201 did not have the cognition to consent to a sexual relationship. The resident suffered a severe [MEDICAL CONDITION] and although she had made progress since the injury she lacked the capacity to consent. Physician #409 indicated he visited Resident #201 every month and he last evaluated her in (MONTH) (YEAR). Physician #409 indicated he was not notified of the sexual contact between Resident #150 and Resident #201 and if he had been notified he would have directed staff to send the resident to the emergency room for evaluation. Interview on 02/15/18 at 10:06 A.M. with Licensed Speech Therapist (LST) #410 revealed she had been working with Resident #201 for several months. LST #410 indicated Resident #201 communicated with headshakes, gestures and/or facial expressions. LST #410 indicated Resident #201 had cognitive impairment. During therapy sessions Resident #201 accurately followed one and two step commands. A follow up interview on 02/15/18 at 10:17 A.M. with RN #403 indicated she was a new hire and 01/25/18 was her first day working independently. She was not sure of the time but thought it may have been around 1:00 A.M. when an STNA called her into Resident #201's room. Upon entering the room, the lights were on and she observed Resident #150 sitting on the side of Resident #201's bed with his incontinence brief around his ankles. When spoken to Resident #150 did not make eye contact, his head was down. Resident #201 was wearing a gown and two incontinence briefs; she was lying on her back with no covers. RN #403 said she asked Resident #201 if the sexual contact was consensual and the resident did not respond. RN #403 indicated she turned her back to walk out of the room and the STNA indicated the resident shook her head 'no' although RN #403 did not witness this. Resident #150 had exited the room at this point. RN #403 indicated she contacted ADON #411 and was directed to complete a head to toe assessment and was told Resident #150 and Resident #201 might have had an established relationship but ADON #411 would talk to the DON about it. RN #403 indicated because of the gravity of the incident she also contacted the administrator. She was instructed by the administrator to write a witness statement but not document the incident in the record because the encounter may have been consensual. A second attempt to interview Resident #201 on 02/15/18 at 10:46 A.M. was successful. Resident #201 was asked to respond with a gesture of thumbs up for yes and gesture of a thumbs down for no and then demonstrated understanding by giving the thumbs up when asked how she would answer yes and the thumbs down when asked how she would respond no. When asked if she was comfortable living in the facility she responded with a thumbs up, when asked if she had any unwanted contact with another resident she responded with a thumbs down. When asked if she had a boyfriend she gave a thumbs down. When asked if she was having sexual relations with anyone she gave a thumbs down. When asked to identify the current season by giving a thumbs up when the correct season was verbalized she gave a thumbs down for winter and summer and a thumbs up for fall. When asked to do the same for the current year she gave a thumbs down for (YEAR) and thumbs up for (YEAR). Interview on 02/15/18 at 11:08 A.M. with ADON #411 indicated she received a call from RN #403 indicating Resident #150 was in Resident #201's bed with his pants down and his penis on top of Resident #201's incontinence brief. ADON #411 instructed RN #403 to complete a head to toe assessment and ensure the safety of all residents. She also instructed RN #403 she would be receiving a call from the administrator with further direction. ADON #411 indicated after speaking with RN #403 she immediately called the administrator to relay the facts. ADON #411 denied that she told RN #403 the encounter could have been consensual or that the two residents may have had an established relationship. ADON #411 was not sure of the timing of the phone calls but thought it may have been around 3:30 A.M. A follow up interview on 02/15/18 at 11:35 A.M with Resident #201's roommate, Resident #151 revealed she was awakened by the STNA telling Resident #150 to get out of Resident #201's bed. She sat upright in the bed and observed Resident #150 with his pants around his ankles and his (penis) hanging out. She said she clearly saw Resident #150, there was light coming in from the hallway and the window and her view was unobstructed. I can even tell you his pants were grey. Resident #150 could not provide a specific time of the incident. Two attempts to contact STNA #404 by phone on 12/14/18 and one attempt on 12/15/18 were unsuccessful. Review of the facility Abuse policy dated (MONTH) 2008 indicated abuse included sexual abuse and sexual abuse was defined as but not limited to non-consensual sexual contact of any type, sexual harassment, sexual coercion or sexual assault. 2. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Further review of the medical record revealed there was not a specific behavioral care plan with interventions for management of inappropriate behaviors; however, there was a Psychiatric Medication Care Plan dated 01/05/18. Review of this Psychiatric care plan revealed no specific interventions for behaviors including monitoring and supervision. Review of a progress note dated 02/01/18 at 9:25 A.M. revealed Resident #19 was to be sent to the emergency room for a psychiatric evaluation after a physical altercation with another resident. Interview on 02/14/18 at 9:50 A.M. with Resident #19 regarding the 02/01/18 altercation revealed the other resident was calling her names and she could not take it any longer so she hit the resident. Review of a Self-Reported Incident (SRI) investigation for physical abuse dated 02/01/18 revealed Resident #33 and Resident #19 got into an argument in the dining room which escalated to both residents attempting to hit each other. Resident #33 had a small scratch on his nose and no other injuries were noted. Resident #33 alleged that during the altercation, Resident #19 hit him in the nose. Resident #19 admitted to hitting Resident #33. The allegation of physical abuse was substantiated. Review of Resident #19's progress note dated 02/05/18 at 4:27 P.M. revealed the resident was standing at the nursing station when another resident stated the resident was a fat pig. Resident #19 was shouting back at him and the other resident continued name calling. Resident #19 went up to the other resident and hit him in the head and scratched his face. The DON pulled Resident #19 from the other resident and the ambulance was called to pick Resident #19 up for a psychiatric evaluation. Interview on 02/14/18 at 9:50 A.M. with Resident #19 revealed the resident could not recall information related to the incident which occurred on 02/05/18. Review of SRI investigation for physical abuse dated 02/05/18 revealed Resident #19 was standing at the nursing station and Resident #17 was calling the resident a fat pig. Resident #19 shouted back and Resident #17 continued to call the resident names. Resident #19 went up to Resident #17 and hit him in the head and scratched his face. The DON separated the residents and the ambulance was called to pick up Resident #19 for a psychiatric evaluation. The allegation was substantiated. Interview on 02/14/18 at 10:01 A.M. with the DON verified the resident to resident abuse between Resident #19 and Resident #17 occurred and therefore the SRIs were substantiated.

Based on clinical record review, observations and staff interviews, the facility failed to provide a safe environment, free of burn hazards, for one resident (#2) when her low-bed was placed next to a baseboard heater. This resulted in Immediate Jeopardy for one (#2) of seven cognitively impaired residents with low beds when Resident #2 sustained third-degree burns to both feet. The facility census was 40 residents. On 09/05/12 at 5:15 P.M., the administrator and director of nursing (DON) were notified that Immediate Jeopardy began on 08/11/12 at 5:00 A.M. when the facility staff found Resident #2 with both feet off the side of the bed and resting on the baseboard heater next to her bed. Blood was observed on the resident's toes. The DON said she was notified by the hospital on [DATE] at approximately 11:00 A.M. that the resident sustained [REDACTED]. The Immediate Jeopardy was removed on 08/15/12 when the facility implemented the following actions: - On 08/11/12, the administrator and (DON) instructed staff to check all beds in the facility to ensure they were positioned a safe distance away from the baseboard heaters and to assure the heat was turned off. The administrator and DON monitored to ensure this directive was implemented. - On 08/11/12, the facility placed strips of tape on the floors by all resident beds next to the baseboard heaters to indicate the beds were kept a safe distance from the heater, and assured the bed wheels were locked. - On 08/11/12, all residents (20) whose beds were next to the baseboard heaters were assessed regarding cognition, mobility of the resident, and placement of their beds to ensure safety. - On 08/11/12 the facility began inservices for all staff about the safe distance of the beds from baseboard heaters. The inservices were completed on 08/15/12 for 25 state tested nursing assistants (STNA), four registered nurses (RN), 15 licensed practical nurses (LPN), 17 dietary staff, six housekeeping and maintenance staff, and 16 ancillary staff. - On 08/11/12 the facility began daily auditing rounds (on each shift), for the placement of all beds, which were reviewed by the surveyor on 08/20/12. - On 08/15/12, locked thermostat boxes were installed in each resident room to ensure that the heat could not be regulated by the residents without staff intervention. Although the Immediate Jeopardy was removed when the facility established systems to ensure the resident's beds were in a safe position in the room away from the baseboard heater, and the residents could not access the thermostat controls, the facility remained out of compliance at severity level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility planned to install a new heating unit for Resident #2's room; however, the unit was not scheduled for installation until 09/06/12. Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment, dated 07/25/12, revealed she had severely impaired cognition; was totally dependent with the assistance of one staff person for her bed mobility; and was dependent on staff for all care needs. According to the ADL Functional/Restorative Assessment completed on 07/25/12, Resident #2 was a high risk for falls. A care plan entry dated 05/18/12, indicated the resident's bed was to be against the wall away from the window. The plan of care was last updated on 07/25/12, and indicated the resident used a low bed with floor mats beside the bed, and bolsters by her sides. This care plan also indicated the resident had impaired cognition and decision making, requiring re-orientation and reminders. The resident was dependent on staff for all care, required turning and repositioning every two to three hours, incontinence care, and used a wheelchair to move about the facility. Nursing notes written by Registered Nurse (RN) #10, dated 08/11/12 at 5:00 A.M., identified Resident #2 was found with her legs off the bed and by the wall. State tested Nursing Assistant (STNA) #14 was called to the room to help reposition the resident. When the bed was pulled out from the wall the resident's feet were found resting on the top of the baseboard heater and she had blood on her toes. Both of her legs were placed back on the bed and cool compresses were applied. Both feet were hot and blistered. There were no measurements or any further description of the blisters on the resident's feet. According to this nursing note, the physician was notified and ordered a treatment of [REDACTED]. According to RN #10's nursing note dated 08/11/12 at 5:00 A.M., she rechecked the resident after talking to the physician on 08/11/12, and noticed a border to the blister on the right lateral side of the foot which was dark red. There were no measurements or further description of the blisters observed on this resident's feet in this nursing note. The physician was again notified and ordered an oral antibiotic twice a day for 10 days; laboratory work (complete blood count and basic metabolic panel) to be drawn; keep the resident's feet moist; and staff were to inform him of changes. The family was notified as well. The resident's bed was moved to the opposite wall away from the window and baseboard heater. The note identified the resident was to be transferred with a mechanical lift until her feet were healed. On 08/12/12 at 11:23 A.M., Licensed Practical Nurse (LPN) #11 documented in the nursing notes that she changed the dressings on Resident #2's feet, and the blisters were still intact but with some drainage. Some of the dressings were saturated with clear drainage. The laboratory results were also called to the physician on 08/12/12; no new orders given by the physician. On 08/13/12 at 12:20 P.M., LPN #13 documented that RN #18, who was the wound nurse from an outside agency, observed the resident's feet and recommended Resident #2 to be seen in the emergency room /burn unit. According to RN #18's Wound Treatment Orders, dated 08/13/12, the resident's right foot (plantar) had a full thickness burn with an intact fluid filled blister and a moderate amount of thin clear exudate. The wound measured 14.50 centimeters (cm) in length by 14.50 cm in width. The resident's left foot (plantar) had a full thickness burn with an intact fluid filled blister and a moderate amount of thin clear exudate. The wound measured 15.00 cm in length by 11.00 cm in width. Telephone orders written by the wound nurse on 08/13/12 included cleansing the feet with normal saline; applying a topical treatment; wrapping and keeping the feet from resting on the wound bed; and contacting the physician for evaluation at the emergency room /burn unit. On 08/13/12, the resident was transported to the emergency room /burn unit as ordered by the physician. Interview with the DON on 08/20/12 at approximately 11:00 A.M., revealed Resident #2 was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. The resident remained hospitalized as of 08/21/12. Further interview with the DON on 08/21/12 at 1:00 P.M., confirmed Resident #2's care plan indicated the resident's bed was to be placed away from the window due to the resident previously injuring her toe on the window on 05/18/12, causing the right nail to become detached from the nail bed. She said the resident's bed was away from the window for some time, but she did not know when or why it was placed back by the window as discovered on 08/11/12. Further interview with the administrator and DON on 08/20/12 at 11:15 A.M., revealed Resident #2's roommate (Resident #3) was interviewed and said she was cold and turned the heat up in the room on the night of the incident. On 08/21/12 at 11:30 A.M., interview with RN #10 revealed she observed Resident #2's feet resting on the baseboard heater by her bed. The resident's right foot was lying directly over the baseboard heater with her left foot resting on top of the right foot. The left big toe and the ball of her left foot near the big toe were touching the baseboard heater. Her right foot was on the baseboard heater from the heel to the little toe to the big toe. One large "water blister" was observed on the right foot and both feet were red. The left foot blister was open. The physician was notified immediately and treatment was ordered. Upon rechecking the feet, the water blister on the right foot was observed to have a dark red tint/opaque border. The physician was notified immediately of the new finding, and ordered an antibiotic and lab work. RN #10 said she was not aware the care plan indicated Resident #2's bed was not to be placed next to the window. On 08/21/12 at 11:55 A.M., interview with STNA #15 revealed she made rounds on Resident #2 at 1:00 A.M., 3:00 A.M., and 5:00 A.M., when the nurse called her to the resident's room. She said RN #10 and STNA #14 had already pulled Resident #2 up in bed and repositioned her. The resident was able to move her legs and displayed no signs or symptoms of pain. The resident's bed was in a low position, locked and parallel to the window above the baseboard heater. She said she did not notice that the baseboard heater was on. She said the resident was to be checked every 2 hours. STNA #15 said she was not aware of care plan indicated Resident #2's bed was not to be placed next to the window. On 08/20/12 at 3:45 P.M., an environmental tour was conducted with the administrator. Tape strips were observed in place by all beds that were near the baseboard heaters. The beds did not cross over the tape strips to ensure a safe distance from the baseboard heaters, which were only located beneath the window near bed 2 in the rooms. Some beds were placed perpendicular to the wall by the window with the feet facing toward the door. Locked boxes were observed in place over all thermostats in all rooms. The surveyor observed these measures remained in place on 08/21/12. Interview with the administrator on 08/24/12 at 1:25 P.M., revealed he did not have any printed manufacturer's specifications or recommendations for the baseboard heaters. The administrator revealed that according to information he received by phone from the manufacturer, the baseboard heaters could reach temperatures up to 160-165 degrees Fahrenheit. This deficiency substantiates Complaint Number OH 820.