Every finding on record at Lakeridge Villa Health Care Center

Based on medical record review, resident interview, observation, staff interview, review of the facility policy review, the facility failed to ensure residents were able to have private phone conversations. This affected two (Residents #5 and #83) of 18 residents sampled for communication. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident # 5 revealed an admitted [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), morbid obesity, type two diabetes, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 01/03/25 revealed the resident had moderately impaired cognition. 2. Review of the medical record for Resident # 83 revealed an admitted [DATE] with diagnoses including quadriplegia, incomplete paraplegia, neuromuscular dysfunction of the bladder, adjustments disorder with mixed anxiety and depressed mood, and osteomyelitis. Review of the MDS assessment for Resident #83 dated 11/27/24 revealed the resident was cognitively intact. Interview on 03/03/25 at 10:17 A.M. with Resident #83 confirmed he did not have a phone in his room or a cell phone and had to make all phone calls using the phone at the nurses' station. Resident #83 confirmed using the phone at the nurses' station made him very uncomfortable because there was no privacy, and everyone around could hear his conversation. Interview on 03/03/25 at 2:07 P.M. with Resident #5 confirmed she was unable to have a private conversation on the phone because she had to use the phone at the nurses' station. Resident #5 stated she had reported to staff that this made her very uncomfortable, but nurses told the phone at the nurses' station was the only phone available to the residents. Observation 03/05/25 at 3:43 P.M. revealed the first-floor nurses' station had one telephone at the corner of the station sitting on a ledge that was approximately waist high. Licensed Practical Nurses (LPNs) #38 and #39 were seated behind the nurses' station. Interview on 03/05/25 at 3:44 P.M. with LPNs #38 and #39 confirmed the phone in the first-floor nurses' station was the only phone available to staff and residents at the station. LPN #38 and #39 confirmed when residents were making telephone calls from the phone at the nurses' station, they could hear details of the residents' phone conversations. Further interview confirmed if the situation were reversed, they would not feel comfortable making personal calls from the phone at the nurses' station. LPNs #38 and #39 confirmed they had received complaints from multiple residents including Residents #5 and #83 regarding lack of privacy during telephone conversations. Observation on 03/06/25 at 11:10 A.M. revealed Resident #5 was sitting in front of the nurses' station talking on the facility phone with two nurses and multiple residents nearby. Resident #5 was easily overheard vocalizing her feelings about her day and care received. Review of policy titled Dignity dated February 2021 revealed staff promoted, maintained, and protected resident privacy.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident representatives of a change in condition. This affected one (Resident #87) of two residents reviewed for change in condition. The facility census was 90 residents. Findings include: Review of the closed medical record for Resident #87 revealed an admitted [DATE] with diagnoses including Parkinson's Disease, dementia without behavioral disturbance, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/07/24 revealed the resident #87 had severely impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #87 dated 01/05/25 revealed the resident had remained in bed for the last two days, refused food, and had minimal fluid intake. The note did not include documentation the resident's guardian had been informed of the change in condition. Interview on 03/06/25 at 11:04 A.M. with the Director of Nursing (DON) confirmed the facility staff had discussed a hospice referral for Resident #87 due to the resident's change in condition, but they did not feel Resident #87 was appropriate yet. The DON confirmed the facility's plan was to obtain labs, but then the resident declined rapidly and passed away. The DON confirmed there was no documentation of notification to Resident #87's guardian regarding the resident's change in condition. Review of the policy titled Change in a Resident's Condition or Status revised February 2021 revealed the facility would promptly notify the resident's representative of changes in the resident's medical condition or status.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility staff failed to ensure the accuracy of comprehensive resident assessments. This affected one (Resident #55) of four residents reviewed for comprehensive assessments. The facility had a census of 90 residents. Findings include: Review of the medical record for Resident #55 revealed an admitted [DATE] with diagnoses including end stage renal disease, diabetes, and chronic pulmonary obstructive disease (COPD) Review of the Minimum Data Set (MDS) assessment for Resident #55 dated 01/23/25 revealed the resident required substantial to maximum assistance with toileting, bathing, and upper and lower body dressing. Interview on 03/03/25 at 4:30 P.M. with Resident #55 confirmed he was independent with toileting, bathing, and dressing. Resident #55 further confirmed he had experienced occasional episodes of weakness and fatigue following dialysis and the staff monitored showers if taken after dialysis but never provided hands-on care. Interview on 03/03/25 at 4:35 P.M with Certified Nursing Assistant (CNA) #16 confirmed Resident #55 was independent with toileting, bathing, and dressing. Interview 03/03/25 at 4:52 P.M. with Licensed Practical Nurse (LPN) #38 confirmed Resident #55 was independent with toileting, bathing and dressing and had been so siince admission on 08/20/24. LPN #38 further confirmed Resident #55's MDS dated [DATE] was not accurate regarding the resident's functional status and abilities. Review of the facility policy titled Resident Assessments dated March 2022 revealed all persons who had completed any portion of the MDS must sign a form attesting to the accuracy of the information.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to appropriately revise care plans. This affected one (Resident #85) of three residents sampled for smoking. The facility census was 90 residents. Findings include: Review of the medical record for Resident # 85 revealed an admitted [DATE] with diagnoses including rheumatoid arthritis, unspecified mental disorder, and cognitive communication deficit. Review of the smoking safety evaluation for Resident #85 dated 01/09/25 revealed the resident was able to hold, light, and extinguish a cigarette safely. Review of care plan for Resident #85 dated 01/15/25 revealed the resident had a potential for injury related to smoking cigarettes. Interventions included the following: complete smoking assessments quarterly and with significant change, observe clothing daily for burn holes, secure cigarettes and lighters at the nurses' station, staff to check room regularly for cigarettes and lighters. Review of smoking safety evaluation for Resident #85 dated 01/15/25 revealed the resident had balance problems, had limited range of motion in arms/hands, and followed the facility's smoking policy. Observation on 03/03/25 at 11:16 A.M. revealed Resident #85 had a box of menthol in the pocket of his jacket hanging in his room. Interview on 03/03/25 at 11:17 A.M. with Resident #85 confirmed he was an independent smoker and was permitted to keep his cigarettes and lighter in his coat pocket and could go out to smoke anytime he wanted to do so. Interview on 03/05/25 at 11:19 AM with the Administrator confirmed residents who were deemed safe were permitted to keep smoking supplies on their person and in their rooms, unless otherwise care planned. Interview on 03/05/25 at 12:02 P.M. with the Director of Nursing (DON) confirmed the former Administrator wanted all resident smoking supplies to be kept at the in the nurses' station regardless of the resident's ability to safely smoke independently. The DON confirmed Resident # 85 was independent with smoking and was able to keep his smoking supplies in his room. The DON further confirmed Resident #85's care plan had not been updated to reflect the new policy that independent smokers were able to keep smoking supplies in their rooms. Review of the facility policy titled Smoking undated revealed residents who were deemed unsafe were not permitted to hold smoking materials on their person or in their room. Review of the facility policy titled Care Plan Revisions Upon Status Change dated 2024 revealed care plans were modified as needed by the MDS Coordinator or other designated staff member. .

Based on medical record review, observation, resident interview, and staff interview the facility failed to provide resident diets in accordance with the physician's orders and resident preference. This affected one (Resident #192) of five residents reviewed for food. The facility census was 90 residents. Findings include: Review of the medical record for Resident #192 revealed an admitted [DATE] with diagnoses including diabetes, mild intellectual disability, and bilateral below the knee amputations. Review of the physician's orders for Resident #192 revealed an order dated 02/27/25 for the resident to receive double portions of food due to weight loss. Review of meal ticket dated for Resident #192 dated 03/03/25 revealed the resident was to receive double portions of country chicken and dumplings, peas and carrots, cornbread, and cake. Interview on 03/03/25 at 10:09 A.M. with Resident #192 confirmed he was supposed to be getting double portions on his trays, but he only received small portions, and it was not enough food for him. Observation of Resident #192's dinner tray on 03/03/25 at 4:42 P.M. revealed the tray did not have double portions of any food item. Interviews on 03/03/25 at 4:42 P.M. with Certified Nursing Assistants (CNAs) #05 and #11 confirmed Resident #192 only received single portions at dinner on 03/03/25.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff properly secured their hair while serving resident meals. This affected two (Residents #70 and #1) of 17 residents observed for meal service. The facility census was 90 residents. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE] with diagnoses including dementia, congestive heart failure, and chronic kidney disease. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including dementia, diabetes mellitus type two, osteoarthritis, and peripheral vascular disease. Observation on 03/05/25 at 5:17 P.M. revealed Licensed Practical Nurse (LPN) #30 was serving meal trays to Residents #70 and #1. LPN #30 had long hair which was unsecured and falling into the residents' meal trays. Interview on 03/05/25 at 5:32 P.M. with LPN #30 confirmed her long hair was unsecured and had fallen onto the plates of Residents #70 and #1. Review of facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices undated revealed all employees who served food would be trained in safe food handling practices prior to serving food to residents. Hair nets or caps must be worn to keep hair from coming in contact with residents' food.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #53) of five residents observed for medication administration. The facility census was 90 residents. Findings include: Review the medical record for Resident #53 revealed an admitted [DATE] with diagnoses including encephalopathy, depression, anxiety, acute kidney failure, urine retention, and alcohol abuse. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 02/07/25 revealed the resident had no cognitive deficits and required minimal assistance with activities of daily living (ADLs). Review of the physician's orders for Resident #53 revealed an order dated 08/24/24 for Lexapro 15 milligrams (mg) one time per day. Observation of medication administration for Resident #53 on 03/05/25 at 8:21 A.M. per Licensed Practical Nurse (LPN) #38 revealed the nurse administered Lexapro 7.5 mg to the resident. Interview on 03/05/25 at 11:52 A.M. with LPN #38 confirmed Resident #53's Lexapro order was for 15 mg daily and she had given the wrong dose on 03/05/25 and every day she had worked in January and February 2025. LPN #38 confirmed she had made the same medication error with Resident #53's Lexapro dose on 23 days in January and February 2025. Review of the staffing schedule dated 01/01/25 to 02/28/25 revealed LPN #38 worked on the following 23 days and administered medications to Resident #53: 01/03/25, 01/06/25, 01/08/25, 01/11/25, 01/12/25, 01/17/25, 01/17/25, 01/20/25, 01/29/25, 01/31/25, 02/03/25, 02/08/25, 02/09/25, 02/10/25, 02/12/23/25, 02/26/25, 02/27/25, 02/28/25. Review of the facility policy titled Administering Medications dated April 2019 revealed medications should be administered in a safe and timely manner, and as prescribed.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when providing direct care to residents in enhanced barrier precautions (EBP). This affected one (Resident #83) of three residents observed for EBP. The facility census was 90 residents. Findings include: Review of the medical record for Resident #83 revealed an admitted on 10/03/24 with diagnoses including unspecified quadriplegia, incomplete paraplegia, neuromuscular dysfunction of the bladder, and osteomyelitis. Review of care plan for Resident #83 dated 10/07/24 revealed the resident was in EBP due to active wounds, indwelling catheter, and colostomy. Interventions include to educate the resident and family on use of EBP and proper PPE and to post EBP signage on the resident's door. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 11/27/24 revealed the resident was cognitively intact. Review of care plan for Resident #83 dated 12/09/24 revealed the resident had an indwelling catheter related to diagnosis of neurogenic bladder. Observation on 03/05/25 at 5:04 P.M. of catheter care for Resident #83 per Certified Nursing Assistants (CNAs) #115 and #20 revealed the aides entered the resident's room wearing face masks and donned clean gloves. Neither aide donned a gown before transferring the resident from the chair to the bed using a Hoyer lift, removing the resident's pants, emptying the resident's catheter bag, performing catheter care, and placing a clean brief on the resident. Interview on 03/05/25 at 5:20 P.M. with CNA #115 confirmed neither she nor CNA #20 donned a gown prior to providing direct care to Resident #83 who was on EBP. Review of the facility policy titled Enhanced Barrier Precautions dated August 2022 revealed employees should don gowns when providing care to a resident on EBP.

Based on medical review, observation, staff interview, and review of the facility policy, the facility failed to ensure nurses properly documented administration of narcotic medications. This affected three Residents (#14, #32, and #67) of three residents reviewed for medication reconciliation. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including right femur fracture, malnutrition, personality disorder, and anxiety. Review of the controlled substance count sheet for Resident #14 revealed there were three doses of Tramadol remaining. Observation on 03/05/25 at 11:04 A.M. with Licensed Practical Nurse (LPN) #30 revealed there were only two doses of Resident #14's Tramadol in the cart. Interview on 03/05/25 at 11:04 A.M. with LPN #30 confirmed she had given a dose of Tramadol to Resident #14 earlier in the day on 03/05/25 but had not documented administration of the medication. 2.Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses including cerebral infarction, aphasia, anxiety, dementia, and depression. Review of the controlled substance count sheet for Resident #32 revealed there were 12 doses of Ativan remaining. Observation on 03/05/25 at 11:05 A.M. with LPN #30 revealed there were only 11 doses of Resident #32's Ativan in the cart. Interview on 03/05/25 at 11:05 A.M. with LPN #30 confirmed she had given a dose of Ativan to Resident #32 earlier in the day on 03/05/25 but had not documented administration of the medication. 3.Review of the medical record for Resident #67 revealed Resident #67 an admitted [DATE] with diagnoses including cirrhosis, asthma, respiratory disorders, and depression. Review of the controlled substance count sheet for Resident #67 revealed there were 40 doses of Ativan remaining. Observation on 03/05/25 at 11:06 A.M. with LPN #30 revealed there were only 39 doses of Resident #67's Ativan in the cart. Interview on 03/05/25 at 11:06 A.M. with LPN #30 confirmed she had given a dose of Ativan to Resident #67 earlier in the day on 03/05/25 but had not documented administration of the medication. Review of the facility policy titled Storage of Medications dated November 2020 revealed when the nurse should document medication administration in the resident's medical record at the time of administration.

Based on observation, medical record review, policy review, resident interview, and staff interviews, the facility failed to ensure adequate supervision was provided to maintain safety and prevent potential injury during smoke breaks for one (#02) of seven sampled residents. The facility further failed to ensure staff completed a smoking safety evaluation for one (#01) of seven sampled residents. The faciliy census was 91. Findings included: 1. Review of Resident #01's medical record revealed an admitted [DATE]. Resident #01's diagnoses included: end stage renal disease, dependence on renal dialysis, diabetes, chronic obstructive pulmonary disease (COPD), depression, anxiety, obstructive sleep apnea, congestive heart failure, heart attack, and stroke. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/07/24, revealed Resident #01 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #01 used tobacco during the assessment period. Review of care plans revealed Resident #01's care plans did not include a focus area or interventions related to smoking. Review of Resident #1's medical record revealed no evidence to indicate the facility assessed the resident and determined any restrictions on smoking based on observation or completion of a smoking assessment as required per facility policy. Interview on 09/18/2024 at 2:15 P.M., with Resident #01 stated they smoked outside of the designated smoking times and smoked at the front of the facility. Resident #01 stated someone from the activities department told the resident the facility needed to put something up about smoking in the resident's room. Resident #01 stated the resident told staff, that the resident would smoke whenever the resident wanted. Resident #01 stated no one had spoken with the resident about a smoking assessment or smoking during designated times. Interview on 09/19/2024 at 11:07 A.M., with State tested Nurse Aide (STNA) #1 stated she observed Resident #01 smoking. 2. Review of Resident #02's medical record revealed an admitted [DATE]. Resident #02's diagnoses included: encephalopathy, epilepsy, nicotine dependence, major depressive disorder, and insomnia. Review of quarterly MDS assessment, with an ARD of 07/17/24, revealed Resident #02 had a BIMS score of 13, which indicated the resident had intact cognition. According to the MDS, the resident did not use tobacco during the assessment period. Review of Resident #02's care plan included a focus area initiated on 10/23/23, indicating the resident was a smoker and required supervision due to poor decision making and judgement and for the safety of the resident and others. The care plan revealed the resident had a history of noncompliance with the smoking policy. Per the care plan, the resident's family had been educated that the resident was unable to keep cigarettes and/or a lighter and that the facility was required to hold the items and supervise the resident while smoking. According to the care plan, the resident remained non-compliant with the smoking policy and became increasingly agitated and aggressive when staff attempted to redirect the resident, which led to a history of staff calling the police. Interventions initiated on 10/23/23 directed staff to supervise all smoking activities; keep the resident's smoking materials in a safe, secure area; make the resident's legal representative, friends, and other visitors aware of the facility's smoking policy; monitor the resident's room for any prohibited materials and report to the nurse; re-educate the resident on the facility's smoking policy; ensure a smoking apron was utilized; remind the resident of the smoking schedule and distribute cigarettes appropriately; and supervise smoking in designated areas only. The care plan did not specify the frequency at which staff should monitor the resident's room for prohibited materials. Review of Resident #02's admission Smoking Safety Evaluation, dated 12/22/23, revealed supervision would be required for all residents during designated smoking times. Review of Resident #2's quarterly Smoking Safety Evaluation, completed 03/12/24, revealed supervision would be required for all residents during designated smoking times. Observation on 09/18/24 at 8:26 A.M., revealed a metal ashtray was observed on a concrete ledge at the front doorway of the facility. There were approximately 15 cigarette butts in the ashtray and ashes were observed along the concrete wall. Interview on 09/18/24 at 8:38 A.M., with the Director of Nursing (DON), indicated there was a dedicated smoking area in the back of the building, but some residents wandered to the front to smoke. The DON indicated there was a designated smoking room on the second floor of the building for the residents on the secured unit. Interview on 09/18/24 at 8:50 A.M., with the DON stated the ashtray was placed on the ledge at the front door so that Resident #02 would not throw cigarette butts on the ground. Interview on 09/18/24 at 11:05 A.M., with State tested Nurse Aide (STNA) #01 indicated she was aware that Resident #02 who had been smoking at the front of the facility. STNA #01 indicated when that occurred, staff tried to redirect the resident. Interview on 09/18/24 at 1:44 P.M., with Licensed Practical Nurse (LPN) #04 indicated Resident #02 was non-compliant with the designated smoking times. Observation on 09/18/24 at 3:04 P.M., revealed Resident #02 was sitting on the ledge, under the covered driveway, near the front entrance of the facility. The resident had a cigarette, lighter, and a small metal ashtray sitting on the ledge beside them. The resident proceeded to smoke while not wearing a smoking apron and with no staff supervision. Interview on 09/19/24 at 9:07 A.M., with Assistant Director of Nursing (ADON) #05 indicated Resident #02 required redirection and staff had to take the resident's smoking materials and lock them up. ADON #05 indicated the resident had a lot of visitors and was unsure whether family members were bringing smoking materials to the resident. ADON #05 indicated the ability to take smoking materials from the resident depended on the resident's mood. She stated if she was not able to redirect the resident, she waited outside with the resident until they were finished smoking. Interview on 09/19/24 at 9:39 A.M., with Activity Aide (AA) #02 stated Resident #02 smoked during designated smoking times, but the resident had their own cigarette and lighter and refused to wear an apron. AA #02 stated she notified nursing staff of the resident's refusals, but she was not sure what they did with the information. AA #02 also stated she felt Resident #02 was a safe smoker and had never seen the resident drop any ashes on themselves or burn themselves. Interview on 09/19/24 at 9:55 A.M., the Administrator stated Resident #02 was very independent and when addressing the resident's non-compliance, he felt they had to be careful. The Administrator stated he felt giving the resident a 30-day discharge would escalate the situation and confronting the resident each time they violated a rule would only make the situation worse. The Administrator stated there had been discussions about allowing independent smokers to be able to smoke on their own, and from what he observed of Resident #2 everyday, the resident was a safe smoker. The Administrator stated he had never seen any burn holes in the resident's clothing or burns on the resident's body. Interview on 09/19/24 at 10:17 A.M., with LPN #06 stated she observed Resident #02 smoking at the front and back of the facility, unsupervised, but the resident never appeared unsafe. LPN #06 revealed she had never seen the resident drop ashes or burn themselves. Interview on 09/19/24 at 10:51 A.M., with the Social Service Director (SSD) indicated she witnessed Resident #02 be noncompliant with designated smoking times and designated areas for smoking. The SSD stated the facility tried to redirect the resident each time and she had taken the resident's smoking materials. The SSD indicated she had never observed the resident being an unsafe smoker. Interview on 09/20/24 at 9:10 A.M., Resident #02 stated they used to turn over cigarettes to the facility staff, but now they keep their own cigarette and lighter. Resident #02 indicated the facility tried to make them follow the rules, but they did not have to take orders from staff and would smoke whenever they wanted. Interview on 09/20/24 at 3:18 P.M., with the DON and Administrator, the Administrator stated the facility wanted everyone to abide by facility policy, but this was the residents' home and if they were not doing something egregious, they tried to work with the resident by educating them and going over the policy. Review of the undated policy titled Resident Smoking/Use of Electronic Cigarette Policy, revealed, this facility shall establish and maintain safe resident smoking/use of electronic cigarette practices. The policy specified, No resident shall hold on their person or in their room; cigarettes, cigars, tobacco, lighters, matches or electronic cigarettes. Per the policy. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking/use of electronic cigarettes based on observation and completion of Smoking Assessments. - Any smoking/use of electronic cigarette-related restrictions and concerns shall be noted on the care plan, including the ramifications if Smoking/Use of Electronic Cigarette Policy is not followed. All personnel caring for the resident shall be alerted to any potential issues. Per the policy, All residents shall wear a smoking apron while smoking; it is the responsibility of the staff to secure and remove apron, as necessary. Residents who refuse to wear a smoking apron will not be provided smoking/electronic cigarette supplies.

Based on observation, staff interview and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and the dishwasher had the appropriate level of chemicals in order to prevent foodborne illness. This had the potential to affect all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: 1. Observation of the kitchen on 05/06/24 at 8:15 A.M. revealed there were food debris built up in the oil and on the edges of the fryer. There was also food debris on the fryer basket and a brown splatter on the side of the fryer. There was brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. Interview with Dietary Manager (DM) #68 on 05/06/24 at 8:15 A.M. verified there was food debris built up in the oil, food basket and on the edges of the fryer. DM #68 also confirmed there was brown splatter on the side of the fryer and brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. 2. Observation of the facility's dishwasher on 05/06/24 at 9:15 A.M. revealed the dishwasher temperature was 125 degrees fahrenheit for the wash and rinse cycles. DM #68 was observed testing the chemical levels in the dishwasher and the dishwasher tested at zero parts per million (ppm). Dietary staff were observed actively running dishes in the dishwasher from 05/06/24 at 8:15 A.M. to 9:15 A.M. Interview with DM #68 on 05/06/24 at 9:15 A.M. verified the dishwasher temperature was 125 degrees fahrenheit for the wash and rinse cycles. DM #68 confirmed the dishwasher was a low temperature dishwasher and required chemicals to sanitize the dishes. DM #68 verified the dishwasher was running at zero ppm of chemical sanitizer and dietary staff were actively running dishes in the dishwasher on 05/06/24 from 8:15 A.M. to 9:15 A.M. Review of the Food Preparation and Service policy, dated November 2022, revealed all food service equipment and utensils will be sanitized according to current guidelines and manufacturer instructions. This deficiency represents non-compliance investigated under Complaint Number OH00152883.

Based on review of the menu, review of the substitution log, observation, staff interview, and policy review, the facility failed to ensure the menu was followed. This affected all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: Review of the breakfast menu, dated 05/06/24, revealed residents on a regular diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a mechanical diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a pureed diet were to be served six ounces of pureed cereal, a number sixteen scoop or two ounces of pureed cheesy scrambled eggs, and a number sixteen scoop or two ounces of pureed toast. Review of the substitution log from 02/23/24 to 05/06/24 revealed English muffins as a substitution for toast was not on the substitution log. Observation of Dietary Manager (DM) #68 serving meals on 05/06/24 at 8:18 A.M. revealed DM #68 served residents on a regular diet six ounces (oz) of oatmeal, a number ten scoop of eggs, two sausage links and a whole English muffin. DM #68 served residents on a mechanical diet six oz of oatmeal, a number ten scoop of eggs, a number eight scoop of mechanical sausage and a whole English muffin. DM #68 served residents on a pureed diet six oz of oatmeal, a number ten scoop of pureed eggs, a number eight scoop of pureed sausage and a number eight scoop of pureed bread. Interview with DM #68 on 05/06/24 at 8:18 A.M. verified DM #68 served residents on a regular diet six oz of oatmeal, a number ten scoop of eggs, two sausage links and a whole English muffin. The interview verified DM #68 served residents on a mechanical diet six oz of oatmeal, a number ten scoop of eggs, a number eight scoop of mechanical sausage and a whole English muffin. Additionally, the interview verified DM #68 served residents on a pureed diet six oz of oatmeal, a number ten scoop of pureed eggs, a number eight scoop of pureed sausage and a number eight scoop of pureed bread. DM #68 stated he did not have the correct scoop sizes for the regular eggs, mechanical eggs, pureed eggs, and pureed bread because he was missing the correct scoops sizes and had to order them. The interview verified the number ten scoop size was a different portion size than the number sixteen scoop size. DM #68 also reported sausage was not on the menu, but he liked to add a different protein to the daily menu because the menu from the company did not have a lot of variety for protein at breakfast besides eggs. Observation of tray line on 05/06/24 at 8:45 A.M. revealed DM #68 was serving a full English muffin with two halves to residents that were on mechanical diets and regular diets. Part of the way through tray line, DM #68 started to serve one half or one slice of a English muffin to residents. Resident #52, #53, #54, #56, #57, #58, #59, #62, #63 and #88 were observed to receive only one half or one slice of an English muffin. Interview with DM #68 on 05/06/24 at 8:45 A.M. verified DM #68 served one half or one slice of an English muffin to Residents #52, #53, #54, #56, #57, #58, #59, #62, #63 and #88. DM #68 stated he stopped serving a whole or two halves of an English muffin because he thought he was going to run out of English muffins. DM #68 stated he was going to give residents more eggs instead of a whole English muffin. Interview with the Director of Nursing (DON) on 05/06/24 at 10:57 A.M. verified English muffins were served instead of toast on 05/06/24, the English muffins were not listed on the substitution log, and there was no documentation that the dietitian was aware of the substitution. Review of the facility Substitutions policy, dated April 2007, revealed the food service manager in conjunction with the dietitian may make food substitutions as appropriate and necessary. All substitutions are noted on the menu and filed in accordance with established dietary policies.

Based on observation, staff interview and policy review, the facility failed to ensure residents were not provided plastic utensils with meals. This affected 46 residents (#47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, and #92) out of 90 residents in the facility who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: Observation of tray line on 05/06/24 at 8:30 A.M. revealed the facility ran out of silverware and used plastic silverware for the residents who resided on the second floor. Interview with Dietary Aide (DA) #93 on 05/06/24 at 8:30 A.M. verified the facility ran out of silverware and they used plastic silverware for the residents who resided on the second floor. Review of the facility Disposable Dishes and Utensils policy, dated November 2007, revealed the facility will use single service items only in extenuating circumstances such as dish machine failure, individual resident needs and requests, or other documented reasons. This deficiency represents non-compliance investigated under Master Complaint Number OH00153346.

Based on medical record review, staff interview, and policy review, the facility failed to administer an anticoagulant medication as ordered by the physician. This affected one (#4) of three residents reviewed for medication administration. The census was 94. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses including cerebral infarction, dysphagia, morbid obesity, aphasia, cystic fibrosis, respiratory failure, hemiplegia, insomnia, epilepsy, hypertension, and sleep apnea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe cognitive deficits, required total assistance with activities of daily living, and was frequently incontinent of bowel and bladder. Review of Resident #4's physician orders revealed an order dated 05/16/23 for Resident #4 to receive the anticoagulant Eliquis five (5) milligrams (mg) twice a day via gastrostomy tube (a surgically placed device that provides direct access to the stomach) with no stop date. Review of Resident #4's medication administration record (MAR) from 05/17/23 through 06/14/23 revealed no Eliquis was administered to the Resident #4. Interview on 06/14/23 at 3:50 P.M. with the Director of Nursing (DON) verified Resident #4 had not received Eliquis 5 mg twice a day from 05/17/23 through 06/14/23 as ordered. Review of the medication administration policy, dated April 2019, revealed medications are administered in accordance with the prescriber orders, including any time frames. This deficiency represents non-compliance investigated under Complaint Number OH0000142882.

Based on medical record review, observation, staff interview, policy review, and review of the manufacturers recommendations the facility failed to to provide a sanitary environment to prevent the spread and development of communicable disease and infections when they failed to wash their hands appropriately after changing gloves during a dressing change. This affected one resident (#90) of three reviewed for pressure ulcers. The facility identified four residents (#12, #26, #52 and #90) with pressure ulcers. In addition, the facility failed to clean the blood glucose monitoring machine between resident use. This affected two residents (#49 and #67) of three reviewed. The facility identified four residents (#49, #60, #66, and #67) on the 200 to 214 hallway who received blood glucose monitoring checks. The facility census was 90. Findings include: 1. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired and required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident used a wheelchair to aid in mobility and was always incontinent of bowel and bladder. Review of a Physician Order dated 03/25/22 revealed to cleanse the right buttock with normal saline, apply wound gel and a dry clean dressing daily and as needed every day shift. Observation of Resident #90's wound care on 04/19/22 at 10:45 A.M. revealed Licensed Practical Nurse (LPN) #12 gathered the supplies and washed her hands and put on gloves. LPN #12 removed the resident's incontinence brief and observed the wound site. There was not a dressing on the wound. LPN #12 removed her gloves and put on a new pair of gloves. The LPN #12 had not washed her hands or used hand sanitizer after removing the soiled gloves. LPN #12 cleaned the wound with normal saline and gauze she then removed her gloves and put on new gloves. LPN #12 had not washed her hands or used hand sanitizer after removing the soiled gloves. LPN #12 then put medi honey wound gel on the wound and applied a border gauze to the wound. Interview with LPN #12 on 04/19/22 at 10:57 A.M., verified she had not washed her hands or used hand sanitizer after removing her gloves and putting on clean gloves during the dressing change. Review of the facility policy titled Handwashing/Hand Hygiene undated revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Wash hands with soap and water for the following situations: when hands are visibly soiled. Use an alcohol based hand rub containing at least 62% alcohol or soap and water for the following situations: after handling used dressings, contaminated equipment, and after removing gloves. 2. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician order dated 11/02/21 revealed [MEDICATION(S)] (insulin) KwikPen Solution Pen-injector Inject per the sliding scale: if blood glucose was 150 milligrams per deciliter (mg/dL) to 199 mg/dL give two units; 200 mg/dL to 249 mg/dL give four units; 250 mg/dL to 299 mg/dL give seven units; 300 mg/dL to 349 mg/dL give 10 units; 350 mg/dL to 400 mg/dL give 12 units subcutaneously four times a day for diabetes mellitus. If the blood sugar was greater than 349 mg/dL contact the physician. 3. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's physician order dated 12/10/21 revealed [MEDICATION(S)] (insulin) [MEDICATION(S)] Solution Pen-injector Inject as per sliding scale: if blood glucose was 60 mg/dL to 150 mg/dL give zero units; 151 mg/dL to 200 mg/dL give three units; 201 mg/dL to 250 mg/dL give five units; 251 mg/dL to 300 mg/dL give seven units; 301 mg/dL to 350 mg/dL give nine units; 351 mg/dL to 400 mg/dL give 11 units subcutaneously before meals for diabetes mellitus type two. Call the physician for blood glucose levels greater than 401 mg/dL. Observation on 04/19/22 at 11:42 A.M. revealed Registered Nurse (RN) #13 completed a finger stick and blood glucose monitoring for Resident #49. RN #13 used a lancet and drew blood from Resident #49's left hand and his blood sugar reading was 276 mg/dL. RN #13 cleaned the blood glucose monitoring machine with an alcohol wipe and she returned to the medication cart. Observation on 04/19/22 at 11:50 A.M. revealed RN #13 gathered her supplies to complete a blood glucose monitoring check for Resident #67. RN #13 entered Resident #67 room just before the blood glucose was obtained the surveyor intervened and asked to speak with RN #13. RN #13 verified she was going to use the same blood glucose monitoring machine used on Resident #49 for Resident #67. RN #13 verified she only cleaned the blood glucose monitoring machine with alcohol. She stated she had no bleach containing wipes. RN #13 went through the medication cart there was a bleach wipe container in the bottom of the cart. RN #13 stated it was empty when she opened the container it only had one wipe in it and she dropped it on the floor when she opened the container. Review of the facility policy titled Obtaining a Fingerstick Glucose Level undated revealed equipment includes disinfected blood glucose meter and to clean and disinfect reusable equipment between uses according to the manufacturers instructions and current infection control standards of practice. Review of a facility provided manufactures recommendation for Ark Care Technical Brief Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System revised 09/01/19 revealed To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. These are approved wipes: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipe, and Caviwipes. Obtain a commercially available EPA-registered disinfectant detergent or germicide wipe. Disinfect the meter by diluting 1 milliter of household bleach /5-6% sodium hypochlorite solution) in 9 milliters water to achieve a 1:10 dilution. This deficiency substantiates Complaint Number OH 700. This is an example of continued non-compliance from the survey dated 03/18/22.

Based on observation, record review and staff interview, the facility failed to ensure food items were stored in a sanitary manner, the ice machine was kept in a sanitary manner and food items were held at the proper temperature. This affected all residents except Resident #9 that received no food by mouth. The facility census was 94. Findings include: Observation of the facility's ice machine located outside of the kitchen doors on 03/07/22 at 7:36 A.M. revealed there to be a brown and red substance on the white ledge on the inside of the ice machine. Further observation of the kitchen revealed Cook #347 took a paper towel and wiped the white ledge of the ice machine and the brown and red substance came off the inside of the ice machine and onto the paper towel. Interview with Cook #347 on 03/07/22 at 7:36 A.M. verified there was a brown and red substance on the inside of the ice machine. Observation of the kitchen on 03/08/22 at 4:45 P.M. revealed Dietary Manager #306 to take the temperature of the pureed soup on the tray line. The pureed soup was 120 degrees Fahrenheit (F). After taking the temperature of the soup, Cook #346 started to serve pureed diets eight ounces of pureed soup. Interview with Dietary Manager #306 on 03/08/22 at 4:45 P.M. verified the soup was 120 degrees F after she took the temperature of the soup a second time. Dietary Manager #306 stated she did not realize the soup was being held at 120 degrees F on the steam table and she had the pureed soup that was portioned out put back into the pan and placed into the oven to be heated up to temperature. Review of the facility's list of diets dated 03/10/22 revealed Resident #9 received no food by mouth. Review of the facility's food preparation and service policy dated April 2019 revealed the danger zone for food temperatures was between 41 and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats and milk. The longer the food remains in the danger zone the greater the risk for growth of harmful pathogens. Therefore, food must be maintained below 41 or above 135 degrees F. This deficiency substantiates Complaint Number OH 672.

Based on record review, observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance and review of the facility's policy, the facility failed to perform proper hand hygiene during a dressing change for a pressure ulcer. This affected one (Resident #23) of four facility-identified residents with pressure ulcers. The facility also failed to implement quarantine precautions for Resident #486 which had the potential to affect all of the residents residing in the facility. The facility also failed to ensure staff performed appropriate hand hygiene while serving the resident meals which affected seven residents (Resident #16, #30, #55, #57, #75, #83, and #536). The facility census was 94. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively impaired and was required extensive assistance of one to two staff with personal hygiene. Review of the care plan for Resident #23 dated 06/01/18 revealed Resident #23 had DM and received insulin. Interventions included refer to podiatrist and/or nurse for nail care and to cut long nails. Review of the March 2022 monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound grid for Resident #23 revealed resident had a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the right buttock measuring 1.5 centimeters (cm) by 0.5 cm by 0.5 cm in depth. Stage II pressure ulcer to the left buttock measured 1.5 cm by 2.0 cm by 0.5 cm in depth. Observation on 03/07/22 at 2:52 P.M. of Licensed Practical Nurse (LPN) #420 perform wound care for Resident #23 revealed LPN #420 washed her hands and donned gloves and removed the soiled dressings from the pressure ulcers to resident's right and left buttocks. LPN #420 then cleansed the wounds with wound cleanser (normal saline) in a spray bottle. While nurse was cleansing the wounds, Resident #23 began to have a bowel movement (BM). LPN #420 did not change gloves and perform hand hygiene. LPN #420 then applied [MEDICATION(S)] to wound by squirting a small amount from the tube onto the wound bed and then used her gloved finger, still wearing the same gloves donned prior to the procedure, and distributed the [MEDICATION(S)] to each wound bed. LPN #420 did not change gloves and perform hand hygiene. LPN #420 then applied a clean dry dressing to the right and left buttock wounds still wearing the same gloves donned prior to the procedure. LPN #420 then provided incontinence care and removed the small amount of BM from resident's perianal area and applied a clean incontinence brief. Interview on 03/07/22 at 3:10 P.M. with LPN #420 confirmed she did not provide incontinence care prior to performing dressing change and attempted instead to work around the BM Resident #23 was having during the procedure. LPN #420 confirmed she did not remove gloves and perform hand hygiene during the dressing change after she removed the soiled dressing and after she cleansed the wound. LPN #420 confirmed she used a contaminated gloved finger to distribute [MEDICATION(S)] to the resident's wound beds. Review of the policy titled Handwashing/Hand Hygiene, dated 2021, revealed the use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. Hand hygiene should be performed in the following instances which include: before handling clean or soiled dressings, gauze pads, etc. before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc., after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, after removing gloves. 2. Review of the medical record for Resident #486 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #486's immunization record revealed Resident #486 refused the COVID-19 vaccination. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #486 had intact cognition. Observation on 03/07/22 at 8:17 A.M. revealed no signs nor bin outside of Resident #486's room to indicate she was under any type of transmission-based precautions. Interview on 03/07/22 at 8:29 A.M. with LPN #310 stated Resident #486 was was under quarantine precautions related to being a new admission. LPN #310 further confirmed there were no signs nor bin containing PPE outside Resident #486's room to indicate the need for PPE upon entrance. LPN #310 further confirmed Resident #486 was not in her room at the time of the observation and should remain in the room while under transmission-based precautions. Observation on 03/07/22 at 8:43 A.M. revealed Resident #486 was observed walking on the first floor, near the dining room, not wearing a mask. Observation and interview on 03/07/22 at 10:26 A.M. with Resident #486 was observed in the hallway outside of her room without a mask. Resident #486 stated nobody had talked to her about the need for her to quarantine in her room because she was a new admission and not vaccinated. Observation on 03/08/22 at 4:13 P.M., revealed Resident #486 out in the hallway, not wearing a mask, and talking with an unidentified nurse. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated 02/02/22, revealed under 'Create a Plan for Managing New Admissions and Readmissions', in general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Review of the policy titled, Isolation-Categories of Transmission-Based Precautions, dated 10/2018, revealed, when a resident is placed on transmission-based precautions, appropriate notification is to be placed on the room entrance door so personnel and visitors are aware of the need for and the type of precaution. The signage is to inform staff of the CDC precaution (s), instructions for use of PPE, and/or instructions to see a nurse before entering. 3. During a continuous observation of breakfast trays service on 03/07/22 beginning at 8:32 A.M. revealed the breakfast food cart was delivered to the second floor and State tested Nurses Aide (STNA) #327 pushed the cart down the hallway. Observation revealed STNA #327 removed a tray for Resident #16, delivered and placed the tray on resident's bedside table. STNA #327 repositioned the bed side table over Resident #16, opened the milk carton, juice carton and jelly. STNA #327 exited resident's room, returned to the food cart and pushed the cart down the hallway and delivered a tray to Resident #83, repositioned the bed side table and opened the milk and juice. STNA #327 exited Resident #83's room, pushed the cart down the hallway and delivered a tray to Resident #75. STNA #327 continued with delivery of trays to Residents #55 and #57, then delivered a tray to Resident #536. STNA #327 was observed delivering and setting up all the trays without any hand hygiene observed. During continued observation at 8:43 A.M. revealed STNA #327 was standing at the food cart in the common dining area, used his right hand to wipe off sweat from his forehead and wiped his hands on his pants. Continued observation revealed STNA #327 wiped sweat off forehead again and wiped his hands on his pants. STNA #327 removed and delivered a tray to Resident #30 who was seated at the dining room table. Continued observation revealed STNA #327 picked up each piece of bread, used contaminated hands and buttered and returned the bread to resident's trays. Observations revealed STNA #327 never used any hand hygiene during the breakfast tray service. Interview with STNA #327 on 03/07/22 at 8:49 A.M. verified above findings and verified he did not complete any hand hygiene during the breakfast service of trays. STNA #327 additionally verified he wiped sweat off his forehead and buttered Resident #30's bread with his contaminated hands. STNA #327 stated he should have used hand hygiene throughout the breakfast service, but stated he forgot. This deficiency substantiates Complaint Numbers OH 269, OH 137, OH 672, and OH 296.

Based on review of the facility's policy, observation, record review and staff interview, the facility failed to residents were treated in a dignified manner. This affected three (#8, #35, and #50) of four residents reviewed for dignity. The facility census was 94. Findings include: 1. Review of the Resident #50's medical record revealed Resident #50 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #50's room on 03/07/22 at 11:24 A.M. and on 03/08/22 at 3:45 P.M. revealed a sign on Resident #50's door that stated Please do not give Resident #50 anything to drink without thickener. Also she cannot have her bed flat. Please elevate her bed. Thank you Day shift Aide. The sign was noted to face into the facility's hallway when the door was shut. Interview with Licensed Practical Nurse (LPN) #310 on 03/08/22 at 3:45 P.M. verified there was a sign on Resident #50's door that stated Please do not give Resident #50 anything to drink without thickener. Also she cannot have her bed flat. Please elevate her bed. Thank you Day shift Aide. Review of the facility's dignity policy, dated February 2020, revealed staff will protect confidential clinical information including ensuring signs indicating the resident's clinical status or care needs are not openly posted in the resident's room. 2. Review of the Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #25 required supervision with eating. Observation of the facility on 03/07/22 at 8:29 A.M. revealed staff were passing trays on the first floor. Further observation of dining revealed a room tray was provided to Resident #65 but was not provided to Resident #35. Resident #35 and Resident #65 were roommates and were both eating in the same room. Resident #35 was observed asking State tested Nurse Aide (STNA) #329 where her food was and STNA #329 stated her food was on the next cart. Observation of the facility on 03/07/22 at 8:42 A.M. revealed Resident #35 was walking in the hallway asking for her breakfast tray. STNA #329 was observed to tell Resident #35 that her food was on the next cart. Interview with STNA #329 on 03/07/22 at 8:44 A.M. verified Resident #35 and Resident #65 were roommates and Resident #65 had received her tray, but Resident #35's food was on a different cart despite them both eating in their room. Observation of the facility on 03/07/22 at 8:49 A.M. revealed Resident #35's tray arrived in her room. Review of the facility's dignity policy, dated February 2020, revealed residents will be treated with dignity and respect at all times. 3. Review of the medical record for Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severely impaired cognition, had no behaviors, did not reject care, and the resident was noted with an indwelling catheter. Review of the plan of care, dated 07/11/19, revealed Resident #8 had alteration in bladder control related to dementia, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)], and the resident was at risk for complications related to indwelling suprapubic catheter. Interventions included to position catheter bag and tubing below the level of the bladder and away from entrance room door. The plan of care was silent for any notes about the catheter bag being covered. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of the common dining room during breakfast service on 03/07/22 at 8:52 A.M. revealed Resident #8 was situated at the dining room table in a wheelchair and alongside numerous other residents. Resident #8 resident had an indwelling catheter bag hanging from the rear of wheelchair and without being covered. Interview with State tested Nurses Aide (STNA) #361 on 03/07/22 at 8:54 A.M. verified Resident #8 was seated in the common dining room with his catheter bag uncovered and attached to his wheelchair. STNA #361 stated Resident #8 should have had his catheter bag covered. Review of the facility's policy titled Quality of Life - Dignity, dated 12/01/20, revealed the resident shall be cared for in a manner that promotes and enhances well-being, level of satisfaction with life, feeling of self-worth and self esteem and residents are treated with dignity at all times. Notes also indicated demeaning practices and standards of care that compromise dignity was prohibited and staff are expected to promote dignity and assist residents with keeping urinary catheter bags covered. This deficiency substantiates Complaint Number OH 269.

Based on observation, staff interview, resident interview, and review of facility policy and documents, the facility failed to ensure resident rooms and common areas on the second floor of the facility were clean and sanitary. This affected Residents #10, #23, #26, #55, #62, and #77. This had potential to affect all 44 residents who resided on the second floor. The facility census was 94. Findings include: Observation on 03/07/22 at 8:02 A.M. revealed the floors in the hallways and common areas on the second floor has visible debris, stains, and were sticky throughout. The trash receptacles in the dining area where residents were seated and awaiting breakfast were overflowing with waste which was spilling onto the floor. Interview on 03/07/22 at 8:02 A.M. with Licensed Practical Nurse (LPN) #353 confirmed the floors in the hallways and the dining area were dirty and needed to be cleaned and the trash was overflowing. LPN #353 confirmed she didn't think they had housekeeping staff over the weekend. Interview on 03/07/22 at 8:07 A.M. with Floor Technician (FT) #334 confirmed he worked Monday through Friday and there was not currently a floor tech available on the weekends. FT #334 confirmed the floors on the second floor including the hallways and dining area were dirty and had not been swept and mopped since he did them on Friday. FT #334 confirmed the trash cans in the dining room were overflowing and needed to be emptied. Interview on 03/07/22 at 8:10 A.M. with Resident #62 stated the floors in the hallway and the dining room were dirty and no one had been in over the weekend to clean them. Interview on 03/07/22 at 8:17 A.M. with Housekeeper #356 confirmed the floor technicians swept and mopped the hallways and common areas and emptied trash in the common areas and the housekeepers cleaned individual resident rooms. Housekeeper #356 confirmed the floor on the second floor in the hallways and dining area was dirty and needed to be swept and mopped as soon as possible. Housekeeper #356 confirmed the trash receptacles in the second-floor dining room were overflowing and needed to be emptied. Review of the facility housekeeping scheduled for 02/28/22 through 03/06/22 revealed there was no floor technician scheduled for the weekend dates of 03/04/22 and 03/05/22. During observations of the second floor resident rooms on 03/07/22 beginning at 8:28 A.M. revealed the following: a. Resident #10's room and bathroom had unknown sticky substance throughout the floor. The bathroom had dried stool throughout the inside of the toilet, toilet seat appeared to have stool on it, unknown dark substance in the floor around the toilet and floor was littered with paper and what appeared to be food particles. Interview with Resident #10 at same time, indicated the room had not been cleaned for a few days. b. Residents #26 and #77's room had sticky substance throughout the floor, alcohol pads, trash, and food particles/crumbs throughout the floor. Interview with State tested Nursing Aide (STNA) #361 verified the room's condition. STNA #361 stated she did not know when resident's rooms were last cleaned. c. Resident #55's room had sticky substance throughout the floor and trash on the floor. Resident #55 indicated the room had not been cleaned in a while. d. Resident #23's bed frame had dark dried substance which appeared to be dried crusted food throughout the side of the bed frame which was closest to the door. Observation at same time revealed STNA #361 donned gloves, sprayed, scraped, and cleaned the substance off of the bed. Interview with STNA #361 at same time verified the bed frame had dried food throughout the bed frame. Interview with Housekeeping Aide #356 on 03/07/22 at 9:15 A.M. indicated she was the housekeeper on duty over the weekend and was not able to clean the second floor. Housekeeping Aide #356 verified the Resident #10, #26, #77, #55, and #23's room conditions. Housekeeping Aide #356 indicated she was tasked with cleaning resident rooms and stated her expectations would be for each resident to have their rooms cleaned daily. Review of the undated facility document titled Housekeeper's Checklist revealed staff should make sure the dining room is swept and mopped. This deficiency substantiates Complaint Numbers OH 672 and OH 906.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure a resident's pharmacy recommendations were addressed in a timely manner. This affected five (#26, #40, #49, #53, and #71) of five residents reviewed for unnecessary medications. The facility census was 94. Findings include: 1. Review of the Resident #71's medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Review of Resident #71's pharmacy recommendation dated 01/08/22 revealed Resident #71 was on [MEDICATION(S)] 10 milligrams (mg) twice a day for depression and [MEDICATION(S)] 50 milligrams daily for depression. The pharmacy recommendation stated a dose evaluation was due per regulations and to please evaluate the continued need and consider a dose reduction or document. Resident #71's [MEDICATION(S)] was reduced to 25 mg per day. The pharmacy recommendation was signed by the physician 44 days later on 02/21/22. Review of Resident #71's pharmacy recommendation dated 01/08/22 revealed Resident #71 was prescribed [MEDICATION(S)] 5.0 mg at bedtime for behaviors. The pharmacy recommendation stated to please evaluate for a gradual dose reduction (GDR). Further review of the pharmacy recommendation revealed a reduction was clinically contraindicated because Resident #71 was at high risk for decompensation. The pharmacy recommendation was signed by the Certified Nurse Practitioner (CNP) 44 days later on 02/21/22. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 12:45 P.M. verified Resident #71's pharmacy recommendations dated 01/08/22 were not addressed by the CNP or physician until 02/21/22. 2. Review of the record for Resident #53 revealed he was admitted to the facility on [DATE]. Diagnoses included unspecified [CONDITION(S)] and dementia with behavioral disturbance. Review of his quarterly MDS assessment dated [DATE] revealed Resident #53 had short and long term memory loss and was severely impaired for daily daily decision making. Review of Resident #53's pharmacist recommendation dated 08/25/21 revealed a recommendation for a reduction of [MEDICATION(S)]. The recommendation was signed as contraindicated as a reduction may cause psychiatric instability by the CNP approximately three months later on 11/22/21. During an interview with the Corporate Business Office Manager (CBOM) #405 on 03/09/22 at 3:45 P.M., he verified the recommendation was not signed timely. He stated the psychiatric doctor in place at the time of the recommendation was not answering calls and emails and his services were terminated. The practitioner from the new practice then signed the recommendation when they started in November 2021. 3. Review of the medical record for the Resident #26 revealed an admitted [DATE]. Diagnoses included dementia and [CONDITION(S)]. Review of the MDS assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of Resident #26's pharmacy recommendations dated 12/16/21 revealed the resident was on [MEDICATION(S)] 25 mg once a day at night for depression. The pharmacist recommended a dose evaluation and considered a GDR or document criteria if no dose reduction is elected. Response notes by CNP dated 01/15/22 indicated for [MEDICATION(S)] to be discontinued. The CNP addressed the same pharmacist recommendations again on 02/18/22 and indicated the CNP disagreed with the recommendations due to [CONDITION(S)]. Review of the physician orders for Resident #26, dated 08/04/21, revealed the resident was ordered [MEDICATION(S)] 25 mg at bedtime for depressive disorder. The Trazadone was not discontinued timely per the CNP note on 01/15/22 to discontinue the [MEDICATION(S)]. The Trazadone was not discontinued until 02/21/22. The CNP recommendations on 02/18/22 were not addressed by the facility to not discontinue the [MEDICATION(S)]. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 12:45 P.M. verified Resident #26's pharmacy recommendations dated 12/16/21 were addressed on 01/15/22 and CNP indicated for [MEDICATION(S)] to be discontinued. Assistant Regional Director of Clinical Operations #400 verified the CNP addressed the same pharmacist recommendations again on 02/18/22 and indicated CNP disagreed with recommendations due to [CONDITION(S)]. Assistant Regional Director of Clinical Operations #400 verified Resident #26's [MEDICATION(S)] was discontinued on 02/21/21. Assistant Regional Director of Clinical Operations #400 stated they were not sure why the discrepancy and delay in discontinuing of [MEDICATION(S)]. 4. Review of the medical record for the Resident #40 revealed an admitted [DATE]. Diagnoses included dementia. Review of the MDS assessment dated [DATE] revealed Resident #40 was cognitively intact. Review of Resident #40's pharmacy recommendations dated 09/27/21 revealed the resident was on [MEDICATION(S)] 50 mg once a day at night for dementia. The pharmacist recommended a dose evaluation and considered a GDR or document criteria if no dose reduction is elected. Response notes by CNP dated 11/22/21 indicated a GDR was clinically contraindicated due to persistent symptoms of anxiety. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 1:00 P.M. verified the CNP did not timely respond until two months to the pharmacy recommendations made on 09/27/21. 5. Review of the medical record for the Resident #49 revealed an admitted [DATE]. Diagnoses included anxiety, [CONDITION(S)], and dementia. Review of the MDS assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the physician orders for Resident #49 dated 08/14/21 and discontinued on 02/10/22 revealed the resident was ordered [MEDICATION(S)] 0.5 mg twice daily for [CONDITION(S)]. Review of Resident #49's pharmacy recommendations dated 08/25/21 revealed the resident was on [MEDICATION(S)] 0.5 mg twice daily for [CONDITION(S)]. The pharmacist recommended a GDR evaluation and if no dose reduction is elected, document criteria. Response notes by CNP dated 11/22/21 indicated a GDR was clinically contraindicated due to potential cause for psychiatric instability. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 1:00 P.M. verified the CNP did not respond until three months later to the pharmacy recommendations made on 08/25/21. Review of the facility policy titled Antipsychotic Medication Use revealed the facility physician shall respond appropriately by changing, stopping problematic doses of medications, or clearly documenting why the benefits of the medication outweigh the risk or suspected confirmed adverse consequences.

Based on medical record review, review of hospital records, staff interview, review of facility policy and review of medication information from Medscape, the facility failed to administer medications as ordered by the physician resulting in a significant medication error. This resulted in Actual Harm for Resident #56 who missed nine doses of her anti-[CONDITION(S)] medication ([MEDICATION(S)]) and was subsequently transferred to the hospital where the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#56) of three residents reviewed for medication administration. Facility census was 90. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #56 dated 08/07/21 revealed Resident #56 was at risk for trauma and injury related to [CONDITION(S)] disorder. Interventions included to administer anti-[CONDITION(S)] medication as ordered by the physician. Review of the October 2021 monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] Resident #56 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of controlled substance sheet for Resident #56 revealed the resident had a dose of [MEDICATION(S)] at 9:00 A.M. on 10/29/21. Further review of the controlled substances sheet revealed Resident #56 had nine missed doses of [MEDICATION(S)] on 10/29/21 at 9:00 P.M., on 10/30/21 at 9:00 A.M. and 9:00 P.M., on 10/31/21 at 9:00 A.M. and 9:00 P.M., on 11/01/21 at 9:00 A.M. and 9:00 P.M., on 11/02/21 at 9:00 A.M. and 9:00 P.M. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., on 10/30/21 at 9:00 A.M. and 9:00 P.M., on 10/31/21 at 9:00 A.M. and 9:00 P.M., on 11/01/21 at 9:00 A.M. and 9:00 P.M., on 11/02/21 at 9:00 A.M. and 9:00 P.M. Review of nurse progress note for Resident #56 dated 10/30/21 revealed the resident's [MEDICATION(S)] was not available, and the pharmacy was called to STAT (immediately) out the order Review of the nurse progress for Resident #56 dated 11/01/21 revealed the [MEDICATION(S)] was not available, and nurse called pharmacy and was awaiting a return call. Review of the nurse progress notes for Resident #56 dated 11/02/ 21 revealed the [MEDICATION(S)] was not available, and nurse called pharmacy and was awaiting a return call. Review of an addition nurse progress note for Resident #56 dated 11/02/21 revealed the [MEDICATION(S)] was not available, and the Director of Nursing (DON) was aware. Review of nurse progress notes for Resident #56 dated 10/30/21 through 11/04/21 revealed the notes contained no documentation regarding physician notification of the missed doses of [MEDICATION(S)]. Review of nurse progress note for Resident #56 dated 11/04/21 revealed staff observed the resident having a [CONDITION(S)] and called nine-one-one (911) and the resident was transferred to the hospital. Review of hospital records, after visit summary for Resident #56 dated 11/04/21 revealed the reason for the visit was seizures secondary to subtherapeutic anticonvulsant (anti-[CONDITION(S)]) medication. Interview on 11/24/21 at 1:30 P.M. with the Administrator confirmed Resident #56 missed nine doses of her anti-[CONDITION(S)] medication and subsequently had a [CONDITION(S)] requiring hospital treatment. Review of facility policy titled Administering Medications dated December 2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. Review of medication information from Medscape revealed [MEDICATION(S)] is an anticonvulsant and is administered to control seizures. This deficiency substantiates Complaint Number OH 605 and Complaint Number OH 488.

Based on medical record review, interviews with facility staff, hospital record review, observations, and facility policy review, the facility failed to provide adequate behavioral health services for one Resident (#3) with a known history of [CONDITION(S)] and suicide attempts. This resulted in Immediate Jeopardy when Resident #3 cut himself on three separate dates (05/18/21, 07/19/21, and 09/01/21) in an attempt to commit suicide. This affected one Resident (#3) out of three residents (#3, #10, and #11) identified by the facility with a history of [CONDITION(S)]/attempts. The facility census was 89. On 09/08/21 at 4:53 P.M., the Administrator, Director of Nursing (DON), Assistant Regional Director of Clinical Operations #20, Assistant Director of Nursing (ADON) #25, and the Minimum Data Set (MDS) Nurse #26 were notified Immediate Jeopardy began on 05/18/21 when Resident #3, who had a known history of [CONDITION(S)] and attempts, was sent to the hospital on 05/18/21 for psychiatric evaluation and treatment due to an attempted suicide using an aluminum can. On 07/19/21, Resident #3 was walking down the hallway screaming out that he was bleeding and when asked what happened Resident #3 stated he was cut by an aluminum soda can opener on the inside of his left elbow and that the voices in his head told him to cut himself. On 09/01/21, Resident #3 was in his bathroom when the nurse arrived to give him his night time medications. When the nurse entered the bathroom, Resident #3 was standing and dripping blood from his left antecubital and neck from cuts. Resident #3 stated he cut his neck because he didn't have any money. The Immediate Jeopardy was removed on 09/09/21 when the facility implemented the following corrective actions: · On 09/08/21, Resident #3 was initiated on one-on-one observation indefinitely or until other arrangements could be made such as transfer to a psychiatric hospital. · On 09/08/21, resident room sweeps were conducted for Resident #3, Resident #10, and Resident #11. There were no negative findings. · On 09/08/21, DON or designee assessed all like residents to ensure proper interventions were in place for [CONDITION(S)] such as: counseling services, medication adjustment, behavioral health consultants, observation of signs or symptoms of [CONDITION(S)], and daily monitoring of thoughts and feelings. · On 09/08/21, the DON and ADON #25 placed notifications at the nurse ' s station and timeclock informing staff to notify the Administrator, DON, ADON #25, physician, and responsible party regarding events such as: elopements, falls with injury, injuries, [CONDITION(S)], thoughts or acts of harming others, and deaths. · On 09/08/21, the DON or designee educated all contracted agencies and informed them to educate all agency staff before sending them to the facility. The education included the following information: any resident that reports [CONDITION(S)] must be immediately placed on one-on-one supervision, and the responsible party must be notified immediately along with the DON, ADON, or Administrator. Additionally, the physician, and psychiatric physician are to be notified immediately for new orders. · By 09/09/21, all staff were educated by DON or designee that any resident who reports [CONDITION(S)] must be immediately placed on one-on-one supervision and the DON, ADON, or Administrator as well as the responsible party must be notified. Additionally, the physician and psych physician must be notified immediately for new orders. · DON or designee will audit for self-harm behaviors three times a week for four weeks to ensure residents with self-harm behaviors are placed on one-on-one supervision and that the Administrator, DON, ADON, physician, psych physician, and responsible party were notified appropriately. Although the Immediate Jeopardy was removed on 09/09/21, the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was transferred to a psychiatric hospital on 09/16/21 at 8:36 P.M. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact and required limited assistance with transfers and extensive assistance with dressing, eating, toileting, and personal hygiene. The assessment further revealed Resident #3 received anti-depressant and anti-psychotic medication. Review of Resident #3's care plan dated 05/18/21 revealed Resident #3 was at risk for fluctuation in mood and behavior related to diagnoses, denial of depression, and refusal to see a counselor. The care plan further revealed Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed no new interventions were implemented after 05/18/21. Review of the History and Physical dated 04/30/21 completed by Medical Director #31 revealed Resident #3 transferred from the hospital where he was admitted with paranoia and suicidal ideation. Review of the Psychiatric Evaluation Note dated 05/07/21 revealed Resident #3 had a long history of multiple hospitalization s and suicidal attempts. Resident #3 denied current suicidal or homicidal ideation and seemed to be doing fairly well in the nursing home. The note further revealed the plan was to monitor Resident #3's symptoms and then make changes in medication as needed and follow up in 12 weeks or earlier per the nursing home's discretion. Review of Resident #3's medical record revealed no evidence of any other psychiatric evaluation notes. Review of the nursing note dated 05/18/21 at 1:26 P.M. revealed Resident #3 was sent to the emergency room (ER) via medics 911 for psychiatric evaluation and treatment due to attempted suicide. Resident #3 was noted with dried blood to left wrist, forearm, and front of neck. Police and medics arrived at the facility in order to escort Resident #3 to the hospital. All paperwork was sent to the ER and the physician and family were notified. Review of the nursing note dated 05/21/21 at 6:42 P.M. revealed Resident #3 returned to the facility and was instructed to call for help when feeling unsafe or expressing suicidal thoughts. Staff remained present with Resident #3 for safety and Resident #3's room was searched for safety items. Review of the Interdisciplinary Team (IDT) Post Incident Summary dated 05/18/21 revealed Resident #3 was sent to the ER for evaluation and new interventions included increased supervision, check for items to be used as tools for harm, and allow resident to vent and verbalize feelings. Review of hospital ER documentation for services rendered on 05/18/21 revealed Resident #3 presented to theER on [DATE] after he stated he was hearing voices which told him to cut his wrist and throat. Resident #3 presented with cuts to his neck and left wrist which he made with a pop can at the facility. Resident #3 stated he has been at the facility for about a month and has been hearing voices and believed that he heard someone talking about him. Resident #3 eventually lacerated his left wrist and forearm. Resident #3 had multiple superficial lacerations. Resident #3 stated that the voices were telling him other things as well but he was unable to describe them. He stated he has heard voices in the past and occasionally they tell him to hurt himself. Resident #3 stated he does not want to hurt himself, but the past makes him do crazy stuff. Resident #3 stated he wanted to harm himself to punish himself over his prior behaviors. Resident #3 had a prior suicide attempt in 2013 when he lived with his mother. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing note dated 07/19/21 at 5:59 P.M. revealed Licensed Practical Nurse (LPN) #30 witnessed Resident #3 walking down the hallway screaming out that he was bleeding. There was blood coming out of the inside of Resident #3's elbow. When asked what happened, Resident #3 stated he was cut by an aluminum soda can opener. Resident #3 stated that the voices in his head told him to cut himself. There was a small cut approximately an inch wide on the inside of his left elbow, and distal to that, there was a small slit noted on his left forearm. Both cuts were cleansed with normal saline and bandaged. Due to the cuts and the amount of blood noted along with suicidal thoughts, Resident #3 was placed on temporary suicide precautions until the emergency medical team arrived on the unit. Resident #3 was sent to the hospital, on a stretcher, via ambulance at 5:30 P.M. The physician was notified, and a message was left for Resident #3's mother. Review of the IDT Post Incident Summary dated 07/19/21 revealed LPN #30 witnessed Resident #3 walking down the hallway yelling that blood was coming out of his elbow. Resident #3 stated he was cut by an aluminum can top and was hearing voices. Resident #3 had his left elbow cleansed with normal saline, a dry clean dressing was applied, and he was sent to ER. No new interventions were implemented at this time. Review of hospital record documentation for services rendered on 07/19/21 revealed Resident #3 presented to the ER from his long-term care facility with reports of an attempt at self-harm. He stated he was feeling suicidal for approximately 45 minutes before he arrived at the ER. Resident #3 stated that he took a soda can tab and cut his left wrist and left antecubital. A bandage was placed at the facility. Resident #3 reported that he still felt suicidal and denied homicidal ideation. He did not want to hurt anyone else but wanted to hurt himself, however, Resident #3 had no specific plan. Resident #3 had an extensive psychiatric history and had received psychiatric services for several weeks. Resident #3 had not tried any other treatments for his symptoms and nothing else seemed to make him better or worse. Review of the nursing note dated 07/20/21 at 2:20 A.M. revealed Resident #3 returned to the facility via stretcher. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #3 revealed no evidence of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nursing note dated 09/03/21, late entry for 09/01/21, revealed LPN #28 walked down to Resident #3's room to administer evening medications. LPN #28 called out to Resident #3 and Resident #3 stated I am in the bathroom; I will be out. The nurse continued to wait on Resident #3 to come out of the bathroom. LPN #28 then went into Resident #3's room and knocked on the bathroom door. Resident #3 stated come in, I have to show you something. The nurse opened the door and Resident #3 was standing, dripping blood from the left antecubital and neck from what appeared to be a cut. Resident #3 said he cut his neck because he didn't have any money. The area was assessed and bandaged. Resident #3 was sent the ER for further evaluation. The Medical Director, psychiatric physician, and family were notified. Review of the IDT Post Incident Summary dated 09/01/21 revealed Resident #3 created open areas to his arm and neck and a new intervention for staff to assess Resident #3 for feeling of self-harm/self-injury every shift, document, and notify medical director was implemented on 09/02/21. Review of the nursing note dated 09/02/21 at 2:02 A.M. revealed a room audit and safety check was completed for any items that could be used as a weapon. No items that could be used as a weapon were found in Resident #3's room at that time. Review of hospital documentation for services rendered on 09/01/21 revealed Resident #3 presented to the ER with complaints of a suicidal attempt and cutting behavior. Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was found in the bathroom at his facility earlier today with a safety razor cutting his neck and arm. Emergency 911 was called, a 72-hour hold was signed by police, and the resident was transported to the hospital without any significant intervention. Resident #3 reported he had increased auditory hallucinations that were telling him to harm himself. Resident #3 stated that he was still suicidal. Review of the Psychiatric Social Worker Assessment Consult Note dated 09/02/21 revealed Resident #3 cut his wrist and throat with a razor and stated he had nothing to live for. Resident #3 stated he was going through drawers in his room when he came across some razors. This is the third time in the past five months that Resident #3 tried to cut himself while at the facility. Resident #3 reported that he sees Doctor #31 for his medication. The last time Resident #3 saw Doctor #31 was about two and a half months ago. Resident #3 was not aware of any upcoming appointments with Doctor #31 and was not engaged in any counseling. Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 still vaguely endorsed self-injury and stated he didn't want to live. Resident #3 denied homicidal ideation and visual hallucinations and reported active auditory hallucinations with a female voice which told him to kill himself. Review of the IDT note dated 09/09/21 revealed new interventions were initiated for Resident #3 which included one-on-one supervision indefinitely for safety, daily room sweeps to ensure safety from potential weaponry, and resident to receive paper utensils indefinitely. Review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/02/21 at 10:40 A.M. with Resident #3 revealed his mom brought him pop cans when he was first admitted . Resident #3 would not state how he got the pop can in July 2021. Resident #3 stated in September 2021 he was going through his dresser looking for something to wear and found the razors. When asked how he was feeling, Resident #3 stated I'm okay, but now they are probably going to throw me out you know, strike three and all. Observation on 09/07/21 from 3:50 A.M. to 5:00 A.M. revealed no staff entered Resident #3's room to check on Resident #3's status. Interview on 09/07/21 at 5:00 A.M. with the DON, verified no staff entered Resident #3's room to check on him and someone should have at least twice. When asked about how frequently staff should check on Resident #3, the DON stated I don't know, but more often than that. Interview on 09/07/21 with State tested Nursing Assistant (STNA) #32, revealed she was unaware Resident #3 had suicidal ideation and was not told to check on him more often, so she was just doing her routine every two hours checks. Observation on 09/09/21 at 10:45 A.M., revealed STNA #33 was in the room with Resident #3. Resident #3 was lying down in bed with blankets covering his body. STNA #33 reported she stayed with Resident #3 during her entire shift from 7:00 A.M. to 7:00 P.M. Interview on 09/09/21 at 10:50 A.M., revealed Resident #3 reported he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 reported he did not want to stay in the facility because they want to get rid of him and throw him out. Resident #3 reported he can hear staff and residents talk about him outside of his door. Resident #3 stated he does not have any family and he is familiar with staff at the psychiatric hospital. Observation on 09/09/21 at 2:00 P.M., revealed Resident #3 was sitting in the common area with STNA #34. STNA #33 went on a 15-minute break. Interview on 09/09/21 at 2:21 P.M., revealed Assistant Director of Nursing (ADON) #25 reported STNAs were required to document every 15 minutes regarding Resident #3's feelings, behaviors and suicidal ideation. ADON #25 reported whichever staff monitored him more than 15 minutes must document his behaviors and attitude. Phone interview on 09/14/21 at 3:13 P.M. with LPN #29 revealed she only worked once at the facility on 07/19/21 and she was not familiar with Resident #3 but did remember that he had cut himself, but she was unsure of the time. LPN #29 reported that she saw the resident in the common area during lunch, then he went to smoke with the others, and the next time she saw Resident #3 was about 30 minutes later when Resident #3 had cut himself and was coming down the hall. LPN #29 stated she did not receive any information about Resident #3 having previous [CONDITION(S)]. Phone interview on 09/14/21 at 3:31 P.M. with STNA #33 revealed she could not remember details about Resident #3 cutting himself on 05/18/21 and 07/19/21, and she didn't remember receiving any training or information about Resident #3's history of [CONDITION(S)]. STNA #33 stated there was an in-service about a week ago but that was the only in-service and education she received regarding Resident #3. Phone interview on 09/14/21 at 4:48 P.M. with STNA #27 revealed she knew Resident #3 well. She stated Resident #3's triggers were not having any money, snacks, or cigarettes/[MEDICATION(S)], and if the resident didn't have any of that then he would get agitated, and his self-injurious behaviors would increase. STNA #27 reported after Resident #3 cut himself on 05/18/21 the ADON #25 said there were to be no cans accessible to residents on the floor, however, there was no formal in-service or education provided. STNA #27 was not sure how Resident #3 got the pop can on 07/19/21 but suspected he got it from activities since they bring a snack cart with pop to the floor for residents. STNA #27 stated on 09/01/21 she told the nurse that Resident #3 was upset due to not having any money or cigarettes. STNA #27 reported she was not sure how Resident #3 found the razor that he used to cut himself and stated it was the same kind of razor that the facility uses to shave residents. STNA #27 reported she was in-serviced on [CONDITION(S)] and what to do when a resident is exhibiting signs/symptoms and that Resident #3 was on one-on-one since 09/08/21. Observation on 09/15/21 at 12:30 P.M. of vending machines on the first floor revealed there were only two items in the machine that were pop cans, the rest were plastic bottles. Interview on 09/15/21 at 3:30 P.M. with Activity Aide #35 revealed they mostly use two liters for pop and the residents drink from a cup. She reported Resident #3 usually declines to join in the activities, and that she herself has never given Resident #3 a pop can. Phone interview on 09/15/21 at 3:10 P.M. with Medical Director #31 revealed when asked what he thought the facility should have done to prevent Resident #3 from inflicting self-harm, the Medical Doctor stated they should be following their policy and protocol. Review of the Suicide Threats Policy, dated 12/2007, revealed all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the residents' behavior immediately, if the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present, and staff shall document details of the situation objectively in the resident's medical record. This deficiency substantiates complaint number OH 406.

Based on medical record review, observations, staff interviews, review of witness statements, review of the facility restraint use policy, and review of facility abuse policies, the facility failed to ensure residents were free from any physical restraint imposed for staff convenience, to restrict movement, and not required to treat the resident's medical symptoms. This resulted in Immediate Jeopardy and the potential for physical harm, psychosocial harm, and mental anguish for one resident (#37) who, as any reasonable person would be, was dehumanized by being tied to the bed like an inanimate object with the use of bed sheets and was not being treated in a dignified manner in full recognition of their individuality. In addition, when two State tested Nursing Assistant (STNAs) #61 and agency STNA #93 reported to nurses (#76 and #82) that the resident was restrained with bed sheets, the nurses failed to report the allegation/observations immediately to the Administrator or to the Director of Nursing (DON). This affected one (#37) of four residents reviewed for abuse. The facility census was 92. On 02/12/21 at 12:12 P.M., the Administrator was notified that Immediate Jeopardy began on 02/01/21 at approximately 5:00 A.M. when Resident #37 was observed by agency STNA #93 restrained with two sheets tightly wrapped around her waist/torso and tied to the bed frame. STNA #93 untied/loosened one of the sheets and went to report her observation to other staff members, working on the same floor with her, including agency STNA #61 and facility STNA #63. The nurse for Resident #37, Registered Nurse (RN) #76, was not readily available when STNA #93 was looking for someone to report too, that Resident #37 was restrained with bed sheets. Both STNA #61 and STNA #63 went to Resident #37's room at separate times and witnessed the resident tied/secured to the bed with a bed sheet that had been rolled around her waist/torso with the end(s) tied to the bed frame. STNA #93 was present when STNA #61 and #63 observed the resident restrained in bed. STNA #93 also reported she had observed the resident restrained in bed with bed sheets to RN #82, on the adjacent unit, who told her to report to RN #76 the nurse assigned to Resident #37. By the time RN #76 came to Resident #37's room, STNA #93 had completely untied the sheet(s), but STNA #93 reported to RN #76 that she had found the resident restrained in bed with the use of bed sheets. Neither RN #76 or RN #82 reported STNA #93's observations or allegations regarding the resident being tied in bed to the Administrator or to the DON. STNA #61 contacted the DON on 02/02/21 during the afternoon regarding the allegations of Resident #37 being restrained/tied; however, no actions were taken to thoroughly investigate the allegations, report the allegation of abuse/mistreatment to the Ohio Department of Health (ODH), or measures implemented to protect Resident #37 or like residents until 02/04/21. The Immediate Jeopardy was removed on 02/12/21 at 2:00 P.M. when the facility implemented the following corrective actions: · On 02/04/21 at 4:29 P.M., the DON submitted a facility Self-Reported Incident (SRI) regarding the allegation of Resident #37 being restrained with bed sheets, and an investigation into the incident was initiated including interviews of agency and facility nursing staff who were present during the night shift of duty on 01/31/21. The DON submitted the SRI after the surveyor informed the DON a staff person had indicated the resident was restrained in bed with a bed sheet. · On 02/04/21 at 4:59 P.M., Licensed Practical Nurse (LPN) #39 completed a full body assessment of Resident #37 with no negative findings. The resident did have a fading bruise to the left side of her face from a fall that occurred on 01/21/21. · On 02/04/21 at 5:00 P.M., Clinical Advisor LPN #200, the Administrator, and/or DON conducted in-service education of all staff present in the facility regarding the facility Abuse Policy, Reporting of Abuse, Resident Rights, Restraint Policy, and Social Media Policy. The education was completed on 02/12/21 at 2:00 P.M. when 100% of all staff had been educated. · On 02/04/21 at 6:14 P.M., Clinical Advisor LPN #200 notified Resident #37's physician regarding the incident. · On 02/04/21 at 7:00 P.M., the DON and/or Clinical Advisor LPN #200 began interviewing all facility staff who cared for the resident before or at the time of discovery of the resident being restrained. Interviews were conducted with RN #76, STNA #14, STNA #58, and STNA #61. Interviews were completed on 02/05/21 at 3:00 P.M. Written statements were also requested from each staff member. · On 02/04/21 at 7:00 P.M., the facility prohibited any agency staff person from providing one-to-one (1:1) care to Resident #37 and Resident (#52) who also required 1:1 care. This was added to the nurse/nurse aide assignment sheet. It was posted that only facility staff could provide 1:1 care to residents, and a facility staff member was assigned by the DON for each shift. · On 02/04/21, facility STNA #58 was suspended pending facility investigation into the incident. STNA #58 was assigned to Resident #37 on 01/31/21 from 7:00 A.M. to 7:00 P.M. prior to agency STNA #93 being assigned to provide 1:1. · On 02/04/21, Social Services Designee (SSD) #05 completed interviews with all interviewable residents on the second floor regarding any concerns with their care. There were no negative findings. · On 02/05/21 at 9:00 A.M., the DON placed agency STNA's #63, #70, and #93 on indefinite hold from returning to the facility pending investigation. · On 02/05/21 at 6:19 P.M., LPN #45 notified Resident #37's family/representative regarding the incident. The family/representative did not want the authorities contacted. · On 02/09/21, STNA #58 was permitted to return to work, then was removed from the schedule again on 02/12/21, pending investigation of additional information provided by the nurse aide. · On 02/12/21 at 7:00 A.M., LPN #39 provided education to agency staff on facility policies regarding Abuse, Reporting of Abuse, Resident Rights, Restraint policy, and Social Media policy. Education is to be provided to agency staff as they are scheduled to work. The education will be on-going as new agency staff are sent to work at the facility. The education will be provided by the DON/designee. · On 02/12/21, at 8:00 A.M., Human Resources Staff (HRS) #40, was notified to ensure all new employees receive education during orientation on the facility policies regarding Abuse, Reporting of Abuse, Resident Rights, Restraint Policy and Social Media policy. · On 02/12/21, the facility implemented auditing to be conducted three times a week for four weeks, then once a week for four weeks, to ensure that staff understand what abuse is and how and who to report abuse to. The audits will also include assessments of residents to ensure no restraints are being used. This audit will be conducted by the DON/designee. · On 02/12/21, an audit was completed to monitor which staff person provided the 1:1 care to Resident #37 and #52. · On 02/12/21, from 9:00 A.M. to 11:00 A.M., Clinical Advisor LPN #200 completed an audit of all facility residents to ensure no physical restraints were used, with no negative findings identified. · On 02/08/21, STNAs #51, #61, and LPN #52 were interviewed, on 02/09/21, STNAs #58 and #88 were interviewed, and on 02/10/21, LPN #94 was interviewed, regarding the facility's policies and procedures regarding prohibition of abuse/neglect and mistreatment and reporting of resident abuse/neglect and mistreatment. All staff interviewed reported they had received in-service education on the facility's abuse/neglect and mistreatment prohibition and reporting policies and procedures, and were able to verbalize actions to take regarding protecting residents and reporting suspicions, allegations, or observations of abuse/neglect or mistreatment of [REDACTED]. Although the Immediate Jeopardy was removed on 02/12/21, the facility remained out of compliance as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility in August of 2016. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits, poor memory and recall, inattention and disorganized thinking which changed in severity, and wandering and other behavioral symptoms daily. The resident required physical assistance of one staff person to complete all Activities of Daily Living (ADL), and used no physical restraints or alarms. Review of fall risk assessments dated 01/10/21 and 01/21/21 revealed the resident was at high risk for falling. Review of the resident's physician's orders dated 01/25/21 revealed an order to monitor the resident 1:1 due to the resident's lack of safety awareness and to assist with a decrease of falls/injury. The resident did not have any order for any physical restraints or personal safety alarms. Review of the resident's current comprehensive plan of care, with a target date of 04/01/21, revealed a goal was for the resident to remain free of injury due to falls through the next review. The care plan identified the resident as being at risk for injury due to falls related to a need for assistance with ADLs, a shuffling gait, impaired balance, difficulty negotiating high traffic areas, having a [DIAGNOSES REDACTED]. The care plan also noted the resident with a behavior of sitting on the floor in the hall or other areas to rest related to compulsive walking. The interventions included 1:1 monitoring of the resident due to the resident's lack of safety awareness and to assist with decreasing falls/injury. Observation of the resident on 02/04/21, at 4:12 P.M., revealed the resident resting quietly in a low bed with STNA #59 sitting in a chair directly next to the resident's bed. The right side of the resident's bed was along the wall, and the resident was facing the wall. She had a fading bruise on the right side of her head from a fall from a couple of weeks ago (per STNA #59). The nurse aide stated the resident was able to ambulate, but was not safe to ambulate on her own due to unsteadiness and risk of falling. STNA #59 reported the resident's hospice aide had just left and the hospice aide had given her a bath/shower. Interview with agency STNA #63 on 02/04/21 at 5:19 P.M., revealed she was assigned to work the second floor during the night shift of duty on 01/31/21 through the morning of 02/01/21 (7:00 P.M. - 7:00 A.M.). She reported she was on the North Hall with RN #82 and facility STNA #61. Agency STNA #63 stated on the other hall, South Hall, there was RN #76, and three STNAs; one male and two females. The three STNAs present on the South Hall, included facility STNA #14, and agency STNAs #70 and #93. STNA #63 shared that STNA #93 did not come up to the second floor until after the start of the shift, and STNA #93 was assigned to take care of Resident #37, who required a 1:1 sitter. Agency STNA #63 communicated during the morning of 02/01/21, sometime close to the end of the shift, agency STNA #93 was questioning who the aide was that was assigned to Resident #37 before her. STNA #93 was asking for the nurse, as she needed to report something to the nurse. STNA #63 reported STNA #93 went back to sit with Resident #37. Not long after that, STNA #93 was again questioning who the aide was that took care of Resident #37 before her. STNA #93 then said something about Resident #37 being wrapped up or tied up, and that she hadn't remove it as she wanted the nurse to see it. STNA #63 communicated she went to see Resident #37 and she saw the resident lying on her side, facing the wall, and a sheet wrapped around her stomach/hip area, and saw the end of the sheet tied to the bed. She stated she thought that both ends of the sheet were tied to the same side of the bed. STNA #63 stated that STNA #93 told her that there were three sheets at first, but STNA #93 had removed two as they were tied tight and she left the one so the nurse could see it. STNA #63 communicated after she left the room, and returned to her area/hall, she saw facility STNA #61 walking from the direction of Resident #37's room, and RN #76 walking towards Resident #37's room. She stated since she saw RN #76 going to Resident #37's room, she believed STNA #93 would report to RN #76 about Resident #37 being tied in bed. Interview with agency STNA #93 on 02/05/21 at 2:55 P.M., and on 02/08/21 at 2:10 P.M., along with review of her witness statement dated 02/09/21 revealed she was assigned to provide 1:1 supervision and care for Resident #37 on 01/31/21. STNA #93 stated when she arrived for night shift of duty on 01/31/21, she was originally assigned to the first floor. Around 7:30 P.M., she was sent up to the second floor and was assigned to provide care and 1:1 with Resident #37. She communicated when she arrived on the second floor there was another agency nurse aide, STNA #70, in the room/checking on the resident, and then STNA #93 took over. STNA #93 stated that STNA #70 kept coming into the room and telling her the resident was fine, that she had changed her, and she was dry. She shared that both STNA #70 and facility STNA #14 had sat with Resident #37 when she took her breaks. STNA #93 reported she checked the resident for incontinence and changed the resident around 3:00 A.M. and did not notice any restraint but communicated she did not remove the top sheets off the resident when doing this or observed under her bed gown. She stated at about 5:00 A.M. she removed the resident's sheets/cover to check the resident and this was when she observed the resident's upper waist/below breasts was restrained with what appeared to be two sheets. STNA #93 described the sheets as being tied around her waist and connected, twisted in a roll, two sheets tied together then bunched under the bed springs and tied to the bed frame in knots. She reported to the best of her knowledge the resident was not restrained like that when she started sitting with the resident at 7:30 P.M. STNA #93 stated she removed one of the sheets, and left one tied to go find the nurse so the nurse could be witness. The nurse was not on the floor, and she reported what she observed to agency STNA #63 and facility STNA #61. STNA #93 communicated she also tried to report what she observed to the other nurse on the floor, RN #82, but he told her to go report to the resident's nurse, RN #76 . She stated RN #82 did not come to observe the resident while she was restrained. STNA #93 affirmed that facility STNA #61 did witness Resident #37 tied to the bed. STNA #93 stated by the time RN #76 came to Resident #37's room she had completely untied the resident, as she was not going to leave her like that. She stated she reported to RN #76 that she had found the resident restrained/tied to her bed with bed sheets. STNA #93 communicated during interview, and also documented in her written statement, that STNA #70 was present when RN #76 came to the room, and STNA #70 admitted that she had done it but she hadn't tied it tight and the sheet was just laying/wrapped around the resident. STNA #93 verbalized she reported what she observed to both RN #82 and RN #76 at the time of discovery. She stated neither nurse asked her to write a statement. She expected the nurses would report the incident to the Administrator/DON. STNA #93 denied the resident was struggling, during the night, to get out of bed while she was sitting with her throughout her shift of duty. Observation of the resident on 02/08/21, at 12:00 P.M., revealed the resident was resting quietly in a low bed with STNA #104 sitting in a chair positioned directly next to the bed. STNA #104 reported the resident was able to ambulate but was unsafe to do so on her own. She stated she walks with the resident during the day when the resident wants to walk. Interview with STNA #61 on 02/08/21 at 2:26 P.M., and review of her written witness statement dated 02/04/21, revealed STNA #61 observed Resident #37 restrained in her bed via the use of a sheet tied or tucked tightly into the bed frame. STNA #61 explained the sheet was rolled and wrapped around the resident's waist with one end tied to the sheet making a loop around the resident's waist/torso, and the other end was either tied or tucked tightly into the bed frame, stating that when the end of the sheet in the frame was pulled it did not come loose. She stated it was not something the resident could do on her own. STNA #61 reported during interview during the morning of 02/01/21, near the end of the night shift of duty, agency STNA #93, who was assigned to sit with Resident #37, asked her to come to the resident's room to see something. STNA #61 stated when she went to the resident's room, she observed a sheet tied around the resident's waist, and the end of the sheet was tied to the bed frame. She shared that STNA #93 asked if tying the resident to the bed was something the facility normally did, and she told the nurse aide no it was not, and the incident needed to be reported. STNA #61 communicated that STNA #93 did not untie the bed sheet at that time as she wanted the resident's nurse, RN #76, to see it. She stated she went and told the nurse (RN #82) who she was working with, about what she observed. STNA #61 reported she saw the resident's nurse (RN #76) on a smoke break with agency STNA #70. She explained STNA #70 was at the door to the smoke room and she asked STNA #70 to ask RN #76 if she was aware Resident #37 was tied to the bed, and if RN #76 was going to come see the resident. STNA #61 indicated that STNA #70 said that RN #76 said to just untie her. STNA #61 indicated she did not speak directly with RN #76. She went back to Resident #37's room and told STNA #93, that STNA #70 said, RN #76 said to untie the resident. STNA #61 denied ever seeing the resident struggling to get out of bed while restrained. She explained she tried to report the incident of Resident #37 being restrained to Assistant Director of Nursing (ADON) #43 on Monday 02/01/21 but her call was not returned. STNA #61 stated on Tuesday 02/02/21 she reported the incident to the DON about Resident #37 being restrained, and the DON told her to write a statement when she came in. Interview with STNA #58 on 02/09/21 at 3:36 P.M., along with review of a written witness statement dated 02/05/21 revealed STNA #58 was providing 1:1 care to Resident #37 on 01/31/21 from 7:00 A.M. through 7:00 P.M. STNA #58 reported during interview the resident was up and walking around the unit a couple of times, and that she was active during the day. The resident was up in her chair for all meals that day and STNA #58 spoon fed her. She explained typically when the resident walks, it is just for a minute or two and then the resident tries to drop to the floor. STNA #58 reported on the evening of 01/31/21, when she left, she covered the resident with an extra sheet and gave the resident her bear, and then left. She denied the resident was restrained when she left. She stated the oncoming staff was still deciding who was going to sit with the resident as a specific staff person had not yet been assigned. Interview with Unit Manager LPN #45 on 02/09/21 at 3:48 P.M., revealed Resident #37 had been on 1:1 supervision since at least the end of December 2020. Observation of the resident on 02/10/21 at 11:45 A.M. revealed the resident was up sitting in a chair directly facing STNA #104 who was also sitting in a chair directly in front of the resident. The resident was in street clothes and noted with good grooming and hygiene. She did not make eye contact or acknowledge the surveyor when greeted. STNA #104 stated the resident was up for lunch, and they were waiting on the resident's lunch to arrive. The nurse aide had to support the residents left elbow so the resident could sit up straight in the chair as she was leaning to the left over the side of the chair. When the resident's food came, STNA #104 fed the resident in an unhurried manner. The resident was noted to have a good appetite at the time of the observation. Observation of the resident on 02/10/20 at 1:37 P.M. revealed the resident was still dressed in street clothes and sitting up in bed. She appeared restless and agitated as evidenced by rocking and cursing loudly and repetitively, but not necessarily at anyone. STNA #104 was still providing 1:1 care. The resident appeared to be delusional and yelling and cursing at a person(s) that was not present. She was trying to lean and/or climb out of the bed. STNA #104 positioned her chair mid bed, and calmly talked to the resident and attempted to reposition the resident from coming out of the bed. STNA #104 stated that this was typical behavior for the resident when she was agitated, and that the resident would sometimes just drop to the floor from the standing position when walking. Review of STNA #58's witness statement dated 02/15/21, which was obtained after the facility completed further investigation, revealed the nurse aide admitted to swaddling the resident with a sheet and tucking it under the moveable part of the rail. She added in the statement that no one was in the room with the resident at that time and she didn't want the resident to fall. Review of the facility policy titled Restraint Use in the Facility dated 03/23/15 specified the facility was restraint free. The policy included the following language: this means that no physical restraint may be used on a resident for convenience or punishment. Furthermore, the physician must be aware and have ordered any appliance that is utilized on any resident. Review of the facility policy titled Abuse Investigation and Reporting revised in 03/2019 revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatments and/or injuries of unknown source shall be promptly reported to local, state and federal agencies, as defined by current regulations and thoroughly investigated by facility management. Review of the facility policy titled Abuse Prevention Program revised on 03/2019 revealed residents of the facility had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This policy defined abuse/neglect to include 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. Review of the facility policy titled Preventing Resident Abuse revised in 02/2021 revealed the facility's abuse prevention/intervention program included but was not necessarily limited to, the following: Direct all personnel, residents, family members, visitors, or any person who is aware of signs, reports, or suspected incidents of abuse to immediately report to members of facility supervision or management. Members include the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse, Human Resources, Admissions, Dietary Manager, Social Service Designee, Activities Director, or Charge Nurse. This deficiency substantiates Complaint Number OH 973.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, observation, interviews, review of facility self-reported incident (SRI), review of policy for portable lifting machine and review of falls clinical protocol policy the facility failed to ensure a Resident was properly transferred. This affected one Resident (#7) of four residents reviewed for abuse. This resulted in actual harm to Resident #7 who sustained a fracture as a result of an improper transfer. The facility identified 11 residents whom required a mechanical lift for transfers. The facility census was 93 Residents. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) comprehensive assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with transfers, and Resident #7 was totally dependent for toileting and personal hygiene. Review of a care plan dated 06/05/15 revealed a hoyer lift (mechanical lift) with two person assist was to be utilized for all transfers. Review of the nursing progress note dated 05/12/16 at 10:30 P.M. revealed Resident #7 was observed with a large area of swelling and slight discoloration to the right upper thigh. Resident #7 was agitated and refused to allow the nurse to touch or assess the area. A physician order [REDACTED]. Review of the right hip x-ray dated 05/13/16 revealed acute fracture of the right femur (thighbone). Review of the orthopaedic surgery consult note dated 05/13/16 revealed right intertrochanteric hip fracture with recommended operative treatment for [REDACTED]. The resident was discharged from the hospital back to the facility on [DATE] as the family declined surgery. Review of the physician progress notes [REDACTED].#7 fell recently which resulted in a right hip fracture. The resident does not ambulate and family opted for no surgical treatment. Review of the facility SRI tracking number 8 dated 05/12/16 revealed Resident #7 was found in bed on 05/12/16 at 9:00 P.M. with discoloration to the right leg, right hip, and right buttocks. Upon assessment by the nurse, redness and swelling were observed from the right buttocks to the thigh and Resident #7 guarded his leg and would yell at staff as attempts were made to assess the leg. Resident #7 was transferred to the hospital for further evaluation. On 05/13/16, it was discovered Resident #7 had a fractured femur. An investigation was initiated and all staff who had worked the days prior were interviewed. State tested nursing assistant (STNA) #98 cared for Resident #7 on 05/12/16 and had placed him in bed prior to the injury to his leg being discovered. STNA #98 denied Resident #7 had any injuries including redness, swelling, or bruising to his body upon being placed in bed on 05/12/16 at 6:00 P.M. STNA #98 reported Resident #7 was transferred with the use of a mechanical lift to bed without the assistance of any other staff member but denied Resident #7 fell or obtained any injuries during the transfer. STNA #98 was unable to explain the reasons Resident #7 was placed in bed unusually early for his routine. Resident #7 was interviewed at the hospital on [DATE] at 2:00 P.M. by the Director of Nursing (DON) and by Assistant Director of Nursing (ADON)#47 and reported staff didn't use the hoyer lift and dropped him on the floor. An observation on 08/18/16 at 3:14 P.M. revealed Resident #7 was seated in the hall in a wheelchair with legs elevated. An interview with Resident #7 at the time of the observation reported his leg wasn't alright but he was unable to provide any further information due to his altered mental status. An interview on 08/18/16 at 3:38 P.M. with ADON #47 and the Administrator reported on 05/12/16 STNA #95 went to provide incontinence care to Resident #7 at 9:00 P.M. and discovered discoloration to the right leg, hip, and buttocks. STNA #95 informed the nurse who immediately assessed the resident and discovered discoloration and swelling to the right leg. The resident guarded his leg when staff attempted to touch the leg. Resident #7 was transported to the hospital for evaluation. The hospital notified the facility on 05/13/16 at 5:00 A.M. that Resident #7's right femur had a complete fracture. All staff whom provided care to Resident #7 were interviewed. STNA #98 was interviewed and reported there weren't any problems transferring Resident #7 to bed on 05/12/16. Resident #7 was a hoyer lift transfer and two staff were required for transfer. Upon further questioning, STNA #98 admitted Resident #7 was transferred without the assistance of another staff member and she had given false information in order to keep her job. STNA #98 denied any injuries to Resident #7 when he was placed in bed and denied any incidents with the transfer or of Resident #7 falling on the floor. Resident #7 was interviewed on three separate occasions on 05/13/16 and again upon return from the hospital on [DATE] and reported on all occasions that a staff member transferred him without the hoyer lift and dropped him on the floor. Resident #7 would not have been physically capable of independently getting off the floor had he fallen. Based upon observation of the injury compared to the bruising chart guidelines and medical text, it was determined the injury occurred on 05/12/16. Resident #7 reported he was dropped related to an inappropriate transfer and there wasn't any other reasonable explanation to explain the injury. Interview on 08/18/16 at 4:28 P.M. with former STNA #98 reported she placed Resident #7 in bed on 05/12/16 with a mechanical lift without the assistance of any other staff member. STNA #98 denied any incidents with the transfer or any injuries to Resident #7 at the time he was placed in bed and reported Resident #7 would not be physically capable of independently getting up after a fall. STNA #98 reported it was facility protocol for two staff members to be present with use of a mechanical lift and she did not provide an explanation for the failure to obtain required assistance. Review of the policy for using a portable lifting machine policy last revised 2016 revealed two STNA's or nurses were required to perform this procedure. Review of a clinical protocol for falls revised 04/2013 revealed the staff will evaluate and document falls that occur while the individual is in the facility including when and where they happen and any observed events. The deficiency was corrected on 05/19/16 when the facility implemented the following actions: · On 05/13/16 STNA #98 was interviewed, placed on leave pending an investigation, and terminated for inappropriately transferring a Resident. · · On 05/13/16, all nursing staff were in-serviced by Licensed Practical Nurse (LPN) nurse educator #64 on fall protocol and mechanical lift policy and procedures including demonstration of proper technique and skills checklist. A repeat in-service was conducted with all nursing staff on 06/22/16 and 07/22/16. In-services are to be completed monthly for six months. · · On 05/18/16 all components of all the facility mechanical lifts were inspected for proper functioning. Repeat inspections were completed on 06/17/16 and 07/29/16. Inspections (monitoring) of the mechanical lifts are to be completed monthly for six months. · · · On 05/19/16 a weekly risk meeting was held to review current falls. This monitoring is to be completed weekly for the next six months. · On 05/19/16 a quality assurance committee meeting with the medical director and the DON was held and the injury to Resident #7 was reviewed.

Based on observation, medical record review, and staff interview, the facility failed to provide nutritional supplements for residents to prevent weight loss. This resulted in actual harm to Resident #94, who suffered a significant unplanned 15.8% weight loss of 31 pounds over 180 days. The facility also failed to provide all supplements as ordered for Resident #61 to improve oral intake and deter weight loss. Three residents were reviewed for nutritional status, of 22 Stage 2 residents sampled. The census was 94 residents. Findings include: Resident #94 was admitted to the facility 10/07/13 with [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed Resident #94 was severely cognitively impaired, suffered delusions, [MEDICAL CONDITION], and disorganized thinking, and at times rejected care. Resident #94 required only set up for meals and fed himself. Review of the Weight Records for Resident #94 revealed a significant weight loss over 180 days. In January 2014, the resident weighed 196 pounds and was 70 inches tall; February 2014, 184 pounds; March 2014, 181 pounds; April 172 pounds, which represented a 12.2% weight loss over 90 days (three months); May 2014, 169 pounds; June 162 pounds; and July 2014, 165 pounds, which represented a 15.8% weight loss over 180 days (six months). Review of the Care Plan initiated 04/16/14, revealed Resident #94 was identified at risk for significant weight loss with the intervention, "supplements as ordered". Review of the dietary notes by Dietetic Technician (DTR) #246, dated 04/21/14 at 11:09 A.M., revealed the significant weight loss of 11% was identified. On that date, RD #153 recommended the initiation of 240 milliliters (mls) of a nutritional supplement three times daily for additional calories and protein to promote weight maintenance. Review of the Nutritional Assessment for Resident #94, dated 05/05/14, revealed Resident #94 was assessed and identified to have a significant weight loss of greater than 5% over 30 days, greater than 7.5% over 90 days, and greater than 10% over 180 days. Resident #94 was assessed as able to self feed. A review of the physician orders dated 10/07/13, 01/01/14, 02/01/14, 03/01/14, 04/01/14, 05/01/14, 06/01/14, and 07/01/14 revealed a diet order for a mechanical soft diabetic, low cholesterol. There was no physician order for [REDACTED]. Review of the Meal Intake Record for Resident #94 dated October 2013, November 2013, February 2014, March 2014, April 2014, and July 2014 revealed Resident #94 consumed approximately 80% of recorded meals. There were no documented meal intakes for December 2013, January 2014, May 2014, and June 2014. On 07/15/14 at 5:34 P.M., Resident #94 was observed in the dining room with his supper meal served. Resident #94 immediately fed himself the meal including fish, carrots, potato steak fries, and a lemonade beverage. There was no nutritional supplement served with the meal. Resident #94 consumed 100% of the meal. On 07/16/14 at 12:30 P.M., Resident #94 was observed in the dining room. Resident #94 fed himself and consumed 75% of the lunch meal including beans and ham, mixed vegetables, a whole wheat roll, fruit cocktail, and a cold beverage. Resident #94 did not receive a supplement or extra servings of food. On 07/17/14 at 8:15 A.M., Resident #94 was observed to feed himself 100% of the breakfast meal including eggs, meat, juice, and coffee. On 07/17/14 at 12:25 P.M., an interview with DTR #246 revealed the facility protocol for dietary recommendations dictated all recommendations were given to the facility Nursing Unit Supervisor, who then communicated the recommendation to the Primary Care Physician (PCP) for orders to put the recommendation in place. Also, DTR #246 and RD #153 were to follow up on all dietary recommendations to establish effectiveness. DTR #246 revealed the dietary recommendation for a nutritional supplement for Resident #94 was never communicated to the PCP, thus Resident #94 never received any supplement and continued to lose weight. In addition, DTR #246 revealed she and Registered Dietitian (RD) #153 failed to follow up regarding the recommendation for a nutritional supplement which contributed to Resident #94's significant unplanned weight loss. During interview on 07/17/14 at 12:30 P.M., the Director of Nursing (DON) corroborated these findings. Review of the facility policy, Weight Policy and Procedure, undated, revealed, "The Registered Dietician/Diet Technician assesses each resident with a significant weight change, makes appropriate recommendations to physicians, and updates the resident's plan of care. A significant weight loss is indicated by: 3% weight loss over 14 days, 5% weight loss over 30 days, 7.5% weight loss over 90 days, 10% weight loss over 180 days." 2. Resident #61 was originally admitted to the facility in 2011, and most recently readmitted to the facility 04/17/14 after hospitalization related to a right [MEDICAL CONDITION]. Review of Resident #61's medical record revealed the resident had [DIAGNOSES REDACTED]. The facility completed a significant change comprehensive assessment of the resident dated 04/24/14 which identified the resident as having short and long term memory problems, poor recall, being rarely understood or understanding others, and requiring the physical assistance of at least one staff person to complete all activities of daily living including eating. Review of Resident #61's comprehensive plan of care revealed a care plan for altered nutrition initiated 03/31/14. Interventions included providing a frozen nutritional supplement at each meal, and providing supplements as ordered. Review of Resident #61's medical record revealed current physician's orders for a regular pureed diet with thin liquids, frozen nutritional supplement (4 ounce) three times a day with meals, and 480 milliliters of house supplement three times a day with meals. Resident #61's weight records were reviewed and revealed that each resident's monthly weight was taken during the first five days of each month. Resident #61's 2014 monthly weights were recorded as follows: April, 182 pounds; May, 170 pounds; June, no weight recorded; and July,15 pounds. In addition, there was one weekly weight recorded the week of 05/19/14 of 157 pounds. Review of Resident #61's food intake records for July 2014 revealed the resident routinely consumed less than 50% of food served, which was characterized on the intake record as the resident having a poor appetite. However, documentation reflected the resident had fair to good consumption of dietary supplements offered. RD #153 completed a dietary progress note on 04/09/14 at which time she documented the resident's weight was obtained on that date and was 176 pounds, and the resident had no pedal [MEDICAL CONDITION]. RD #153 noted the resident was refusing most foods and that supplementation would be trialed and recommended to prevent weight loss. On 06/30/14 DTR #246 completed a nutritional assessment of Resident #61. DTR #246 documented the resident was at risk for altered nutrition due to progressing senile dementia and history of [MEDICAL CONDITION]. She noted the resident resident required assistance to finish a meal however he would refuse, is a poor self feeder, and is unaware of his nutrition/hydration needs. DTR #246 documented the resident was noted to have a history of enjoying sweet food. Two servings of house supplement and frozen nutritional supplement would be provided each meal in an attempt to provide sweets with additional calories in an effort to promote weight maintenance, and the resident's family would also bring in sweets/favorite foods in an effort to promote oral intake. However, DTR #246 noted the resident is now refusing these items which the Registered Dietitian discussed with family. Staff continues to encourage increased oral intake however the resident will turn his head and state " I am done". She documented that the resident consumes his supplements well at times and often will be the only items consumed during meals. DTR #246 summarized at the end of the assessment that unavoidable/anticipated weight loss is noted for Resident #61 due to "intractable" oral intake, resistance to nurse aides during meal, history of [MEDICAL CONDITION], and progressing dementia. Resident #61 was observed in his room, in bed, being assisted with his supper meal on on 07/15/15, at 5:43 P.M., by STNA #16. The resident was alert, with confusion and had limited communication skills. Resident #61 had his supper tray in front of him which included pureed food per the planned menu and two eight ounce glasses of house supplement. However, there was no 4 ounce container of frozen nutritional supplement with the meal as ordered by the physician. STNA #16 affirmed that there was no frozen nutritional supplement on his meal tray when discovered by the surveyor. She reported it should have been sent from the kitchen with his meal. Resident #61 was and was attempting to drink his supplement, and feed himself a couple bites. STNA #16 stated the resident prefers sweets and did not want his supper tonight. STNA #16 went to kitchen to retrieve a frozen nutritional supplement for the resident after the surveyor discovered it was not on the tray. Review of the resident's tray card indicated that a frozen nutritional supplement was supposed to be served with each meal. On 07/16/14, at 8:32 A.M., Resident #61 was in his room in bed being assisted with his breakfast by STNA #137. The resident received a pureed diet with two eight ounce glasses of house supplement. However, there was no 4 ounce container of frozen nutritional supplement with the meal as ordered by the physician. STNA #137 affirmed that no frozen nutritional supplement had been served with the resident's breakfast when it was discovered by the surveyor. The resident refused his breakfast, but did drink eight ounces of the house supplement. Review of the resident's tray card indicated that a frozen nutritional supplement was supposed to be served with each meal.

Based on record review, observation and staff interview, the facility failed to ensure a resident assessed as a fall risk, received assistance to prevent a fall with injuries. This resulted in harm for one resident (#11) of three residents reviewed for falls. Resident #11 suffered a right tibia and fibula fracture and a left tibia fracture as a result of the fall. This had the potential to affect 94 residents in the facility on that day identified by the facility as being at risk for falls. Findings include: Resident #11 was admitted to the facility in 2007 [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] indicated Resident #11 was totally dependent on staff for bed mobility and transferring, required 2+ person assistance by staff. Review of the facility fall risk assessment dated [DATE] indicated Resident 11 was deemed a "20"; any rating above a 10 indicated a high risk for falls. A risk for falls care plan was in place dated 03/15/10, with a goal date of 06/30/12. Interventions included: hoyer lift (a mechanical lift) for transfers and ? side rails. Review of the nurse's notes dated 04/30/12 at 1:00 A.M. indicated Resident #11 sustained a fall while being turned in bed by staff. The nurse's notes indicated Resident #11 flipped out of the bed below the side rail and fell on to the floor before staff could stop him from falling. The physician was notified and requested Resident #11 be sent to the hospital for evaluation. Review of the hospital discharge record dated 04/30/12 revealed Resident #11 was diagnosed with [REDACTED]. Review of the Medication Administration Record (MAR) for April 2012 revealed no narcotic pain medication requested by the resident. Review of the MAR for May 2012 revealed Resident #11 required 13 doses of narcotic pain medication so far in May due to complaints of leg pain. On 05/15/12 at 10:00 A.M. an observation was made of Resident #11 lying in his bed, he was not interviewed due to cognitive deficits. His bed was in the low position, mats were beside the bed on the floor and there were ? side rails in place. On 05/15/12 at 10:00 A.M. an interview with Licensed Practical Nurse (LPN) #2 was conducted. She stated the facility investigation revealed Resident #11 was being assisted in bed by State tested Nurse Aide (STNA) #3. LPN #2 stated STNA #3 was turning Resident #11 in bed towards himself and Resident #11 somehow came out of the bed and onto the floor. She stated there was another STNA in the room, but he was in the bathroom getting supplies and was not assisting with Resident #11. On 05/15/12 at 1:55 P.M. an interview with the Director of Nursing (DON) was conducted. She affirmed Resident #11 currently has ? side rails, not ? as indicated in the plan of care. She affirmed the side rails on the bed were the same that were in place prior to the fall on 04/30/12. On 05/15/12 at 2:30 P.M. LPN#2 affirmed the facility investigation determined STNA #3 was at fault for attempting to move Resident #11 without assistance. LPN #2 stated STNA #3 was counseled and educated that night about proper transferring of a dependent resident. On 05/15/12 at 2:50 P.M. an interview was conducted with STNA #1. He stated he was in the room assisting STNA #3 at the time of Resident #11's fall. STNA #1 stated he told STNA #3 to wait before moving Resident #11 while he gathered needed supplies. He stated STNA #3 moved Resident #11 anyway, and Resident #11 landed on the bare floor on his knees. He stated he told Resident #11 to remain still and summoned the nurse for assistance. Resident #11 was then sent to the hospital for treatment. On 05/15/12 at 4:00 P.M. an interview was conducted with STNA #3 who was providing care to Resident #11 the night of the incident. He stated he was in Resident #11's room with STNA # 1 and turned Residents #11 in bed towards him without the assistance of STNA #1. STNA #3 stated Resident #11 began to slide on the sheets and he was unable to stop Resident #11 from sliding to the floor. He stated Resident #11 slid knees first and landed on the floor. STNA #3 stated he knew he should not have attempted to move the resident without assistance. On 05/16/12 at 6:30 A.M. an interview was conducted with LPN #10 who was working the night of the incident. She stated she was at the nurse's station and heard STNA# 3 call for help. When she entered the room, Resident#11 was on the floor, on his knees, sitting upright. She stated Resident #11 was assessed and sent to the hospital via emergency squad. She stated Resident #11 was always a two person assist and required a hoyer lift to get out of bed. She stated Resident #11's lower legs were stiff so he was prone to sliding when care is provided. She stated that when STNA #3 reported the fall to her, he requested that she call the squad immediately because he heard bones crack when Resident #11 hit the floor. On 05/16/12 at 6:40 A.M. an interview with STNA #7 was conducted. STNA #7 was working the night of the incident but was not assigned to Resident #11 that evening. She stated that she was in the break area and heard STNA #3 call for help. She stated she entered the room and saw Resident #11 on the floor. STNA #7 stated Resident #11 was always supposed to be a two person assist. This citation substantiates Complaint Number OH 479.

Based on medical record review, review of the facility ' s Self Reported Incident (SRI), review of the facility ' s Resident Abuse policy and procedure, observation, and staff, resident, and physician interviews, the facility failed to ensure Resident #52 was free from sexual abuse by Resident #84. This resulted in Immediate Jeopardy for one (#52) of four sampled female residents identified with dementia and wandering behaviors. The facility identified five of 95 residents with inappropriate sexual behaviors. On 06/23/11 at 12:20 P.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 06/19/11 at 4:15 P.M. when Licensed Practical Nurse (LPN) #22 opened the door to Resident #84 ' s room and observed him engaged in sexual intercourse with Resident #52, who had end stage dementia. When Resident #84 was asked if he had intercourse with Resident #52, stated " Yes " . Immediate Jeopardy was removed and the deficiency was corrected on 07/01/11 at 7:00 P.M. when the facility implemented the following actions: - On 06/19/11 at 5:50 P.M., the facility called the police department and a police officer arrived at the facility around 6:00 P.M. and started an investigation. - On 06/19/11 at 7:00 P.M., Resident #52 was sent to the local hospital for evaluation. -On 6/19/11 at 7:00 P.M., the facility sent Resident #84 to the hospital for psychiatric evaluation and he was admitted to the psychiatric unit. The facility sent Resident #84 a discharge notice and he is not permitted to return to the facility. -On 06/24/11, the facility developed a policy titled, " Wandering Resident " . The policy included the importance of staff awareness of resident ' s whereabouts and use of diversion or activity to keep them safe. -On 06/25/11, a policy and procedure titled, " Sexual Practice Guidelines " was developed to aid staff in the assessment and documentation of sexual behaviors. The policy had four levels of sexual behavior. Each level had a description of sexual behavior and staff response to the behavior. The facility implemented this policy on 06/27/11. -On 06/28/11, the facility completed in-service training for nurses and nurse aides on the Monitoring Tool for Sexual Activity /Wandering/ Elopement. This included the Daily Risk Management Report sheet that included behaviors, need for psychiatric services, any other concerns and 12 Hour Charge Nurse Report Sheets. The monitoring tool is used to identify any concerns to aid in appropriate assessment, documentation and interventions. The facility monitors the 12 Hour Charge Nurse Report sheet daily. -On 07/01/11, nursing completed an audit of all 89 residents that resided in the facility to identify any residents at high risk for sexual behaviors using the Short Portable Mental Status Questionnaire. The facility identified Residents #58, #60, #62, #70, and #85 had a history of [REDACTED]. -On 07/01/11, the facility completed all staff training on the policies and procedures listed above. - On 7/06/11, interviews with two nurses, three nurse aides and activity staff revealed they were all aware of the new policies, procedures, training, and monitoring for inappropriate sexual behaviors. - On 07/06/11 and 07/14/11, observations revealed no residents exhibited inappropriate sexual behaviors. Findings include: Review of Resident #52 ' s medical record revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] stated Resident #52 was unable to complete the interview process, had short and long term memory impairment, had moderately impaired decisions making skills, required extensive assistance with dressing and wandered daily. A plan of care dated 04/30/11 for potential for elopement related to impaired cognition and inability to comprehend need for assistance, indicated the resident attempts to go on the elevator unassisted and verbalized her desire to go home on a daily basis. Interventions included monitoring the resident ' s location on unit frequently every shift. Review of Resident #84 ' s medical record revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified he was able to be interviewed, had verbal behavioral symptoms (threatening, screaming and cursing) directed toward others that occurred one to three days, and had other behavioral symptoms (physical symptoms such as hitting and disrobing) not directed towards others daily. The resident was also assessed as ambulatory with an unsteady gait. A review of his plan of care for mood /behavior updated 01/22/10, with a goal date of 07/31/11, included interventions to monitor for changes in behavior or environment, document behavior as per facility policy, monitor for changes and notify the physician. On 04/07/11 Resident #84 was discharged to the local hospital. Review of a hospital progress note dated 04/10/11 at 3:20 P.M. documented Resident #84 was admitted for psychiatric treatment for [REDACTED]. The resident had remained disorganized and showed bizarre behavior around his sexuality with cross dressing. Resident #84 returned to the facility on [DATE] with no interventions to address any sexual behaviors. A nursing note dated 06/18/11 at 6:50 P.M by LPN #22 documented Resident #84 made several sexually inappropriate remarks to the nurse and attempted to touch the nurse inappropriately several times. Resident #84 had no assessment and no comprehensive plan of care for sexually inappropriate behaviors. Review of the facility ' s SRI dated 06/23/11 indicated on 06/19/11 at 4:15 P.M., LPN #22 knocked on Resident #84 ' s door. She witnessed Resident #84 engaged in sexual intercourse with Resident #52. LPN #22 walked over to the bed and touched Resident #84 on his shoulder. Resident #84 immediately " stopped " and got off of Resident #52. Resident #84 sat down in his wheelchair. Review of a nursing note dated 06/19/11 at 4:15 P.M. by LPN #36 documented she was called to Resident #84 ' s room by LPN #22. LPN #36 observed Resident #52 lying on her back naked in Resident #84 ' s bed. Resident #52 was assisted out of bed and a head to toe assessment performed. Resident #52 complained of abdominal pain. The nursing note further documented Resident #52 was assisted to her room and (the nurse) observed Resident #52 doubled over with discomfort. A nursing note dated 06/19/11 at 4:25 P.M., by LPN #36; documented Resident #52 was unable to verbalize what happened due to Alzheimer ' s disease and dementia. A nursing note dated 06/19/11 at 5:00 P.M. stated a private ambulance service was present to transport the resident to the hospital; however, it (the transport) was put on hold per the police department. At 7:00 P.M., a nursing note stated the resident was transferred to the hospital for evaluation and treatment. A nursing note dated 06/19/11 at 11:00 P.M. documented the resident returned from the hospital and was quiet and withdrawn with flat expression on her face. Review of the facility ' s Resident Abuse policy and procedure dated 2011 revealed " Sexual Abuse " includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy documented all alleged violations involving mistreatment, neglect or abuse is reported immediately to the administrator, director of nursing. On 06/23/11 at 3:45 P.M., Resident #52 was observed seated in a chair near the nurses ' station. Resident #52 was asked how she was; she stated well and had some incoherent garbled speech. She was unable to complete sentences. She complained of pain but was unable to state where she had the pain. She stated, " No " when asked if anyone had been mean to her. At 3:50 P.M. on 06/23/11, Resident #52 was observed getting up from the chair walking around the unit. Interview with LPN #22 on 06/23/11 at 4:35 P.M., revealed Resident #84 tried to touch her breast and made inappropriate sexual comments to her on 06/18/11. LPN #22 stated she was not aware of any sexually inappropriate behaviors before this time. LPN #22 affirmed she did not notify the physician of the change in behaviors. LPN #22 stated she was passing medications on 06/19/11 around 4:00 P.M. when she noted Resident #84 door was closed. LPN #22 stated she knocked and did not get a response. She opened the door and saw Resident #84 naked on the bed with someone. LPN #22 stated she approached Resident #84 and touched him on the shoulder. He withdrew his penis from Resident #52 ' s vagina, got up, and sat in his wheelchair. LPN #22 stated Resident #52 was also naked. LPN #22 called LPN #36 to the room and told Resident #84 to put on his clothes. Interview with LPN #36 on 06/23/11 at 4:16 P.M., revealed she saw Resident #52 by the nurse ' s station at about 3:45 P.M. At about 4:15 P.M., she was called to Resident #84 ' s room by LPN #22. She observed Resident #52 naked on Resident #84 ' s bed and Resident #84 was naked in his wheelchair. LPN #22 stated Resident #84 admitted that he disrobed Resident #52 and had intercourse with her. LPN #22 stated she assessed Resident #52 and she indicated her stomach hurt. On 06/25/11 at 7:00 A.M., Nurse Aide (NA) #45 stated Resident #84 had groped and touched her (NA #45) breast, " crotch, " and buttocks about two weeks ago. NA #45 stated Resident #84 tried to punch her when she told him to stop. NA #45 further stated Resident #84 had exposed his penis to her and some of the residents. NA #45 could not recall the date it happened. During an interview with the MDS nurse LPN #23 on 06/28/11 at 8:14 A.M., she stated there was no assessment or plan of care for Resident #84 ' s sexually inappropriate behaviors. On 06/28/11 at 10:05: A.M., the DON stated any incidents that are documented in the nurse ' s notes should also be written on the 24 hour report sheet. The DON stated the 24 hour report should have anything of importance regarding residents and should have included the inappropriate touching of and sexual comments to LPN #22 by Resident #84. The report sheet was reviewed every morning at morning meeting team. After the reports were reviewed, the staff completed assessments and care plans as appropriate. The DON stated she was not aware Resident #84 had sexually inappropriate behaviors that had been reported to and witnessed by staff. On 06/28/11 at 9:45 A.M. during a confidential resident interview, the resident stated about a month ago, Resident #84 had attempted to grab her breasts and she told him no. The resident stated Resident #84 was mad when she told him no, and staff made him leave me alone. She was unable to identify the nurse aide that intervened. On 06/28/11 at 10:05 A.M. during a confidential resident interview, the resident stated she had observed Resident #84 rubbing his genitals and reaching to grab women. The resident stated Resident #84 had tried to grab her crotch, but she just walked away and then stayed away from him. The resident stated about one month ago she had observed Resident #84 naked and masturbating in the hallway. A nurse aide told him (Resident #84) to go to his room and Resident #84 tried to punch the nurse aide. The resident was unable to identify the nurse aide. Interview with Psychiatrist #37 on 06/28/11 at 12:27 P.M. revealed she was not informed of Resident #84 ' s sexual behaviors prior to 06/19/11. Psychiatrist #37 stated she spoke with nursing staff when she came to see residents and they did not reported any sexually inappropriate behaviors including the two incidents that occurred approximately one month ago as described during confidential interview with female residents. Psychiatrist #37 stated if had she known of the sexually inappropriate behaviors, she would have addressed them. Psychiatrist #37 stated Resident #84 was capable of making the decision to have sex and was aware of what he was doing. On 06/28/11 at 2:15 P.M., Psychiatrist #37 was interviewed regarding Resident #52. Psychiatrist #37 stated Resident #52 could not in any way make any type of informed decision or consent to sex. Psychiatrist #37 stated Resident #52 would not even recognize the sex act being initiated on her. She said Resident #52 would not be able to consent to sex because she was very end stage dementia. This citation substantiated Master Complaint Number OH 393.