Every finding on record at Laurels of Huber Heights the

Based on review of the medical record, self-reported incidents (SRI) review, witness statement review, text messages review, staff schedules review, police report review, employee personnel file review, staff and resident interviews, observations, and policy review, the facility failed to ensure a resident was free from resident-to-staff sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental, and/or psychosocial harm, when on 08/03/26 during the early morning hours, Resident #56 asked for a shower and Certified Nursing Assistant (CNA) #10 volunteered to give Resident #56 a shower. While in the shower, CNA #10 and Resident #56 engaged in sexual activity. This affected one (Resident #56) of the three reviewed for abuse. The facility census was 72. On 08/13/26 at 4:16 P.M., the Administrator was notified Immediate Jeopardy began on 08/03/26 in the early morning hours, when CNA #10 engaged in sexual acts with Resident #56's while providing her with a shower. CNA #10 and Resident #56 kissed, and CNA #10 penetrated Resident #56's vagina with his fingers. CNA #10 attempted anal intercourse with his penis and Resident #56 touched CNA #10's penis. The Immediate Jeopardy was removed on 08/14/26 when the facility implemented the following corrective actions:On 08/05/26 at 12:14 P.M., an SRI was created by the Administrator related to a sexual abuse allegation. Resident #56 reported to Activities Aide (AA) #50 that she kissed CNA #10) on the lips on 08/02/26 around 11:45 P.M. while they played Nintendo. CNA #10 stated Resident #56 tried to kiss him, but he denied the action happened. Resident #56's care plan was updated to only have female caregivers and CNA #10 was placed on a new assignment. The SRI was completed at 08/06/26 at 5:37 P.M. and was not substantiated as the evidence did not support abuse. On 08/12/26 at 8:15 A.M., Resident #56 displayed text messages between her and CNA #10 to Licensed Practical Nurse (LPN) #20 who was on duty. The messages talked about Resident #56 and CNA #10 kissing and CNA #10 touched Resident #56's vagina with his fingers. On 08/12/26 at 8: 45 A.M., Unit Manager/Registered Nurse (RN) #35 completed a head-to-toe assessment on Resident #56 with no abnormal findings. On 08/12/25 at 8:45 A.M., the abuse policy was reviewed by the Administrator, Regional [NAME] President of Operations (RVPO) #110 and Regional Director of Clinical Services (RDCS) #105. There were no changes. On 08/12/26 at 8:45 A.M., RVPO #110 and RDCS #105 provided the facility and handbook abuse education to the Administrator and Director of Nursing (DON). On 08/12/26 at 8:53 A.M., CNA #10 was called and asked to come to the facility. CNA #10 arrived at 11:52 A.M. and was immediately terminated. On 8/12/26 at 9:00 A.M., Medical Director (MD) #100 was notified of the incident between Resident #56 and CNA #10. There were no new orders. On 08/12/26 beginning at 9:00 A.M., interviews with cognitively intact residents were started by the Administrator, Human Resources Director (HRD) #80, Social Services Director (SSD) #40, Business Office Manager (BOM) #70, Admissions Director #60, Environment Services Director (ESD) #90, Minimum Data Set (MDS) RN #30, Scheduler #95, and Activity Director (AD) #85. The interviews were completed by the end of the day and there were no abnormal findings. On 08/12/26 beginning at 9:00 A.M. skin checks were initiated on cognitively impaired residents by the DON, Assistant Director of Nursing (ADON) #34, Unit Manager/LPN #24, Unit Manager/RN #35 and Wound Nurse/LPN #25. All skin checks were completed by the end of the day and there were no abnormal findings. On 08/12/26 beginning at 9:00 A.M., all scheduled staff on duty at the time of the incident on 08/02/26 were re-interviewed by the Administrator, the DON and HRD #80. There were no abnormal findings. On 08/12/26 at 9:00 A.M., The Administrator and the DON educated the Department Heads (HRD #80, BOM #70, Admissions Director #60, SSD #40, Maintenance Director #120, ESD #90, Dietary Manager #125, AD #85, and ADON #34. Following this education, those department heads then educated their staff in the individual departments. Those staff members who were not in the facility were provided education verbally on the phone by their respective department heads, as well as by HRD #80 and via electronic transmission of Dayforce (a cloud-based HR system that has a built-in communication hub to create and route direct messages online for staff training). On 08/13/26, BOM #70 followed up via telephone calls with staff to ensure those who had not been reached had received their Dayforce communication. Only two staff members had not answered, but they have not been back to the facility. They will be provided with education when they return. On 08/12/2026 at 11:00 A.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the event involving Resident #56 and CNA #10 and to review the QAPI plan. The QAPI team consisted of the Administrator, DON, MD #100, ADON #34, and SSD #40. On 08/12/26 at 11:41 A.M, a subsequent SRI was created by the Administrator related to a sexual abuse allegation. The facility received additional details related to the sexual abuse allegation between CNA #10 and Resident #56. Resident #56 was tearful and when asked why, the resident handed LPN #20 her phone. LPN #20 discovered sexual text messages between the resident and CNA #10, and the messages indicated they were engaged in inappropriate touching with one another. The SRI was completed on 08/19/26 and the sexual abuse allegation was substantiated. On 08/12/26 at 12:30 P.M., the local police department was called. The officers arrived and took the report at 2:30 P.M. The investigation and the case were ongoing. On 08/12/26, the DON and MDS/RN #36 reviewed care plans to ensure appropriate interventions were in place for two Residents (#56 and #53) the facility identified with sexual behaviors. Resident #56's care plan was updated on 08/05/26 and there were no issues identified for Resident #53. On 08/12/26, to identify like residents that have the potential to be affected, the DON/designee completed interviews on cognitively intact residents to ensure no other residents had any sexual interactions. No negative findings. On 08/12/26, to identify like residents that have the potential to be affected, the DON/designee completed skin checks and observed for changes in behaviors, signs of withdrawal or change in normal activity for residents who were cognitively impaired. No negative findings. Beginning on 08/13/26, to monitor and maintain ongoing compliance, the DON/designee will conduct resident interviews on five cognitively intact residents and complete five skin checks for cognitively impaired residents weekly for four weeks then monthly for two months to identify any unreported incidents of abuse. The results will be taken to QAPI for review and revision as needed.Beginning on 08/13/26, to monitor and maintain ongoing compliance, the Administrator/designee will complete abuse questionnaires on five random employees weekly for four weeks then monthly for two months to determine continued education needs of staff. The results will be taken to QAPI for review and revision as needed.Although the Immediate Jeopardy was removed on 08/14/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance.Findings include:Review of the medical record for Resident #56 revealed an admission date of 06/27/26. Diagnoses included Parkinson's disease, dysphonia, muscle wasting and atrophy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had intact cognition and required partial assistance with toileting, bathing, dressing, and supervision with transfers.Review of the time punches for CNA #10 revealed he worked day shift (7:00 A.M to 7:00 P.M.) on Friday 07/31/26, then night shift (7:00 P.M. to 7:00 A.M.) on 08/01/26, 08/02/26 and 08/03/26. CNA #10 worked day shift on 08/08/26, 7:00 A.M. to 2:30 P.M. on 08/09/26, night shift on 08/10/26 and was terminated on 08/12/26. Review of text messages exchanges between CNA #10 and Resident #56 revealed the following: On 08/03/26 at 2:19 A.M., CNA #10 wrote to Resident #56 stating RN #30 was out here and at 3:39 A.M., CNA #10 wrote he wondered what would have happened if RN #30 didn't walk in on them. Immediately afterwards, CNA #10 sent a text stating the resident got him all hot and bothered and Resident #56 immediately responded with so do you. On 08/04/26 at an unknown time, Resident #56 sent a message to CNA #10, stating she loved every second of CNA #10 playing with her vagina and immediately afterwards, CNA #10 responded back with he did too and he would see her tomorrow. Resident #56 messaged CNA #10 asking about a hug. CNA #10 called the resident babe and stated he wanted to hug her, but there was too much talk going on and he couldn't be seen hugging her right now and he was sorry. Review of the SRI for sexual abuse created 08/05/26 at 12:14 P.M., revealed Resident #56 reported she kissed CNA #10 on the lips. Resident #56 informed AA #50 that on 08/02/26, she kissed CNA #10 while playing video games and CNA #10 was surprised but they continued playing video games. Resident #56 stated she felt safe and wished more would have happened between her and CNA #10. CNA #10 was removed from the schedule pending investigation. A head-to-toe assessment was completed on Resident #56 with no new findings, and the resident denied any new psychosocial needs. CNA #10 was interviewed and stated Resident #56 attempted to kiss him, but he denied it happened. CNA #10 explained he had to redirect Resident #56 during his shifts because she liked to wait on him while he was doing his rounds. During staff interviews, one staff noted the resident asked for a shower and CNA #10 volunteered to give the resident a shower. Another staff stated CNA #10 spent extra time with the resident, and she cautioned him to be careful because of her cognitive status, and she could develop a crush or like him. Others noted Resident #56 and CNA #10 walked around the facility together, but Resident #56 was a fall risk. A staff member reported that CNA #10 brought in a Nintendo game system for Resident #56 to use. The residents were interviewed with no concerns noted. Resident #56's care plan was updated to reflect female caregivers only. CNA #10 was placed on a new work assignment. All staff were educated on sexual behaviors and how to handle them. The SRI was completed on 08/06/26 at 5:37 P.M. and not substantiated. Review of the nursing progress note dated 08/05/26 at 4:47 P.M. and authored by the DON, revealed he was informed that Resident #56 reported to another staff member that she kissed a male staff member on night shift. Resident #56 was taken to safe environment and interviewed about interactions with the staff member. Resident #56 had no negative psychosocial impact noted. A head-to-toe assessment completed with no negative findings and the care plan was updated. MD #100 was notified with no new orders and psychiatric providers were notified. Resident #56 refused to have the responsible party notified. Review of the weekly skin observation dated 08/05/26, revealed Resident #56 had no new skin issues. There was small, scattered bruising to left arm with multiple stages of healing and scattered bruising to right shin with multiple stages of healing. Review of a witness statement dated 08/05/26 from AA #50, revealed CNA #10 brought in his Nintendo to let Resident #56 play and CNA #10 told AA #50 that he played games with her. On Monday 08/03/26, Resident #56 reported that her and CNA #10 kissed. Resident #56 said she asked for the kiss. Review of a witness statement dated 08/05/26 from CNA #11, revealed CNA #10 and Resident #56 walked at late hours of the night and one day, Resident #56 asked for a shower and CNA #10 volunteered. CNA #10 was in Resident #56's room for at least 30 minutes playing video games. Review of a witness statement dated 08/05/26 from CNA #13, revealed CNA #10 gave Resident #56 more attention to meet her needs.Review of a witness statement dated 08/05/26 from LPN #24, revealed Resident #56 and CNA #10 spent a lot of time together, and she waited for him outside of rooms.Review of a witness statement dated 08/05/26 from RN #30, revealed Resident #56 followed CNA #10 around and would walk together around the building. She asked for a hug, but he declined. Review of a second SRI for sexual abuse, created 08/12/26 at 11:41 A.M., revealed an occurrence date of 08/03/26 at 1:00 A.M. in the shower room. Resident #56 was tearful and when asked why by the nurse (LPN #20), the resident stated that CNA #10 had stopped responding to her text messages and handed the nurse her phone. LPN #20 discovered numerous text messages between Resident #56 and CNA #10 involving sexual acts. Numerous messages talked about the resident and CNA #10 planning on living together and how they engaged in appropriate touching with one another. CNA #10 was called to the facility and was immediately terminated. The local police were called and a report was taken. The police case is pending. Review of a nursing progress note dated 08/12/26 at 6:57 P.M. and recorded as late entry on 08/13/26 at 11:01 A.M. by the DON, revealed he was informed Resident #56 was upset when LPN #20 entered the resident's room to administer morning medications. LPN #20 asked what was wrong and Resident #56 showed LPN #20 the text messages between her and CNA #10. Resident #56 was taken to safe environment and interviewed about interactions with a staff member. Resident #56 had no negative psychosocial impact noted and a head-to-toe assessment completed with no negative findings. The care plan was updated, MD #100 was notified with no new orders, and the psychiatric providers were notified. Resident #56 refused to have her responsible party notified. Review of a witness statement dated 08/12/26 from CNA #10 revealed on 08/01/26 Resident #56 came out and asked for a bath around 2:00 A.M. CNA #10 told Resident #56 to check with RN #30, who said it was okay. CNA #10 stated he washed her hair and back. RN #30 walked in while Resident #56 was getting dressed. CNA #10 denied touching Resident #56 inappropriately. CNA #10 stated he gave Resident #56 his phone number about a month ago so she could reach out to him directly because she was not too fast with her communication app. CNA #10 stated Resident #56 was messaging him non-stop and he ignored her and didn't talk to her. Review of a witness statement dated 08/12/26 from AA #50, revealed she and Resident #56 were the same age and they just clicked. Resident #56 found comfort with her and shared personal things with her. Resident #56 told AA #50 that she and CNA #10 kissed but didn't want her to tell anyone. AA #50 stated she saw Resident #56 texting someone listed as B in her phone. Resident #56 stated B was CNA #10. AA #50 reported she also had Resident #56's phone number and they exchanged text messages occasionally. Review of a witness statement dated 08/12/26 from CNA #14, revealed the only employee Resident #56 appeared to close to was CNA #10 but denied seeing any inappropriate behavior.Review of a witness statement dated 08/12/26 from CNA #11, revealed she did not know of any inappropriate behaviors but Resident #56 would follow CNA #10 around.Review of a witness statement dated 08/12/26 from CNA #12, revealed she did not know of any inappropriate behaviors but Resident #56 would follow CNA #10 around and they would walk around in the building together.Review of a witness statement dated 08/12/26 from BOM #70, revealed around 12:00 P.M., Resident #56 came into her office and asked when CNA #10 would be at work again. BOM #70 stated she did not know because that was not her department. Resident #56 asked if CNA #10 had blocked her on the phone. BOM #70 was unaware they had contact over the phone. Resident #56 asked how long she had to stay at the facility because she wanted to be discharged to go live with CNA #10. BOM #70 directed Resident #56 to speak with social services.Review of a witness statement dated 08/12/26 from LPN #24, revealed Resident #56 would follow CNA #10 around and would cry if he couldn't sit with her or spend time with her. LPN #24 denied seeing Resident #56 text with staff, but she saw CNA #10 and Resident #56 both on their phones and then they would meet up. Review of a witness statement dated 08/12/26 from RN #30, revealed she had not personally seen any inappropriate behaviors, but she heard about a possible kiss. Review of the police report dated 08/12/26, revealed a sexual battery allegation between CNA #10 and Resident #56 and it was pending investigation. During an interview on 08/13/26 at 8:32 A.M., LPN #20 stated CNA #10 gave his phone number to Resident #56, and they had been exchanging messages. On 08/09/26, LPN #20 worked and asked Resident #56 about kissing a boy because she heard about the incident. LPN #20 stated Resident #56 confided in her and reported CNA #10 touched her while she was naked including her breasts and vagina. Resident #56 also stated she touched CNA #10's penis. LPN #20 reported findings to RN #31, who reported to the DON. LPN #20 stated the DON asked if this information was before or after the kiss from 08/02/26. The DON informed staff to have CNA #10 escorted from the facility for the remainder of his shift. LPN #20 stated the DON told her the incident was already investigated and he wasn't looking into the incident again. During an interview on 08/13/26 at 9:55 A.M., Resident #56 stated on 08/03/26 while in the shower room, she and CNA #10 had a sexual encounter. Resident #56 explained it was just her and CNA #10 in the shower room for about an hour. Resident #56 stated CNA #10 penetrated her vagina with his fingers, touched her breasts, attempted anal intercourse with his penis, and she touched his penis. Resident #56 stated she and CNA #10 were in a relationship, and she was going to live with him after she was discharged . Resident #56 also admitted this was not the first time something physical had happened between the two of them. Resident #56 became upset and tearful when asked about the incident with CNA #10. During an interview on 08/13/26 at 11:21 A.M., CNA #10 stated he gave Resident #56 a bath on 08/03/26 but denied any sexual activity occurred. CNA #10 admitted to communicating via the phone with Resident #56. CNA #10 also stated he would be up to talking to Resident #56 after she was discharged from the facility. During an interview on 08/13/26 at 11:39 A.M., AA #50 stated on 08/03/26, Resident #56 told her about a kiss between her and CNA #10, and the resident asked her not to tell anyone. AA #50 stated she did not tell any of the leadership about the kiss until 08/05/26 when she told HR #80 and completed a witness statement. During an interview on 08/13/26 at 1:32 P.M., the DON stated on 08/05/26, Resident #56 admitted to kissing CNA #10 while playing video games. The DON notified the Administrator, assessed and interviewed Resident #56, suspended CNA #10, and started an investigation. The DON reported the investigation was closed on 08/06/26 because the resident stated she kissed CNA #10 and he denied it. The DON stated on 08/09/26, LPN #20 and RN #31 reported more information regarding the incident between CNA #10 and Resident #56 on 08/03/26. The DON stated he did not complete any further investigation because it was already completed on 08/06/26. The DON stated on 08/12/26, Resident #56 showed LPN #20 text messages between her and CNA #10 which verified sexual relations had occurred between the two. The DON stated another SRI was created since additional information came out. The DON stated Resident #56 was assessed, CNA #10 was terminated, police were notified, and the staff were educated. Review of CNA #10's personnel file revealed he was hired on 10/17/24, had an active unrestricted CNA certification, and received initial abuse training upon hire. There were no disciplinary actions prior to being terminated on 08/12/26 related to a critical offense of physical abuse and dishonestly authored by HRD #80 and the Administrator. Review of the facility policy, Ohio Resident Abuse Policy, revised on 07/22/26, revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable and state agencies in accordance with the procedures in this policy. If a staff member was accused of abuse, neglect, involuntary seclusion, exploitation, or misappropriation of resident property, the facility would immediately remove the staff member from the resident care area and request a written statement from the accused staff member. The accused staff member would remain under direct supervision until a statement was completed and/or law enforcement arrived if possible. The accused staff member would then be removed from the facility and the schedule pending the outcome of the investigation.This deficiency represents non-compliance investigated under Complaint Number 3155210.

Based on review of the medical record, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were implemented correctly during incontinence care. This affected one (#19) of the three residents reviewed for incontinence care. The facility census was 72.Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/28/26. Diagnoses included type II diabetes mellitus (DM II), peripheral vascular disease (PVD), and end stage renal disease (ESRD). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two. This resident was assessed to require setup with eating, dependent with toileting, partial assistance with bathing, substantial assistance with dressing and transfers. Observation of incontinence care on 08/25/26 at 2:56 P.M. by Certified Nursing Assistant (CNA) #17 revealed CNA #17 provided peri-care to the resident's vaginal area with a washcloth. CNA #17 placed the soiled washcloth in trash bag. When CNA #17 turned Resident #19 to her side to clean her backside, CNA #17 grabbed a soiled washcloth out of trash bag to clean Resident #19's bowel movement. CNA #17 did not rinse after cleansing the area. CNA #17 used a towel to dry the resident, but there was still visible stool on the towel. CNA #17 did not change her soiled gloves before applying new depend. During an interview on 08/25/26 at 3:05 P.M., CNA #17 verified she used the same soiled washcloths from front to back and did not change her gloves. Review of the facility policy titled, Hand Hygiene Policy, revised 04/03/26 revealed hand hygiene was the most important component for preventing the spread of infection. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, and after contact with blood, body fluids, or contaminated surfaces.

Based on review of the medical record and staff interviews, the facility failed to ensure physician progress notes were completed at the time of visit. This affected three (#11, #22, and #56) of the three residents reviewed for physician visits. The facility census was 72.Findings include: 1) Review of the medical record for Resident #11 revealed an admission date of 04/09/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus (DM II), and seizures. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require dependent with toileting, bathing, dressing, and transfers. Review of the physician progress notes for Resident #11 revealed he was seen on 07/18/26 but not completed and signed until 07/27/26, seen on 07/19/26 but not completed and signed until 07/26/26, and seen on 08/13/26 but not completed and signed until 08/17/26. 2) Review of the medical record for Resident #56 revealed an admission date of 06/27/26. Diagnoses included Parkinson's disease, muscle wasting and atrophy, and dysphonia. Review of the admission MDS assessment dated [DATE], revealed Resident #56 had intact cognition as evidenced by a BIMS score of 15. This resident was assessed to require setup with eating, partial assistance with toileting, bathing, dressing, and supervision with transfers. Review of the physician progress notes for Resident #56, revealed she was seen on 07/11/26 but not completed and signed until 08/02/26, seen on 07/19/26 but not completed and signed until 07/26/26, seen on 07/25/26 but not completed and signed until 07/28/26, seen on 08/06/26 but not completed and signed until 08/10/26, and seen on 08/07/26 but not completed and signed until 08/10/26. 3) Review of the medical record for Resident #22 revealed an admission date of 12/05/25. Diagnoses included type II diabetes mellitus (DM II), heart failure, and seizures. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #22 had moderate cognitive impairment as evidenced by a BIMS score of 10. This resident was assessed to require supervision with eating, dependent with toileting, substantial assistance with bathing, dressing, and transfers. Review of the physician progress notes for Resident #22 revealed he was seen on 07/16/26 but not completed and signed until 07/27/26, seen on 07/19/26 but not completed and signed until 07/26/26, and seen on 08/11/26 but not completed and signed until 08/13/26. During an interview on 08/17/26 at 11:15 A.M., the Director of Nursing (DON) verified the physician progress notes were not signed at the time of visit for Resident #11, #22, and #56.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure interventions were implemented for residents with pressure ulcers. This affected one (#63) of the three residents reviewed for pressure ulcers. The facility census was 72.Findings include : Review of the medical record for Resident #63 revealed an admission date of 07/17/26. Diagnoses included osteomyelitis of vertebra, acute and chronic respiratory failure, heart failure, and end stage renal disease (ESRD). Review of the nurse's progress note dated 07/17/26 at 8:07 P.M., revealed Resident #63 admitted to the facility with a pressure area to the coccyx. Review of the admission/readmission observation dated 07/17/26, revealed Resident #63 was noted to have a pressure ulcer to the sacrum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #63 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require supervision with eating, dependent with toileting, partial assistance with bathing and transfers, and substantial assistance with dressing. Review of the July 2026 medication administration record (MAR) and treatment administration record (TAR), revealed Resident #63 did not receive wound treatments for the pressure ulcer on 07/17/26, 07/18/26, and 07/19/26. During an interview on 08/24/26 at 2:52 P.M., Registered Nurse (RN) #35 verified wound treatments were not implemented for Resident #65 on 07/17/26, 07/18/26, and 07/19/26. Review of the facility policy titled, Pressure Injury Prevention and Management Policy, revised 12/17/25 revealed residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Pressure injuries identified will be documented and orders obtained from providers for treatment.

Based on review of the medical record, interviews, review of the self-reported incident (SRI), and facility policy, the facility failed to ensure a thorough investigation was completed related to a sexual abuse allegation by a resident. This affected one (#56) of the three residents reviewed for abuse. The facility census was 72. Review of the medical record for Resident #56 revealed an admission date of 06/27/26. Diagnoses included Parkinson's disease, muscle wasting and atrophy, and dysphonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, partial assistance with toileting, bathing, dressing, and supervision with transfers. Review of the nurse's progress note dated 08/05/26 at 4:47 P.M. and authored by the DON, revealed he was informed that Resident #56 reported to another staff member that she kissed a male staff member on night shift. Resident #56 was taken to safe environment and interviewed about interactions with the staff member. Resident #56 had no negative psychosocial impact noted. A head-to-toe assessment completed with no negative findings and the care plan was updated. MD #100 was notified with no new orders and psychiatric providers were notified. Resident #56 refused to have the responsible party notified. Review of an SRI for sexual abuse, created 08/12/26 at 11:41 A.M., revealed an occurrence date of 08/03/26 at 1:00 A.M. in the shower room. Resident #56 was tearful and when asked why by the nurse (LPN #20), the resident stated that CNA #10 had stopped responding to her text messages and handed the nurse her phone. LPN #20 discovered numerous text messages between Resident #56 and CNA #10 involving sexual acts. Numerous messages talked about the resident and CNA #10 planning on living together and how they engaged in appropriate touching with one another. CNA #10 was called to the facility and was immediately terminated. The local police were called and a report was taken. The police case is pending. Review of a nurse's progress note dated 08/12/26 at 6:57 P.M. and recorded as late entry on 08/13/26 at 11:01 A.M. by the DON, revealed he was informed Resident #56 was upset when LPN #20 entered the resident's room to administer morning medications. LPN #20 asked what was wrong and Resident #56 showed LPN #20 the text messages between her and CNA #10. Resident #56 was taken to safe environment and interviewed about interactions with a staff member. Resident #56 had no negative psychosocial impact noted and a head-to-toe assessment completed with no negative findings. The care plan was updated, MD #100 was notified with no new orders, and the psychiatric providers were notified. Resident #56 refused to have her responsible party notified. Review of a witness statement dated 08/12/26 from AA #50, revealed she and Resident #56 were the same age and they just clicked. Resident #56 found comfort with her and shared personal things with her. Resident #56 told AA #50 that she and CNA #10 kissed but didn't want her to tell anyone. AA #50 stated she saw Resident #56 texting someone listed as B in her phone. Resident #56 stated B was CNA #10. AA #50 reported she also had Resident #56's phone number and they exchanged text messages occasionally. Review of the police report dated 08/12/26, revealed a sexual battery allegation between CNA #10 and Resident #56 and it was pending investigation. During an interview on 08/13/26 at 8:32 A.M., LPN #20 stated CNA #10 gave his phone number to Resident #56, and they had been exchanging messages. On 08/09/26, LPN #20 worked and asked Resident #56 about kissing a boy because she heard about the incident. LPN #20 stated Resident #56 confided in her and reported CNA #10 touched her while she was naked including her breasts and vagina. Resident #56 also stated she touched CNA #10's penis. LPN #20 reported findings to RN #31, who reported to the DON. LPN #20 stated the DON asked if this information was before or after the kiss from 08/02/26. The DON informed staff to have CNA #10 escorted from the facility for the remainder of his shift. LPN #20 stated the DON told her the incident was already investigated and he wasn't looking into the incident again. During an interview on 08/13/26 at 9:55 A.M., Resident #56 stated on 08/03/26 while in the shower room, she and CNA #10 had a sexual encounter. Resident #56 explained it was just her and CNA #10 in the shower room for about an hour. Resident #56 stated CNA #10 penetrated her vagina with his fingers, touched her breasts, attempted anal intercourse with his penis, and she touched his penis. Resident #56 stated she and CNA #10 were in a relationship, and she was going to live with him after she was discharged . Resident #56 also admitted this was not the first time something physical had happened between the two of them. Resident #56 became upset and tearful when asked about the incident with CNA #10. During an interview on 08/13/26 at 1:32 P.M., the DON stated on 08/05/26, Resident #56 admitted to kissing CNA #10 while playing video games. The DON notified the Administrator, assessed and interviewed Resident #56, suspended CNA #10, and started an investigation. The DON reported the investigation was closed on 08/06/26 because the resident stated she kissed CNA #10 and he denied it. The DON stated on 08/09/26, LPN #20 and RN #31 reported more information regarding the incident between CNA #10 and Resident #56 on 08/03/26. The DON stated he did not complete any further investigation because it was already completed on 08/06/26. The DON stated on 08/12/26, Resident #56 showed LPN #20 text messages between her and CNA #10 which verified sexual relations had occurred between the two. The DON stated another SRI was created since additional information came out. The DON stated Resident #56 was assessed, CNA #10 was terminated, police were notified, and the staff were educated. Review of the facility policy, Ohio Resident Abuse Policy, revised on 07/22/26 revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable and state agencies in accordance with the procedures in this policy. If a staff member was accused of abuse, neglect, involuntary seclusion, exploitation, or misappropriation of resident property, the facility will immediately remove staff member from resident care area and request a written statement from accused staff member. The accused staff member will remain under direct supervision until statement was completed and/or law enforcement arrived if possible. The accused staff member will then be removed from the facility and the schedule pending the outcome of the investigation. This deficiency represents non-compliance investigated under Complaint Number 3155210.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a psychotropic medication was administered with an appropriate diagnosis. This affected one (#5) of five residents reviewed for unnecessary medications. The facility census was 70.Findings include:Review of the medical record for Resident #5 revealed an admission date of 03/16/26. Diagnoses included anxiety disorder and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment.Review of the physician order dated 03/16/26 revealed Resident #5 was ordered Seroquel (atypical antipsychotic) 100 milligrams (mg), give 100 mg by mouth two times a day for anxiety. The physician order dated 03/17/26 revealed Resident #5 was ordered Seroquel 50 milligrams (mg), give 50 mg by mouth one time a day for anxiety. Interview on 05/19/26 at 2:41 P.M. with Director of Nursing (DON) revealed Resident #5 was admitted to the facility with the physician order for Seroquel and verified Resident #5 did not have an appropriate diagnosis for the use of Seroquel. The DON verified Resident #5 was not being seen by psych services.Review of the facility policy titled Psychoactive Medication Management dated 01/28/26 revealed the facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize the use of psychotropic medications in managing behaviors when non-pharmacological interventions had failed. Residents who received psychoactive medications to treat behavioral symptoms were evaluated, monitored, and managed by the interdisciplinary team including, but not limited to, facility clinical staff, practitioner, and a pharmacist.

Based on review of the medical record, interviews, and policy review, the facility failed to ensure treatments were in place upon admission for a pressure sore. This affected one (#10) of two residents reviewed for pressure ulcers. The facility census was 70.Findings include:Review of the medical record for Resident #10 revealed an admission date of 04/03/26. Diagnoses included displaced fracture of left femur, chronic kidney disease stage four, and peripheral vascular disease (PVD). Review of the admission skin assessment dated [DATE] revealed Resident #10 had a wound to coccyx with a description it was a fissure and a wound to right shoulder and it was an intravenous hemodialysis port. There was no other description or assessment of the coccyx wound. Review of the progress note dated 04/03/26 at 11:32 A.M. revealed Resident #10 admitted to the facility with the coccyx covered by protective mepilex.Review of the treatment administration record (TAR) dated April 2026 revealed Resident #10 did not have any treatments ordered from 04/03/26 through dayshift 04/06/26.Review of the progress note dated 04/06/26 at 3:58 P.M. revealed Resident #10 was assessed. Two open areas noted to the right buttock and coccyx. Area washed with normal saline water and pat dried. Dry clean dressing applied and placed a referral for wound doctor.Review of the physician order dated 04/06/26 revealed Resident #10 was ordered encourage application of barrier cream to bilateral buttock/sacrum every shift. Review of the physician orders revealed on 04/06/26, an order to encourage Resident #10 to turn and reposition while in bed, chair, wheelchair, or like device every shift and nursing to complete weekly skin check every Saturday on dayshift. On 04/07/26, an order to wash with normal saline/sterile water to the right gluteus and pat dry. Apply calcium alginate to wound bed and cover with dry covered dressing daily and as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition and required dependent on staff assistance with toileting and supervision with transfers. Resident #10 had one unstageable pressure ulcer (Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar.).Interview on 05/19/26 at 10:31 A.M. with Licensed Practical Nurse (LPN) #85, who was also a wound nurse, verified Resident #10 was not accurately assessed upon admission on [DATE] and verified there were no treatment orders for Resident #10's coccyx wound until 04/07/26. Review of the facility policy titled Skin Management, dated 01/28/26 revealed residents with wounds and/or pressure injury and those at risk for skin compromise were identified, evaluated, and provided appropriate treatment to promote prevention and healing. Residents admitted with any skin impairment would have appropriate interventions implemented to promote healing, a physician's order for treatment, and skin impairment location, measurements, and characteristics documented.

Based on observations, staff interview, medical record review, and policy review, the facility failed to ensure infection control measures were appropriately implemented during incontinence care for a resident. This affected one (#5) of two residents reviewed for urinary tract infections. The facility census was 70.Findings include:Review of the medical record for Resident #5 revealed an admission date of 03/16/26. Diagnoses included type II diabetes mellitus, congestive heart failure, anxiety disorder, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff assistance with toileting.Observation on 05/19/26 at 9:56 A.M. revealed Certified Nursing Assistant (CNA) #97 provided Resident #5 with incontinence care. During care, CNA #97 performed peri care to the front side, placed soiled wash cloths in a trash bag, and then removed those same wash cloths out of the trash bag to perform peri care to her backside. CNA #97 did not remove soiled gloves and continued to touch Resident #5 and assisted her with dressing and touching bed controls.Interview on 05/19/26 at 10:09 A.M. with CNA #97 verified she used the same wash cloths while providing care. CNA #97 also verified she did not change gloves during care and touched the resident, bed controls, and clean clothes with soiled gloves.Review of the facility policy titled Perineal Care of the Patient Assigned Female, dated 05/24/24 revealed gather and prepare the necessary equipment and supplies. Use gentle downward strokes, clean the perineal area from front to back of the perineum to prevent intestinal organisms from contaminating urethra or vagina. Use a clean section of the washcloth for each stoke by folding each used section inward to prevent contamination with secretions or discharge.

Based on medical record review, observations, and resident and staff interviews, the facility failed to complete a thorough investigation into a resident sustaining blisters on her hand and implement timely corrective actions to ensure the resident(s) had a safe environment free of accident hazards. This affected one (#10) of three residents reviewed for general skin concerns. The facility census was 70.Findings include:Review of the medical record for Resident #10 revealed an admission date of 04/03/26. Diagnoses included displaced fracture of left femur, peripheral vascular disease (PVD), and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition, and required setup from staff with eating, partial assistance from staff with bathing, and substantial assistance from staff with dressing.Review of the progress note dated 04/25/26 at 2:24 P.M. revealed Resident #10 accepted a shower, and skin check was completed. Redness was noted to bilateral hands. Blister to right hand noted. The physician in facility made aware. There was nothing documented in the medical record on how the resident sustained the burns on 04/25/26 or 04/26/26.Review of the physician order dated 04/25/26 revealed Resident #10 was ordered triple antibiotic ointment (TAO) to bilateral hands every day and night shift for 10 days.Review of the progress note dated 04/27/26 at 11:00 A.M. revealed Resident #10 informed staff she burned her hand over the weekend on the water in her bathroom. Top of right hand was bright red in color and blisters noted across the knuckles.Review of the physician order dated 04/27/26 revealed Resident #10 was ordered Silver Sulfadiazine one percent (%) cream, apply to blisters on right hand topically every shift for wound care and wrap lightly with kerlix to protect blisters and burn.Review of the progress note dated 04/29/26 at 10:56 A.M. revealed Resident #10 reported blisters and windburn noted to bilateral hands on 04/25/26. Resident #10 was an independent smoker and chose to smoke during windy conditions.The facility was unable to provide an investigation into Resident #10's blisters found on her hand.Observation and interview on 05/19/26 at 9:06 A.M. revealed Resident #10 had pink scarring on right hand across her knuckles and middle and ring fingers. Resident #10 revealed she got burned on the water in her bathroom in her previous room.Interview on 05/19/26 at 10:46 A.M. with Licensed Practical Nurse (LPN) #85, who was also the wound nurse, reported Resident #10 had redness to right hand with blisters noted. She reported the concern to the Administrator and Maintenance Director (MD) #57. Interview on 05/19/26 at 2:15 P.M. with the Administrator revealed he was not made aware of Resident #10's blisters on her hand.Interview on 05/19/26 at 2:35 P.M. with Director of Nursing (DON) revealed Resident #10 reported her story changed from windburn/sunburn to the water and then back to windburn. The DON verified the facility did not obtain staff statements regarding the incident and to interview other residents who may have witnessed the resident sustaining blisters from smoking and/or assess other residents to see if they obtained any blisters due to inclement weather and/or water temperatures. The DON also stated MD #57 was informed of the situation and was advised to check water temperatures.Interview on 05/19/26 at 4:19 P.M. with MD #57 stated this was the first time he had heard about water temperatures possibly causing blisters to a resident's hand. MD #57 verified he was not told to check Resident #10's water temperature in her room.

Based on record reviews, observations, resident and staff interviews, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received timely and adequate assistance with personal hygiene and bathing. This affected three (#1, #9, and #95) of three residents reviewed for activities of daily living. The facility census was 70.Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 04/12/26. Diagnoses included acute respiratory failure, anxiety disorder, type II diabetes mellitus, and pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and required substantial assistance from staff with bathing. Review of the ADL task log dated April 2026 revealed Resident #1 did not receive a shower on 04/14/26, 04/17/26, and 04/24/26.The ADL task log dated May 2026 revealed Resident #1 did not receive a shower on 05/08/26 and 05/15/26. Interview on 05/17/26 at 3:28 P.M. with Resident #1 revealed she had not had a shower in over a week. Resident #1 also reported she had one shower at midnight and was unable to fall asleep due to wet hair and being cold. Resident #1 stated she had asked several staff members to give her a shower during the day but was told it wasn't her time.Interview on 05/19/26 at 2:53 P.M. with the Director of Nursing (DON) verified showers were not completed on 04/14/26, 04/17/26, 04/24/26, 05/08/26 and 05/15/26. The DON also reported he would get Resident #1's showers changed to days.2. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] and discharged from the facility on 03/27/26. Diagnoses included nontraumatic intracerebral hemorrhage, muscle wasting and atrophy, hemiplegia and hemiparesis following cerebral infarction, and heart disease.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #95 was had moderate cognitive impairment, had no behaviors, did not reject care, and did not wander. Resident #95 was dependent on staff with bathing. There was no documentation that Resident #95 was offered and or received a shower or bath during her stay at the facility. There was no documentation that Resident #95 refused bathing. Interview on 05/19/26 at 11:43 A.M. with DON revealed all showers/bathing or refusals were documented in the resident medical records. The DON confirmed there was no documentation for any showers/bathing for Resident #95 during her stay at the facility.3. Review of the medical record for Resident #9 revealed an admission date of 05/07/25. Diagnoses included end stage renal disease, type II diabetes mellitus, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition and required substantial to maximum assistance from staff with personal hygiene.Observation on 05/19/26 at 9:27 A.M. revealed Resident #9 had gray facial hairs lined across her chin and down her jawline.Interview on 05/19/26 at 9:29 A.M. with Resident #9 revealed she was bothered by the facial hair and wanted them shaved.Interview on 05/19/26 at 9:31 A.M. with Certified Nursing Assistant (CNA) #86 verified Resident #9 had chin hairs present.Review of the facility policy titled Routine Resident Care dated 03/12/25 revealed residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Daily personal hygiene minimally included assisting or encouraging residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing dental care. Showers, tub baths, and/or shampoos were scheduled according to person centered care or state specific guidelines.This deficiency represents non-compliance investigated under Complaint Number 3008891.

Based on medical record review, staff interview, and policy review, the facility failed to ensure timely notification to the physician and responsible party when a residents wound changed. This affected one (#83) out of three residents reviewed for wounds. The facility census was 83. Findings Included:Review of the medical record revealed Resident #83 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis lumbar, end stage renal disease, dependent on renal dialysis, anemia, and type two diabetes.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #83 had a Brief Interview of Mental Status (BIMS) of 13 indicating he was cognitively intact. Resident #83 required substantial to maximal assistance for bathing, dressing the upper body, oral care, and personal hygiene. Resident #83 was dependent on placing shoes on and off feet, dressing the lower body, and toileting hygiene. Resident #83 was set up for all meals. Resident #83 used a wheelchair at the facility to ambulate.Review of the plan of care dated 09/11/25 revealed Resident #83 was at risk for complications related end stage renal disease and the need for dialysis. Interventions included do not drawing blood or taking blood pressure in arm with graft, right arm. Encouraged residents to go for scheduled dialysis appointments, observe for signs and symptoms of infection, and observe for signs of fluid retention. Review of a progress note dated 10/02/25 written by Wound Nurse #201 documented treatments continue as ordered. Resident #83 had an infected back surgical wound. The third finger on the right hand remained infected awaiting for surgical amputation scheduled. The guest remained in good spirits and cooperated with care. Will have the wound doctor continue to see Resident #83 wounds.Review of a progress note dated 10/08/25 written by Wound Nurse #201 documented dressing changed as ordered for Resident #83. Resident #83 had large amount of bloody/purulent drainage noted from back wound. Wound Nurse #201 stated Resident #83 wound was cleansed and packed with Iodoform 1/4 inch and a dressing was applied. Resident #83 tolerated procedure well.Review of the order dated 10/12/25 revealed Resident #83 had an order for a treatment to the lower back to wash with normal saline and pat dry. Pack with Iodoform gauze packing every day and as needed. Cover with a dry clean dressing.Review of a progress note dated 10/12/25 written by Registered Nurse (RN) #212 documented Resident #83 had purulent drainage noted from the back wound. The dressing was changed per the physician's order. Interview on 01/20/26 at 3:50 P.M., the Wound Physician #206 stated he was unsure if he was notified by staff about Resident #83's thoracic surgery site having had pus or drainage. The Wound Practitioner #206 stated if he was notified, he would not have changed the treatment until he came back into the facility. The Wound Practitioner #206 said Resident #83 had a messy wound on his back and came to the facility after having back surgery with hard appliances added. Interview on 01/20/26 at 4:36 P.M., the Director of Nursing (DON) stated on 10/12/25 Registered Nurse (RN) #212 had not notified a physician or the family in the progress note for Resident #83's thoracic wound. The DON stated she would expect the nurse to at least notify the on-call physician for any new development. The DON stated if it was a new development, the nurses were responsible to notify the physicians. Interview on 01/20/26 at 4:46 P.M., RN #212 said it had been a long time since she wrote the progress note for Resident #83 and could not remember if she notified the family or the physician of the purulent drainage on the date of 10/12/25. RN #212 verified she had not documented the notification in the progress note she wrote on 10/12/25.Review of the facility policy titled Notification of Change dated 02/14/24 revealed the facility must inform the resident, consult with resident's practitioner, and notify consistent with his or her authority, the resident representative when there was a change in status. Even when a resident was mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status unless the resident does not want the notification.This deficiency represents non-compliance investigated under Complaint Number 2685424.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#20) out of two residents observed for medication administration. The facility census was 75. Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/30/21 with medical diagnoses of cerebral infarction, dysphagia, vascular dementia, hypertension, and diabetes mellitus. Review of the medical record for Resident #20 revealed physician orders dated 08/03/24 for Oyster Calcium tablet 500 milligram (mg) one tablet by mouth daily, galantamine 12 mg one tablet by mouth daily, and Memantine 5 mg one tablet by mouth daily, physician orders dated 08/04/25 for aspirin 81 mg one tablet by mouth daily, chlorthalidone 12.5 mg one tablet by mouth daily, senna 8.6-50 mg one tablet by mouth daily, nifedipine 90 mg one tablet by mouth daily, and an order for Depakote 125 mg three tablets by mouth three times per day. Observation on 09/11/25 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #207 prepared medications for Resident #20 and was observed placing aspirin tablet, Oyster Calcium tablet, and senna tablet into her bare hands prior to placing the medications into the medication cup. LPN #207 was observed placing medications into a plastic sleeve and crushing the medications prior to placing them into a medication cup along with applesauce. LPN #207 was observed to administer medications to Resident #207. Interview won 09/11/25 at 9:27 A.M. with LPN #207 confirmed she placed Resident #20's aspirin, Oyster Calcium tablet, and senna tablet into her bare hands prior to medication administration. Review of the facility policy titled, Medication Administration, revised 10/17/23 stated resident medications are to be administered in an accurate, safe, timely, and sanitary manner. The policy stated medications are administered in accordance with written orders of the attending physician. The policy stated staff are to perform hand hygiene prior to medication preparation for each medication pass and after direct resident contact. The policy stated to place medications in medicine cups without touching the inside of the cup and if medications come into contact with the bare hands of the nurse/med tech or with the care, the medication should be disposed of per policy and new medications obtained. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to complete pressure ulcer assessments upon admission and failed to timely initiate treatment for pressure ulcers. This affected one (#16) out of the three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record for Resident #16 revealed an admission date of 05/23/25 with medical diagnoses of aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus (DM). Review of a quarterly Minimum Data Set (MDS) assessment, dated 08/16/25, indicated Resident #16 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene and bathing, partial/moderate staff assistance for bed mobility and was dependent upon staff for transfers. The MDS indicated Resident #16 admitted with two deep tissue injuries (DTI), DM foot ulcer, and surgical wound. Review of a nursing comprehensive assessment, dated 05/23/25, indicated under the skin assessment that Resident #16 had right toe amputation, redness to bilateral buttocks, coccyx, and heels. The assessment did not contain documentation to support measurements or description of skin issues. Review of wound/skin evaluations completed 05/28/25 indicated Resident #16 admitted with a vasculitic injury to left dorsum fifth digit (toe) which measured 2.0 centimeters (cm) by 1.8 cm with 20% slough and 50% eschar, a vasculitic injury to left heel which measured 4.2 cm by 3.2 cm and had 100% eschar, an other skin issue to right lateral malleolus which measured 3.0 cm by 2.5 cm with 100% eschar, a DTI to right heel which measured 5.2 cm by 3.8 cm with 100% eschar, an other skin issue to left lateral malleolus which measured 1.6 cm by 1.2 cm with 100% eschar, a surgical site to right dorsum first digit with partial dehiscence which measured 8.7 cm by 3.6 cm, an other skin issue to right dorsum foot which measured 1.9 cm by 1.3 cm, an other skin issue to left lateral midfoot which measured 2.1 cm by 1.9 cm and moisture associated skin damage (MASD) to sacrum with no measurements noted. Review of the physician orders for Resident #16 revealed no documentation to support treatment was initiated for the above wounds until 05/29/25. Review of medical record for Resident #16 revealed documentation to support Resident #16 was seen by a wound physician weekly starting 06/03/25 until discharged on 06/27/25. Review of the wound physician note dated 06/24/25 indicated Resident #16 had a DTI ulcer to left heel, unstageable pressure ulcer to right anterior ankle (formerly documented as right lateral malleolus), a surgical wound to right distal foot, an unstageable pressure ulcer to right dorsal foot, and a DTI to right heel. Interview on 09/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #203 confirmed the medical record for Resident #16 did not have documentation to support the wounds were evaluated upon admission on [DATE] until 05/28/25 and that a treatment for the wounds was not initiated until 05/29/25. Review of the facility policy titled, Skin Management, revised 09/19/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic health record. The policy stated any residents admitted with any skin impairment would have appropriate interventions to promote healing, a physician's order for treatment and skin impairment location, measurements, and characteristics documented. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record reviews, staff interview, and policy review, the facility failed to complete wound assessments at the time of admission and/or failed to timely initiate treatment for wounds. This affected two (#16 and #32) out of three residents reviewed for wounds. The facility census was 75. Findings include: 1.Review of the medical record for Resident #16 revealed an admission date of 05/23/25 with medical diagnoses of aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus (DM). Review of a quarterly Minimum Data Set (MDS) assessment, dated 08/16/25, indicated Resident #16 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene and bathing, partial/moderate staff assistance for bed mobility and was dependent upon staff for transfers. The MDS indicated Resident #16 admitted with two deep tissue injuries (DTI), DM foot ulcer, and surgical wound. Review of a nursing comprehensive assessment, dated 05/23/25, indicated under the skin assessment that Resident #16 had right toe amputation, redness to bilateral buttocks, coccyx, and heels. The assessment did not contain documentation to support measurements or description of skin issues. Review of wound/skin evaluations completed 05/28/25 indicated Resident #16 admitted with a vasculitic injury to left dorsum fifth digit (toe) which measured 2.0 centimeters (cm) by 1.8 cm with 20% slough and 50% eschar, a vasculitic injury to left heel which measured 4.2 cm by 3.2 cm and had 100% eschar, an other skin issue to right lateral malleolus which measured 3.0 cm by 2.5 cm with 100% eschar, a DTI to right heel which measured 5.2 cm by 3.8 cm with 100% eschar, an other skin issue to left lateral malleolus which measured 1.6 cm by 1.2 cm with 100% eschar, a surgical site to right dorsum first digit with partial dehiscence which measured 8.7 cm by 3.6 cm, an other skin issue to right dorsum foot which measured 1.9 cm by 1.3 cm, an other skin issue to left lateral midfoot which measured 2.1 cm by 1.9 cm and moisture associated skin damage (MASD) to sacrum with no measurements noted. Review of the physician orders for Resident #16 revealed no documentation to support treatment was initiated for the above wounds until 05/29/25. Review of medical record for Resident #16 revealed documentation to support Resident #16 was seen by a wound physician weekly starting 06/03/25 until discharged on 06/27/25. Review of the wound physician note dated 06/24/25 indicated Resident #16 had a DTI ulcer to left heel, unstageable pressure ulcer to right anterior ankle (formerly documented as right lateral malleolus), a surgical wound to right distal foot, an unstageable pressure ulcer to right dorsal foot, and a DTI to right heel. Interview on 09/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #203 confirmed the medical record for Resident #16 did not have documentation to support the wounds were evaluated upon admission on [DATE] until 05/28/25 and that a treatment for the wounds was not initiated until 05/29/25. 2. Review of the medical record for Resident #32 revealed an admission date of 07/17/25 with medical diagnoses of diabetes mellitus with foot ulcer, chronic ulcer of left heel and midfoot with fat layer exposed, congestive heart failure, anemia, and atrial fibrillation. Review of the admission MDS assessment, dated 07/24/25, indicated Resident #32 was cognitively intact and required partial/moderate staff assistance for bed mobility and was dependent upon staff for toilet hygiene, showers/bathing, and transfers. The MDS indicated Resident #32 had an infection to her foot with a surgical wound present. Review of nursing comprehensive assessment, dated 07/17/25, indicated Resident #32 had stitches to left small toe and left outer foot. The assessment did not include measurements or description of wounds. Review of medical record for Resident #32 revealed a physician order dated 07/18/25 for left foot surgical site to apply Vashe moistened gauze to surgical site five to ten minutes then remove, pat dry, apply xerofoam, abdominal pad, and wrap with kerlix and ace wrap. And to change every 48 hours. Review of treatment administration record revealed documentation to support treatment was completed as ordered. Review of the medical record for Resident #32 revealed documentation to support Resident #32 was seen by wound physician on 07/22/25. A wound physician note on 07/22/25 indicated Resident #32 had surgical site to left lateral foot which measured 6.5 cm by 2.5 cm with five interrupted sutures in place. Interview on 09/11/25 at 11:26 A.M. with LPN #203 confirmed Resident #32 admitted to the facility with surgical wounds on 07/17/25 but the medical record did not have documentation to support Resident #32 wounds were not measured until 07/22/25. Review of the facility policy titled, Skin Management, revised 09/19/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic health record. The policy stated any residents admitted with any skin impairment would have appropriate interventions to promote healing, a physician's order for treatment and skin impairment location, measurements, and characteristics documented. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff implemented enhanced barrier precautions when changing wounds that require dressings. This affected one (#26) of three residents reviewed for wound care. The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an admission on 06/18/24 with diagnoses including cerebral infarction (stroke), heart failure, end stage renal disease, type two diabetes and severe vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed a severely impaired cognition. Resident #26 requires extensive assistance for activities of daily living. Review of the plan of care for Resident #26 dated 04/02/24 revealed resident has venous stasis skin impairment to left [NAME] related to peripheral vascular disease (PVD). Interventions include skin injury will decrease in size, enhanced barrier precautions, observe and report signs and symptoms of infection, and evaluate wound for size, depth, and margins. Review of the active physician orders for Resident #26 reveal an order dated 03/15/25 to cleanse area to right frontal lateral leg, pat dry and apply adaptic (petroleum gauze), cover with abdominal dressing (ABD) and wrap with kerlix daily and as needed, an or dated 03/19/25 to cleanse laceration wound to right mid anterior shin and right mid lateral skin with normal saline, pat dry, apply xeroform to eschar, cover with ABD, wrap with Kerlix and secure with ace bandage daily, an order dated 03/29/25 to cleanse skin tear to left buttock with normal saline, apply xeroform to wound bed, cover with silicone dressing every day, and cleanse wound to left medial calf (hematoma) with normal saline, pat dry and apply xeroform, cover with ABD, wrap with kerlix daily and as needed. Observation on 04/08/25 at 8:00 A.M. of signage for Resident #26 to the right of the entrance and above her name revealed the resident was on enhanced barrier precaution. The sign stated everyone must clean their hands before entering and when leaving the room. Additionally, the sign stated that providers and staff must also wear gloves, and a gown for the following high contact resident care activities including dressing, bathing, showering, transferring, changing linen, providing briefs or assisting with toileting, device care for central line, urinary catheter, feeding tube and tracheostomy and wound care for any skin opening requiring a dressing Observation on 04/08/25 at 8:10 A.M. revealed Licensed Practical Nurse (LPN) #5 and Certified Nurse Assistant (CNA) #84 enter Resident #26's room and donned gloves. LPN #5 advised Resident #26 that they were going to remove old dressing and measure the areas. LPN #5 removed the dressing to Resident #26's bilateral legs leaving dressing in place on the lower extremities. Wound Physician #101 donned gloves and entered room and addressed the resident, advising her he was there to measure the wounds. Wound Physician #101 measured each of the three wounds using separate disposable wound measuring devices. LPN #5 changed gloves completed hand hygiene and donned new gloves and applied dressing to left lower hematoma, leaving the right wound uncovered as the physician discontinued treatment and advised they were resolved. CNA #84 assisted Resident #26 to roll onto her right side for the physician to measure the wound to her left buttocks. Treatment to area was discontinued and physician documented area was resolved. Interview on 04/08/25 at 8:25 A.M. with LPN #5, CNA #84, Wound Physician #101 all verified they did not don gowns prior to entering the room for Resident #26 and should have. LPN #5, CNA #84 and Wound Physician #101 confirmed Resident #26 was to be in enhanced barrier precautions. Interview on 04/08/25 at 8:30 A.M. with the Director of Nursing (DON) verified the facility did not have a three chest drawer in the hallway to store personal protective equipment for use with Resident #26 and would get one in place outside of the door for Resident #26. The DON confirmed Resident #26 was to be in enhanced barrier precautions. Review of the facility policy titled Infection Preventions Program Overview dated 02/28/25 stated the facility established a program (infection prevention and control program) that is based on the facility assessment and follows accepted national standards. This deficiency represents non-compliance investigated under Complaint Number OH00162510.

Based on medical record review, staff interviews, policy review and review of the Ohio Revised Code (ORC), the facility failed to ensure the administration of total parental nutrition (TPN) was completed in accordance with professional standards of practice. This affected two (#57 and #89) of three residents reviewed for intravenous (IV) administration. The facility census was 88. Findings include: 1. Medical record review for Resident #57 revealed an admission on 08/07/24 with diagnoses with surgical aftercare on the digestive system, fistula of intestine, chronic pain syndrome, colostomy status and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #57 dated 02/27/25 revealed impaired cognition. Resident #57 required set up assistance for eating and maximum assistance for toileting assistance and dependent for transfers and bed mobility. Review of the plan of care for Resident #57 revealed resident has an alteration in nutritional and hydration related to fistula of intestine. Resident #57 has history of TPN discontinued on 11/03/24. Interventions include administer medication as ordered, administer diet as ordered and obtain laboratory/diagnostic tests as ordered. Review of the physicians orders for Resident #57 revealed an order dated 08/09/24 and discontinued on 11/03/24 for TPN adult cyclic on day shift nonstandard TPN. Registered Nurse (RN) to mix Infuvite (multivitamin) 10 milliliters (ml) start at 55 ml/hour (hr) and increase to 178 ml/hr for nine hours, decrease to 50 ml/hr for one hour the discontinue every day shift. Review of the Medication Administration Record (MAR) for Resident #57 for the month of October 2024 revealed Licensed Practical Nurse (LPN) #5 signed Resident #57's TPN as administered on 10/02/24, 10/05/24, 10/06/24, 10/10/24, 10/16/24, 10/19/24, 10/20/24, 10/24/24, 10/15/24, 10/30/24 and 10/31/24. LPN #29 signed Resident #57's TPN as administered on 10/03/24 and 10/17/24. LPN #35 signed Resident #57's TPN as administered on 10/09/24 and 10/28/24. LPN #31 signed Resident #57's TPN as administered on 10/11/24, 10/12/24, and 10/23/24. 2. Medical record review for Resident #89 revealed an admission on 06/11/24 and a discharge on 02/17/25 with diagnoses including surgical after care following digestive system for perforation of the intestine, severe protein malnutrition and adult lymphoma leukemia. Review of the plan of care for Resident #89 dated 06/19/24 revealed resident was at nutritional risk related to diagnoses of lymphoma. Resident #89 had a history of TPN discontinued on 12/04/24. Interventions include administer medications as ordered, refer to dietitian as needed and obtain laboratory test as ordered. Review of the quarterly MDS assessment dated [DATE] for Resident #89 revealed resident had an intact cognition. Resident #89 requires supervision for eating, bed mobility, transfers and toileting. Review of the physician's orders for Resident #89 for the month of November 2024 revealed an order dated 07/18/24 and discontinued on 12/10/24 for TPN adult cyclic on day shift nonstandard TPN, 5.5 percent (%) AA, seventeen % dextrose and three % intravenous lipid emulsion ([NAME]) kilocalorie's (KCAL) provided per day 1713 protein grams/day. RN to mix Infuvite (multivitamin) 10 milliliters (ml) start at 60 mix mix one hour, increase to 120 ml/hr times twelve house and decrease to 60 ml per hour and then discontinue every day shift for nutrition. Review of the MAR for Resident #89 for the month of November 2024 revealed LPN #31 signed the TPN as administered on 11/01/24, 11/04/24, 11/07/24, 11/09/24, 11/10/24, 11/12/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/21/24, 11/23/24, 11/24/24, 11/26/24 and 11/29/24. LPN #25 signed Resident #89's TPN as administered on 11/03/24, 11/06/24, 11/08/24, 11/11/24, 11/13/24, 11/16/24, 11/17/24, 11/20/24, 11/22/24, 11/25/24, 11/27/24, 11/28/24 and 1130/24. Interview on 04/08/24 at 3:07 P.M. with the Director of Nursing (DON) states she was unaware that the LPN's were documenting on the MAR indicating they were administering the TPN solution for Resident #57 or #89. DON verified that LPN's cannot administer TPN as it is out of their scope of practice. Additionally, the DON stated that once it was brought to her attention, she interviewed the LPN's regarding who was administrating the solution. LPN's reported the RN's working administered the TPN solution and the LPN's had just signed the MAR off as completed. DON verified LPN's should not be signing for the administration of TPN or documenting it on the MAR as administered. DON confirmed LPN's can not initiate or maintain TPN. Interview on 04/08/25 at 4:09 P.M. with LPN #31 verified that he did not administer any TPN solution for Resident #57 and #89. LPN #31 only signed the MAR as completed. LPN #31 confirmed LPN's can not initiate or maintain TPN. Interview on 04/09/25 at 2:00 P.M. with Unit Manager LPN #76 denied any knowledge of any LPN's completing the administration of TPN and that they were just signing off the MAR for the RN. LPN #76 verified administration of TPN solution was out of the scope of practice for LPN's. LPN #76 confirmed LPN's can not initiate or maintain TPN. Review of the facility policy titled Total Parental Nutrition dated 12/10/24 revealed staff should monitor for signs of complications related to TPN administration. Review of the facility policy titled Medication Administration dated 10/17/23 revealed under authorized personnel medications are prepared, administered and recorded only by licensed nursing authorized by state law and regulations. Review of the ORC Section 4723.18 titled Administration of Adult Intravenous Therapy at https://codes.ohio.gov/ohio-revised-code/section-4723.18 revealed LPN's shall not perform any of the following: initiate or maintain any intravenous therapy procedures that include solutions for total parental nutrition. This deficiency represents non-compliance investigated under Complaint Number OH00162510.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to complete timely and thorough investigations and failed to protect residents during an abuse investigation by suspending accused staff. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents. Findings include: 1.Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.) Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel. Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with staff on abuse and neglect prevention. Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87. Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation. Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25. Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including occlusion and stenosis of right carotid artery and diabetes. Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25. Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25. Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25 Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed. This deficiency represents noncompliance investigated under Complaint Number OH00161688.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents. Findings include: 1.Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.) Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel. Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87. Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation. Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including occlusion and stenosis of right carotid artery and diabetes. Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25. Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25. Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25 Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed. This deficiency represents noncompliance investigated under Complaint Number OH00161688.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility to honor resident smoking rights. This affected one (Resident #3) of one resident reviewed for smoking. The facility identified 10 residents who smoked independently. The facility census was 85 residents. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating, and substantial/maximum assistance for toileting, bed mobility, and transfers. Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out to the smoking area and look for cigarette butts to smoke or ask other residents that smoked for cigarettes. Interventions included the following: staff members to distribute smoking materials to residents who smoke at the designated times, staff to supervise and maintain safety during smoking, staff members to maintain all smoking paraphernalia for unsafe and safe smokers such as cigarettes and lighters. Review of smoking assessment for Resident #3 dated 11/01/24 revealed the resident was an unsafe smoker because he couldn't safely light the smoking materials, couldn't hold the materials safely, couldn't dispose of ashes in the ashtray safely, couldn't extinguish cigarette safely, and couldn't follow the policy. The summary of the assessment revealed Resident #3 was an unsafe smoker and he would be a supervised smoker. Interview on 01/29/25 at 8:30 A.M with the Director of Nursing (DON) confirmed if a resident was admitted into the facility and could smoke independently the resident could smoke outside whenever they wished. If a resident was assessed as an unsafe smoker, the resident was not permitted to smoke on the facility grounds. The DON further confirmed the facility did not offer supervised smoking. Interview on 01/29/25 at 10:20 A.M. with Resident #3 confirmed the resident was able to answer questions appropriately. Resident #3 confirmed he had been a smoker for quite some time and the facility would not allow him to smoke and he didn't know why. Review of the facility policy titled Smoking Policy dated 10/17/23 revealed if the interdisciplinary team (IDT) determined that a resident was an unsafe smoker, the resident was required to wear a protective smoking vest/apron and should be supervised while smoking. The degree of supervision was determined by the team and was based on the smoking evaluation, the physical attributes of the smoking area, and other relevant factors. Staff members would maintain all smoking paraphernalia for all unsafe and safe smokers, e.g., cigarettes, cigars, pipes, lighter fluid, or any other matter or substance that contained a tobacco product. Staff members would distribute smoking materials to residents that were unsafe to smoke at the designated smoking times. Review of the facility policy titled Resident Rights dated 05/14/24 revealed the facility must promote the exercise of rights for each resident, including any who face barriers such as communication problems, hearing problems and cognition limits in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to follow and implement the abuse policy regarding allegations of abuse by failing to report abuse to the state agency in a timely manner, failing to provide abuse education as detailed in the SRI, failing to protect residents during an abuse investigation by suspending accused staff, and failing to complete a timely and thorough abuse investigation. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents. Findings include: 1.Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.) Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel. Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with the staff on abuse and neglect prevention. Further review of the SRIs revealed there was no SRI initiated for the complaint received from the insurance company regarding Resident #87. Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation. Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25. Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including occlusion and stenosis of right carotid artery and diabetes. Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25. Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25. Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25. Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed. This deficiency represents noncompliance investigated under Complaint Number OH00161688.