Every finding on record at Louisville Gardens Care Center

Based on record reviews, observations, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to maintain infection control practices to prevent the spread of the coronavirus-19 infection (COVID-19 / SA RS-Co Y-2) in the facility and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #56's incontinence care. This affected four residents (#7, #30, #51, and #45) of 16 residents (#3, #6, #7, #14, #17, #26, #27, #30, #38, #44, #45, #51, #55, #56, #65, and #67) with a positive COVID-19 infection, one resident (#31) out of four residents reviewed for smoking tobacco products, one resident (#56) out of three residents reviewed for incontinence care. This had the potential to affect all the residents in the facility. The facility census was 66.Findings include:The facility identified 16 residents (Resident #3, Resident #6, Resident #7, Resident #14, Resident #17, Resident #26, Resident #27, Resident #30, Resident #38, Resident #44, Resident #45, Resident #51, Resident #55, Resident #56, Resident #65, Resident #67) who tested positive for COVID-19 in the facility from 11/26/25 to 12/09/25. A review of each of the residents' record listed above revealed a positive test for COVID-19 and a physician order for droplet isolation precautions.1. A review of Resident #7's clinical record revealed an admission date of 03/31/25 and readmission date of 05/11/25 with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, mild dementia with agitation, deep vein thrombosis of lower extremity, asthma, depression, diabetes mellitus, type two, gastroesophageal reflux disease, heart failure, high blood pressure and cholesterol, and iron deficiency anemia,A review of Resident #7's nursing progress note dated 12/08/25 indicated Resident #7's daughter, Power of Attorney (POA), was notified that Resident #7 had tested positive for COVID-19 infection.An observation on 12/09/25 at 9:24 A.M. of Resident #7's room revealed no signage to alert staff and visitors that personal protective equipment (PPE) should be worn due to isolation precautions for a resident who tested positive for the COVID-19 infection.An interview with Licensed Practical Nurse (LPN) #70 on 12/09/25 at 9:24 A.M. verified Resident #7 had tested positive for COVID-19 infection on 12/08/25, and staff should have placed a sign outside her room to alert the staff/visitors to wear PPE. LPN #70 verified there was no signage outside of Resident #7's room.An interview with the Director of Nursing (DON) on 12/09/25 at 9:58 A.M. stated the facility had an outbreak of COVID-19 infections. All residents who had tested positive for COVID-19 were supposed to have a sign posted on the door outside their room to alert staff and visitors to see the nurse before entering the resident's room and to wear PPE for isolation precautions. The facility followed CDC guidance to control the spread of the COVID-19 viral infection. The facility had six additional residents who had tested positive for COVID-19 on 12/08/25 and currently had 16 residents (#3, #6, #7, #14, #17, #26, #27, #30, #38, #44, #45, #51, #55, #56, #65, and #67) who had tested positive for COVID-19 with one resident (#67) currently in the hospital. 2. An interview with Resident #31 on 12/09/25 at 9:46 A.M. revealed she was concerned about contracting the COVID-19 virus. Resident #31 stated the staff allowed the residents who had tested positive for the COVID-19 viral infection to smoke at the same time as the residents who had tested negative for the COVID-19 infection.An interview with the DON on 12/09/25 at 9:58 A.M. verified the staff had allowed Resident #7 who had tested positive for COVID-19 to smoke with the residents who had tested negative for COVID-19 on 12/08/25.An interview with Resident #7 on 12/09/25 at 1:15 P.M. verified she had tested positive for COVID-19 infection on 12/08/25 and was allowed to smoke with the rest of the residents including the residents who had tested negative for COVID-19 infection.3. An observation and interview with LPN #74 on 12/10/25 from 7:00 A.M. to 7:43 A.M. revealed Resident #30's and Resident #51's room had a sign indicating droplet precautions be implemented when providing care. Resident #30 and Resident #51 resided together in one room, and the door was left open. LPN #74 stated both residents had tested positive for COVID-19 infection. LPN #74 verified the door was left open because the residents liked to have the door open. LPN #74 agreed the door had been left open for an extended period of time. An observation and interview with the Therapy Director on 12/10/25 at 9:21 A.M. verified Resident #45's door was open, and Resident #45 had a sign on the door to implement droplet isolation precautions when entering the room and verified Resident #45 had tested positive for COVID-19 infection.A review of the facility policy and procedure titled Coronavirus Disease (COVID-19) -Infection Prevention and Control Measures, dated 04/29/24, indicated the facility followed infection prevention and control (IPC) practices recommended by the CDC to prevent the transmission of COVID-19 within the facility. The infection prevention and control measures that are implemented to address the SA RS-Co Y-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses;b. providing resources and counseling about the importance of receiving the COVID-19 vaccine;c. identifying and managing ill residents and staff;d. ensuring everyone is aware of recommended IPC practices in the facility, including the use of visual alerts with dates to reflect that recommendations are current; e. a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following criteria:- Symptoms of COVID-19; or - close contact with someone with SARS-[NAME]-2 infection (for residents and visitors) or a higher-risk exposure (for healthcare personnel [HCP]).f. Implementing source control measures;g. implementing universal use of PPE for staff;h. optimizing engineering controls and indoor air qualityi. A positive viral test for SARS-[NAME]-2; following current environmental infection prevention and control recommendations;j. performing testing as recommended by current guidelines;k. responding to SARS-[NAME]-2 exposures; andl. implementing outbreak investigations when indicated. A review of the CDC's guidance titled infection Control Guidance: SARS-CoV-2 indicated this guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. The IPC (Infection Prevention Control) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multi-Drug Resistant Organisms (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process.Facilities could consider designating entire units within the facility, with dedicated Health Care Personnel (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes.CDC infection control regarding laundry and bedding, dated 01/08/24, indicated the following guidance for laundry obtained from patients/residents in isolation areas:When collecting, transporting, and sorting contaminated textiles and fabrics in healthcare facilities ensure bags of contaminated laundry are clearly identified with labels, color-coding or other methods so the healthcare workers handle the items safely, regardless of whether the laundry is transported within the facility or a designated off-site laundry service.4. A review of Resident #56's clinical record revealed an admission date of 08/26/25 with diagnoses including sepsis, stroke, skin cancer, vitamin B12 and Vitamin D deficiency, hypocalcemia (low calcium blood level), expressive language disorder, seizures, type two diabetes mellitus, right lower leg cellulitis, stage 3 chronic kidney disease, paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerosis heart disease and right leg arteries, high blood pressure and cholesterol, gastroesophageal reflux disease, and depression.A review of Resident #56's care plan initiated on 08/26/25 indicated Resident #56 was at risk for bladder incontinence related to stage three kidney disease. A review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56 was always incontinent of bladder.Interventions on the care plan included cleaning peri-area with each incontinence episode, monitor and document signs/symptoms of urinary tract infections, and possible causes of bladder incontinence including infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects.An observation of CNA #75 on 12/10/25 at 11:40 A.M. provide Resident #56 with incontinence care revealed a failure to perform hand hygiene to prevent cross contamination of germs. CNA #75 entered Resident #56's room and did not perform hand hygiene and donned a pair of gloves. CNA #75 obtained a soapy washcloth and cleaned Resident #56's perineal area and then rinsed the area with a warm wet washcloth and dried the area. CNA #75 then removed her glove from her left hand, did not perform hand hygiene and opened Resident #56's furniture drawer and moved personal items in the drawer around looking for moisture barrier cream. CNA #75 then donned another glove to her left hand and applied the moisture barrier cream to Resident #56's perineal area and then with the same gloved hands replaced the moisture barrier cream back in the drawer with Resident #56's other personal items without removing her gloves or performing hand hygiene. CNA #75 then removed her glove from her right hand, did not perform hand hygiene and used her right hand to readjust Resident #56's bed linens and use the bed remote to adjust the bed position. An interview with CNA #75 on 12/10/25 at 11:55 A.M. verified the above findings and agreed she should have performed hand hygiene after removing her each disposable glove and prior to starting the task.A review of the policy titled Handwashing/Hand Hygiene, dated 10/2023, indicated the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.4. Personnel are educated regarding ways to prevent contact dermatitis and other skin irritation, and provided with supplies that support healthy hand skin.a. Facility-supplied lotions are compatible with antiseptics and gloves.b. ABHRs, soaps and lotions are free of allergenic surfactants, preservatives, fragrances and dyes.c. Triclosan-containing soaps are not recommended for use or supplied by the facility.5. Environmental measures are taken to reduce contamination associated with sinks and sink drainage, including:a. Hand washing sinks that are constructed and installed according to health department codes;b. Sinks that are dedicated to handwashing, when possible;c. The use of disinfectants that are EPA-registered for biofilm removal to clean sinks and faucets daily; andd. Surveillance for waterborne pathogens.6. Residents, family members and/or visitors are encouraged to practice hand hygiene. Fact sheets, pamphlets and/or other written materials promoting hand hygiene practices are provided at the time of admission and/or posted throughout the facility.Indications for hand hygiene included:1. Hand hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);c. after contact with blood, body fluids, or contaminated surfaces d. after touching a resident;e. after touching the resident's environment f. Before moving from work on a soiled body site to a clean body site on the same resident andg. immediately after glove removal2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 3. Wash hands with soap and water: a. when hands are visibly soiled; and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.4. Single-use disposable gloves should be used:a. before aseptic procedures; b. when anticipating contact with blood or body fluids; and c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 5. The use of gloves does not replace hand washing/hand hygiene.This deficiency represents non-compliance investigated under Master Complaint Number 2688125.

Based on record review, observation and interview, the facility failed to ensure staff administered Resident #32's wound treatment as ordered by the physician. This affected one resident (#32) out of three residents reviewed for wounds. The facility census was 66.Findings include:A review of Resident #32's clinical record revealed an admission date of 10/12/25 with diagnoses including morbid obesity, cognitive communication deficit, obstructive and reflux uropathy, pneumonia, type two diabetes mellitus, congestive heart failure, atrial fibrillation (irregular heart rhythm), high blood pressure, chronic kidney disease, depression, anxiety, disorientation and rotator cuff tear of the right shoulder.A review of Resident #32's wound assessment dated [DATE] indicated the presence of a deep tissue injury (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) to the right lateral heel.A review of Resident #32's physician orders dated 12/01/25 revealed an order to cleanse the right lateral heel with normal saline, pat dry, apply betadine (antiseptic), cover with abdominal (ABD) pad and wrap with gauze daily and as needed during the night shift.A review of Resident #32's Treatment Administration Record (TAR) dated 12/01/25 to 12/31/25 revealed documentation the wound treatment was performed on 12/09/25.An observation on 12/10/25 at 12:00 P.M. of Resident #32's right lateral heel revealed the dressing was dry and intact and the date of the dressing was documented as 12/08/25 and initialed by the nurse.An interview on 12/10/25 at 12:00 P.M. with Certified Nursing Assistant (CNA) #75 and CNA #78 verified the above findings and agreed the wound treatment was not changed on 12/09/25.This deficiency represents non-compliance investigated under Complaint Number 2640234 and Complaint Number 2680110.

Based on record review, interview and facility policy review, the facility failed to ensure medications were available to administer to Resident #21 and Resident #39 in a timely manner. This affected two residents (#21 and #39) out of five residents reviewed for medication administration. The facility census was 66.Findings include:1. A review of Resident #21's clinical record revealed an admission date of 10/23/25 with diagnoses including pleural effusion, hemiplegia and hemiparesis following a stroke, atelectasis, trouble swallowing, cognitive communication deficit, tracheostomy, epilepsy, malnutrition, type two diabetes mellitus, chronic pancreatitis, depression, anxiety, high cholesterol and blood pressure, and acute/chronic respiratory failure requiring ventilator support.A review of Resident #21's clinical record revealed an admission to the facility on [DATE] following a hospitalization for acute respiratory failure.A review of Resident #21's physician orders dated 10/23/25 revealed an order to administer lacosamide (medication used to control seizures) 150 milligrams (mg) via percutaneous endoscopic gastrostomy (PEG) tube two times a day.A review of Resident #21's Medication Administration Record (MAR) dated 10/01/25 to 10/31/25 indicated the lacosamide medication was not administered on 10/23/25 and 10/24/25.A review of Resident #21's nursing progress notes dated 10/24/25 indicated the lacosamide medication was not administered because the pharmacy needed a prescription for the medication.An interview with Licensed Practical Nurse (LPN) #79 on 12/10/25 at 8:58 A.M. revealed Resident #21's lacosamide medication was not available in the facility to administer to Resident #21. LPN #79 stated she notified Certified Nurse Practitioner (CNP) #80 who was in the facility at the time. CNP #80 called the pharmacy to inform them of the need for Resident #21's lacosamide medication. LPN #79 stated this occurred at the end of her shift and the oncoming nurse (unnamed) would need to administer the lacosamide medication when it arrived from the pharmacy.Three attempts to speak to the oncoming nurse (LPN #81) were unsuccessful from 12/09/25 to 12/11/25 and an interview with CNP #80 on 12/09/25 at 2:32 P.M. verified she had called the pharmacy on 10/24/25 to obtain the lacosamide medication for staff to administer to Resident #21. CNP #80 stated she was unaware the staff did not receive the lacosamide medication prior to Resident #21's readmission to the hospital on [DATE].An interview with the Director of Nursing (DON) on 12/10/25 at 10:43 A.M. verified the above findings and agreed the documentation revealed Resident #21 did not receive the lacosamide medication on 10/23/25 and 10/25/25.2. A review of Resident #39's clinical record revealed an admission date of 08/20/18 with diagnoses including cerebral palsy, epilepsy, profound intellectual disability, hypothyroidism, depression, high cholesterol, anxiety and senile degeneration of the brain.A review of Resident #39's clinical record revealed a physician order dated 02/10/25 to administer phenobarbital 32.4 mg (anticonvulsant) rectally three times a day.A review of Resident #39's MAR dated 12/01/25 to 12/31/25 indicated the phenobarbital medication was not administered from 10:00 P.M. on 12/02/25 to 2:00 P.M. on 12/06/25.A review of Resident #39's nursing progress notes dated 12/02/25 indicated an attempt to pull the phenobarbital medication from the facility's stocked medications was unsuccessful due to the pharmacy needed an updated prescription. The note indicated CNP #82 was notified. Multiple nursing progress notes dated 12/02/25 to 12/06/25 revealed several attempts were made to have the pharmacy deliver the phenobarbital rectal suppository medication, and the physician was notified as well.An interview with LPN #74 on 12/10/25 at 9:45 A.M. verified Resident #39's phenobarbital medication was not available in the facility to administer to Resident #39. LPN #74 stated she contacted the pharmacy and spoke to the pharmacy staff who informed her they were unable to provide the phenobarbital medication until a prescription was provided to the pharmacy. LPN #74 stated she emailed and sent two prescriptions for the phenobarbital medication to the pharmacy which the pharmacy denied receiving at least seven times. LPN #74 stated Resident #39 had seizures and was worried she would have a seizure due to not receiving her seizure medication. LPN #74 stated on 12/06/25 CNP #82 sent the prescription via electronic scripts, and the pharmacy finally delivered the phenobarbital medication. LPN #74 verified Resident #39 did not receive the phenobarbital medication from 12/02/25 to 12/06/25. LPN #74 stated Resident #39 received the phenobarbital medication on 12/06/25 at 5:40 P.M.An interview with the DON on 12/10/25 at 10:43 A.M. revealed she reviewed the nursing progress notes daily on all the residents in the facility and verified she was aware there were several doses of the phenobarbital medication missed from 12/02/25 to 12/06/25 due to the pharmacy did not deliver the medication. The DON stated she called the pharmacy herself to ensure after they received the electronic script on 12/06/25 that a drop shipment was made to deliver the phenobarbital medication promptly.The facility policy and procedure titled Medication Orders and Receipt Record, revised 04/2007, revealed the facility would document all medications that are ordered and received in the facility. The Charge Nurse would maintain medication order and receipt records. The DON Services would designate individuals to be responsible for completing medication order/receipt forms. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered/received shall also be entered onto the medication order and receipt record. The receiving nurse shall record medication orders received on the receipt record. The receiving nurse shall verify each delivered medication and check off the order form. Controlled substances shall be verified in the presence of the person delivering the drug order. Noted discrepancies shall be reported to the dispensing pharmacy.This deficiency represents non-compliance investigated under Master Complaint Number 2688125.

Based on record review, review of the facility admission Agreement, interview and facility policy review, the facility failed to ensure Resident #7's admission paperwork was completed in a timely manner and Resident #44's medication administration documentation was accurate. This affected one resident (#7) out of three residents reviewed for admission paperwork and one resident (#44) out of three residents observed during medication administration. The facility census was 66.Findings include:Based on record review, review of the facility admission Agreement, interview and facility policy review, the facility failed to ensure Resident #7's admission paperwork was completed in a timely manner and Resident #44's medication administration documentation was accurate. This affected one resident (#7) out of three residents reviewed for admission paperwork and one resident (#44) out of three residents observed during medication administration. The facility census was 66.Findings include:1. A review of Resident #7's clinical record revealed an admission date of 03/31/25 and readmission date of 05/11/25 with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, mild dementia with agitation, deep vein thrombosis of lower extremity, asthma, depression, diabetes mellitus, type two, gastroesophageal reflux disease, heart failure, high blood pressure and cholesterol, and iron deficiency anemia.Review of the cognitive care plan note dated 09/22/25 and signed by the physician on 09/29/25 revealed a diagnosis of Dementia: Moderate in severity based on the recent local score, this patient does not have a diagnosed history of dementia, based on that Moca score, I would say she certainly should carry that diagnosis of dementia going forward, she does have a Power of Attorney (POA) in place which is her daughter I would encourage her to continue to utilize her listed decision-maker for assistance with needs or medical and financial decisions going forward.A review of Resident #7's admission Agreement revealed the documentation was completed on 09/30/25 and signed by Resident #7. (The resident had a Power of Attorney (POA) that should have been asked to sign the admission paperwork). An interview with Interim Administrator (IA) #76 on 12/10/25 at 11:36 A.M. verified the admission paperwork including the admission agreement was not completed in a timely manner for Resident #7.A review of the facility policy and procedure titled admission Agreement, dated 12/2006, indicated at the time of admission, the resident (or his/her representative) must sign an admission Agreement (contract) that outlines the services covered by the basic per diem rate, as well as any additional services requested by the resident that are not covered by the basic per diem rate.-The admission Agreement (contract) will reflect all charges for covered and non-covered items, as well as identify the parties that are responsible for the payment of such services.-With respect to our admission Agreement, our facility shall not: a. Require individuals applying to reside (or residing) in our facility to waive their rights to benefits under Medicare/Medicaid; b. Require oral or written assurances that such residents or applicants are not entitled or eligible for such benefits; c. Require oral or written assurances that such residents or applicants will not apply for such benefits; d. Require that the sponsor or legal guardian guarantee payment as a condition of admission, or to expedite the admission. (Note: An individual, or guardian, who has access to the resident's income or resources will be required to sign the admission Agreement guaranteeing payment from such funds for the care and services provided to the resident in accordance with the admission Agreement.); and e. In the case of a resident or applicant who is entitled to Medicare/Medicaid benefits for nursing care, charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under Medicare/Medicaid programs, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the applicant to the facility or as a requirement for a resident's continued stay in the facility. (Note: This shall not be construed as preventing the facility from charging Medicare/Medicaid recipients for services the resident requested that are not covered by the facility's per diem rate.)- [NAME]-fide contributions may be accepted and solicited by the facility from a charitable, religious, or philanthropic organization or from a person unrelated to a resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility.-A copy of the admission Agreement will be provided to the resident or his/her representative (sponsor), and a copy will be placed in the resident's permanent file.-Residents will be informed of any change(s) in the costs or availability of services at least sixty (60) days prior to such change(s) taking effect. Changes in services, charges, payments, etc., will require that new agreements be signed.-Inquiries concerning the facility's admission Agreement should be referred to the Administrator and/or business office.2. A review of Resident #44's clinical record revealed an admission date of 09/18/19 and readmission date of 08/13/21 with diagnoses including chronic obstructive pulmonary disease, anemia, fractured left arm, benign tumor of lower limb including hip, bipolar disorder, borderline personality disorder, hemorrhoids, obesity, heart failure, lymph node disorder with lymphedema, chronic left calf non-pressure ulcer, paroxysmal atrial fibrillation (irregular heart rate), chronic venous high blood pressure, type two diabetes mellitus with circulatory complications, anxiety, obstructive sleep apnea, post-traumatic stress disorder, insomnia, stage three chronic kidney disease, hoarding disorder, excessive and redundant skin disorder, overactive bladder, hypothyroidism, restless leg syndrome, vitamin D deficiency, neuropathy, rosacea, high cholesterol and blood pressure and gastroesophageal reflux disease.A review of Resident #44's physician orders and Medication Administration Record (MAR) dated 12/01/25 to 12/31/25 indicated to administer the following medications/treatments at 8:00 A.M. and/or 9:00 A.M.:-Aurality extended release 45-105 milligram (mg) (dextromethorphan, Hydrobromide-Bupropion Hydrochloride) (medication to treat major depressive disorder) one tablet orally-Cranberry oral tablet 450 mg (supplement) tablet orally- Flonase allergy relief nasal suspension 50 micrograms (mcg)/actuation (corticosteroid) one spray each nostril- Lidocaine external patch (local anesthetic) apply topically to shoulder for pain- Oxybutynin chloride extended release 15 mg orally (medication to treat overactive bladder)-Zinc 50 mg orally (supplement)-Zyrtec allergy 10 mg orally (antihistamine)- Cardizem Long Acting 240 mg orally (antiarrhythmic)- Gabapentin 300 mg orally (anticonvulsant)-Magnesium lactate extended release 84 mg orally (supplement)-Megestrol acetate 20 mg orally (hormone)-Metoprolol 50 mg orally (medication to treat high blood pressure, chest pain, and heart failure)- Mucinex extended release 600 mg orally (expectorant)-Artificial tears ophthalmic solution 1.4 percent instill one drop each eye-Vitamin C 1,000 mg orally (supplement)An observation on 12/10/25 at 7:32 A.M. of Licensed Practical Nurse (LPN) #77 administer medications to Resident #44 revealed a failure to document the medication administration accurately. LPN #77 administered the above listed medications but did not administer the Flonase nasal spray, Artificial Tears or Lidocaine patch.A review of Resident #44's MAR dated 12/01/25 to 12/31/25 revealed LPN #77 had documented the administration of the Flonase nasal spray, Artificial Tears and documented the Lidocaine patch was not available to administer to Resident #44.An interview with LPN #77 on 12/10/25 at 11:27 A.M. verified she had failed to administer the Flonase nasal spray and Artificial Tears at the time she administered the other medications because she usually completed her treatments at 10:00 A.M. LPN #77 verified she documented that she had administered the Flonase nasal spray and Artificial tears on Resident #44's MAR at 8:00 A.M. LPN #77 stated she would administer the Flonase and Artificial Tears at 10:00 A.M. LPN #77 stated the Lidocaine patch was not available to administer at the time she administered the other medications to Resident #44, and she would call the pharmacy to have them deliver the Lidocaine patches to the facility.The facility policy titled Administering Medications, revised 04/2019, indicated medications are administered in a safe and timely manner, and as prescribed. Item number nine indicated medications are administered within one (1) hour of their prescribed time, unless otherwise specified. Item number 24 on the policy revealed 24. The individual administering the medication initials on the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Item number 25 indicated 25. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug.The facility policy titled Documentation of Medication Administration (undated) indicated1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's MAR.2. Administration of medication must be documented immediately after (never before) it is given.3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage. c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); f. Signature and title of the person administering the medication; and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.).This deficiency represents non-compliance investigated under Complaint Number 2640234.

Based on observations, payroll-based journal review, facility assessment review, policy review and interview, the facility failed to ensure adequate staffing to meet resident needs. This had the potential to affect all residents residing within the facility. The facility census was 53. Findings include: 1. Review of the Facility Assessment Tool updated 08/11/25 revealed the staffing included seven nurses per day; ten certified nursing assistants (CNAs) per day; two other nursing personnel; one dietitian, seven food and nutrition services staff, and one respiratory care services staff. The facility provides adequate staffing to meet needed residents' daily needs, preferences, and routines to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being. This includes services of a registered nurse (RN) for at least (8) consecutive hours a day, seven days a week and a designated licensed nurse to serve as a charge nurse on each tour of duty as well as adequate staffing on each shift to ensure that the resident's needs and services were met by registered and licensed nursing staff, certified/state tested nursing assistants, and other support services that include but were not limited to dietary, activities/recreational, social, therapy and environmental. Review of the second quarter (2025) PBJ revealed the facility had a one-star rating. Review of resident records revealed Residents #6, #14, #21, #27, #31, #47 and #48 did not receive showers as scheduled. Interview on 09/02/25 at 9:13 A.M. with Licensed Practical Nurse (LPN) #539 confirmed there were not enough staff at times, and showers, as well as appointments, were always an issue. Interview on 09/02/25 at 9:16 A.M. with CNA #506 revealed there used to be a shower aide, and the facility took the shower aide away. CNA #506 stated she could not complete showers timely due to lack of staffing. Interview on 09/02/25 at 10:38 A.M. with Resident #49 revealed she had to wait 30 to 40 minutes for a call light response depending on the day. Interview on 09/02/25 at 10:41 A.M. with Resident #47 revealed the call light was not answered timely due to lack of staffing. Interview on 09/02/25 at 10:45 A.M. with Resident #25 revealed there were not enough staff, and she regularly had to wait 90 minutes for care. Interview on 09/02/25 at 11:47 A.M. with Resident #21 revealed there was not enough staff for timely resident care. Review of the Staffing policy, dated 03/09/22, revealed the facility was to provide adequate staffing to meet the care and services the resident population required. Under the heading titled Policy Interpretation and Implementation revealed the following: section one of the policy noted the facility provided staffing to ensure resident care needs and services were met by licensed nursing staff, and section two noted that CNAs were available to meet needed resident care and services. 2. Observation on 09/02/25 at 4:35 P.M. revealed two call lights were on upon arrival to the 400-unit, including Resident #1's call light and Resident #60's call light. The nurse was in hall at the medication cart preparing medications, talking loudly and giggling (nobody else was near the medication cart). No aides were observed on the unit. Observation on 09/02/25 revealed the meal cart arrived and was left in hall by nursing station at 4:40 P.M. Observation of Resident #42's call light on 09/02/25 at 4:50 P.M. revealed it was triggered while RN #585 was in the resident's room administering medications. RN #585 exited the room a few minutes later, leaving the call light on. After exiting the room, RN #585 was heard asking another staff member walking briefly through the hall with a clipboard if there was an aide assigned to the unit, adding that the meals needed passed and there were three call lights that needed answered. That staff member responded that they did not know. RN #585 was then observed entering the secured memory care unit, leaving the meals undelivered and three call lights unanswered. Observation on 09/02/25 from 5:00 P.M. to 5:08 P.M. revealed CNA #502 exited the secured memory care unit and began passing meal trays and responding to call lights. Response to the call light were as follows: Resident #42's call light was answered at 5:03 P.M. (13 minutes). Resident #1's call light was answered at 5:06 P.M. (after 31 minutes observed). Resident #60's call light was answered at 5:08 P.M. (after 33 minutes observed). Observations further revealed the last dinner tray was delivered at 5:08 P.M. (28 min. to get trays passed after arriving on the unit). Interview on 09/02/25 at 5:10 P.M. with CNA #502 confirmed she was not the assigned aide for the 400 unit and did not know where the aide was but was instructed by the nurse to deliver trays and respond to call lights. Interview on 09/02/25 at 5:14 P.M. with RN #585 acknowledged Resident #1 and #60 had their call lights on when the surveyor entered the hall and confirmed she was not made aware that there was no aide for the unit. During the interview, RN #585 only became aware there was no aide when she got to the end of the hall near the nurses' station and saw that call lights remained unanswered and the meal trays remained undelivered. She requested the memory care aide pass trays and answer call lights while she passed medications and monitored the dining on the memory care unit. Interview on 09/02/25 at 5:22 P.M. with the Director of Nursing (DON) confirmed there should have been an aide scheduled for the 400 unit and was unaware that no aide was there. As far as expectations for timely response to call lights, the DON responded it depends on whether meal trays were being passed or what else was going on at the time, but call lights should not go unanswered for longer than 30 minutes. Interview on 09/03/25 at 9:50 A.M. with CNA #567 revealed concerns getting assistance for two person tasks, stating the nurse working the unit on 09/02/25 (LPN #586) did not sign any of the shower sheets upon CNA #567's request and refused to assist with the transfer and toileting of Resident #23. CNA #567 reported the inability to have the aide from memory care assist because the unit should not be left unattended and had to get a nurse from another unit to come help with Resident #23's care. During the interview, CNA #567 reported that the aide that was scheduled at 3:00 P.M. on 09/01/25 and on 09/02/25 did not show up and had been a no-call, no-show several times. CNA #567 further reported informing the scheduler there was no aide to relieve her and later received a text message thanking her for staying and then telling CNA #567 that she was good to go home. CNA #567 confirmed leaving the facility with only one nurse working on the 400 unit and no aide on the afternoon shift of 09/02/25. Interview on 09/03/25 5:10 P.M. interview with Resident #1 confirmed he had placed his call light on just before dinner on 09/02/25, and it remained unanswered for greater than 30 minutes. By the time someone came in the room with his dinner tray, he had forgotten why he activated the light on in the first place (during the interview, Resident #1 recalled he had some bleeding from his backside he thought he should report to someone). Review of the policy titled Answering the Call Light, last revised March 2021, revealed staff were to provide a timely response to resident's requests and needs. The policy further revealed that if staff were able to perform the requested task, it should be completed within five minutes of knowledge of what they needed/requested. This deficient practice represents noncompliance investigated under Complaint Number 1395034 (OH00167579).

Based on record review, interview and facility policy review, the facility failed to ensure care conferences were completed at least quarterly for Residents #5, #21, and #27, and the facility failed to ensure care plan accuracy regarding incontinence care for Resident #40 and an updated care plan to reflect Resident #51's fall. This finding affected three (Residents #5, #21, #27) of three residents reviewed for care conferences and two (Residents #51 and #40) of 25 residents reviewed for care planning. The facility census was 53. Findings include: 1. Review of the medical record for Resident #27 revealed in admission date of 12/02/24 24. Diagnoses included cognitive communication deficit, depression, muscle weakness, anxiety, insomnia and diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact. She required setup help for eating and partial to moderate assistance for oral hygiene, toileting, showering, dressing, and hygiene. Interview on 09/02/25 at 9:47 A.M. with Resident #27 revealed she did not get invited to care conferences. Review of the social service notes dated 12/04/24 through 09/04/25 revealed the resident had a 72-hour meeting on 12/04/24 to discuss care needs, and a care conference was scheduled for 07/22/25. There was no documented evidence this meeting occurred. Interview on 09/04/25 at 12:53 P.M. with the Administrator confirmed there were no formal care conferences for Resident #27 because the social service designee (SSD) was in regular contact with Resident #27's son; however, she identified the necessity for a care conference in which the resident would be included. 2. Review of the medical record for Resident #40 revealed an admission date of 04/04/25. Diagnoses included cognitive communication deficit, dementia, anxiety, depression, elevated blood pressure, chronic obstructive pulmonary disease, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 was cognitively intact. She required setup help for eating, oral hygiene, toileting, personal hygiene and substantial or maximum assistance for showering. She was always continent of bowel and bladder. Review of the care plan dated 07/03/25 revealed Resident #40 was at risk for developing complications secondary to bowel incontinence. Interventions included checking the resident every two hours and assisting with toileting as needed, observing for patterns of incontinence and initiating a toileting schedule if necessary and providing a bedside commode. Resident #40 was also at risk for bladder incontinence and had an indwelling urinary catheter. Interventions included cleaning the peri area with each incontinent episode, ensuring the resident had an unobstructed path to the bathroom, ensuring her call light was within reach and monitoring, documenting and reporting possible causes for incontinence. Interview on 09/03/25 at 3:05 P.M. with Resident #40 revealed she did not need help to go to the bathroom; she used the bathroom on her own and did not wear an incontinence brief. She also revealed she never had accidents of either bowel or bladder. Interview on 09/03/25 at 3:08 P.M. with Licensed Practical Nurse (LPN) #539 revealed she had no knowledge of Resident #40 ever having a catheter and confirmed she was continent of both bowel and bladder. Interview on 09/04/25 at 9:16 A.M. with the Director of Nursing (DON) confirmed Resident #40 had never had a catheter, and she could not explain why her care plan identified her as incontinent of both bowel and bladder when she was in fact continent. Review of the facility policy titled Care Plans, Comprehensive Perso-Centered revealed care plan interventions were chosen after gathering data and careful consideration of the relationship between the resident's problems and their causes and relevant clinical decision making. Assessments were ongoing and care plans would be revised as conditions changed. The interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition or at least quarterly in conjunction with their required quarterly MDS assessment. 3. Review of the medical record for Resident #51 revealed an admission date of 02/24/25 with diagnoses including hypertensive heart disease with heart failure, anxiety, major depressive disorder, morbid obesity, obstructive sleep apnea, chronic pain, restless leg syndrome, and generalized muscle weakness. Further review of the medical record revealed diagnoses were added in June 2025, including unstable burst fracture of the second lumbar vertebrae, fusion of lumbar and thoracic region of the spine, urinary retention, thrombocytopenia, type II diabetes mellitus, and lymphedema. Review of the care plan initiated on 02/27/25 revealed Resident #51 was at increased risk for falls related to deconditioning, gait and balance problems, age-related debility, and use of a straight cane for mobility. Interventions included encouraging Resident #51 to use the call light for assistance as needed, provide physical therapy evaluation or treatment as ordered or as needed, keep the floors clean from spills and/or clutter, and provide adequate, glare-free lighting. Further review of the care plan revealed the last intervention was added on 02/28/25 for therapy to evaluate Resident #51 for appropriate assistive devices for ambulation. There were no care plan updates indicating Resident #51 sustained a fall with major injury or any revision of the fall care plan focus or intervention section after the fall (sustained on 05/20/25). Review of the quarterly MDS 3.0 assessment completed on 06/06/25 revealed Resident #51 had intact cognition, used a walker as a mobility device, and needed supervision or touching assistance for transfers from the chair to the bed. Further review of the MDS revealed Resident #51 sustained one fall with major injury since facility admission or re-entry. Review of the progress notes revealed a note dated 06/10/25 at 5:36 P.M. indicating Resident #51 requested to go to the emergency department due to an increase in back pain. Review of the hospital discharge paperwork revealed Resident #51 was admitted to the hospital for increased back pain since a fall at the facility. The hospital paperwork further revealed Resident #51 had magnetic resonance imaging (MRI) of the spine on 06/12/25 which revealed a burst fracture of the second lumbar spine (L2 fracture) which required surgery. Interview on 09/02/25 at 11:25 A.M. with Resident #51 revealed her L2 vertebra exploded when she fell at the facility in May 2025. Resident #51 further revealed she had immediate back pain that worsened over time, and the fracture was not found until a few weeks later, but was attributed to the fall. Review of the fall investigation with the DON on 09/03/25 at 1:40 P.M. revealed the immediate interventions post fall included to educate Resident #51 to use the call light, do a therapy evaluation, and declutter the room. The DON further confirmed the care plan had these interventions in place at the time of the fall. Interview on 09/03/25 at 2:53 P.M. with the DON confirmed that when the facility learned Resident #51 had a major injury related to the fall sustained on 05/20/25 (which required an acute care inpatient stay and surgery), the fall care plan was not updated upon Resident #51's return to the facility. Review of the policy titled Care Plans, Comprehensive Person-Centered, last updated in March 2022, revealed care plans were to be revised or updated as changes occurred, when the desired outcome was not met, and after inpatient hospitalizations. Review of the policy titled Falls and Fall Risk, last revised December 2007, revealed that if a resident fell, despite the initial interventions put into place, staff were to implement additional or different interventions or indicate why new approaches were not implemented. 4. Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, bipolar disorder and unspecified dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #5 exhibited intact cognition. Review of Resident #5's medical record revealed the resident was her own responsible party and she had a guardian of person. Review of Resident #5's medical record revealed a care conference was held for the resident on 04/24/25. The medical record did not have evidence care conferences were held for the fourth quarter 2024, the first quarter 2025 or the third quarter 2025. Interview on 09/04/25 at 9:00 A.M. with SSD #566 confirmed the above findings. Review of the Comprehensive Person-Centered Care Plans policy, revised 03/2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. 5. Review of Resident #21's medical record revealed an admission date of 04/02/25 with diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, anxiety, psychosis, diabetes mellitus type II, asthma, chronic pain, and non-Hodgkin lymphoma. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact and required minimal assistance with activities of daily living. Interview on 09/02/25 at 11:50 A.M. with Resident #21 revealed they did not get invited to care conferences. Record review revealed a social services progress note for an initial care conference on 04/17/25, with no other care conferences documented. Interview on 09/04/25 at 10:18 A.M. with SSD #566 confirmed a care conference was not completed for the third quarter of 2025. Review of the facility policy titled Care Plans, Comprehensive Perso-Centered revealed care plan interventions were chosen after gathering data and careful consideration of the relationship between the resident's problems and their causes and relevant clinical decision making. Assessments were ongoing and care plans would be revised as conditions changed. The interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition or at least quarterly in conjunction with their required quarterly MDS assessment.

Based on record reviews, interviews and facility policy review, the facility failed to ensure residents received showers as scheduled. This finding affected seven residents (Residents #6, #14, #21, #27, #31, #47 and #48) of seven residents reviewed for activities of daily living (ADL) and had the potential to affect 30 additional residents (Residents #3, #5, #7, #8, #9, #11, #12, #13, #18, #20, #25, #28, #29, #30, #32, #33, #35, #36, #37, #39, #40, #42, #43, #44, #45, #46, #51, #52, #58 and #59) the facility identified as requiring extensive assistance or totally dependent on staff assistance for showers. The facility census was 53. Findings include: 1. Review of Resident #14's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including unspecified dementia, urinary incontinence and emphysema. Review of Resident #14's ADL self-care care plan revealed an intervention dated 05/23/25 indicating the resident's usual performance was partial/moderate assist with showers. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 exhibited intact cognition. Review of the shower schedules revealed Resident #14 was scheduled for showers on Tuesdays and Fridays on the 6:00 A.M. to 6:00 P.M. shift. Review of Resident #14's shower documentation from 08/02/25 to 09/02/25 revealed the resident received showers on 08/07/25, 08/12/25, 08/15/25, 08/19/25, 08/28/25 and 08/30/25. Resident #14 did not receive showers as scheduled on 08/01/25, 08/05/25 and 08/22/25. Interview on 09/03/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #536 confirmed Resident #14 did not receive showers as scheduled. Review of the Shower/Tub Bath policy, revised 10/2010, revealed the purposes of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 2. Review of the medical record for Resident #6 revealed an admission date of 08/02/25. Diagnoses included systemic lupus erythematosus (an autoimmune disease), muscle weakness, adult failure to thrive, and dysphagia (difficulty swallowing). Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and was dependent on staff for all care needs. Review of the activity assessment dated [DATE] revealed it was somewhat important for Resident #6 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan dated 08/04/25 revealed Resident #6 has a self-care deficit related to disease process. Interventions included the resident was dependent for shower care, dressing, and bed mobility. Review of the shower schedule revealed Resident #6 was scheduled to receive a shower on Wednesdays and Saturdays. Review of the shower sheets for 08/2025 revealed Resident #6 received a bed bath on 08/08/25, a shower on 08/13/25, a shower on 08/16/25, 08/20/25, and a shower on 08/23/25. Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents. 3. Review of the medical record for Resident #21 revealed an admission date of 04/02/25. Diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, anxiety, psychosis, diabetes mellitus type II, asthma, chronic pain, and non-Hodgkin lymphoma. Review of the care plan dated 05/07/25 revealed Resident #21 had a self-care deficit related to disease process. Interventions include avoid scrubbing and pat dry sensitive skin, set up and supervision from staff for showering, and showering two times a week and as needed. Review of the activity assessment dated [DATE] revealed it was very important for Resident #21 to choose between a tub bath, shower, bed bath, or sponge bath Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact and required minimal assistance with ADL. Review of the shower schedule revealed Resident #21 was scheduled to receive a shower on Tuesdays and Saturdays. Review of the shower sheets for 08/2025 revealed Resident #21 had a shower on 08/02/25, a shower on 08/10/25, a shower on 08/12/25, a shower on 08/16/25, a shower on 08/19/25, a shower on 08/23/25, and a shower on 08/31/25. Interview on 09/02/25 at 11:45 A.M. with Resident #21 revealed she did not always get showers twice a week. Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents. 4. Review of the medical record for Resident #48 revealed an admission date of 01/02/18. Diagnoses included aphasia (a communication disorder), dysphagia (a swallowing disorder), cognitive communication deficit, hemiplegia (paralysis on one side of the body), hemiparesis (one sided muscle weakness), and muscle contracture. Review of the activity assessment dated [DATE] revealed it was very important for Resident #48 to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #48's care plan dated 06/12/25 revealed a self-care deficit related to disease process. Interventions included extensive one-person assistance for showering, showering twice a week, and showering as needed. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #48 was cognitively intact and required maximal assistance for showering. Review of the shower schedule revealed Resident #48 was scheduled to receive a shower on Mondays. (His preference was one to two showers a week). Review of the shower sheets for 08/2025 revealed Resident #48 had a shower on 08/04/25, refused a shower on 08/07/25 due to a dental appointment, a shower on 08/08/25, a shower on 08/11/25, refused a shower on 08/14/25, a shower on 08/21/25, and refused a shower on 08/25/25 due to not feeling well. There was no documented evidence Resident #48 was offered a bed bath or shower on a different day or time after the refusal of the showers except for the refusal on 08/07/25. Interview on 09/03/25 at 9:54 A.M. with Resident #48 revealed they don't always get twice weekly showers. Interview on 09/03/25 at 1:31 P.M. with LPN #538 verified showers aren't always being completed twice weekly. Interview on 09/04/25 at 11:25 A.M. with Certified Nurses Aid (CNA) #590 verified they weren't able to get all assigned showers completed on 09/03/25. Interview on 09/04/25 1:44 PM. with the Administrator confirmed she was aware the facility had not been consistently providing showers for residents. Review of the Shower/Tub Bath policy, revised 10/2010, revealed the purposes of the procedure were to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 5. Review of the medical record for Resident #27 revealed in admission date of 12/02/24. Diagnoses included cognitive communication deficit, depression, muscle weakness, anxiety, insomnia, and diabetes. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed it was very important for Resident #27 to choose between a tub bath, shower, bed bath or sponge bath. Review of the care plan dated 07/08/25 revealed Resident #27 had an ADL performance deficit due to musculoskeletal impairment. Interventions included providing a sponge bath, a full bath or shower could not be tolerated and avoiding scrubbing the skin. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact. She required set-up help for eating and partial to moderate assistance for oral hygiene, toileting showering dressing and hygiene. Interview on 09/02/25 at 9:47 A.M. with Resident #27 revealed she did not always get showers at least twice weekly. Review of the shower schedule revealed Resident #27 was scheduled to receive showers on Sundays and Fridays. Review of the shower sheets for August 2025 revealed Resident #27 received a shower on 08/08/25, 08/14/25, 08/17/25 and 08/26/25. She received a bed bath after refusing a shower on 08/22/25. Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents. 6. Review of the medical record for Resident #31 revealed an admission date of 01/19/23. Diagnoses included Multiple Sclerosis, muscle weakness, heart disease, left hip prosthesis, anxiety, and cervical disc degeneration. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed it was very important for Resident #31 to choose between a tub bath, shower, bed bath or sponge bath. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact. She required set-up assistance for eating and oral hygiene, partial to moderate assistance for dressing and hygiene and substantial to maximum assistance for showering Review of the care plan dated 07/03/25 revealed Resident #31 needed assistance with showers. Interventions included the residents' preference for showers on Tuesdays and Friday evenings between 2:00 P.M. and 8:00 P.M., asking the resident their bathing preference quarterly and as needed, filling out shower sheets upon completing a resident shower or bath and notifying the charge nurse of shower or bath refusals. Review of the shower schedule revealed Resident #31 was scheduled to receive showers on Tuesdays and Fridays. Review of the nursing note dated 08/19/25 at 10:25 P.M. revealed Resident #31 refused a shower due to chronic pain; the shower was rescheduled for 8/20/25. Review of the shower sheets for August 2025 revealed Resident #31 received a shower on 08/05/25, 08/13/25, 08/20/25 and 08/29/25. She refused a shower on 08/08/25 and 08/19/25. There was no documented evidence Resident #31 was offered a bed bath or shower on a different day or time after the refusal of the showers. Interview on 09/02/25 at 10:28 A.M. with Resident #31 revealed she didn't get showers like she wanted because the facility no longer had a shower aide. Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents. 7. Review of the medical record for Resident #47 revealed an admission date of 08/22/23. Diagnoses included schizoaffective disorder, diabetes, muscle weakness, asthma, and post-traumatic stress disorder. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed it was very important for Resident #47 to choose between a tub bath, shower, bed bath or sponge bath. Review of the care plan dated 06/30/25 profile Resident #47 had an ADL self-care performance deficit due to the disease process. Interventions included two staff members assisting the resident with a shower twice per week, offering a bed bath if a shower was refused and filling out the shower sheet upon completion of the shower or bed bath, notifying the nurse if the resident refuses. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 was cognitively intact. She was totally dependent on staff for all ADL. Review of the shower schedule revealed Resident #47 was scheduled to receive showers on Sundays and Wednesdays. Review of the shower sheets for August 2025 revealed Resident #47 revealed she received a shower on 08/24/25 and a bed bath on 08/10/25. She refused a shower on 08/13/25, 08/17/25, 08/20/25 and 08/27/25. There was no documented evidence Resident #47 was offered a bed bath or shower on a different day or time after the refusal of the showers. Interview on 09/02/25 at 10:39 A.M. with Resident #47 revealed she did not get showers because the facility no longer had a shower aide. Interview on 09/04/25 at 7:50 A.M. with CNA #508 revealed she was often not able to get all showers completed each day. Interview on 09/04/25 1:44 P.M. with the Administrator confirmed she was aware the facility had not been consistently providing showers to residents. Review of the facility policy titled Shower/Tub Bath, dated 2001, revealed the facility would document the date and time the shower or bath was performed and the name of the individual assisting the resident with the shower or bath. If the resident refused, the reasons why and the interventions taken would be documented as well. This deficiency represents noncompliance investigated under Complaint Number 1395034 (OH00167579).

Based on observation, record review, interview and facility policy review, the facility failed to ensure meals were served as stated in the dietary menus. This finding had the potential to affect all residents who receive mechanical soft diets and residents who require gravy during meals including Residents #2, #5, #15, #22, #25, #28, #32, #37, #38, #43, #47, #51 and #53. The facility census was 53. Findings include:Review of the Daily Production Lunch Menu dated 09/02/25 revealed the meal consisted of eight ounces of beefy tater casserole with one to two ounces of gravy on the side for mechanical soft diets, four ounces of mixed vegetables (four ounces of carrots for residents on a mechanical soft diet), four ounces of mandarin oranges with whipped topping and eight ounces of iced tea/lemonade/fruit punch. Observation of staff plating the lunch meal on 09/02/25 at 11:22 A.M. revealed the lunch meal consisted of beefy tater tot casserole two four-ounce scoops, four ounces of mixed vegetables (carrots for mechanical soft diets and mixed vegetables for regular diets), four ounces of mandarin oranges and iced tea/lemonade/fruit punch. Observations did not reveal evidence of gravy placed on the side for the residents who required gravy or for residents on mechanical soft diets and the mandarin oranges did not have whipped cream on top. Interview on 09/02/25 at 11:33 A.M. with Dietary Manager (DM) #543 confirmed the facility ran out of the whipped topping for the mandarin oranges. Interview on 09/02/25 at 12:10 P.M. with DM #543 confirmed she was not aware the menu included gravy for those residents on mechanical soft diets. Review of resident diets revealed Residents #2, #5, #15, #22, #25, #28, #32, #37, #38, #43, #47, #51 and #53 were ordered mechanical soft diets or required gravy on the side or with meat items. Review of the Food and Nutrition Services policy, revised 10/2017, revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on review of the medical record, interview, and review of facility policy, the facility failed to ensure resident wishes regarding advanced directives were accurately identified or that the medical record contained the appropriate documentation of these wishes. This affected one resident (Resident #51) of one resident reviewed for advanced directives. The facility census was 53. Findings include:Review of the medical record for Resident #51 revealed an admission date of 02/24/25. Diagnoses included hypertensive heart disease with heart failure, anxiety, major depressive disorder, morbid obesity, obstructive sleep apnea, chronic pain, restless leg syndrome, generalized muscle weakness, unstable burst fracture of second lumbar vertebrae, fusion of lumbar and thoracic region of the spine, urinary retention, thrombocytopenia, type two diabetes mellitus, and lymphedema. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/06/25 revealed Resident #51 had intact cognition and minimal signs of depression. Review of the physician orders in the electronic medical record (EMR) revealed two active orders regarding resuscitation in the event of cardiac or respiratory arrest. The first order was dated 08/28/25 at 2:28 P.M. indicating Resident #51 was a full code (use all available life saving measures in the event of an emergency, including cardiopulmonary resuscitation). The second order was dated 08/28/25 at 3:49 P.M. indicating Resident #51 was a Do Not Resuscitate Comfort Care- Arrest (DNRCC-A), life-saving treatments may be administered before respiratory or cardiac arrest, but not after an arrest. Once cardiac or respiratory arrest occurs, only comfort care measures may be provided. Interview on 09/02/25 at 12:48 P.M. with Licensed Practical Nurse (LPN) #586 confirmed the hard chart (paper chart at the nurses' station) should contain the signed do not resuscitate (DNR) orders if a resident was not a full code. When informed there were advanced directives in the hard chart, LPN #586 opened the resident profile in the EMR and stated that Resident #51 was a DNRCC-A and would have to locate the order, print it, and place it in the chart. Interview on 09/02/25 at 12:55 P.M. with the Director of Nursing (DON) confirmed that if a resident was a DNR, the order should be in the hard chart. During the interview, the DON confirmed that there were two active orders for Resident #51 in the event of an arrest, including one order listing Resident #51 as a full code and one order listing Resident #51 as a DNRCC-A, which the DON stated she did not believe was correct. The DON was unable to confirm Resident #51's code status at the time of this interview. Interview on 09/02/2025 at 1:06 P.M. with LPN #536 revealed LPN #586 located the signed DNR order form dated 08/28/25 in a pile of paperwork to be filed. During the interview, LPN #536 confirmed there was no DNR order form in either the EMR or the hard chart. Review of the policy titled Advanced Directives, last revised September 2022, revealed the wishes of each resident related to advanced directives were to be communicated appropriately to direct care staff and placed in a prominent, accessible location in the medical record.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed as required for Resident #21. This affected one resident (Resident #21) out of one resident sampled for baseline care plans. The facility census was 53. Findings include: Review of Resident #21's medical record revealed an admission date of 04/02/25 with diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, anxiety, psychosis, diabetes mellitus type II, asthma, chronic pain, and non-Hodgkin lymphoma. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of the medical record revealed the absence of a baseline care plan. Interview on 09/04/25 at 10:28 A.M. with the Director of Nursing (DON) confirmed the absence of a baseline care plan for Resident #21.

Based on observation, interview, review of the facility nurse signature list and review of facility policy, the facility failed to ensure nurses followed appropriate professional standards when documenting medication administration. This affected one resident (Resident #20) of three residents who were observed for medication administration. The facility census was 53. Findings include:Review of the medical record for Resident #20 revealed an admission date of 08/11/25 with diagnoses including hereditary and idiopathic neuropathy, retention of urine, type two diabetes mellitus, acute kidney failure, atrial fibrillation, unspecified protein-calorie malnutrition, gastroesophageal reflux disease (GERD), cognitive communication deficit, irritable bowel syndrome (IBS), depression, epilepsy, and gastroparesis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition with no rejection of care or other behaviors. Further review of the MDS revealed Resident #20 received medications from high-risk categories, including antidepressant, antibiotic, antiplatelet, hypoglycemic, and anticonvulsant. Review of the current physician's orders revealed orders for morning medications that were scheduled for administration at 8:00 A.M. and 9:00 A.M., including:Citalopram hydrochloride (HCL) 40 milligram (mg) oral tablet, one tablet by mouth daily for depressionLetrozole 2.5 mg tablet, one tablet by mouth every day for breast cancerNadolol 20 mg, give one tablet by mouth once daily for hypertensionClopidogrel bisulfate 75 mg tablet once daily for cerebrovascular accident (CVA)Vitamin E oral tablet 400 international units (IU) by mouth once daily for vitamin deficiencyHydralazine hydrochloride oral tablet, 25 mg by mouth twice daily for hypertensionLevetiracetam (Keppra) 500 mg by mouth twice a day for seizuresMetformin HCL 250 mg by mouth twice a day for diabetes mellitusPantoprazole sodium oral delayed release (DR) tablet, one tablet by mouth two times a day for GERDRifaximin 550 mg tablet, one tablet by mouth two times a day for IBSSucralfate (Carafate) one gram by mouth two times a day for GERDDicyclomine HCL 10 mg oral capsule, one capsule by mouth three times a day related to gastroparesisReview of the current physician's orders also revealed Resident #20 was to have blood sugar checks every morning with a blood glucose meter (BGM). Observation on 09/02/25 from 8:10 A.M. to 8:20 A.M. revealed Licensed Practical Nurse (LPN) #600 prepared the morning medications and blood glucose meter for the blood sugar test for Resident #20, entered the resident's room, and checked Resident #20's blood sugar with the BGM with no noted concerns. Continued observation revealed Resident #20 pulled a pill out of the medicine cup, handed the pill to the nurse, immediately took the rest of the medications that were in the medication cup, and then informed LPN #600 she was no longer taking Keppra because it upset her stomach. LPN #600 informed Resident #20 the pill she handed over was Carafate (sucralfate) to help coat her stomach and that she already swallowed the Keppra. Resident #20 continued to refuse the sucralfate after education was provided, and LPN #600 was observed dropping the tablet into the trash can at the bedside. After exiting the room of Resident #20, LPN #600 was observed beginning to give report to the nurse who just arrived for duty. There was no observation of medication administration documentation at that time.Follow-up interview on 09/02/2025 at 9:33 A.M. with Resident #20 confirmed that she did not take the morning dose of sucralfate. Review of the medication administration record (MAR) revealed a nurse with the initials AATT signed off the administration of all ordered medications and blood glucose monitoring scheduled for 8:00 A.M. and 9:00 A.M. on 09/02/25, including the successful administration of sucralfate (the medication Resident #20 was observed removing and discarding the during medication administration). Upon further review, the MAR appeared to be signed off using initials that did not belong to LPN #600.Review of the facility signature list revealed the initials AATT belonged to LPN #586 and not LPN #600. Further review of the signature list revealed LPN #600's initials for MAR documentation were THCB. Telephone interview on 09/03/25 at 2:04 P.M. with LPN #586 confirmed she signed off all the scheduled morning medications for Resident #20 but had not given any of them. LPN #586 further revealed LPN #600 told her she was unable to sign for the morning medication and told LPN #586 it was okay for her to sign all the morning medications and treatments off as competed. During the interview, LPN #586 did admit to being informed earlier that Resident #20 refused one of her medications, but wasn't sure which one, just that it was not the Keppra.Interview on 09/02/25 at 2:50 P.M. with the Director of Nursing (DON) confirmed LPN #600 had access to chart in the electronic medical record, and the DON was never informed by LPN #600 that there was an access issue. During the interview, the DON confirmed that the nurse that administered the medication was the nurse required to document the medication administration, and no nurse should ever sign for care rendered by someone else. Review of the policy titled Administering Medications, last revised in April 2019, revealed the person administering the medications was required to document administration in the medical record. The policy further revealed when a drug was refused, the nurse responsible for that medication administration was to complete the appropriate documentation in the MAR related to that omitted drug and dose.

Based on observation, record review, review of pharmacy invoices, interview and facility policy review, the facility failed to ensure Resident #16's skin treatments were implemented as ordered and Resident #1's dialysis medications were available for resident use. This finding affected one resident (Resident #16) of three residents reviewed for pressure ulcers and general skin conditions and one resident (Resident #1) of one resident reviewed for dialysis services. The facility census was 53. Findings include:1. Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnoses including dementia, cognitive communication deficit, and muscle weakness. Review of the wound grid dated 06/18/25 revealed Resident #16 had a left buttock Stage II pressure ulcer (partial-thickness loss of skin, affecting only the epidermis and dermis layers, which appears as a shallow open wound or a serum-filled blister) which measured zero cm (centimeters) length, zero cm width and zero cm depth which improved with delayed wound closure and 70% (percent) epithelial and 30% granulation tissue with attached intact scarring. Review of Resident #16's physician's orders dated 06/18/25 revealed an order dated 06/18/25 to apply Skin Prep (creates a protective film) to the left sacrum and cover with a bordered dressing every Monday, Wednesday and Friday for preventative measures. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 exhibited intact cognition. Interview on 09/03/25 at 1:42 P.M. with Licensed Practical Nurse (LPN) #536 confirmed Resident #16's left sacrum Stage II pressure wound healed on 06/22/25, and the facility put treatments in place to prevent the area from reopening. Observation on 09/03/25 at 2:25 P.M. with Nurse Practitioner (NP) #850 and LPN #536 of Resident #16's left sacrum wound care revealed LPN #536 washed both hands, put on gloves, removed the existing dressing to the left sacrum which was dated 08/28/25, removed the gloves, washed the hands, replaced the gloves and completed the wound care as ordered. Interview on 09/03/25 at 2:30 P.M. with LPN #536 confirmed Resident #16's left sacrum dressing should have been changed on 09/01/25 per the physician's order, and LPN #851 documented on the treatment administration record (TAR) dated 09/01/25 that Resident #16's left sacrum wound care was completed. LPN #536 also confirmed LPN #539 documented on 09/02/25 that Resident #16's left sacrum wound care was completed in error. Interview on 09/03/25 at 3:09 P.M. with LPN #539 revealed the nurse had documented Resident #16's left sacrum wound care was completed on 09/02/25 in error and the nurse thought the documentation was to confirm the dressing was intact. Review of the Pressure Ulcers/Injuries Overview policy, revised 07/2017, revealed the purpose of the procedure was to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors. 2. Review of the medical record for Resident #1 revealed an admission date of 05/19/25 with diagnoses including end stage renal disease, unspecified protein-calorie malnutrition, paroxysmal atrial fibrillation, major depressive disorder, essential (primary) hypertension, ventricular tachycardia, type II diabetes mellitus, diabetic neuropathy, acquired absence of right leg below knee, acquired absence of the left leg below the knee, and dependence on renal dialysis. Review of the quarterly MDS 3.0 assessment completed on 07/17/25 revealed Resident #1 had intact cognition and end stage renal disease. Further review of the MDS revealed Resident #1 received dialysis. Review of the care plan dated 05/21/25 through 10/15/25 revealed Resident #1 was at risk for malnutrition due to obesity, blood pressure problems, wounds, unspecified protein-calorie malnutrition, and end stage renal disease with dialysis. Interventions included providing all dietary interventions and medications as prescribed. Review of the orders revealed an order dated 06/26/25 for Resident #1 to begin at 6:00 A.M. on 06/27/25 to take sevelamer hydrochloride (HCL) 800 milligram (mg) tablets, two tablets by mouth before meals as a potassium binder. Further review of the order revealed instructions for staff to call the number listed on the paper in the chart and provide the identification (I.D.) number to reorder the sevelamer. Review of the July 2025 medication administration record (MAR) revealed the ordered sevelamer to be taken before meals not given 07/01/25 through 07/05/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M., 07/06/25 at 6:00 A.M. or 11:00 A.M., 07/07/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M., 07/08/25 at 4:00 P.M., or 07/09/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M. Review of the progress notes from 07/05/25 through 07/31/25 revealed the following linked electronic MAR (eMAR) notes when the sevelamer was not given: 07/05/25 at 6:26 A.M. pending dialysis providing 07/05/25 at 9:36 A.M. Unavailable 07/05/25 at 10:32 A.M. medication was unavailable and awaiting delivery from dialysis. The note also indicated the physician was aware. 07/05/25 at 3:50 P.M. medication was unavailable, and the physician was aware. 07/06/25 at 9:49 A.M., 10:33 A.M., and 4:18 P.M. notes revealed the medication was unavailable 07/07/25 at 5:18 A.M. and 4:42 P.M. the notes indicated the medication was on order and pharmacy was to send it. 07/08/25 at 7:56 A.M. and 4:31 P.M. the notes indicated the medication was not in the medication cart. 07/09/25 at 5:09 A.M. and 4:52 P.M. revealed the medication was not in the cart. 07/09/25 at 12:01 P.M. the note revealed the nurse spoke with the pharmacy, verified medication was sent, and would arrive at the facility in three to five days. The note further revealed the physician was notified. The notes further revealed Resident #1 was transferred to the hospital at 9:00 P.M. and remained hospitalized until 07/12/25 at 11:30 A.M. Review of the August 2025 MAR revealed sevelamer was not given on 08/08/25 at 11:00 A.M. or 4:00 P.M., 08/09/25 at 6:00 A.M., 08/13/25 at 4:00 P.M., 08/15/25 at 4:00 P.M., 08/24/25 at 4:00 P.M., 08/25/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M., 08/26/25 at 6:00 A.M. and 11:00 A.M., or 4:00 P.M., 08/27/25 at 6:00 A.M. or 11:00 A.M., 08/28/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M., 08/29/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M., 08/30/25 at 11:00 A.M. or 4:00 P.M., and 08/31/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M. Review of the progress notes from 08/01/25 through 08/31/25 revealed the following linked eMAR notes: 08/08/25 at 4:14 P.M. revealed the medication was not available. 08/09/25 at 5:32 A.M. revealed the medication was on order from the pharmacy, and the nurse practitioner was aware. 08/15/25 at 4:57 P.M. revealed the medication was not available and reordered. 08/24/25 at 4:08 P.M. revealed the medication was not available and on order. 08/25/25 at 5:13 A.M. and 5:01 P.M. and 08/26/25 at 5:10 A.M. revealed the medication was not available. 08/26/25 at 10:10 A.M. revealed the pharmacy rejected the medication and it would not be delivered. 08/26/25 at 1:50 P.M. revealed the medication was no available. 08/27/25 at 5:21 A.M. and 6:26 P.M. revealed the medication was not available and further revealed a call was placed to the dialysis center. 08/28/25 at 5:15 A.M. and 10:58 A.M. revealed the medication was on order. 08/29/25 at 6:39 A.M. revealed the medication was on order. 08/30/25 at 10:27 A.M. and 3:57 P.M. revealed the medication was not available. 08/31/25 at 5:05 A.M., 12:07 P.M., and 3:56 P.M. revealed the medication was not available. Review of the September 2025 MAR revealed Resident #1 did not receive the ordered sevelamer on 09/01/25 at 6:00 A.M., 11:00 A.M., or 4:00 P.M. or on 09/02/25 at 6:00 A.M. Review of the progress notes from 09/01/25 through 09/04/25 revealed the following linked eMAR notes: 09/01/25 at 5:09 A.M. and 4:14 P.M. revealed the medication was not available, and notes for the lunch dose revealed Resident #1 was at dialysis. 09/02/25 at 5:25 A.M. revealed the medication was not available Interview with Resident #1 on 09/02/2025 at 9:02 A.M. revealed he had not been getting his phosphorus binder, the sevelamer, for at least a week or more. The dialysis physician had told him it was taken care of, and nobody was able to explain why he still did not have the medication. Interview on 09/04/2025 at 10:12 A.M. with Resident #1 confirmed he received the sevelamer the last two days, but there were gaps when he did not receive the medication for several days at a time. Resident #1 further revealed when not taking the medication, he felt nauseous and would often experience diarrhea, with more prominent symptoms after meals. Interview on 09/04/2025 at 10:16 AM with Licensed Practical Nurse (LPN) #589 confirmed she thought the pharmacy had not been sending the sevelamer, but then another nurse had told her it had to be special ordered. During the interview, LPN #589 also reported once the medication was ordered, it seemed to take a long time before it was delivered. Review of the medication bottle at the time of the interview revealed the medication came from Health [NAME] Pharmacy in Lakeland, Florida. Interview on 09/04/2025 at 1:35 PM with the Director of Nursing (DON) verified the dates the sevelamer was reordered included 07/08/25 and 08/27/25. During the interview, the DON was unable to confirm the date the medication was received by the facility, stating the medication went directly to the resident, and the facility did not have a process to record receipt of medications from this particular pharmacy. Review of the prescription reorder information form revealed sevelamer was reordered on 07/08/25 and 08/27/25. Review of the shipping invoice from Health [NAME] Pharmacy revealed the sevelamer was last shipped to the facility, to the attention of the DON, on 08/27/25. The facility did not have the shipping invoice for previous sevelamer orders. Review of the policy titled Medication Orders and Receipt Record, last revised April 2007, revealed the charge nurse was to maintain medication order and receipt records and that medications were to be ordered in advance based on the pharmacy's required lead time. This deficiency represents noncompliance investigated under Master Complaint Number 2600257 and Complaint Number 1395034 (OH00167579).

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, witness statement reviews, interview and facility policy review, the facility failed to ensure Resident #45 was provided with adequate supervision to prevent a burn. This finding affected one resident (Resident #45) of six residents reviewed for accidents and hazards. The facility census was 53. Findings include:Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, and schizoaffective disorder. Review of Resident #45's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and anxiety. Review of Resident #45's malnutrition care plan revealed an intervention dated 09/16/24 to provide the physician prescribed diet and notify nursing of any changes in appetite, feeding performance, or compliance concerns. Provide assistance with all meals, snacks and supplements as needed. Review of Resident #45's physician orders revealed an order dated 01/13/25 revealed the resident self-propels in a custom wheelchair without footrests; and an order dated 01/13/25 for a regular diet, regular texture with a regular thin consistency. Review of Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #45's progress note dated 06/16/25 at 5:16 A.M. authored by Licensed Practical Nurse (LPN) #855 indicated Resident #45 was given coffee by another resident (Resident #21) in the common area, and the resident spilled the coffee on herself and had a reddened area in the shape of a C on the left abdominal side. Resident #45 complained of pain with wincing and saying ouch, oh!. The resident was washed with cool water and the resident's shirt was changed. Review of Resident #45's progress note dated 06/16/25 at 2:13 P.M. (documented as a late entry) authored by the Director of Nursing (DON) which indicated the provider was notified the resident spilled coffee with no injury present. The Wound Nurse Practitioner (NP) #850 was notified as well. Review of Resident #45's progress note dated 06/16/25 at 2:42 P.M. authored by Registered Dietitian (RD) #853 revealed she was notified by the DON on this date that the resident spilled some of her coffee beverage on her stomach. The skin was assessed and slightly red. No open areas were noted. The RD did not anticipate increased needs related to the resident's skin at this time. Review of Resident #45's physician progress note dated 06/16/25 at 11:59 P.M. revealed at the time of the documentation, the resident was independent with bed mobility, required assistance for sit-to-stand, all transfers, and toileting. The resident also required assistance for putting on footwear, dressing, bathing and required partial assistance for oral hygiene. She required supervision with eating. Review of Resident #45's witness statement dated 07/09/25 at 10:48 A.M. authored by certified Nursing Assistant (CNA) #509 revealed after the coffee incident with Residents #21 and #45, the DON and CNA #509 immediately informed Resident #21 that coffee cannot be provided to certain residents because the resident could not hold it properly. Resident #45 was also educated that the resident needed to make sure the coffee cups had a lid and a straw so that she did not harm herself with hot coffee and to ask for help for coffee. Interview on 09/03/25 at 2:46 P.M. with the DON revealed Resident #21 provided Resident #45 a cup of hot coffee from the servery on the 100/200 unit adjacent to the common area. The DON revealed Resident #45's coffee cup did not have a lid, and the resident spilled the coffee on her stomach which caused a reddened burn, but the burn did not blister. Review of the Food and Nutrition Services policy, revised 10/2017, revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The deficiency was corrected on 06/18/25 when the facility implemented the following corrective actions: On 06/16/25 at 5:16 A.M., CNA #509 assessed Resident #45 after identification of the abdominal burn, washed the abdomen with cool water and changed the resident's shirt. On 06/16/25 at 2:13 P.M. LPN #852 notified the physician of Resident #45's abdominal burn. On 06/16/25 at 3:51 P.M., LPN #852 completed a skin assessment for Resident #45's abdominal burn. The assessment revealed the abdomen had a pink area related to the spill. No sizes were identified on the form. On 06/16/25 at 4:00 P.M., LPN #852 completed a pain assessment for Resident #45's abdominal burn. The assessment indicated the resident had mild pain. On 06/16/25, Rehab Director #573 screened Resident #45 for occupational therapy (OT). The determination was that it was an isolated event with lids on drinks, and the resident was put on the caseload. On 06/16/25, Maintenance Director #507 turned off the hot water to the servery on the 100/200 units. On 06/16/25, CNA #509 and the DON educated Residents #21 and #45 to ask for assistance for hot coffee, and Resident #21 was educated to not provide hot coffee to other residents. On 06/16/25, Dietary Manager #543 started audits of hot liquids served in cups three times a week for eight weeks with no negative findings. On 06/17/25, the DON obtained a work order to remove the hot water valve on the servery on the 100/200 units. The work was completed on 06/18/25. On 06/19/25 at 1:08 P.M., LPN #519 completed a skin assessment for Resident #45, and no redness or blisters were identified. On 06/26/25, LPN #582 completed a skin assessment for Resident #45 and no redness or blisters were identified. On 06/26/25, the DON completed an in-service for all nursing staff including all nurses and CNAs. The education stated residents must be assisted with getting coffee and ensure the coffee was in a cup with a lid.

Based on review of the medical record, interview and review of the facility policy, the facility failed to ensure appropriate assessments were consistently completed before and after dialysis. This affected one resident (Resident #1) of one resident reviewed for dialysis. The facility census was 53. Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/19/25 with diagnoses including end stage renal disease, unspecified protein-calorie malnutrition, paroxysmal atrial fibrillation, major depressive disorder, essential (primary) hypertension, ventricular tachycardia, type II diabetes mellitus, diabetic neuropathy, acquired absence of the right leg below the knee, acquired absence of the left leg below the knee, and dependence on renal dialysis. Review of the physician orders revealed an order dated 05/20/25 that Resident #1 was to receive dialysis every Monday, Wednesday, and Friday and for facility staff to check for a bruit (a swishing sound heard over a blood vessel) and thrill (a palpable vibrating sensation over a blood vessel) to the left arteriovenous (AV) fistula every shift. Further review revealed orders initially dated 05/21/25 to monitor the left arm fistula site for infection every shift and to weigh Resident #1 three days a week prior to dialysis. Review of the care plan dated 05/21/25 through 10/15/25 revealed Resident #1was at risk for developing complications related to hemodialysis. Interventions included monitoring for a bruit and thrill every shift, monitoring and reporting any signs of infection to the dialysis access site and reporting significant changes in vital signs immediately. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/17/25 revealed Resident #1 had intact cognition and end stage renal disease. Further review of the MDS revealed Resident #1 received dialysis. Review of the July 2025 treatment administration record (TAR) revealed no documentation of weights 07/09/25 (listed as refused), 07/11/25 (Resident #1 was in the hospital), 07/14/25, and 07/16/25, 07/18/25 (listed as refused), 07/21/25, and 07/28/25. The July TAR further revealed no documentation the nurse assessed for a bruit and thrill on 07/25/25 or 07/27/25 on night shift and that the assessment was not applicable on 07/26/25. The July TAR review also revealed no documentation the AV shunt site was assessed for signs and symptoms of infection on 07/25/25 on night shift. Review of the August 2025 TAR revealed no documentation that Resident #1 went to dialysis on 08/13/25, 08/18/25, or 08/29/25 or that weights were obtained on 08/08/25, 08/13/25, 08/15/25, 08/18/25, 08/29/25. Further review of the August TAR revealed no documentation on 08/13/25 morning shift, 08/18/25 morning shift, 08/26/25 morning shift, or 08/29/25 morning shift that Resident #1's AV fistula was assessed for a bruit and a thrill. Also, the presence of the bruit or thrill was documented as not applicable on 09/01/25, 09/02/25, and 09/10/25 night shifts. Review of the August TAR also revealed that there was no documentation of assessment for signs and symptoms of infection of the AV fistula site on 08/13/25 day shift, 08/15/25 day shift, 08/18/25 day shift, 08/26/25 day shift, and 08/29/25 day shift. Review of the September 2025 TAR revealed no documentation that Resident #1 was weighed before dialysis, no documentation the AV fistula was assessed for signs of infection and no documentation that the nurse checked for a bruit or thrill during day shift on 09/01/25. Interview on 09/02/2025 at 9:02 A.M. with Resident #1 revealed the facility was supposed to obtain a weight prior to leaving for dialysis, but there were recent dialysis treatment dates that the weight was not obtained before leaving for dialysis because there was only one aide on the unit when it was time for him to get ready to depart for dialysis. Interview on 09/04/2025 at 10:16 A.M. with Licensed Practical Nurse (LPN) #589 confirmed there was a folder for dialysis communications regarding Resident #1 and that Resident #1 often takes off for dialysis without taking his folder or getting weighed. During the interview, LPN #589 confirmed the scale was not on the resident's unit (400 hall) but located up front near the 100 and 200 halls. LPN #589 was unable to locate the dialysis binder for Resident #1 at the time of this interview but sent Certified Nurse Aide (CNA) #567 to find it. Interview on 09/04/2025 at 10:26 A.M. with the Director of Nursing (DON) confirmed the INPOC Dialysis assessments were to be completed daily when residents were scheduled for dialysis, both before and after dialysis. Interview on 09/04/2025 at 10:27 A.M. with LPN #589 revealed the belief the facility was only supposed to perform a pre dialysis assessment. Review of the list of dates between 07/01/25 and 09/04/25 provided by the Administrator revealed Resident #1 received dialysis on 07/02/25, 07/04/25, 07/07/25, 07/15/25, 07/16/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/28/25, 07/30/25, 08/01/25, 08/04/25, 08/06/25, 08/11/25, 08/13/25, 08/15/25, 08/18/25, 08/20/25, 08/22/25, 08/25/25, 08/27/25, 08/29/25, 09/01/25, and 09/03/25. Review of the assessment titled INPOC Dialysis completed between 06/01/25 and 09/03/25 revealed this assessment had been completed pre and post dialysis on 06/02/25, 06/04/25, and 06/27/25 and on 07/23/25 at 12:26 P.M. Further review of the INPOC Dialysis assessments revealed the assessment forms contained no prompts or assessment data related to vital signs, including a blood pressure, or resident weight. There were no INPOC Dialysis assessments completed after 07/23/25. Review of the Dialysis Communication Record revealed this was a form for interfacility communication (between the facility and the dialysis center) on dialysis days. Further review of the dialysis communication records revealed the facility was to complete the pre-dialysis assessment and send with the resident and the dialysis staff sent back the post assessment completed on the bottom of the form, when it was sent with the resident. Dialysis Communication Records that were available included: 06/04/25 with no weight or nurse signature for the preassessment. The post assessment completed by the dialysis center contained only Resident #1's weight. 06/09/25 had no weight or assessment of the dialysis site. 06/11/25, 06/13/25, and 06/16/25 had the facility's pre-dialysis assessment completed. 06/18/25 and 06/23/25 had no assessment of the dialysis site on the pre-dialysis facility assessment. 06/20/25 had no assessment of the dialysis site on the pre-dialysis facility assessment and no evidence the center (or the facility) conducted a post-dialysis assessment. 06/25/25, 06/27/25, and 06/30/25 had the pre-dialysis assessment completed by facility staff. 07/25/25 with no pre-dialysis facility assessment of the dialysis access site. 07/30/25 with no pre-dialysis weight. 08/25/25 with no dialysis access site assessment pre-dialysis. There were three completed undated pre-dialysis communication notes. None of the three contained the dialysis access site assessment and one contained no post-dialysis assessment from the dialysis center. None of the above Dialysis Communication Records contained a facility post-dialysis assessment. There were no Dialysis Communication Records completed on 07/02/25, 07/07/25, 07/15/25, 07/16/25, 07/18/25, 07/21/25, 07/28/25, 08/01/25, 08/04/25, 08/06/25, 08/11/25, 08/13/25, 08/15/25, 08/18/25, 08/20/25, 08/22/25, 08/27/25, 08/29/25, 09/01/25, or 09/03/25. Interview on 09/04/25 at 1:35 P.M. the DON confirmed there were no additional pre or post dialysis assessments other than what had been already provided. Review of the policy titled End-Stage Renal Disease, Care of Resident with, last revised September 2010, revealed staff caring for residents receiving dialysis would be trained on the type of assessment data that must be collected on a daily or per shift basis, how to recognize and intervene in medical emergencies, such as hemorrhaging or sepsis, recognize and properly manage equipment-related complications, timing and administration of medications before and after dialysis, and care of grafts or fistulas. There was no record of what facility staff education consisted of related to required pre and post dialysis assessments Review of the Nursing Home Dialysis Transfer Agreement in effect 07/20/22 revealed the facility was to provide for the interchange of information necessary for the care of the dialysis resident. Review of the policy titled Hemodialysis Access Care, last revised September 2010, revealed the nursing staff were to document post-dialysis observations.

Based on record review and interview, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the personnel file for Activities Director #208 revealed a hire date of 01/16/24 in the position of receptionist. Her job description changed on 03/08/25 to Activities Director. Review of the Activity Director job description signed by the Administrator and Activities Director #208 on 03/10/25 revealed she must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the state and is eligible for certification as a recreation specialist or as an activities professional; or must have a minimum of two years experience in a social or recreation program within the last five years, one of which was full-time in a patient activities program in a health care setting; or must be a qualified occupational therapist or occupational therapy assistant; or must have completed a training course approved by this state. There was no evidence in Activities Director #208's employee file to prove she had the qualifications. Interview on 04/14/25 at 9:35 A.M. with Human Resources Director (HR) #200 revealed Activities Director #208 was transferred to her position from receptionist on 03/08/25. She stated Activities Director #208 did not have the qualifications required and was not registered for a training course approved by the state. Interview on 04/14/25 at 11:06 A.M. with the Administrator revealed the facility would be enrolling Activities Director #208 into a training course. She stated she believed Activities Director #208 was already enrolled in a course through the corporate office. Interview on 04/16/25 at 8:04 A.M. with Activities Director #208 verified she did not have the qualifications required for the Activity Director role. She stated she had been unsure on how to sign-up for the course and the facility had not provided her information on enrolling her until 04/14/25. This deficiency represents non-compliance investigated under Complaint Number OH00164095.

Based on record review, observation, and interview, the facility failed to accurately document and put a treatment in place in a timely manner for Resident #34 that was admitted with a pressure ulcer. This affected one (Resident #34) out of three residents reviewed for pressure ulcers. Facility census was 38. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses that included surgical aftercare and a pressure ulcer to the right buttock. Review of the admission skin assessment dated [DATE] revealed Resident #34 had a pressure ulcer to the left gluteal fold that measured one centimeter (cm) long, one cm wide, and 0.1 cm deep. Review of the treatment administration record revealed no evidence of a treatment being done to Resident #34's right or left gluteal/buttock from 01/13/25 until 01/17/25. A weekly skin assessment dated [DATE] revealed Resident #34 had a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to right gluteal that measured two cm long and 7.5 cm wide. A wound assessment dated [DATE] by the wound nurse practitioner (NP) revealed Resident #34 had a Stage II pressure ulcer to right buttock that measured four cm long, three cm wide, and 0.1 cm deep. An order was received on 01/16/25 to cleanse Resident #34's right buttock with normal saline, pat the area dry, apply Triad (a zinc oxide-based hydrophilic paste), and cover with a dressing every day. An observation on 01/28/25 at 10:26 A.M. revealed Resident #34 had a Stage II pressure ulcer to the right buttock. An interview on 01/28/25 at 1:55 P.M. Regional Clinical Director verified the documentation of pressure ulcer to the left gluteal fold was incorrect and should have been the right gluteal or buttock. Regional Clinical Director also stated the measurements by the floor nurse must of have been incorrect due to the measurements completed by the wound NP. Regional Clinical Director verified a treatment for the Stage II pressure ulcer to Resident #34's right buttock was not put in place for three days. This deficiency represents non-compliance investigated under Complaint Number OH00161526.

Based on observation, record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance of the facility and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hire agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 02/16/24 when the lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization , displacement due to potential interruption in staffing and/or outside service providers. This had the potential to affect all 32 residents residing in the facility. On 03/06/24 at 4:00 P.M., Administrator #710 was notified Immediate Jeopardy began on 02/16/24 when the onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying staff in a timely manner and having outstanding balances with vendors and providers. This included, but was not limited to, insufficient funds to meet staff payroll on 02/16/24 and 03/01/24, delinquent balances owed to nutrition services which resulted in dietitian services being cut from 03/01/24 through 03/04/24, delinquent balances for the Medical Director and Psychiatrist, delinquent balances for Therapy services, and sanitation. The Immediate Jeopardy remains ongoing, as the facility failed to implement corrective measures to remove the Immediate Jeopardy situation. Findings Include: Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various supplies/vendors removing the likelihood of situations of neglect. However, at the time of post-survey revisit on 02/08/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance and Performance Improvement Program was effective to ensure on-going compliance with the delivery of care including payment to financial obligations for therapy services and arranged payment plans with Premier Staffing and Avalon Foods. Interview on 02/27/24 at 9:25 A.M. with Licensed Practical Nurse (LPN) #201 revealed on the last payroll period dated 02/16/24 LPN #201's paycheck was returned due to insufficient funds. LPN #201 stated, I deposited my check on Friday 02/16/24 and on Wednesday 02/21/24 my bank contacted me because my paycheck had bounced. I notified the Administrator, and the company wired my paycheck into my account on Friday 02/23/24, but they did not pay for the wire fee my bank charged me. Interview on 02/27/24 at 9:30 A.M. with Housekeeper #164 revealed on the last payroll period dated 02/16/24 Housekeeper #164's paycheck was returned due to insufficient funds. Housekeeper #164 stated, This was my first paycheck here at the facility. I had deposited my check into my bank account on that Friday of payday. Then my bank notified me the next week, like four days later, that my check was not cashed because of insufficient funds. I told my supervisor, and she notified the Administrator and then the company wired my money to the account on Friday 02/23/24, but I had to pay for the wiring fees. My husband wants me to quit working here because of not getting paid on time. Interview on 02/27/24 at 9:35 A.M. with the Housekeeping/Laundry Manager #108 revealed her paycheck was not cashed by the bank due to insufficient funds. Housekeeping/Laundry manager #108 stated, This was the second time my check has bounced. After the first time back in October, I had changed banks because my other one would hold my check up to two weeks until they cashed it. I deposited this check on Friday 02/16/24 and by the following Wednesday, 02/21/24, my bank notified me that this check had been returned due to insufficient funds. I notified the Administrator, and she had the company wire my money into my account on that Friday 02/23/24. I did have to pay for the fees from my bank, so I had to pay for my paycheck. Interview on 02/27/24 at 8:48 A.M. with LPN #202 revealed LPN #202's paycheck had been returned due to insufficient funds on the last pay day on 02/16/24. LPN #202 stated, I had deposited my check on Friday 02/16/24. I had heard that several people had their banks notify them on the following Wednesday that their check had been returned. I hadn't heard anything from my bank, so I thought things were good with my check and so I paid my Jeep payment and some other bills. On that Friday, 02/23/24, my bank contacted me had said that my paycheck had been returned due to insufficient funds. That made my Jeep payment return along with the other bills I had paid. I notified the Administrator, and the company wired my money into my account later that Friday, about 4:45 P.M. I had to pay for the wiring fees and the overdrawn fees, about $20.00, because the company did not cover those fees. Interview on 02/27/24 at 9:43 A.M. with State tested Nursing Assistant (STNA) #134 revealed STNA #134's paycheck had been returned due to insufficient funds. STNA #134 stated, On this last pay day on 02/16/24 it was a Friday. My bank notified me that my check had bounced on the following Wednesday. I notified the Administrator, and she got the company to wire my money into my account on that Friday 02/23/24. I had to pay the wiring fees and the overdraft fees for the bounced check. Interview on 02/27/24 at 9:56 A.M. with STNA #132 revealed STNA #132's paycheck had been returned due to insufficient funds on the pay day dated 02/16/24. STNA #132 stated, I had deposited my check on that Friday of payday. But I didn't know that it had bounced because I had to get a new bank card. Then my bank notified me that my paycheck had been returned due to insufficient funds. I finally got my new card last week and the company had wired my money on that Friday 02/23/24 like everybody else who had issues with their money. Interview on 02/27/24 at 3:06 P.M. with LPN #112 revealed LPN #112's paycheck had been returned due to insufficient funds. LPN #112 stated, This was the second time that this has happened to me about my checks. I only work as needed for the facility, but I'm not going to pick up anymore because of the issues with the paychecks. I had deposited my check on Monday 02/19/24 and then on Wednesday my bank contacted me had said that my check had bounced. I notified the Administrator and then the company wired my money into my account on that Friday 02/23/24. I had to pay the wiring fees which was about $15.00. Interview on 02/28/24 at 3:02 P.M. with Chief Financial Officer (CFO) #600 revealed there was a system funding error which caused the lack of funds to meet payroll on the pay day dated 02/16/24. CFO #600 stated, There was an error with the positive pay files. We have taken different steps as far as how the files are uploaded into the system now and the process is now started a couple days prior to payday instead of the night before payday. CFO #600 shared starting the process earlier would help ensure the files were uploaded accurately. Interview on 02/28/24 at 3:21 P.M. with the Administrator revealed there were 16 staff members who had their paychecks returned due to insufficient funds on the payday dated 02/16/24. The Administrator verified employees were paid every two weeks. The Administrator stated, I notified the corporate office as soon as the staff notified me of the problems with their paychecks being returned, it was the following Wednesday 02/21/24 that the staff were notified by their banks. The company then wired the money into their (the employee) accounts on that Friday 02/23/24. The CFO never told me what the problem was that caused the paychecks to be returned. Review of the facility provided list of employees with returned/bounced paychecks on 02/16/24 identified Receptionist #200, Business Office Manager #100, Social Services #220, Activity Director #106, Housekeeping Supervisor #108, Housekeeper/Laundry #162 and #164, Dietary Aide #154, State tested Nursing Assistant (STNA) #132, #134, #136, #142, #144 and Licensed Practical Nurse (LPN) #112, #201 and #202 were affected. Observation on 03/01/24 from 9:30 A.M. to 11:45 A.M. revealed Business Office Manager (BOM) #100 passing out the staff paychecks to staff members. The paychecks were issued as paper checks and required the staff to deposit into their bank accounts for processing. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated on 02/16/24 there was also an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those are paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) # 601, Director of Finances (DOF) #603 and he (CFO #600) handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Astoria Place of Barnesville. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. They stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank it was a banking error. In addition to the staff pay roll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 today. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 12:00 P.M. an interview with BOM #100 revealed all the staff payroll checks were being returned for insufficient funds from the 03/01/24 pay date. She stated she had received texts and telephone calls from staff yesterday (03/03/24) and today. She stated she was sending the information to the facility's corporate office so they could wire transfer the money to the employees' accounts. She stated Social Service #220 and STNA #146 quit yesterday (03/03/24) due to their pay not clearing and 22 employees (STNA #132, #130, #144, #142, #134 and #146; LPN #120, #112, #124, #210, #202, #126; Dietary #154, #158, #152; Maintenance #104, BOM #100, Receptionist #200, Social Service #220, Housekeeping #164 and 108; and Hospitality Aide #168) have had their checks return from the 03/01/24 pay for insufficient funds as of this time. The BOM shared the prior Administrator resigned effective 03/01/24 due to the facility's financial issues (missed payroll and payments to vendors/outside services). On 03/04/24 at 12:20 P.M. an interview with STNA #134 revealed her bank had called her today to inform her that funds had been wired transferred into her account but not until today for her paycheck. On 03/04/24 at 12:22 P.M. an interview with LPN #116 revealed his check from 03/01/24 had been returned for insufficient funds. He stated the money and fees were wired into his bank account but not until today. On 03/04/24 at 12:24 P.M. an interview with STNA #132 revealed this was the fourth time her paycheck had not cleared the bank and the second pay in a row (02/16/24 and 03/01/24) that had not cleared. She stated she still had not been paid from the 03/01/24 pay as of this date. On 03/04/24 at 12:26 P.M. an interview with Laundry #162 revealed this was the second time her paycheck had not cleared the bank. The first time was 02/16/24 and this pay was the second time. She stated she still had not been paid from the 03/01/24 as of this date. On 03/07/24 at 11:21 A.M. a telephone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met and stated this was due to an identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation has been provided. On 03/07/24 at 2:48 P.M. an interview with BOM #100 revealed the paycheck from 03/01/24 for Dietary #156 had been returned for insufficient funds. She stated the wire transfers (from the corporation) were starting to clear the bank (six days after the expected pay day for the employees). On 03/08/24 at 10:40 A.M. an interview with BOM #100 revealed the paycheck from 03/01/24 for Dietary #155 had been returned for insufficient funds. The BOM stated she was still waiting on several wire transfers to clear from the bank. (The BOM did not share which staff were awaiting wire transfers to clear as of this time). On 03/11/24 at 8:50 A.M. an interview with the BOM #100 revealed the paychecks for LPN #118, STNA #136, Marketing #300, and Maintenance #301 had been returned for insufficient funds. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: a. Review of the Dominion Energy statement dated 02/15/24 revealed the facility had a past due amount of $2690.71 and a current amount of $2276.73 for a total amount due by 03/04/24 of $4967.44. The statement indicated it was a shut off notice and $2690.71 needed to be paid by 03/04/24 to prevent the gas from being shut off. Review of the Dominion Energy receipt dated 03/01/24 revealed the facility paid $2670.71 to prevent the gas from being shut off. b. On 03/04/24 at 10:54 A.M. an interview with Physician #130 revealed he had not been paid for almost a year. He stated he received a paper check in November 2023, but it bounced. He stated he had called the corporate office in Florida and just gets the run-a-around. He stated that although he did not have any current plans to discontinue services at this this time, he hoped the company resolved the issue. The facility did not have evidence Physician #130 had been paid for services. c. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023 however CFO #600 stated they were sending out checks this week. Review of the email from Broad River Therapy dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $82,149.01. The following invoices were provided: invoice dated 11/02/23 and due on 12/02/23 was 94 days past due for the amount of $17,359.07; invoice dated 12/01/23 and due on 12/31/23 was 65 days past due for the amount of $21,299.52; an invoice dated 01/02/24 and due on 02/01/24 was 33 days past due for the amount of $23,103.50; and an invoice dated 02/02/24 and due on 03/03/24 was two days past due for the amount of $20,386.92. d. Review of Republic Services (trash) invoice dated 02/18/24 revealed the facility had a 30-day past due amount of $1,020.05 due now and a current amount of $1,046.61 due 03/09/24 for a total due of $2,066.66. As of 03/10/24, this had not been paid. e. Review of the NutriTech Consulting company's invoice dated 01/31/24 revealed the facility had the amount of $843.75 due for nutrition services/consult rendered. On 03/04/24 at 12:39 P.M. an interview with Dietitian #135 revealed the facility has to pre-pay for services because she has heard from other suppliers there were concerns with receiving payment. She stated today would have been the day they terminated services as they had not received their pre-payment from the facility, but the corporation did reach out this morning and paid the amount they owed. The facility now has until 03/11/24 to pay the March bill or services would be disrupted. An additional interview on 03/04/24 at 1:40 P.M. with Dietitian # 135 revealed the was 60 days past due. She had them prepay ahead for services. She stated she had to call them repeatedly for payment but had never cut services due to non-payment until 03/01/24. She stated they paid this morning, so they were not without a dietitian. Review of the email from Dietitian #135 on 03/07/24 at 10:42 A.M. revealed invoice number 2025 was due on 12/31/23 but wasn't paid until 03/05/24 via electric check and the check was returned for insufficient funds. The facility was currently working on a wire transfer. She stated there would not be a hold on services provided the wire transfer cleared the account. She also shared the facility dietitian was at the facility 03/06/34 to provide services. Further review revealed invoice number 2092 was due on 01/31/24 and was 36 days past due and needed to be paid by 03/11/24 to continue services. Invoice number 2142 due 03/01/24 was still within the 30-day grace period and only six days past due. A follow-up interview on 03/11/24 with Dietitian #135 revealed if payment was not made on this date, services would be terminated. f. On 03/11/24 at 12:54 P.M. interview with the Director of Operations #302 from Premiere Staffing revealed the facility made one payment since services were initiated in October 2023 and that payment was last week. Further interview revealed the facility canceled services with her company last week despite having an agency staff scheduled for a shift and did not have any of her staff scheduled for this week. Director of Operations #302 stated if payment wasn't made this week, services would be stopped with the facility as she does not allow facilities to carry a balance over 90-120 days. Lastly, she stated she issues an invoice weekly, on Thursday, to notify the facility of the amount owed but no payments have been routinely made as previously planned. A follow-up interview at 2:28 P.M. revealed the facility paid the October and November 2023 balance of $4,930.50 last week. The facility still owed $15,225.00 which was for services from December 2023 through 03/07/24. Review of the invoices from Premier Staffing revealed in January 2024, the facility total was $4,800.00 for January and in February 2024 the facility total for February was $6,787.50. Review of the (un-dated) Nursing Facility Admission Agreement, provided to all residents upon admission, revealed the facility was responsible for basic services including room and board, routine nursing care and supplies for residents and such other personal services as may be necessary for the resident's health, well-being and grooming. The facility would also provide meals, linens, housekeeping, social services and activities and other regular services required by law. Review of the Employee Handbook, dated 2020, revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the Facility assessment dated [DATE] revealed the facility's residents were at a clinically complex and special high categories who oftentimes have one or more chronic or comorbid conditions including their acuity. Residents of the facility were at risk for falls, pressure ulcers, infections, incontinence, increased disability, weight loss, depression, and other potential areas of decline. Review of the facility's policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy revised 08/15/22 revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00151331.

Based on record review and interview the facility failed to ensure the use of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 32 residents residing in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility triggered for no RN hours. Continued review of the reporting data, as submitted by the facility revealed the facility had no RN hours on 07/06/23, 07/07/23, 07/11/23, 07/12/23, 07/16/23, 07/20/23, 07/21/23, 07/25/23, 07/26/23, 08/30/23 or 08/31/23. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to Centers for Medicare and Medicaid (CMS). The Administrator verified the information as noted on the PBJ report for Fiscal Year (FY) Quarter 4 2023 as noted above. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258.

Based on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all 32 residents residing in the facility. Findings include: Observation of the posted nursing staff information on 02/26/24 at 7:34 A.M. revealed the posted nursing staff information was dated 02/05/24. Interview on 02/26/24 at 8:02 A.M. with Receptionist #200 confirmed the posted staffing information had not been updated since 02/05/24. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258.

Based on record review, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 32 residents in the facility. Findings include: Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various supplies/vendors removing the likelihood of situations of neglect. However, at the time of post-survey revisit on 02/08/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance and Performance Improvement Program was effective to ensure on-going compliance with the delivery of care. During the onsite investigation, completed on 03/11/24 the following concerns were identified: a. Interview on 02/28/24 at 3:02 P.M. with Chief Financial Officer (CFO) #600 revealed there was a system funding error which caused the lack of funds to meet payroll on the pay day dated 02/16/24. CFO #600 stated, There was an error with the positive pay files. We have taken different steps as far as how the files are uploaded into the system now and the process is now started a couple days prior to payday instead of the night before payday. CFO #600 shared starting the process earlier would help ensure the files were uploaded accurately. Interview on 02/28/24 at 3:21 P.M. with the Administrator revealed there were 16 staff members who had their paychecks returned due to insufficient funds on the payday dated 02/16/24. The Administrator verified employees were paid every two weeks. The Administrator stated, I notified the corporate office as soon as the staff notified me of the problems with their paychecks being returned, it was the following Wednesday 02/21/24 that the staff were notified by their banks. The company then wired the money into their (the employee) accounts on that Friday 02/23/24. The CFO never told me what the problem was that caused the paychecks to be returned. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated on 02/16/24 there was also an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those are paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) # 601, Director of Finances (DOF) #603 and he (CFO #600) handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Astoria Place of Barnesville. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. They stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank it was a banking error. In addition to the staff pay roll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 today. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 12:00 P.M. an interview with BOM #100 revealed all the staff payroll checks were being returned for insufficient funds from the 03/01/24 pay date. She stated she had received texts and telephone calls from staff yesterday (03/03/24) and today. She stated she was sending the information to the facility's corporate office so they could wire transfer the money to the employees' accounts. She stated Social Service #220 and STNA #146 quit yesterday (03/03/24) due to their pay not clearing and 22 employees (STNA #132, #130, #144, #142, #134 and #146; LPN #120, #112, #124, #210, #202, #126; Dietary #154, #158, #152; Maintenance #104, BOM #100, Receptionist #200, Social Service #220, Housekeeping #164 and 108; and Hospitality Aide #168) have had their checks return from the 03/01/24 pay for insufficient funds as of this time. The BOM shared the prior Administrator resigned effective 03/01/24 due to the facility's financial issues (missed payroll and payments to vendors/outside services). On 03/07/24 at 11:21 A.M. a telephone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met and stated this was due to an identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation has been provided. b. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: Review of the Dominion Energy statement dated 02/15/24 revealed the facility had a past due amount of $2690.71 and a current amount of $2276.73 for a total amount due by 03/04/24 of $4967.44. The statement indicated it was a shut off notice and $2690.71 needed to be paid by 03/04/24 to prevent the gas from being shut off. Review of the Dominion Energy receipt dated 03/01/24 revealed the facility paid $2670.71 to prevent the gas from being shut off. On 03/04/24 at 10:54 A.M. an interview with Physician #130 revealed he had not been paid for almost a year. He stated he received a paper check in November 2023, but it bounced. He stated he had called the corporate office in Florida and just gets the run-a-around. He stated that although he did not have any current plans to discontinue services at this this time, he hoped the company resolved the issue. The facility did not have evidence Physician #130 had been paid for services. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023 however CFO #600 stated they were sending out checks this week. Review of the email from Broad River Therapy dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $82,149.01. The following invoices were provided: invoice dated 11/02/23 and due on 12/02/23 was 94 days past due for the amount of $17,359.07; invoice dated 12/01/23 and due on 12/31/23 was 65 days past due for the amount of $21,299.52; an invoice dated 01/02/24 and due on 02/01/24 was 33 days past due for the amount of $23,103.50; and an invoice dated 02/02/24 and due on 03/03/24 was two days past due for the amount of $20,386.92. Review of Republic Services (trash) invoice dated 02/18/24 revealed the facility had a 30-day past due amount of $1,020.05 due now and a current amount of $1,046.61 due 03/09/24 for a total due of $2,066.66. As of 03/10/24, this had not been paid. Review of the NutriTech Consulting company's invoice dated 01/31/24 revealed the facility had the amount of $843.75 due for nutrition services/consult rendered. On 03/04/24 at 12:39 P.M. an interview with Dietitian #135 revealed the facility has to pre-pay for services because she has heard from other suppliers there were concerns with receiving payment. She stated today would have been the day they terminated services as they had not received their pre-payment from the facility, but the corporation did reach out this morning and paid the amount they owed. The facility now has until 03/11/24 to pay the March bill or services would be disrupted. An additional interview on 03/04/24 at 1:40 P.M. with Dietitian # 135 revealed the was 60 days past due. She had them prepay ahead for services. She stated she had to call them repeatedly for payment but had never cut services due to non-payment until 03/01/24. She stated they paid this morning, so they were not without a dietitian. Review of the email from Dietitian #135 on 03/07/24 at 10:42 A.M. revealed invoice number 2025 was due on 12/31/23 but wasn't paid until 03/05/24 via electric check and the check was returned for insufficient funds. The facility was currently working on a wire transfer. She stated there would not be a hold on services provided the wire transfer cleared the account. She also shared the facility dietitian was at the facility 03/06/34 to provide services. Further review revealed invoice number 2092 was due on 01/31/24 and was 36 days past due and needed to be paid by 03/11/24 to continue services. Invoice number 2142 due 03/01/24 was still within the 30-day grace period and only six days past due. A follow-up interview on 03/11/24 with Dietitian #135 revealed if payment was not made on this date, services would be terminated. On 03/11/24 at 12:54 P.M. interview with the Director of Operations #302 from Premiere Staffing revealed the facility made one payment since services were initiated in October 2023 and that payment was last week. Further interview revealed the facility canceled services with her company last week despite having an agency staff scheduled for a shift and did not have any of her staff scheduled for this week. Director of Operations #302 stated if payment wasn't made this week, services would be stopped with the facility as she does not allow facilities to carry a balance over 90-120 days. Lastly, she stated she issues an invoice weekly, on Thursday, to notify the facility of the amount owed but no payments have been routinely made as previously planned. A follow-up interview at 2:28 P.M. revealed the facility paid the October and November 2023 balance of $4,930.50 last week. The facility still owed $15,225.00 which was for services from December 2023 through 03/07/24. Review of the invoices from Premier Staffing revealed in January 2024, the facility total was $4,800.00 for January and in February 2024 the facility total for February was $6,787.50. Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator and to the compliance and ethics officer by scheduling executive board sessions with the compliance and ethics officer that allows for a free flow of information without potential for conflict. The governing body consisted of Chief Financial Officer #203, Chief Executive, Officer #204, and Chief Nursing Officer/Compliance Officer #205. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. Review of the administrator job description revealed they would operate the facility in accordance with the established policies and procedures of the facility. The job description indicated the administrator would supervise the recruitment, employment, and discharge of staff. And work closely with DON to ensure there were adequate numbers of staff to meet the needs of each resident and to comply with the state of Ohio licensure law. The administrator would act as a liaison with the facility owners and the medical, nursing, and other supervisory staff through regular meetings. This deficiency represents non-compliance investigated under Complaint Number OH00151331. This deficiency is also an example of continued non-compliance to the survey dated 02/08/24.

Based on observation, record review and interview, the facility failed to medicate Resident #10 for complaints of pain during wound care. This resulted in harm to the resident when the resident reported complaints of pain during her wound care and was not medicated to alleviate the resident's pain during or following the wound care. This finding affected one (Resident #10) of two residents (#34) reviewed for pain. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #10's care planned interventions included an intervention dated 01/22/21 to evaluate the resident for pain and utilize pain medications as well as non-pharmacological measures for pain relief. Evaluate the need to medicate prior to any wound care. Review of Resident #10's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's medication administration records from 04/01/21 to 04/21/21 revealed the resident had not received pain medications including the Tylenol or [MEDICATION(S)] on 04/20/21 at any point during the day. Observation on 04/20/21 from 11:52 A.M. to 12:03 P.M. with Licensed Practical Nurse (LPN) #801 and State tested Nursing Assistant (STNA) #804 of Resident #10's pressure ulcer wound care revealed at 12:00 P.M. during completion of the wound care, especially of the right right hip, the resident grimaced and complained of pain multiple times and stated it hurts during removal of the soiled dressings and cleaning of the wounds. Wound care included treatment and dressing changes to multiple wounds to the right and left hips, buttocks and feet. Observation of the wounds on the right and left hips revealed exposed hardware from hip prostheses. State tested Nursing Assistant (STNA) #804 asked LPN #801 if the resident was medicated for pain and the nurse indicated the resident was medicated for pain. Interview on 04/21/21 at 6:21 A.M. with STNA #804 indicated Resident #10 grimaced and stated she was in pain when rolled to complete wound care, especially on the right side. Interview on 04/21/21 at 7:31 A.M. with LPN #801 indicated she should have medicated Resident #10 for pain when the resident complained of pain but she got busy as she was assigned to administer medications. Interview on 04/21/21 at 12:21 P.M. with wound Nurse Practitioner (NP) #805 indicated Resident #10 was probably complaining of pain due to the contractures and moving the resident during wound care rather than from the actual wounds. NP #805 indicated the resident might be a good candidate for pre-medication during wound care.

Based on medical record review, staff interview and facility policy, the facility failed to identify resident skin impairment, failed to seek treatment options in a timely manner and failed to implement pressure relieving intervention for Resident #44, (who required total assistance with all activities of daily living) and failed to perform thorough weekly wound assessments on Resident #44 and Resident #6. This resulted in actual harm on 11/29/20 when a coccyx wound for Resident #44 declined to a Stage Four pressure ulcer and she developed deep tissue injuries to both of her heels. This affected two residents (Resident #45 and #6) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was discharged from the facility on 11/30/20 to home with hospice. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had severely impaired cognition, required total assistance with bed mobility, transfers, dressing, eating, toilet use, bathing and personal hygiene. The resident was always incontinent of bladder and bowel and did not have a pressure ulcer or deep tissue injury. Review of the Discharge MDS dated [DATE] revealed Resident #44 had an unhealed stage three in-house pressure ulcer . Review of the November 2020 physician's orders [REDACTED]. every shift to promote healing (11/02/20), cushion boots while in bed every shift (11/04/20), Pro-Stat twice daily for wound healing (11/20/20), Air mattress for comfort and prevention of skin breakdown due to decreased mobility (11/23/20), cleanse area with normal saline (NS), pat dry, pack with calcium alginate silver, cover any other open area with calcium alginate silver, cover with a dry dressing every day and as needed until healed (11/23/20) and Keflex twice daily for infection for ten days. Review of the Braden scale dated 02/26/20 revealed Resident #44 scored 16 which indicated at risk for skin impairment. Review of the nurse's notes dated 08/11/20 at 3:59 A.M. revealed the nurse was notified by the nursing assistant Resident #44 had a red area to the left inner buttock. The area was blanchable, barrier cream was applied to the area and the resident was reposition at this time. The physician and power of attorney were notified. Review of the plan of care dated 08/31/18 revealed Resident #44 was at risk for alteration on skin integrity related to incontinence, [MEDICAL CONDITION], impaired cognition, impaired mobility, [DIAGNOSES REDACTED]. Intervention included; wheelchair with padded side arms(12/08/19), educate resident and family on skin breakdown risk factors and preventative measures, Geri-sleeves to bilateral arms for protection, encourage to float heels while in bed, encourage to turn and reposition every two hours and as needed, offer fluids every two hours, pressure reducing cushion in the chair, pressure reducing mattress to the bed, provide assistance with hygiene including peri-care, record meal intake percentages, and use barrier cream with showers and incontinence care. Review of the plan of care dated 10/08/18 revealed Resident #44 had a potential for alteration in skin integrity due to bowel and bladder incontinence, decreased mobility and lower extremity [MEDICAL CONDITION]. Interventions included to educate the resident and family on skin breakdown risk factors and preventative measure, encourage to float heels while in bed, encourage to turn and reposition every two hours and as needed, off fluids every two hours, pressure reducing cushion in the chair, pressure reducing mattress to the bed, provide assistance with hygiene including peri-care, record meal intake percentages, and use barrier cream with showers and incontinence care. Review of the Braden scale dated 10/13/20 revealed Resident #44 scored 11 which indicated a high risk for skin impairment. Review of the shower/tub bath/ bed bath sheets dated 10/20/20 revealed Resident #44 had an open area to her buttock. Review of the Skin Observation Tool dated 10/24/20 revealed Resident #44 had an area to her left buttock, red area with drainage, no odor, and a treatment was in place. There was no staging or measurements. Review of the nurse's notes dated 11/02/20 4:05 P.M. revealed it was reported to the nurse the heels of Resident #44 were discolored, areas checked, and right heel measured six cm by five cm and were dark blue, purple, black and soft to touch. The left heel measured four cm long by one cm wide and was red, purple, soft to touch, no drainage. The doctor was notified, and a new order was received to apply skin prep and pad and protect with an abdominal dressing and cling twice daily. The family was notified. Review of the Certified Nurse Practitioner (CNP) progress notes date 11/03/20 revealed the visit was due to pressure ulcer to both heels. The resident was being seen for areas to bilateral heels. Nursing reported areas to each heel that was reported yesterday. Right lateral heel had a large deep tissue injury (DTI) dark purple in color, skin was intact, patient acts like it may be painful to touch due to attempted to pull the foot away. The left medial heel had a smaller DTI and did not seem tender to touch. Both wounds are getting skin prep and pad and protect dressing, the wound nurse to assess. The resident has a gradual weight loss. The CNP would order cushion boots, complete blood count (CBC), Complete Metabolic Panel (CMP), and [MEDICAL CONDITION] stimulating hormone (TSH). Review of the Skin Observation Tool dated 11/04/20 revealed Resident #44 had an area to her left buttock, right heel, and left heel. Both heels had dark areas with discoloring, the treatments were in place to pad and protect, and the left buttock was open with a treatment in place. There was no staging or measurements. Review of the signed physician's telephone order dated 11/06/20 revealed a treatment ordered for Resident #44 to treat the open areas to the right buttock, left buttocks and coccyx, clean, apply non-adherent dressing, cover with dry sterile dressing every day. There was no date was to when the order started and was never put on November 2020 Treatment Administration Record (TAR). Resident #44 was sent to the hospital on [DATE] due to a change in mental status and diarrhea. She was readmitted to the facility on [DATE]. Review of the admission re-assessment dated [DATE] revealed the resident had skin impairment to both of her heels. The right heel had a 6.0 centimeters (cm) by 5.0 cm dark blue, purple, black, soft to touch area and the left heel had a 4.0 cm by 1.0 cm wide, red, purple, soft area, both with no drainage. The resident had bruising to the left back of the hand, right wrist left forearm, and right forearm. These pressure areas were documented by the facility, although without measurements and staging, prior to her going to the hospital. Review of the Braden scale dated 11/10/20 revealed Resident #44 scored nine which indicated she was very high risk. Review of the plan of care dated 11/10/20 revealed the resident had an actual skin impairment. Interventions included apply skin prep, pad and protect with abdominal dressing and cling twice daily, elevate heels when in bed, elevate legs as much as resident was able to tolerate, encourage movement of legs, walking, nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there was no signs and symptoms of infection or increased drainage, observed and document character of wound weekly, observe for clinical changes, such as infection and/or worsening of wound, refer to dietician to determine need/no need for dietary intervention, review nutrition/hydration status, encourage fluids, monitor weight loss, see at risk for skin breakdown care plan for preventative measures, skin observation and documentation on bath/shower days. Charge nurse to notify wound nurse, physician and family of any anew areas. Review of the shower/tub bath/ bed bath sheets dated 11/13/20 revealed Resident #44 had red open area on the bottom, and it was bleeding. The nurse was notified. Review of nurse's notes 11/16/20 at 10:59 P.M. revealed Resident #44 was noted to have several open areas on the coccyx, areas cleansed, non-adherent dressing applied and covered with a sterile dressing. Review of the dietary noted dated 11/18/20 at 7:33 P.M. revealed Resident #44 was noted with open areas on the coccyx. Would suggest Nutritional juice every morning for increased protein and fluids. Would monitor acceptance and update as needed. The recommendation was never implemented. Review of the telehealth CNP progress note dated 11/19/20 revealed the reason for the visit was [MEDICAL CONDITION]. Laboratory work shows an elevated sodium level which was up from last week and [MEDICATION NAME] was down even more. Resident was positive for COVID and was not eating or drinking well. Would order Pro-Stat, have nursing push fluids, and repeat Basic Metabolic Panel (BMP) and CBC on Monday. Review of the nurse's notes dated 11/22/20 at 4:31 A.M. revealed Resident #44 had a second-degree pressure ulcer, slightly malodorous, noted on buttocks in the sacral region. The residents positioning had been changed frequently during the past two days (everyone to two hours) with no resolve of symptoms. Moisture wicking dressing was applied to the area with additional absorption padding applied to the genital area for increased dryness. Oncoming staff notified and requested to contact the physician or CNP in the early morning for orders. Decreased appetite and fluid intake was also reported by the first shift nurse and the resident had consumed water throughout the night by using a spoon. Review of the nurse's notes dated 11/22/20 at 12:25 P.M. revealed a call was placed to the physician regarding residents' buttocks and an order was needed until the facility could reach the wound CNP. Daughter was notified. Reviewed of the nurse's note dated 11/22/20 at 6:30 P.M. revealed the staff reviewed the CNP orders for care of buttock wound. Both nurses examined the wound and completed cleaning , packing and dressing of the wound. The resident was repositioned and appears to be comfortable. The resident continues to have decreased appetite at dinner although it was stated that the resident had good nourishment at the lunch hour. The nursing assistance were notified of the need for continues frequent position changes and to abstain from supine placement to promote healing. Review of the CNP progress notes dated 11/22/20 revealed Resident #44 had a telehealth visit. The nurse report progressive worsening to the pressure ulcer to the coccyx. Imaging shows a Stage three with undermining at the wound edges and minimal amount of slough noted. There was also a large area of DTI noted on both buttocks. Both buttocks have open area as will. However, they were harder to stage from imaging. One side appears to be a stage two and the other side a smaller stage three. The treatment was currently a dry dressing. The resident was showing signs of malnutrition. She was started on Pro-Stat supplement on 11/19/20. New treatment was started of calcium alginate with sliver to wound bed, cover with a dry dressing, change daily and as needed. Wound Nurse should assess this Thursday. Review of the nurse's notes dated 11/24/20 at 10:51 A.M. revealed Resident #44's buttock was irrigated and redressed per order, the wound measurement were a one cm circular stage three on right medial aspect of the coccyx, a two cm circular stage three right medial aspect of the above breakdown, 3.5 cm long by one cm wide stage two extending vertically along the right medial aspect of the coccyx (beginning below the previously listed), a four cm by one cm stage two on the left medical aspect of the coccyx. A position change log for this resident would be created and staff advised to track daily. The nursing staff to be advised of wound measuring and charting at each dressing change. Review of the nurse's note dated 11/29/20 at 10:48 A.M. revealed Resident #44 continues to be turned every hour as scheduled. The buttock wound was assessed and found to be a stage four measuring 6.5 cm vertical and 4.5 cm horizontal. The resident appears to be in slight discomfort, the nurse to medicate and contact the physician for further orders. Review of the nurse's notes dated 11/29/20 at 11:07 A.M. revealed the nurse spoke to the CNP regarding Resident #44 pressure ulcer was now at a stage four, measuring 6.5 cm vertical by 4.5 cm horizontal. Photos of the wounds were sent to CNP as requested. New orders were sent for change in wound dressing was well as a prescription. Review of the November 2020 Treatment Administration record revealed there was no documentation of Resident #44 treatments of [MEDICATION NAME], skin prep and cushion boots being done on 11/10/20, 11/11/20, 11/12/20, 11/13/20, 11/15/20, 11/16/20, 11/17/20, 11/20/20, 11/24/20, and 11/29/20. Interview on 12/30/20 at 3:58 P.M. the Administrator indicated the skin observation were all they had on Resident #44. They did not have any more measurements. She verified the weekly skin assessments had not been performed on Resident #44 coccyx wound or the bilateral heel wounds. Interview on 01/05/21 at 9:58 A.M. the Director of Nursing verified the facility had no documentation of the dated of origin, weekly skin assessments, weekly measurements or interdisciplinary review for Resident #44's coccyx or bilateral heels. She also verified there was never a plan of care put into place for Resident #44 coccyx or bilateral heel wounds until 12/29/20 when asked for the plan of care by the surveyor. Interview on 01/05/21 at 5:00 P.M. Dietary Manager #324 indicated the Dietitian was not in the building in November due to a COVID outbreak in the facility. She indicated she would email the dietitian the residents she needed to review, and the dietician would then send her back a report of concerns and recommendation. She indicated she did not receive a report for Resident #44 to have nutritional juice, so it was never started. She indicated she did not follow up with the dietician. Review of the undated facility policy, Skin Care and Wound Management, revealed the facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team (IDT) worked with the resident and family members to identify and implement interventions to prevent and treat potential skin integrity issues. The IDT evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions contributing to it and description of the impairment to determine appropriate treatment. 2. Review of the medical record revealed Resident#6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed Resident #6 had severely impaired cognition, required extensive assistance with all activities of daily living and did not have a pressure ulcer. Review of the December 2020 physician's orders [REDACTED]. Review of the Skin Observation Tool Dated 11/15/20 revealed Resident #6 had a wound to her coccyx and left buttock. There was no staging or measurements. Review of the Braden scale dated 12/07/20 revealed Resident #6 scored 14 which indicated was moderate risk. Review of the Braden scale dated 12/08/19 revealed Resident #6 scored 16 which indicated was at risk. Review of the Skin Observation Tool dated 12/15/20 revealed Resident #6 had a stage two to her coccyx. There were no measurements. Review of the Skin Observation Tool Dated 12/17/20 revealed Resident #6 had a stage two to her coccyx. There were no measurements. Review of the Skin Observation Tool Dated 12/18/20 revealed Resident #6 had a wound to her left buttock. There was no staging or measurements. Review of the Surgical Wound Care Service note dated 12/23/20 revealed Resident #6 had a stage two to her left buttock. There were no measurements. Interview on 01/05/21 at 9:58 A.M. the Director of Nursing verified the facility had no documentation of the dated of origin, weekly skin assessments, weekly measurements or interdisciplinary review for Resident #6's left buttock wound. Review of the undated facility policy, Skin Care and Wound Management, revealed the facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team (IDT) worked with the resident and family members to identify and implement interventions to prevent and treat potential skin integrity issues. The IDT evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions contributing to it and description of the impairment to determine appropriate treatment. This deficiency substantiates Master Complaint Number OH 994, Complaint Number OH 947, and Complaint Number OH 942.

Based on record review and interview the facility failed to prevent significant medication errors for Resident #44. Actual harm occurred on 06/03/20 when Resident #44 was administered the incorrect medications causing a change in her condition requiring medical testing/evaluation and additional medication changes. This affected one of three residents reviewed for medications errors. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home with family on 11/30/20. Review of the medication error report dated 06/03/20 at 7:40 A.M. revealed Resident #44 was given [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (blood pressure medication), [MEDICATION NAME] XL extended release (blood pressure medication), [MEDICATION NAME] (blood pressure medication), and [MEDICATION NAME] (antidepressant), all crushed in applesauce. Resident #44 did not have physician's orders for any of these medications. The nurse incorrectly administered another resident's medications to Resident #44. Review of the eINTERACT Change in Condition Evaluation dated 06/03/20 at 10:05 A.M. revealed Resident #44 had abnormal vital signs, a new irregular pulse, irregular heart rhythm, persistent or recurrent vomiting with or without abdominal pain, bleeding, distention or fever, acute onset of three or more episodes of loose stools, and with unknown congestion. Review of the heart rate or pulse records for Resident #44 revealed on 06/03/20 at 3:32 A.M., a pulse of 77 beats per minute (bpm) with a regular heart rhythm. At 8:40 A.M., a pulse of 78 bpm with a regular heart rhythm. At 10:00 A.M., a pulse of 68 bpm with an irregular heart rhythm (new onset). Then it continued as follows: at 10:06 A.M. a pulse of 68 bpm with a regular heart rhythm; at 1:00 P.M. a pulse of 68 bpm with an irregular heart rhythm (new onset); at 3:00 P.M. a pulse of 60 bpm with an irregular heart rhythm (new onset); at 5:00 P.M. a pulse of 60 bpm with an irregular heart rhythm (new onset); on 06/04/20 at 12:00 A.M. a pulse of 72 bpm with a regular heart rhythm; on 06/10/20 at 2:37 A.M. a pulse of 80 bpm with a regular heart rhythm, and on 06/27/20 at 3:02 A.M. a pulse of 76 bpm with a regular heart rhythm. Review Resident #44's nurse's notes revealed no documentation related to the medication errors. The nurse's notes dated 06/03/20 at 10:31 A.M. revealed Resident #44 had two emesis, tan in color with thin and chunky food consistency. Her skin was dry, she had no change in mental status, respirations were non-labored, wheezing was noted throughout anterior and posterior lung fields, she had no cough and she had a large loose bowel movement. The note indicated staff were awaiting a return call form the physician to update them on her condition. The nurse's noted dated 06/03/20 at 11:00 A.M. revealed physician orders were obtained for Resident #44 to have laboratory tests and an electrocardiogram (EKG) to check her heart. The note indicated the resident remained stable with no signs or symptoms of distress and there were no further emesis or loose stools noted. The resident was resting comfortably in the chair. Review of the EKG results dated 06/03/20 revealed Resident #44 had an abnormal EKG and findings revealed sinus [MEDICAL CONDITION] (slow heart rate) with first degree atrioventricular block and occasional premature [MEDICAL CONDITION] contractions, poor R-wave progression, and nonspecific T-wave abnormality. Review of the physician progress notes [REDACTED].#44 was involved in a staff medication error. The resident's lungs were clear, heart rate irregular, had new onset [MEDICAL CONDITION] with slow ventricular response. The plan was to start her on an anticoagulant and electrocardiogram. Review of a new physician's order dated 06/04/20 revealed Resident #44 was to be started on five milligrams of apixaban (an anticoagulant) to be given twice daily for [MEDICAL CONDITION]. Review of the five-day Medicare Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #44 had severely impaired cognition and required total staff assistance with bed mobility, transfers, dressing, eating, toilet use, bathing and personal hygiene. Interview on 12/29/20 at 11:45 A.M. with the Director of Nursing verified Resident #44 was given the wrong medications which caused a change in her medical condition. Review of the facility policy, General Guidelines for Medication Administration, dated 09/18, revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Personnel authorized to administer medication do so only after they have been properly oriented to the facility medication distribution system. The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. At a minimum, the five rights, right resident, right drug, right dose, right route, and right time should be applied to all medication administration and reviewed at three steps in the process of preparation: when medication was selected, when the dose was removed from the container and after the dose was prepared and the medication was put away. This deficiency substantiates Master Complaint Number OH 994 and Complaint Number OH 942.

Based on staff interview, review of medical records, facility policy and procedure for abuse, facility Self-Reported Incident (SRI), and facility investigation, the facility failed to ensure Residents #37 and #29, who had severe cognitive impairment, were free from physical restraint and sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious emotional harm on 11/27/19 at 7:00 P.M., when Resident #6, who was known to display sexually aggressive behavior, lured Resident #37 into his room and restrained her to his bedside by tightly holding her wrists and refusing to release his grasp; on 12/07/19 Resident #6 physically restrained Resident #37 to his bedside by tightly holding onto her arm and refusing to release his grasp and on 01/14/20 staff had to use scissors to cut the strings of Resident #37's pants in order to free her from Resident #6's grasp. On 01/15/20 Resident #6 was observed grabbing and massaging the breasts of Resident #29 on two separate occasions in a facility common gathering area. This affected two of 38 female residents residing in the facility. The facility census was 60. On 01/31/20 at 3:10 P.M., the Director of Nursing (DON), Social Service Designee (SSD) #107 and Clinical Nursing Officer (CNO) #170 were notified Immediate Jeopardy began on 11/27/19 at 7:00 P.M. when Resident #6, who was admitted on [DATE] with known sexually inappropriate behaviors, lured Resident #37, who had severe cognitive impairment, into his room and physically restrained the resident. After the 11/27/19 incident Resident #6 displayed sexually aggressive behavior daily by grabbing at staff's buttocks and breasts and masturbating in front of staff members and asking them to participate. The facility failed to ensure Resident 6's behavior care plan was implemented as written, updated when interventions were unsuccessful, and ensure adequate monitoring and supervision to ensure the behavior did not continue or escalate. This resulted in a reoccurrence of the physical restraint of Resident #37 on 12/07/19 and 01/14/19 and the groping of Resident #29's breast on 01/15/20. The Immediate Jeopardy was removed on 02/01/20 at 4:00 P.M. when the facility implemented the following corrective action: · On 01/31/20 at 4:00 P.M., Resident #6 was placed on one-to-one supervision. · On 01/31/20 at 7:09 P.M., Licensed Practical Nurse (LPN) #112 notified Resident #6's family and physician of his inappropriate behaviors towards Resident #37 on 11/27/19, 12/07/19 and 01/14/20 as well as with Resident #29 on 01/15/20. · On 01/31/20 at 7:15 P.M., the DON was educated by CNO #170 on the change of condition policy including ensuring documentation was in the medical record. · On 1/31/20 at 7:46 P.M., LPN #112 notified Resident #37's family and physician of the incidents which occurred on 11/27/19, 12/07/19 and 01/14/20 with Resident #6. · Beginning on 01/31/20 at 8:00 P.M., the DON, LPN #103 and LPN #112 began educating all Registered Nurses (RNs), LPNs and state tested nurse aides (STNAs) on the facility's behavior management policy, behavior tracking and documentation, and the abuse policy. All RNs, LPNs and STNAs were educated by 02/01/20 at 5:55 P.M. · Beginning on 01/31/20 at 8:30 P.M., LPN #112 started head to toe skin assessments on all 57 residents. All residents were assessed by 02/01/20 at 12:42 [NAME]M. · On 01/31/20 at 8:30 P.M. Social Service Designee (SSD) #107 interviewed all 57 residents and/or their responsible parties to ensure they felt safe and had not experienced any type of abuse while in the facility. All 57 interviews were completed on 02/01/20 at 1:00 P.M. No additional abuse was discovered or suspected. · Beginning on 01/31/20 at 8:30 P.M., Human Resource Director (HRD) # 117, Dietary Manager (DM) #127, Therapy Director (TD) #179 and Housekeeping Supervisor (HKS) #171 began educating all dietary staff, activities staff, housekeeping staff, therapy staff and the maintenance director (MD). All staff was educated by 02/01/20 at 5:30 P.M. · On 01/31/20 at 8:42 P.M., LPN #112 notified Resident #29's family and physician of the inappropriate sexual contact on 01/15/20 with Resident #6. · On 01/31/20 at 10:00 P.M., Psychiatrist #190 completed an assessment on Resident #6 with no new recommendations. · On 02/01/20 at 10:00 [NAME]M. the DON in-serviced SSD #107, LPN #103, LPN #112, TD #179, HKS #171, the Administrator, DM #127, MD #156 and Transporter #109 on the abuse policy and Resident #6's updated plan of care. · On 02/01/20 at 11:30 [NAME]M., SSD #107, LPN #103, the DON and LPN #112 started a 30 day look back chart review for behaviors and/or significant changes for all 57 residents which was completed on 02/01/20 at 2:30 P.M. There were no additional findings. · On 02/01/20 the DON started daily audits for documentation of behaviors on the 24- hour report, completion of behavior tracking and documentation, and identification and follow up of concerns. After seven days the audits would continue weekly for three weeks and then monthly thereafter. The audits would be reviewed monthly in the Quality Assurance meeting. · On 02/03/20 interviews between 10:45 [NAME]M. and 3:10 P.M., with the DON, SSD #107, RN #105, LPN #129, LPN #120, STNA #146, STNA #101 and STNA #168 revealed the staff were knowledgeable on the new policies and procedures for behavior tracking, documentation and reporting, and the facility's abuse policy and procedure and their specific roles. Although the Immediate Jeopardy was removed on 02/01/20 the deficiency remains at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action and auditing tools. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the immediate needs care plan with an effective date of 11/26/19 and signed as completed on 12/05/19 revealed the care plan did not address sexually aggressive behaviors. Record review revealed Resident #37 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#37 had a brief interview of mental status score (BIMS) of 99 indicating due to the resident's cognitive impairment the assessment could not be completed; she was not able to answer any questions. Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed Resident #29 had a BIMS score of 99 indicating due to the resident's cognitive impairment the assessment could not be completed; she was not able to answer any questions. Review of Resident #6's nurse note dated 11/27/19 at 7:00 P.M. revealed an STNA observed Resident #6 in his bed holding onto Resident #37's wrist. The STNA called for the nurse who entered the room where Resident #6 continued to tightly grip Resident #37's wrist. When asked, Resident #6 would not release Resident #37's wrist. The nurse removed Resident 6's fingers one by one from Resident #37's wrist. Resident #6 was told to keep his hands to himself. There was no documentation indicating the physician was notified. Review of Resident #37's nurse note dated 11/27/19 revealed Resident #37 wandered into Resident #6's room and as she approached his bed, he grabbed a hold of her right hand and arm and refused to let go. Three staff assisted to get Resident #6 to release his grasp. After staff released the grasp, Resident #37's right hand and arm had a pinkish discoloration. The note indicated staff were unable to educate Resident #37 to not wander into Resident #6's room because she did not understand. Review of Resident #37's nurse note dated 12/07/19 at 5:20 P.M. revealed she wandered into Resident #6's room and he grabbed a hold of her left arm and would not let go for a couple of minutes then staff were able to get her arm free from his grasp. Review of the DON's summary, dated 01/27/19, revealed Resident #37's stuffed animal was found on Resident #6's bed when staff entered the room and Resident #6 would not let go of Resident #37. The staff were not sure how long Resident #37 had been in the room but observed her during rounds. The intervention to prevent Resident #37 from entering Resident #6's room in the future was to put a Velcro stop sign across Resident #6's door. Review of Resident #6's mood swing and behavior care plan initiated 11/29/19 revealed the resident grabbed at female staff at inappropriate places on their body, made sexual references while using vulgar language and grabbed at other residents. The interventions included attempt non-pharmacological interventions such as one to one conversation, redirect, change position or scenery, offer food or fluids or a diversional activity, and offer counseling and/or psychological services. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and physical behavior symptoms directed towards others which could include abusing others sexually, grabbing, hitting, kicking and/or punching occurred four to six days out of the seven-day reference period. Review of Resident #6's activities of daily living (ADL) plan of care initiated 12/16/19 revealed the resident was to have two staff for all aspects of care related to his sexual aggression and behaviors toward staff. Review of the behavior note dated 12/21/19 at 9:00 P.M., revealed Resident #6 activated his call light and when the STNA responded Resident #6 made sexually inappropriate requests to the STN[NAME] The STNA informed the nurse who provided one-to-one conversation with the resident. Further review revealed at 9:30 P.M. Resident #6 put on his call light and when the STNA responded the resident went into more detail about what he wanted sexually from the STN[NAME] The STNA informed the nurse who provided one-to-one conversation with the resident. The nurse informed the resident he could not talk to the STNA like that and the resident responded, I don't care. The note indicated at 10:30 P.M. the resident continued to make inappropriate sexual requests to the STNAs and the nurse with one-to-one conversation with the resident ineffective. There was no evidence the physician was notified. Review of the nurse note dated 12/21/19 revealed Resident #6 stopped his tube feeding to make it alarm. Once staff entered the room, he asked them for sex. There was no evidence the physician was notified. Review of the behavior note dated 12/22/19 revealed Resident #6 continued to activate his call light and was requesting staff to watch him masturbate. Redirection was not effective. There was no evidence the physician was notified. Review of the nurse note dated 12/25/19 at 9:45 P.M. revealed Resident #6 activated his call light and when the STNA entered the room the resident was holding his penis and stated, I need you to help me do this. There was no evidence the physician was notified. Review of the behavior note dated 12/25/19 at 10:43 P.M. revealed Resident #6 continued to ask STNAs to assist him with masturbation. One-to-one conversation was ineffective. There was no evidence the physician was notified. Review of the behavior note dated 12/26/19 at 5:42 [NAME]M., revealed Resident #6 continued to request the STNAs watch him masturbate. Redirection from the nurse was ineffective and the resident stated he wanted the day shift STNAs and nurses in his room because he could do whatever he wanted on day shift. Further review of the nurse's note revealed when the STNA entered the resident's room to provide morning care the resident pulled out his penis and began to masturbate indicating he wanted the STNA to watch him. There was no evidence the physician was notified. Review of nurse notes dated 12/28/19 and 12/29/19 revealed Resident #6 had attempted numerous times to grope the nurse while making inappropriate sexual comments. There was no evidence the physician was notified. Review of behavior notes revealed on 01/01/20 at 8:37 P.M., Resident #6 continued to ask the STNAs and nurses to assist and/or watch him masturbate. One-to-one conversation was ineffective. At 8:47 P.M. the resident attempted to grope the nurse during medication pass; at 10:29 P.M. the resident wanted the STNA to give him lotion and assist him with masturbation. The note indicated the resident was asked many times to stop his comments and he smiled and said, I don't have to, I can do what I want. There was no evidence the physician was notified. Review of the behavior note dated 01/02/20 at 2:41 [NAME]M. revealed Resident #6 asked for a specific STNA to come and assist him with masturbation. There was no evidence the physician was notified. Review of the nurse note dated 01/04/20 at 10:02 [NAME]M. revealed Resident #6 continued to activate his call light and when staff responded he was masturbating, and he asked staff to watch. There was no evidence the physician was notified. Review of the behavior note dated 01/07/20 at 10:44 P.M. revealed Resident #6 attempted to grope an STN[NAME] One-to-one conversation was ineffective. There was no evidence the physician was notified. Review of the nurse note dated 01/14/20 at 6:12 P.M. revealed the administrator, SSD #322, and the DON spoke with Resident #6 about using profanity and touching staff and others inappropriately. The resident agreed to stop this behavior. There was no evidence the physician was notified. Review of the behavior note dated 01/15/20 at 1:37 P.M. revealed Resident #6 grabbed at the nurse and when redirected made a fist. There was no evidence the physician was notified. Review of the SRI dated 01/15/20 at 4:45 P.M., revealed Resident #6 was observed groping Resident #29's breast on 01/15/20 at 2:45 P.M. The final report revealed sexual abuse was substantiated. Review of Resident #6's nurse note dated 01/15/20 at 5:10 P.M., revealed SSD #322 attempted to contact two psychiatric facilities to take Resident #6 but due to his age and payor source they would not accept the resident. The facility's in- house psychiatrist was contacted, and a return call had not been received. At 7:15 P.M., the nurse practitioner was contacted and indicated an attempt would be made to get the resident admitted to a local hospital Geropsychiatry unit. Review of the hospital note dated 01/16/20 revealed Resident #6 was admitted to the hospital with [REDACTED]. On 01/17/20 at 11:25 [NAME]M., interview with Resident #25, with family present, revealed the resident and family observed Resident #6 grab and hold onto Resident #29's breast tightly while massaging it in the common area on 01/15/20. Resident #29 was making noises which they interpreted as yelling out for help. They stated Resident #29 was nonverbal and unable to move away. The family member stated he informed the DON of the above on 01/16/20. Resident #25 stated the DON asked him what he observed, and he informed her of the above on 01/16/20. Resident #25 also stated staff had told him about Resident #6 being sexually inappropriate with Resident #37 who was confused and wandered in and out of resident rooms. Resident #25 said Resident #6 would call for Resident #37 to get her to come into his room. On 01/17/20 at 4:00 P.M., interview with STNA #341 revealed she observed Resident #6 trying to get Resident #37 to come into his room many times and she informed the nurse. STNA #341 indicated she had not been trained on how to handle Resident #6's sexual inappropriateness but told the nurse anytime he said or did something inappropriate. STNA #341 stated Resident #6 frequently activated his call light and when she answered it the resident was masturbating and wanted her to watch him. STNA #341 indicated the previous week she had called LPN #329 to assist because Resident #6 had Resident #37 by the shirt and string of her pants and Resident #6 would not let go and kept saying she is mine. LPN #329 had to cut the strings from Resident #37's pants because they could not get Resident #6 to release his grasp. On 01/17/20 at 4:20 P.M., interview with STNA #320 revealed Resident #37 wandered in and out of other rooms, even during the night she was up a lot. STNA #320 observed Resident #37 go into Resident #6's room and when STNA #320 went in to get her out he had a hold of her sleeve and would not let got but she finally got Resident #37 out of the room. STNA #320 also indicated she observed Resident #6 grab Resident #29's breast on two separate occasions on 01/15/20 and she let the nurse know. STNA #320 said Resident #6 would activate his call light and when she answered the light he was masturbating and asked her to stay and watch. STNA #320 left the room and informed the nurse many times. STNA #320 said the DON and administrator had been aware of the behaviors since the resident was admitted but nothing had been done about it. On 01/17/20 at 5:12 P.M., interview with SSD #322 indicated she was aware Resident #6 had inappropriate social boundaries including sexual notations. SSD #322 verified Resident #37 wandered in and out of other resident rooms and redirection was unsuccessful. SSD #332 was aware Resident #37 had wandered into Resident #6's room multiple times. SSD #332 denied being aware of Resident #6 groping Resident #29's breast on 01/15/19 but indicated she was attempting to get him placed into a psychiatric unit for sexual inappropriateness. On 01/17/20 at 5:23 P.M., interview with the DON revealed she was told prior to admitting Resident #6 that he had sexually aggressive behaviors, was abusive towards staff, called staff inappropriate names, grabbed at their private areas and cursed at them. The DON indicated she was informed to keep something in Resident #6's hands as much as possible to prevent him from trying to grab inappropriately when anyone came near him. The DON verified she was aware the second day Resident #6 was admitted there was an incident with Resident #37. Resident #37 who was confused, wandered into his room and he grabbed her and would not let go. The DON did not obtain witness statements related to the incident on 11/27/19. The DON explained she only got witness statements when she was going to submit an SRI to the State Agency. The DON put a Velcro stop sign across Resident #6's door to prevent Resident #37 from wandering into his room but Resident #37 ducked under the sign and continued to enter Resident #6's room. The DON could not recall any other incidents between Resident #6 and Resident #37. The DON was aware of Resident #6' sexually inappropriate behaviors towards staff. The DON verified Resident #6's care plan did not include keeping something in Resident #6's hands to prevent him from grabbing at staff and others. The DON verified after the 11/27/19 incident with Resident #37 another incident occurred when Resident #6 groped Resident #29's breast on 01/15/20. On 01/17/20 at 5:43 P.M., phone interview with LPN #329 revealed Resident #6 had been sexually aggressive since he had been admitted , groping the staff, making sexual comments and putting on his call light wanting the staff to watch him masturbate. LPN #329 revealed on 01/14/20 she was passing medications and heard a noise and went to Resident #6's room and found him holding onto Resident #37's shirt. LPN #329 told Resident #6 to let go but he would not. LPN #329 was standing behind Resident #37 trying to remove Resident #6's hands when he grabbed the strings of Resident #37's pants and would not let go. Resident #6 kept repeating she is mine. LPN #329 stated she removed scissors from her pocket and cut off the strings to Resident #37's pants to release her from Resident #6's grip. LPN #329 revealed she was not asked to write a witness statement about the incident. LPN #329 was not aware of any interventions staff were to initiate related to Resident #6's sexual behaviors. When asked if she felt the confused, wandering residents were safe in the facility she said no, not if Resident #6 got a hold of them. On 01/17/20 at 6:25 P.M., interview with LPN #321, who completed MDS assessments and care plans, revealed an immediate care plan was not put in place for Resident #6 related to inappropriate behaviors. LPN #321 stated she was not informed Resident #6 had sexually inappropriate behaviors prior to being admitted to the facility. LPN #321 verified Resident #6 had behaviors including being sexually inappropriate. LPN #321 stated no care plan related to Resident #6's behavior was initiated until 11/29/19 when the intervention to provide one-to-one conversation was initiated. LPN #321 verified when the one to one intervention was determined to be ineffective the resident was not re-assessed, and the care plan was not updated. LPN #321 indicated the facility did not have a behavior monitoring/tracking system in place. On 01/17/20 at 6:57 P.M., a follow up interview with the DON verified the facility did not reassess and implement new interventions to reduce Resident #6's sexually inappropriate behaviors. The DON verified the resident's attending physician or a psychiatrist were not involved in the development of Resident #6's plan of care related to sexually aggressive behaviors. Review of the nursing note dated 01/28/20 revealed Resident #6 returned from the hospital. On 01/31/20 at 2:20 P.M., Resident #29 was observed reclined in a specialized wheelchair with a seatbelt applied and a chest harness hanging from the back of the wheelchair. The resident was placed in front of the television in the common area. On 01/31/20 at 2:21 P.M., an attempt to interview Resident #29 was unsuccessful. Resident #29 stared and made no verbal response. On 01/31/20 at 5:50 P.M., Resident #6 was observed with one-to-one supervision in place. On 01/31/20 at 6:02 P.M., Resident #6 was observed self-propelling a wheelchair around the common area towards two female residents. As Resident #6 continued toward the female residents he was redirected back to his room by staff. On 01/31/20 at 6:16 P.M., an attempt to interview Resident #6 was unsuccessful. Resident #6 stuck his tongue out and moved it around for approximately 30 seconds. He would not respond to questions. Review of the nurse notes dated 02/01/20 to 02/02/20 revealed Resident #6 continued to display sexually aggressive behavior toward staff. On 02/01/20 at 9:25 [NAME]M., interview with LPN #112 revealed she was the nurse who observed one of the times Resident #6 grabbed Resident #29's breast on 01/15/20. When Resident #6 was observed rubbing Resident #29's arm, LPN #112 and another nurse separated the residents, assessed Resident #29 and took Resident #6 to his room. Resident #29 was kept in the common area so they could keep an eye on her. Resident #6 was then observed trying to go into another confused female resident's room and he was redirected. They brought Resident #6 to the common area to keep from Resident #29. LPN #112 said Resident #6 grabbed her by the shoulder very tightly and would not let go, he held on so tight it hurt very bad but LPN #112 was able to get him to release his grip. Later, when LPN #112 was charting she looked up and saw Resident #6 had wheeled himself up to the front of Resident #29 and was rubbing her breasts. LPN #112 took Resident #6 to his room and had the STNAs put him in bed. On 02/01/20 at 11:30 [NAME]M., interview with LPN #120 revealed prior to 01/31/20 no education had been provided on how they should handle or monitor Resident #6's behaviors. LPN #120 indicated Resident #6 was sexually inappropriate with anyone he could get his hands on. On 02/01/20 at 11:45 [NAME]M., interview with STNA #146 revealed on 01/15/20 she observed Resident #6 touching Resident #29. STNA #146 was coming out of another resident's room and saw Resident #6 wheeling himself towards Resident #29 and his hand wandered up her arm and onto her breast before STNA #146 could separate them. Another STNA moved Resident #29 out of Resident 6's reach. STNA #146 said Resident #29 was non-verbal and was not able to move on her own. STNA #146 said she had heard Resident #6 yelling to Resident #37 to come into his room and Resident #6 told staff he had raped people in the past. On 02/03/20 at 8:15 [NAME]M., 10:45 [NAME]M., 11:38 [NAME]M., 2:50 P.M., 4:20 P.M. and 6:38 P.M., Resident #6 was observed with one-to-one supervision. On 02/03/20 at 8:22 [NAME]M., Resident #37 was observed sitting on her bed holding a large toddler sized stuffed animal. An attempt to interview Resident #37 was unsuccessful. Resident #37 smiled but did not say any words. On 02/03/20 at 9:15 [NAME]M. and 11:28 [NAME]M., Resident #37 was observed holding a large toddler sized stuffed animal walking laps around the facility. On 02/03/20 at 2:52 P.M., Resident #29 was observed reclined in a specialized wheelchair with a seatbelt applied, placed in front of the television in the common area. Review of the facility's undated behavior management policy revealed the facility would identify and address possible causes of behavioral symptoms including medication interactions, psychiatric or psychosocial issues then reduce or eliminate triggers of the behavior; develop a care plan with input from the interdisciplinary team (IDT) and residents; implement and document individualized goals and interventions to treat underlying causes of the behaviors to reduce and/or eliminate triggers; communicate triggers and interventions to the care giving team; monitor and document the resident's response to interventions; evaluate effectiveness of the interventions and progress toward treatment goals at the care plan meeting; review the medication regimen at least monthly with the pharmacist and notify the physician of recommendations and document response; modify and document goals and interventions as indicated with input from the IDT and resident, and notify the IDT if interventions were not effective at the care management meeting. Review of the undated Abuse Prevention, Identification, investigation and Reporting Policy revealed residents must not be subjected to abuse by anyone including other residents. The facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation was in process. This deficiency is an incidental finding as a result of the investigation of Complaint Number OH 307.

Based on staff interview, review of medical records, facility policy and procedure for behavior management and the facility Self-Reported Incident (SRI) the facility failed to ensure Resident #6 received appropriate care and treatment to meet his mental health needs and address sexually aggressive behaviors. This resulted in Immediate Jeopardy and actual harm as evidenced by a deterioration of the resident's mental wellbeing and escalation of unwanted sexually aggressive and predatory behaviors towards facility staff and residents. On 11/26/19 Resident #6 was admitted to the facility from another nursing facility due to sexually aggressive behaviors. The facility did not implement a baseline care plan regarding his mental disorder and sexually aggressive behaviors. On 11/27/19 Resident #6 lured Resident #37, who had severe cognitive impairment into his room and physically restrained the resident. After the 11/27/19 incident Resident #6 displayed sexually aggressive behavior daily including grabbing staff buttocks and breast and masturbating in front of staff. The facility did not notify the resident's physician or consult psychological services regarding the escalating behavior. On 12/07/19 and 01/14/20 Resident #6 again physically restrained Resident #37 and on 01/15/19 sexually assaulted Resident #29 by grabbing her breast. This affected one of three residents reviewed for behaviors, Resident #6. The facility census was 60. On 01/31/20 at 3:10 P.M., the Director of Nursing (DON), Social Service Designee (SSD) #107 and Clinical Nursing Officer (CNO) #170 were notified Immediate Jeopardy began on 11/27/19 at 7:00 P.M. when Resident #6, who was admitted on [DATE] with known sexually aggressive behaviors lured Resident #37, who had severe cognitive impairment into his room and physically restrained the resident at his bedside. After the 11/27/19 incident the facility did not consult with the resident's physician, psychological services, or the pharmacist regarding his medication regimen. Resident #6's behaviors were permitted to continue to escalate, he became oppositional, and sexually assaulted Resident #29 on 01/05/20 by grabbing her breasts. The Immediate Jeopardy was removed on 02/01/20 when the facility implemented the following corrective action: · On 01/31/20 at 4:00 P.M., Resident #6 was placed on one-to-one supervision. · Beginning on 01/31/20 at 8:00 P.M., the DON, Licensed Practical Nurse (LPN) #103 and LPN #112 began educating all Registered Nurses (RNs), LPNs and state tested nurse aides (STNAs) on the facility's behavior management policy, behavior tracking and documentation. All the RNs, LPNs and STNAs were educated by 02/01/20 at 5:55 P.M. · Beginning on 01/31/20 at 8:30 P.M., Human Resource Director (HRD) # 117, Dietary Manager (DM) #127, Therapy Director (TD) #179 and Housekeeping Supervisor (HKS) #171 started educating all dietary staff, activities staff, housekeeping staff, therapy staff and the maintenance director (MD) on the behavior management policy. All staff was educated by 02/01/20 at 5:30 P.M. · On 01/31/20 at 10:00 P.M., Psychiatrist #190 completed an assessment of Resident #6 and had no recommendations. · On 02/01/20 at 10:00 [NAME]M. the DON in-serviced SSD #107, LPN #103, LPN #112, TD #179, HKS #171, the Administrator, DM #127, MD #156 and Transporter #109 on the behavior management policy and Resident #6's updated plan of care. · On 02/01/20 at 11:30 [NAME]M., SSD #107, LPN #103, the DON and LPN #112 started a 30 day look back chart review for behaviors and/or significant changes for all 57 residents which was completed on 02/01/20 at 2:30 P.M. There were no additional findings. · On 02/01/20 the DON started daily audits for documentation of behaviors on the 24- hour report, completion of behavior tracking and documentation, and identification and follow up of concerns. After seven days the audits would continue weekly for three weeks and then monthly thereafter. This will be reviewed monthly in the Quality Assurance meeting. · On 02/03/20 interviews between 10:45 [NAME]M. and 3:10 P.M., with the DON, SSD #107, RN #105, LPN #129, LPN #120, STNA #146, STNA #101 and STNA #168 revealed the staff were knowledgeable on the new policies and procedures for behavior tracking, documentation and reporting, and procedure and their specific roles. Although the Immediate Jeopardy was removed on 02/01/20, the deficiency remains at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action and auditing tools. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the immediate needs care plan with the effective date of 11/26/19 and signed as completed on 12/05/19 revealed the care plan did not address his mental health or sexually aggressive behaviors. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Resident #6's nurse note dated 11/27/19 at 7:00 P.M. revealed an STNA observed Resident #6 in his bed holding onto Resident #37's wrist. The STNA called for the nurse who entered the room where Resident #6 continued to tightly grip Resident #37's wrist. When asked, Resident #6 would not release Resident #37's wrist. The nurse removed Resident 6's fingers one by one from Resident #37's wrist. Resident #6 was told to keep his hands to himself. There was no documentation indicating the physician was notified. Review of Resident #37's nurse's note dated 11/27/19 revealed Resident #37 wandered into Resident #6's room and as she approached his bed, he grabbed a hold of her right hand and arm and refused to let go. Three staff assisted to get Resident #6 to release his grasp. After staff released the grasp, Resident #37's right hand and arm had a pinkish discoloration. The note indicated staff were unable to educate Resident #37 not to wander into Resident #6's room because she did not understand. Review of the DON summary dated 11/27/19 revealed Resident #37's stuffed animal was found on Resident #6's bed when staff entered the room and Resident #6 would not let go of Resident #37. The staff were not sure how long Resident #37 had been in the room but observed her during rounds. The intervention to prevent Resident #37 from entering Resident #6's room in the future was to put a Velcro stop sign across Resident #6's door. Review of Resident #6's mood swing and behavior care plan initiated 11/29/19 revealed the resident grabbed at female staff at inappropriate places on their body, made sexual references while using vulgar language and grabbed at other residents. The interventions included attempt non-pharmacological interventions such as one-to-one conversation, redirect, change position or scenery, offer food or fluids or a diversional activity and offer counseling and/or psychological services. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and physical behavior symptoms directed towards others which could include abusing others sexually, grabbing, hitting, kicking and/or punching occurred four to six days out of the seven-day reference period. Review of Resident #6's activities of daily living (ADL) plan of care initiated 12/16/19 revealed the resident was to have two staff for all aspects of care related to his sexual aggression and behaviors toward staff. Review of the behavior note dated 12/21/19 at 9:00 P.M., revealed Resident #6 activated his call light and when the STNA responded Resident #6 made sexually inappropriate requests from the STN[NAME] The STNA informed the nurse who provided one-to-one conversation with the resident. Further review revealed at 9:30 P.M. Resident #6 put on his call light and when the STNA responded the resident went into more detail about what he wanted sexually from the STN[NAME] The STNA informed the nurse who provided one-to-one conversation with the resident. The nurse informed the resident he could not talk to the STNA like that and the resident responded, I don't care. The note indicated at 10:30 P.M. the resident continued to make inappropriate sexual requests to the STNAs and the nurse with one-to-one conversation being ineffective. There was no evidence the physician was notified. Review of the nurse note dated 12/21/19 revealed Resident #6 stopped his tube feeding to sound the pump alarm. Once staff entered the room, he asked them for sex. There was no evidence the physician was notified. Review of the behavior note dated 12/22/19 revealed Resident #6 continued to activate his call light and was requesting staff to watch him masturbate. Redirection was not effective. There was no evidence the physician was notified. Review of the nurse's note dated 12/25/19 at 9:45 P.M. revealed Resident #6 activated his call light and when the STNA entered the room the resident was holding his penis and stated, I need you to help me do this. There was no evidence the physician was notified. Review of the behavior note dated 12/25/19 at 10:43 P.M. revealed Resident #6 continued to ask STNAs to assist him with masturbation. One-to-one conversation was ineffective. There was no evidence the physician was notified. Review of the behavior note dated 12/26/19 at 5:42 [NAME]M. revealed Resident #6 continued to request the STNAs watch him masturbate. Redirection from the nurse was ineffective and the resident stated he wanted the day shift STNAs and nurses in his room because he could do whatever he wanted on day shift. Further review of the nurse's note revealed when the STNA entered the resident's room to provide morning care the resident pulled out his penis and began to masturbate indicating he wanted the STNA to watch him. There was no evidence the physician was notified. Review of nurse notes dated 12/28/19 and 12/29/19 revealed Resident #6 had attempted numerous times to grope the nurse while making inappropriate sexual comments. There was no evidence the physician was notified. Review of behavior notes revealed on 01/01/20 at 8:37 P.M., Resident #6 continued to ask the STNAs and nurses to assist and/or watch him masturbate. One-to-one conversation was ineffective. At 8:47 P.M. the resident attempted to grope the nurse during medication pass; at 10:29 P.M. the resident wanted the STNA to give him lotion and assist him with masturbation. The note indicated the resident was asked many times to stop his comments and he smiled and said, I don't have to, I can do what I want. There was no evidence the physician was notified. Review of the behavior note dated 01/02/20 at 2:41 [NAME]M. revealed Resident #6 asked for a specific STNA to come and assist him with masturbation. There was no evidence the physician was notified. Review of the nurse note dated 01/04/20 at 10:02 [NAME]M. revealed Resident #6 continued to activate his call light and when staff responded he was masturbating and asking staff to watch. There was no evidence the physician was notified. Review of the behavior note dated 01/07/20 at 10:44 P.M. revealed Resident #6 was attempting to grope an STN[NAME] One-to-one conversation was ineffective. There was no evidence the physician was notified. Review of the nurse's note dated 01/14/20 at 6:12 P.M. revealed the administrator, SSD #322 and the DON spoke with Resident #6 about using profanity and touching staff and others inappropriately. The resident agreed to stop this behavior. There was no evidence the physician was notified. Review of the behavior note dated 01/15/20 at 1:37 P.M. revealed Resident #6 grabbed at the nurse and when redirected made a fist. There was no evidence the physician was notified. Review of the SRI dated 01/15/20 at 4:45 P.M., revealed Resident #6 was observed groping Resident #29's breast on 01/15/20 at 2:45 P.M. Review of the nurse's note dated 01/15/20 at 5:10 P.M., revealed SSD #322 attempted to contact two psychiatric facilities to take Resident #6 but due to his age and payor source they would not accept the resident. The facility's in-house psychiatrist was contacted, and a return call had not been received. At 7:15 P.M. The nurse practitioner was contacted and ordered the resident sent to the emergency department for evaluation because he was an immediate threat to others. Review of the hospital psychiatrist note dated 01/16/20 revealed Resident #6 was seen for inappropriately touching females at the nursing facility and this behavior continued while at the hospital. Resident #6 expressed concerns with sadness but denied any inappropriate sexual behaviors. The resident was on the medical floor and had been diagnosed with [REDACTED]. The plan was to increase the [MEDICATION NAME] to 100 mg in the morning and 200 mg in the evening, discontinue the [MEDICATION NAME] as doses needed for the off label use of the medication was much higher than what was being given and use of the medication was contradictory if a history of or at risk for [MEDICAL CONDITION] (blood clot). Review of the hospital discharge summary dated 01/28/20 revealed the resident was sent back to the facility after recovering from a colectomy. Review of the facility readmission orders [REDACTED]. On 01/17/20 at 4:00 P.M., interview with STNA #341 revealed she observed Resident #6 trying to get Resident #37 to come into his room many times and she informed the nurse. STNA #341 indicated she had not been trained on how to handle Resident #6's sexual inappropriateness but told the nurse anytime he said or did something inappropriate. STNA #341 stated Resident #6 frequently activated his call light and when she responded the resident was masturbating and wanted her to watch him. STNA #341 indicated the previous week she had called LPN #329 to assist because Resident #6 had Resident #37 by the shirt and string of her pants and Resident #6 would not let go and kept saying she is mine. LPN #329 had to cut the strings from Resident #37's pants because they could not get Resident #6 to release his grip. On 01/17/20 at 4:20 P.M., interview with STNA #320 revealed Resident #37 wandered in and out of other rooms, even during the night she was up a lot. STNA #320 observed Resident #37 go into Resident #6's room and when STNA #320 went in to get her out he had a hold of her sleeve and would not let go but she finally got Resident #37 out of the room. STNA #320 also indicated she observed Resident #6 grab Resident #29's breast on two separate occasions on 01/15/20 and she let the nurse know. STNA #320 said Resident #6 would activate his call light and when she answered the light he was masturbating and asked her to stay and watch. STNA #320 left the room and informed the nurse many times. STNA #320 said the DON and administrator had been aware of the behaviors since the resident was admitted but nothing had been done about it. On 01/17/20 at 5:12 P.M., interview with SSD #322 revealed she was aware Resident #6 had inappropriate social boundaries including sexual notations. SSD #332 was aware Resident #37 had wandered into Resident #6's room multiple times. SSD #332 denied being aware of Resident #6 groping Resident #29's breast on 01/15/19 but indicated she was attempting to get him placed into a psychiatric unit for sexual inappropriateness. SSD #332 was not able to provide any evidence of attempts to address Resident #6's hypersexuality including lack of counseling, behavior management plans, psychiatry involvement or evidence an interdisciplinary team (IDT) approach was utilized in an attempt to provide an appropriate and effective plan of care. On 01/17/20 at 5:23 P.M., interview with the DON revealed she was told prior to admitting Resident #6 that he had sexually aggressive behaviors, was abusive towards staff, called staff inappropriate names, grabbed at their private areas and cursed at them. The DON indicated she was informed to keep something in Resident #6's hands as much as possible to prevent him from trying to grab inappropriately when anyone came near him. The DON verified she was aware the second day Resident #6 was admitted there was an incident with Resident #37. Resident #37, who was confused wandered into his room and he grabbed her and would not release his grip. The DON did not obtain witness statements related to the incident on 11/27/19. The DON put a Velcro stop sign across Resident #6's door to prevent Resident #37 from wandering into his room but did not address Resident #6's behavior. The DON was aware of Resident #6's sexually inappropriate behaviors towards staff. The DON verified Resident #6's care plan did not include keeping something in Resident #6's hands to prevent him from grabbing at staff and others. The DON verified after the 11/27/19 incident with Resident #37 another incident occurred when Resident #6 groped Resident #29's breast on 01/15/20. The DON was not able to provide any evidence of attempts to address Resident #6's mental health and hypersexuality including counseling, behavior management plans, psychiatry involvement or an IDT approach. On 01/17/20 at 5:43 P.M., phone interview with LPN #329 revealed Resident #6 had been sexually aggressive since he had been admitted , groping the staff, making sexual comments and putting on his call light wanting the staff to watch him masturbate. LPN #329 revealed on 01/14/20 she was passing medications and heard a noise and went to Resident #6's room and found him holding onto Resident #6's shirt. LPN #329 told Resident #6 to let go but he would not. LPN #329 was standing behind Resident #37 trying to remove Resident #6's hands when he grabbed the strings of Resident #37's pants and would not let go. Resident #6 kept repeating she is mine. LPN #329 stated she removed scissors from her pocket and cut off the strings to Resident #37's pants to release her from Resident #6's grip. LPN #329 was not aware of any interventions staff were to initiate related to Resident #6's sexual behaviors or mental health. On 01/17/20 at 6:25 P.M., interview with LPN #321, who completed MDS assessments and care plans, revealed an immediate care plan was not put in place for Resident #6 related to inappropriate behaviors. LPN #321 stated she was not informed Resident #6 had known sexually inappropriate behaviors prior to being admitted to the facility. LPN #321 verified the resident had behaviors including being sexually inappropriate and a care plan related to his sexual aggression was not implemented until 11/29/19. LPN #321 verified when the one-to-one intervention was determined to be ineffective the resident was not re-assessed, and the care plan was not updated. LPN #321 indicated the facility did not have a behavior monitoring/tracking system in place and the staff was not trained to deal with these behaviors. On 01/17/20 at 6:57 P.M., a follow up interview with the DON verified the facility did not reassess and implement new interventions to reduce Resident #6's sexually inappropriate behaviors. The DON verified the resident's attending physician or a psychiatrist was not involved in the development of Resident #6's plan of care related to his mental health and sexually aggressive behaviors. The DON also confirmed the facility did not have evidence the staff were properly trained to handle Resident #6's behaviors or address his mental health issues. On 01/31/20 at 5:50 P.M., Resident #6 was observed with one-to-one supervision. On 01/31/20 at 6:02 P.M., Resident #6 was observed propelling around the common area towards two female residents. As Resident #6 was approaching the female residents he was redirected to his room by staff. On 01/31/20 at 6:16 P.M., an attempt to interview Resident #6 was unsuccessful. Resident #6 stuck his tongue out and moved it around for approximately 30 seconds. He would not respond to questions. On 01/31/20 at 6:20 P.M., a follow up interview with the DON and SSD #332 revealed upon Resident #6's return from the hospital his medications had been adjusted. Resident #6's care planned interventions had not been modified other than indicating a psychiatry assessment was completed on 01/16/20 and [MEDICATION NAME] was ordered discontinued and [MEDICATION NAME] was ordered to be increased. The DON verified the [MEDICATION NAME] had not been increased as planned. The DON confirmed there was no discussion with the IDT team about trying different medications, obtaining counseling services, having the in-house psychiatrist see the resident, or implementation of a behavior management program. The facility did not attempt to address potential underlying causes of the behaviors which resulted in a deterioration in Resident #6's well-being. On 02/03/20 at 10:55 [NAME]M., interview with Pharmacist #193 revealed he did not have any clinical aspect at the facility. Pharmacist #193 stated he looked at a resident's medications related to behavior if requested by the physician but had not been asked to do so for any resident's including Resident #6. Pharmacist #193 had not completed a medication review for Resident #6. Review of the facility's undated behavior management policy revealed the facility would identify and address possible causes of behavioral symptoms including medication interactions, psychiatric or psychosocial issues then reduce or eliminate triggers of the behavior; develop a care plan with input from the IDT and residents; implement and document individualized goals and interventions to treat underlying causes of the behaviors to reduce and/or eliminate triggers; communicate triggers and interventions to the care giving team; monitor and document the resident's response to interventions; evaluate effectiveness of the interventions and progress toward treatment goals at the care plan meeting; review the medication regimen at least monthly with the pharmacist and notify the physician of recommendations and document response; modify and document goals and interventions as indicated with input from the IDT and resident, and notify the IDT if interventions were not effective at the care management meeting. This deficiency is an incidental finding as a result of the investigation of Complaint Number OH 307.