Every finding on record at Majestic Care of Columbus LLC

Based on record review, review of a facility self-reported incident (SRI) and staff and resident interviews, the facility staff failed to ensure a resident was treated with respect/dignity. The affected one (#23) out one resident reviewed for resident rights. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses include dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant, (CNA) #94 and Resident #23 had a verbal altercation in which profanity was used. The SRI further documented verbal altercation occurred at the nurses' station, where CNA #94 refused to assist Resident #23 with toileting and ostomy care and referred to the resident as a liar. CNA #94 used profanity multiple times in the resident's presence. The incident was witnessed by CNA #59, CNA #113, CNA #74 and Registered Nurse (RN) #133. During an interview on 12/03/25 at 12:15 P.M. Resident #23 confirmed that CNA #94 used profanity multiple times in front of her, though not directly to her. Resident #23 stated the incident made her feel offended at the language being used in her home. During interviews between 1:00 P.M. on 12/02/25 through 10:00 A.M. on 12/03/25 with CNA #59, CNA #113, CNA #74 and Registered Nurse (RN) #133 staff members who were present during the altercation, they all confirmed that CNA #94 was yelling and using profanity in a resident common area. The interviews all confirmed Resident #23 was present in the area during the incident. This deficiency represents non-compliance investigated under Complaint Number 2683509.

Based on record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's advanced directives matched in the paper and electronic health record. This affected one (#7) out of 26 residents in the initial sample. The facility census was 69. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/03/22. Diagnoses include Alzheimer's disease with late onset, dementia in other diseases classified elsewhere with mood disturbance, paranoid schizophrenia, and severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating severe cognitive impairment. Review of the orders for Resident #7 revealed an order that stated, FULL CODE has as Do Not Resuscitate - comfort care (DNR-CC) but POA needs to sign, remains Full Code at this time. The banner at the top of the page of the electronic health record that indicated the code status also stated the same thing. Review of the advanced directive in the paper chart revealed a signed Do Not Resuscitate (DNR) form that was signed with the Certified Nurse Practitioner's (CNP) signature and dated on 11/25/25. Additionally, the code status book at the nurses' station had the CNP-signed advanced directive stating Resident #7 was a DNR-CC. Review of the progress note dated 11/25/25 at 2:22 P.M. for Resident #7 revealed a Physician Assistant note that stated, This provider spoke to patient guardian regarding changes in code status. Approval given for code status change to DNR-CC. Paperwork completed and sent to facility for order change and document upload. Interview on 12/03/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #112 revealed the staff looked at the banner in electronic health record to determine what the code status was. Interview on 12/03/25 at 9:34 A.M. with the Director of Nursing (DON) confirmed staff looked at the banner to determine what the code status was. The DON stated she was not aware the code status book on Resident #7's floor contained the signed DNR-CC form already. The DON stated that the banner in the electronic health record is where the staff would look for the code status, but if they needed a hard copy for emergency personnel, they would look at the code status book. The DON also confirmed that the DNR-CC paperwork was placed in the electronic system. Interview on 12/03/25 at 10:42 P.M., the DON confirmed that the nurse who placed Resident #7's code status in the banner of the electronic health record was being educated and confirmed that the signed code status in electronic health record was the standing code status, and confirmed again that this did not match what the order and banner stated in electronic health record. Interview on 12/03/25 at 11:42 P.M., the DON stated Resident #7's banner in the electronic health record was changed to DNR-CC and the order was changed to match as well. Review of the facility policy titled Advanced Directives, dated 01/02/24, revealed the facility was required to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Upon admission, when a resident had an executed advance directive, copies would be made and placed on the chart as well as communicated to the staff, and the facility would not discharge or transfer a resident should they refuse treatment either through an advance directive or directly unless the criteria for transfer or discharge were otherwise met.

Based on medical record review, review of a facility self-reported incident (SRI), staff and resident interview and facility policy review, the facility failed to ensure allegations of abuse were timely reported to the State Agency. This affected one (#23) of one resident reviewed for abuse. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses include dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant, (CNA) #94 and Resident #23 had a verbal altercation in which profanity was used. The incident was witnessed by CNA #59, CNA #113, CNA #74 and Registered Nurse (RN) #133. During an interview on 12/01/25 at 4:09 P.M. Resident #23 confirmed that CNA #94 used profanity multiple times in front of her on 11/27/25. During an interview with CNA #74 on 12/03/25 at 2:16 P.M. she confirmed that she reported the incident involving CNA #94 and Resident #23 to human resources on 11/27/25. CNA #74 confirmed Regional Nurse Consultant #123 called her to discuss the incident later that morning. During an interview with Regional Nurse Consultant #123 on 12/03/2025 at 3:03 P.M. confirmed that she was the person who initiated the facility's SRI investigation involving CNA #94 and Resident #23. Regional Nurse Consultant #123 confirmed that she was informed about the incident on 11/27/25. Regional Nurse Consultant #123 states she did not open the SRI until 11/30 because that was her first day back in the office following the incident. Regional Nurse Consultant #123 confirmed the SRI involving CNS #92 and Resident #23 was not timely reported to the State Agency. Review of the facility's policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation effective 07/01/25 revealed if any form of abuse is alleged, the administrator or a designee must notify the Department of Health not later than two hours after the allegation is made.

Based on medical record review, review of a facility self-reported incident (SRI), review of a facility investigation, staff interview and facility policy review, the facility failed to ensure a thorough investigation was completed following a potential abuse incident. This affected one (#23) of four residents reviewed for abuse. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant, (CNA) #94 and Resident #23 had a verbal altercation in which profanity was used. The incident was witnessed by CNA #59, CNA #113, CNA #74 and Registered Nurse (RN) #133. Review of the facility investigation documentation pertaining to the alleged verbal abuse incident did not contain a statement from CNA #113. During an interview with CNA #113 on 12/02/2025 at 1:29 P.M. confirmed she did not witness the alleged incident between CNA #94 and Resident #23. During an interview with Regional Nurse Consultant #123 on 12/03/2025 at 3:03 P.M. confirmed that she was the person who initiated the facility's SRI and completed the investigation involving the incident between CNA #94 and Resident #23. Regional Nurse Consultant #123 confirmed that she did not obtain a statement from CNA #113. Review of the facility's policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation effective 07/01/25 revealed the person investigating the incident should interview anyone who witnessed of heard the incident.

Based on record review, review of resident funds, and interview, the facility failed to notify each resident, who received Medicaid benefits, when the amount in the resident's account reached $200 less than the Social Security Income resource limit for one person. This affected two residents (#6 and #48) out of four residents reviewed for personal funds. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 12/09/18. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type two diabetes, chronic combined systolic and diastolic heart failure, vascular dementia, hypothyroidism, schizoaffective disorder bipolar type, bipolar disorder, hyperlipidemia, chronic pulmonary edema, spinal stenosis, anxiety disorder, chronic respiratory failure, blindness left eye category four, muscle weakness, major depressive disorder, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired. Review of the plan of care dated 04/10/25 revealed Resident #6 had a communication problem related to cognitive deficit, cognitive deficits demonstrated by decreased safety awareness, impaired decision making, self-care deficit, and short and long term memory deficits. Review of Resident #6's Resident Statement Landscape revealed the residents funds were within $200 of the Social Security Income resource limit during the months of February 2025, March 2025, April 2025, May 2025, and June 2025. There was no documented evidence of a notification to the resident and/or their representative regarding the funds balance. Interview on 06/12/25 at 11:25 A.M. with Business Office Manager #192 confirmed that notifications of being within the $200 dollars of the Social Security Income resource limit were not sent to Resident #6 or their representative for the months of February 2025, March 2025, April 2025, May 2025, and June 2025. 2. Review of the medical record for Resident #48 revealed an admission date of 09/12/19. Diagnoses included anxiety disorder, bilateral primary osteoarthritis of knee, sleep disorder, irritable bowel syndrome, chronic obstructive pulmonary disease, hypertension, major depressive disorder, myopia, presbyopia, tobacco use, difficulty walking, and chronic or unspecified gastric ulcer with perforation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. Review of Resident #48's Resident Statement Landscape revealed the residents funds were within $200 of the Social Security Income resource limit during the months of March 2025, April 2025, and May 2025. There was no documented evidence of a notification to the resident and/or their representative regarding the funds balance. Interview on 06/12/25 at 11:25 A.M. with Business Office Manager #192 confirmed that notifications of being within the $200 dollars of the Social Security Income resource limit were not sent to Resident #48 or their representative for the months of March 2025, April 2025, and May 2025.

Based on observation, record review, and interview, the facility failed to ensure appropriate care and services were provided, including dignity and proper technique, during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/29/25 with diagnoses of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 01/30/25 revealed Resident #29 was at risk for infection/complications related to the use of a suprapubic catheter with the diagnosis of obstructive uropathy. Interventions included to document catheter output every shift, anchor the catheter to gravity drainage as ordered, catheter/peri-care at least every shift and as needed, and educate resident on risks of infection and safe practices. Review of Resident #29's physician orders dated 02/03/25 revealed orders to cleanse the supra-pubic site every shift with soap and water and cover with split gauze. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact, was dependent on staff for toileting, required an indwelling catheter for urinary needs and was incontinent of bowel. Observation on 06/12/25 at 7:50 A.M., Certified Nursing Assistant (CNA) #161 was observed performing catheter care for Resident #29, assisted by Assistant Director of Nursing (ADON) #135 and Registered Nurse (RN) #136. CNA #161 began by explaining the procedure to the resident. She prepared two containers, one with soapy water and one with rinse water, which were placed on the right side of the table with assistance from ADON #135. In addition, washcloths and bath towels were available for usage. The resident was positioned flat in a Trendelenburg position. CNA #161 asked to remove the resident's pants and rolled the resident from side to side, leaving the residents brief around the knees and fully exposing the resident throughout the procedure. CNA #161 cleansed the catheter insertion site using a washcloth dipped in soapy water. While cleaning, she held the catheter approximately three inches below the insertion point, causing tension on the catheter tubing. Approximately three cleansing passes were completed. The same cleaning process was repeated using rinse water. Interview on 06/11/25 at 11:55 A.M. with the Assistant Director of Nursing (ADON) #135 confirmed proper technique for securing the catheter during cleansing included securing the line at the insertion point and wiping from the insertion site outward. ADON #135 confirmed proper technique was not preformed during supra-pubic catheter care. She further confirmed that the resident should have been covered during catheter care to maintain dignity. Interview on 06/12/25 at 9:39 A.M. CNA #161 confirmed she was taught to secure the catheter at the top and to wipe downward during catheter care. Additionally, CNA #161 stated that Resident #29 should have been kept covered except during the actual peri-care, to maintain dignity. Interview 06/12/25 at 9:42 A.M. with Registered Nurse (RN) #136 confirmed the catheter was not properly secured during cleaning, resulting in tugging on the catheter tubing. Additionally, RN #136 observed the resident was not covered while catheter care was being completed.

Based on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure pressure reducing devices were in place as ordered. This affected one (Resident #61) of three residents reviewed for pressure ulcers. The census was 75. Findings Include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. His diagnoses were cerebral atherosclerosis, bipolar disorder, benign prostatic hyperplasia, dementia, moderate protein calorie malnutrition, hypertension, delusional disorder, anxiety disorder, insomnia, depression, violent behavior, psychosis, visual hallucinations, and Parkinsonism. The record revealed the resident did not have any active wounds. Review of Resident #61's Minimum Data Set (MDS) assessment, dated 03/05/25, revealed he was cognitively intact. Review of Resident #61's care plan dated 06/03/25 revealed a care area related to refusal of care and skin breakdown. The care plan stated he would refuse to allow preventative boots and float heels at times. Review of Resident #61 physician orders, dated 06/09/25, revealed he was to have bilateral heel protectors when in bed for wound prevention. Review of Resident #61's behavior logs, dated June 2025, revealed no documentation of refusal of care, especially no documented refusals of putting on his offloading boots. Review of Resident #61's Treatment Administration Record (TAR), dated June 2025, revealed documentation to support his offloading boots were in place twice daily from 06/09/25 to 06/11/25, and during the morning shift of 06/12/25. Observation on 06/09/25 at 1:57 P.M. revealed Resident #61 was awake, lying in bed, and only had his right offloading boot on. His left foot/heel did not have a boot on it and it was not offloaded in any manner. Observation on 06/11/25 at 2:45 P.M. revealed Resident #61 lying in bed asleep. He had a pillow underneath his calves, which offloaded his heels, but he did not have any offloading boots on either feet. Observation on 06/12/25 at 9:30 A.M. and 11:05 A.M. revealed he was transferred from his bed to his wheelchair. Then he was seen in the dining room, sitting in his wheelchair. At no point did he have his offloading boots on his feet. Interview with Certified Nursing Aide (CNA) #300 on 06/12/25 at 11:06 A.M. stated the aides did not document whether the resident refused care/treatments or not, they would report it to the nurse, and the nurse would document it. She confirmed Resident #61 did not wear his boots today (06/12/25), even while he was in bed. She confirmed she did not know why it would be documented in his medical record that his boots were on. Interview with Registered Nurse (RN) #138 on 06/12/25 at 11:13 A.M. stated they would document twice daily in the medical record as to whether a resident had completed their tasks/treatments or used a device as ordered. She confirmed they had documented Resident #61 was using his offloading boots, but confirmed he was in his wheelchair and in therapy during that morning, which he wouldn't use his boots during those times. She confirmed she documented the order was completed without verifying it was. She confirmed if the resident refused his offloading boots, they would document that in the behavior logs. Review of the facility Wound Management policy, dated 05/30/24, revealed it is the policy of the facility that those residents with impaired skin integrity are recognized by the care team, treated timely, and interventions to heal are not exhausted until the skin is healed. The facility will have a system in place to identify impaired skin integrity development early to prevent further damage and treat the condition as soon as it's identified.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/29/25 with diagnoses of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 01/30/25 revealed Resident #29 was at risk for infection/complications related to the use of a suprapubic catheter with the diagnosis of obstructive uropathy. Interventions included to document catheter output every shift, anchor the catheter to gravity drainage as ordered, catheter/peri-care at least every shift and as needed, and educate resident on risks of infection and safe practices. Review of Resident #29's physician orders dated 02/03/25 revealed orders to cleanse the supra-pubic site every shift with soap and water and cover with split gauze. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact, was dependent on staff for toileting, required an indwelling catheter for urinary needs and was incontinent of bowel. Observation on 06/12/25 at 7:50 A.M., Certified Nursing Assistant (CNA) #161 was observed performing catheter care for Resident #29, assisted by Assistant Director of Nursing (ADON) #135 and Registered Nurse (RN) #136. CNA #161 began by explaining the procedure to the resident and performing hand hygiene. She prepared two containers, one with soapy water and one with rinse water, which were placed on the right side of the table with assistance from ADON #135. In addition, washcloths and bath towels were available for usage. The resident was positioned flat in a Trendelenburg position. CNA #161 asked to remove the resident's pants and rolled the resident from side to side, leaving the residents brief around the knees and fully exposing the resident throughout the procedure. CNA #161 cleansed the catheter insertion site using a washcloth dipped in soapy water. While cleaning, she held the catheter approximately three inches below the insertion point, causing tension on the catheter tubing. Approximately three cleansing passes were completed. The soiled washcloth was then placed back into the container of clean soapy water. The same cleaning process was repeated using rinse water, and the used rinse cloth was disposed of in a trash bag located at the foot of the bed. CNA #161 then retrieved the previously used washcloth that had been left in the soapy water basin and disposed of it in the trash bag. However, she did not replace the soapy water. Instead, she continued catheter care using a clean washcloth dipped into the now-contaminated soapy water and proceeded to cleanse the area around the catheter site. After catheter care was completed, the resident was covered with his own bed blanket which was noted with numerous hairs on it. CNA #161 and ADON #135 obtained fresh water in preparation for perineal care. CNA #161 then uncovered the resident, cleansed the perineal area with a soapy washcloth, and placed the soiled cloth into the clean soapy water basin. She completed a final cleanse using a clean washcloth dipped in rinse water, disposing the cloth in the trash bag at the foot of the bed. CNA #161 then grabbed the washcloth from the soapy water bin and placed it into the trash bag and the resident was re-gowned. Interview on 06/11/25 at 11:55 A.M. with the Assistant Director of Nursing (ADON) #135 confirmed staff should not place soiled washcloths back into the clean wash basin, stating that once used, these cloths should have been placed into soiled laundry or waste containers. Interview on 06/12/25 at 9:39 A.M. CNA #161 acknowledged that she was not supposed to place a soiled washcloth back into the container of clean water, but could not recall whether she did so during this procedure. Interview 06/12/25 at 9:42 A.M. with Registered Nurse (RN) #136 confirmed she observed CNA #161 placed the soiled washcloth into the bucket containing clean soapy water, contaminating the water used for further cleansing of the catheter and insertion site.

2. Review of Resident #59's medical record revealed an admission date of 01/17/25 with diagnoses including bipolar disorder, emphysema, fusion of cervical spine, spinal stenosis, other chronic pain, lumbago with sciatica, and type two diabetes mellitus, Review of Resident #59's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and the resident received scheduled and as needed pain medications. Review of Resident #59's physician order dated 05/19/25 revealed an order for Percocet Oral tablet 325 milligrams (mg) one tablet by mouth every six hours as needed for pain. Review of Resident #59's plan of care revised 06/10/25 revealed the resident had pain related to sciatica pain radiating to legs and a chronic pain diagnosis. Interventions included administering medication as ordered, notifying the physician of unrelieved pain, observing for side effects of pain medications, observing for symptoms of non-verbal pain, offering nonpharmacological interventions, and reporting to the nurse any changes in usual activity. Review of Resident #59's Medication Administration Record (MAR) from 06/01/25 to 06/09/25 revealed Percocet was administered three times on 06/01/25 and 06/02/25, and administered twice on 06/03/25 through 06/09/25. On 06/05/25 Percocet was administered two times for a pain scale of zero out of ten, ten being the worst. Review of Resident #59's progress notes revealed nonpharmacological interventions were not attempted and descriptions of pain were not given for one administration on 06/01/25, one administration on 06/03/25, two administrations on 06/05/25, one administration on 06/07/25, and two administrations on 06/08/25. Nonpharmacological interventions were not documented for one administration on 06/02/25, one administration on 06/03/25, one administration on 06/04/25, two administrations on 06/06/25, and one administration on 06/07/25. Interview on 06/10/25 at 2:28 P.M. with the Director of Nursing (DON) revealed that 'as needed' pain medications should not be given for a pain level of zero. She stated with every administration they should be documenting nonpharmacological interventions and a description of the pain. Review of the policy titled 'Pain Management' revealed documentation of the administration of ordered 'as needed' pain medication were to be initialed in the electronic medication administration record. Additional information including, but not limited to, reasons for administration, and effectiveness of pain medication were to be documented in the medical record. Based on observation, interview, record review, and review of facility policy, the facility failed to establish a pain goal regimen and document effectiveness of pain medication administration for Resident #25. Additionally, the facility failed to administer and document nonpharmacological pain interventions for Resident #59's as-needed pain medication orders. This affected two residents (#25 and #59) of five residents reviewed for unnecessary medications. The facility census was 75. Findings include: Review of the medical record for Resident #26 revealed an initial admission date of 04/17/14. Medical diagnoses included schizoaffective disorder- bipolar type, diabetes mellitus (DM) type two with diabetic polyneuropathy, hypertensive heart disease with heart failure, irritable bowel syndrome, and chronic pain syndrome. Review of Resident #26's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition, no impairment of range of motion, utilized a walker, and required set-up assistance or supervision for self-care and mobility. Review of Resident #26's physician order dated 02/22/24 revealed an order for Oxycodone oral capsule 5 milligrams (mg) with instructions to give one capsule by mouth two times a day for pain, Lidocaine External Patch 4 percent (%) with instructions to apply it to the lower back topically one time a day, Gabapentin 100 mg with instructions to administer one capsule by mouth two times a day for pain, and Acetaminophen 500 mg with instructions to administer one tablet by mouth every eight hours as needed for mild to moderate pain. Review of Resident #26's care plan dated 03/07/19 addressed chronic pain in bilateral lower extremities (BLE) with a goal that the resident would not have discomfort related to side effects of analgesia through the review date. Interventions included administer analgesic medications per orders, evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability and impact on cognition. The care plan dated 02/19/24 revealed the resident was at risk for pain due to depression and DM with the goal that resident will verbalize adequate pain relief. Interventions included notifying the medical doctor (MD) of unrelieved or worsening pain, and therapy to screen quarterly and as needed. Review of Resident #26's last quarterly pain evaluation dated 04/07/25 revealed Resident #26 had pain in the last five days and rated the frequency of the pain as occasionally. Review of Resident #26's Medication Administration Record (MAR) from 01/01/25 through 06/12/25 revealed Oxycodone was administered as ordered and a pain level rating for each administration was also documented; However, there was no evaluation of the effectiveness of the medication after administration. Interview with Resident #26 on 06/12/25 at 11:12 A.M. reported persistent back and hip pain, stating the 5 mg Oxycodone was ineffective. She stated she used therapy techniques such as riding a stationary bike and using her rollator helped with reduction of the pain and she utilized the occasional PRN (as needed) medications during the morning and evening, but she did not consistently notify nursing staff of the ineffective pain management or note a significant concern with her prescribed regimen. Interview with Unit Manager (UM) #197 on 06/12/25 at 11:36 A.M. stated that scheduled pain medication effectiveness was evaluated on the quarterly pain assessment reviews, and she confirmed the pain medication effectiveness was not evaluated after administration of the pain medication. UM #197 stated that staff relied on the residents to tell them if their scheduled pain medications were effective or not. UM #197 stated that if a resident reported continued pain with a scheduled pain medication regimen that staff would conduct a pain assessment and notify the provider. Interview with the Director of Nursing (DON) on 06/12/25 at 1:35 P.M. confirmed the facility did not have a pain rating goal for Resident #26 related to what an acceptable level of pain was. Review of the facility policy titled Pain Management dated January 2020 stated the reasons for administration and effectiveness of pain medication will be documented in the electronic medical record. The licensed nurse will monitor the efficacy of the medication and notify the physician as needed.

Based on medical record review, hospital record review, review of the facility's incident/accident investigation, staff interview, and policy review the facility failed to develop and implement a comprehensive, individualized and effective fall management program to prevent a fall with injury for Resident #1. Actual harm occurred on 12/01/24 at approximately 12:55 P.M. when Resident #1, who had a diagnosis of dementia, fall risk with history of falls, increased lethargy and confusion sustained an avoidable unwitnessed fall out of bed resulting in head trauma/head hematoma which required hospital treatment. Prior to this fall, the resident sustained an unwitnessed fall out of bed on 12/01/24 at 1:30 A.M. with no evidence the facility implemented timely, adequate and effective interventions/measures to prevent the additional fall with injury on the same date. The resident was hospitalized until 12/09/24. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, epilepsy, dementia, atherosclerotic heart disease, anxiety disorder, presence of a urostomy and colostomy, major depressive disorder, cardiac arrhythmia, sick sinus syndrome, bipolar disorder, and presence of cardiac pacemaker. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 (out of 15). The MDS revealed Resident #1 had no impairment of range of motion to the upper extremities but had impairment of her lower extremities bilaterally and used a wheelchair. Review of the care plan dated 03/24/21 (and updated 12/04/24) revealed Resident #1 was at risk for falls with a history of falls. Falls interventions documented on the care plan included color tape applied to the call light to remind Resident #1 to call for help, declutter pathway in room, digital clock in room in line of site, use a self-releasing seatbelt when in the wheelchair, use of non-skid footwear, non-skid strips in front of the sink, bilateral falls mats, Dycem to wheelchair and encourage use of hipsters. Record review revealed the resident also had a plan of care related to non-compliance with an intervention to educate the resident to notify staff and ask for assistance when changing an ostomy bag. Review of a progress note revealed on 12/01/24 at 1:30 A.M. Resident #1 had an unwitnessed fall. Resident #1 was found lying beside her bed. Resident #1 stated she fell trying to change her colostomy bag. The root cause was determined to be resident the resident was known to be resistant to assistance with colostomy/urostomy bags. Current interventions in place included Dycem, skid strips, color tape to call light, signs as visual cues, and bilateral falls mats were all in place at the time of the fall. Interventions added after the fall included sign placed in room specifically reminding resident to call for assistance for cleaning area or providing direct care. Review of the Incident/Accident Investigation form dated 12/01/24 at 1:30 A.M. filled out by Registered Nurse (RN) #400 revealed Resident #1 had an unobserved fall. The resident's call bell was documented to be in reach and was not activated, personal items were in reach, the bed was locked in the lowest position, bilateral floor mats were documented as in place, the floor was not wet, there was proper lighting, and assistive devices were in reach of Resident #1. Resident #1 was described as following usual routine with the comment non-compliant with the process up to change the colostomy bag. Immediate intervention listed was to keep the door open and to do every 15-minute checks until Resident #1 gets up in the morning. However, the medical record (progress note) contained no evidence 15- minute checks were completed throughout the night until the resident awoke. Post fall neurological checks were completed on 12/01/24 at 1:30 A.M., 1:45 A.M., 2:00 A.M., 2:15 A.M., 2:45 A.M., 3:15 A.M., 3:45 A.M., 4:15 A.M., 5:15 A.M., and 6:15 A.M. that were documented as normal where Resident #1 was fully conscious, moves all four extremities, grasp were equal, pupil size was equal and reactive (brisk), and the resident was documented to have had slurred speech. Follow up neurological check done at 7:15 A.M. by LPN #407 revealed all elements were the same except level of consciousness had changed to lethargic. The next neurological check completed at 11:15 A.M. again reflected the same change in the level of consciousness to now reflect the resident was lethargic. There were no additional assessments or progress note follow up to address or explain Resident #1's documented change in level of consciousness. In addition, there was no evidence of changes to the resident's supervisory and/or fall interventions as a result of the identified lethargy on the neurological assessments. The resident's plan of care was updated following the fall on 12/01/24 at 1:30 A.M. with an intervention that signs were placed in Resident #1's room to remind her to call for assistance when getting up. A progress note dated 12/01/24 at 12:10 P.M. revealed Licensed Practical Nurse (LPN) #451 noted the resident was not acting like her normal self. Resident #1's speech was slurred. Resident #1 was very lethargic and seemed confused. LPN #451 contacted the nurse practitioner (CNP) and received new orders for laboratory test of complete blood count, comprehensive metabolic panel, hepatic panel, thyroid stimulating hormone, and a chest x-ray. Resident#1's representative was made aware. However, there were no new fall risk/safety interventions implemented at this time. A progress note dated 12/01/24 at 12:55 P.M. revealed Resident #1 had another unwitnessed fall. Resident #1 was found lying beside her bed. The resident stated she was trying to get up but was unable to answer why. Resident #1 stated she was not in pain but was noted to have a large knot on the back of her head that was bleeding. The CNP was notified, and an order was received to transfer Resident #1 to the hospital for evaluation. The resident representative was notified of fall and transfer to hospital. Review of the hospital after visit summary with a visit date from 12/01/24 to 12/09/24 documented Resident #1's had a hospitalization with diagnoses of hematoma and head trauma. On 01/09/25 at 3:21 P.M. interview with the Director of Nursing (DON) revealed Resident #1 was care planned to request for staff assistance and staff continued to encourage the resident to request help. The DON confirmed Resident #1 had signs in the room to remind the resident to ask for help as a visual cue, and the resident was receiving therapy services to improve strength in her lower extremities to aid in her goal of independence. The DON revealed neurological checks were documented on a form that was included as part of the fall investigation and not in the electronic medical record, and none of the post fall assessment of neurological checks were included in the resident progress notes. The DON verified Resident #1 had a change in her neurological check completed on 12/01/24 at 7:15 A.M. when the resident was documented to be lethargic and the there was no additional neurological checks completed, or assessment of Resident #1 completed until the next routine schedule post fall neurological check at 11:15 A.M. The DON confirmed Resident #1 had progress notes included as part of the medical record dated 12/01/24 at 1:30 A.M. when the resident fell , at 12/01/24 at 12:10 P.M. when the facility notified the practitioner of the change in condition and on 12/01/24 at 12:55 P.M. when the resident had an additional fall which resulted in a hematoma, and head trauma and the need for the resident to have further treatment at the hospital. No other progress notes were part of the medical record on 12/01/24. Review of facility policy titled Fall Prevention dated 01/02/24 revealed each resident's risk factors and environment hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. When a resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as needed, and document all assessments.

Based on observations, staff interviews, and record review the facility failed to ensure safe and sanitary storage of food and drink items in the kitchen to prevent contamination and/or spoilage. This had the potential to affect all 74 of 74 residents residing in the facility. Findings include Observation on [DATE] at 10:06 A.M. of Resident #68 revealed he had consumed chocolate milk from his breakfast tray that had a dated use by [DATE]. Observations on [DATE] beginning at 12:20 P.M. in the facility kitchen revealed the following: In the freezer there was a serving of what appeared to be fish that was unlabeled and undated, green beans were open and undated, chicken fingers were open and undated and chocolate chip cookie dough was open to air and undated. In the refrigerator there were jars of mustard and Worcestershire sauce which were undated as well as an unknown brown juice that was undated. A plastic container with cinnamon apples was undated. A large open bag of baby carrots was found to have a use by date of [DATE]. There were 14 chocolate milk containers in the walk in refrigerator that were left from breakfast service (on [DATE]) that were expired with a use by date of [DATE] and [DATE] and over 60 additional chocolate milk containers also expired with a use by date of [DATE] and [DATE]. Interview on [DATE] at 12:30 P.M. with Kitchen Manager (KM) #500 confirmed all food should be dated when the items were opened and marked with a use by date. Food should be discarded after the used by date had past. KM #500 confirmed all findings related to food being uncovered, undated and expired. He also confirmed the milk which was past the use by date from the walk in refrigerator was put out for service at breakfast on this date. Interview on [DATE] at 5:06 P.M. with Regional Kitchen Manager (RKM) #505 revealed she reviewed and audited the milk and discarded all expired milk. RKM #505 confirmed food should be dated after opening and expired milk should not be served. Observation on [DATE] at 11:25 A.M. revealed eight Trix yogurts were on trays for tray line service for the lunch meal. All eight were found to have a use by expiration date of [DATE]. Interview on [DATE] at 11:55 A.M. with Regional Kitchen Manager #505 confirmed the yogurt had a expiration use by date of [DATE]. Regional Kitchen Manager #505 stated staff checked the order and the yogurt was delivered on [DATE] and stated staff should have more than four days to serve food items. Review of the facility provided resident diet list revealed all residents in the facility received meal trays from the kitchen. There were no residents identified with an allergy to dairy or milk, or who had a dietary preference to not receive milk, yogurt or carrots. Review of facility policy titled, Cold Foods, dated ,d+[DATE] revealed food shall be stored in wrapped or covered containers, labeled and dated.

Based on observations, staff interviews, residents interviews, and record review, facility failed to ensure residents' personal funds were available in a timely manner. This affected one resident (#7) and had the potential to affect 68 additional residents (#1, #2, #3, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #46, #47, #48, #49, #50, #51, #52, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #69, #70, #72, #73, #74, #76, #77, #130, #180, and #182) identified to have personal fund accounts with the facility. The facility census was 74. Findings include Interview on 01/06/25 at 3:12 P.M. with Resident #7 revealed a concern related to accessing money from his personal fund account maintained by the facility. The resident shared he had tried to get money ($30.00) from his account, was told he could only get $10.00 for now and that he would need to come back for the remaining $20.00. Observations from 01/06/25 at 3:15 P.M. to 4:00 P.M. revealed Licensed Practical Nurse (LPN) #425 and Certified Nursing Aide (CNA) #416 were informed by Resident #7 that he wanted more money from his fund account. Resident#7 informed the LPN and CNA he went to the front desk and was told he would need to come back later for the rest. Interview on 01/07/25 at 9:30 A.M. with Resident #7 revealed he still had not received the additional $20.00 he requested from his resident fund account. Interviews and observation on 01/08/25 at 4:13 P.M. with Receptionist #432 and Business Office Manager (BOM) #445 revealed they had $38.00 plus coins in the resident fund box at the front desk. The Receptionist and BOM revealed they try to keep $1,000.00 in the fund box at all times and acknowledged sometimes it would get lower after residents get their money at the beginning of the month but stated staff could go to the bank to re-supply the fund box. The BOM revealed the facility had a staff member at the bank during this interview who was getting money to resupply the fund box. The BOM and Receptionist revealed residents should be able to get $50.00 each day from their account balance and facility should maintain funds for residents to obtain their balances timely upon request. The BOM revealed Resident #7 was provided the additional $20.00 this date (01/08/25) and acknowledged it was over 48 hours after the request for $20.00 was made by the resident. Interview and observation on 01/09/25 at 10:00 A.M. with Receptionist #465 revealed the resident fund box at the front desk had $33.00 in it. Receptionist #465 revealed facility had $38.00 dollars at the start of her shift. She revealed at times she had to tell residents they do not have enough money available to honor their request and they would need to come back later or the next day. Review of the withdrawals from the facility fund box from 01/06/25 to 01/08/25 revealed on 01/06/25 $50.00 was withdrawn, on 01/07/25 $325.00 was withdrawn, and on 01/08/25 $175.00 was withdrawn. Review of facility policy titled, Resident/Patient Account Funds Withdrawal, dated 11/01/24 revealed request withdrawals $50.00 or less shall be dispersed in cash. The facility shall maintain a system of resident funds for withdrawal.

Based on record review and interview, the facility failed to ensure arbitration agreements were thoroughly explained in a language the resident/representative could understand and also failed to ensure all required components and information was included in the context of the agreement. This affected three residents (#25, #27 and #55) and had the potential to affect 23 additional residents (#19, #30, #32, #46, #55, #60, #61, #66, #70, #74, #75, #76, #77, #78, #79, #130, #180, #181, #182, #183, #184, #185, and #186) who were admitted to the facility since 08/05/24. The facility census was 74. Findings include Interview on 01/06/25 at 11:33 A.M. with the Administrator during the biannual survey entrance conference revealed the facility did not have arbitration agreements and did not have any residents that had signed an arbitration agreement. Review of the admission agreement revealed an appendices Q for optional arbitration agreements without any appendix Q provided. Interview on 01/07/25 at 1:40 P.M. with Admissions #414 revealed the facility had no arbitration agreements and Admissions #414 reported the of the facility no longer did them. She confirmed it was in the table of contents of the admission agreement and stated the forms were no longer provided for resident review, but acknowledged agreements already made/signed shall be held in place and honored, and resident would be required to follow it. Review of the arbitration agreement revealed no language stating the agreement was not required and not a condition of admission. Interviews on 01/07/25 from 3:00 P.M. to 6:25 P.M. with the Administrator revealed Admissions #414 did not explain the arbitration agreements and just provided the document for the resident/family to review. The Administrator also revealed the facility had some misunderstandings on what was going on with documents as no staff could definitively state the arbitration process at the facility. The Administrator verified and acknowledged the arbitration agreement documents should be thoroughly explained. The Administrator confirmed specific language should be included in the agreement per the regulation including the agreement was not required and was not a condition of admission. Interview on 01/08/25 at 8:39 A.M. with the Administrator revealed facility was reviewing the arbitration agreements at a corporate level on this date. The Administrator revealed she had identified concerns with the agreement, but it had not been a priority from corporate and the corporate attorney to address any changes until the survey identified concerns. Interviews on 01/08/25 from 1:02 P.M. to 1:35 P.M. with Resident #25, #27, and #55 revealed none of the residents were familiar with the arbitration agreement and could not recall if they were provided or signed an arbitration agreement upon admission.

Based on observation, record review, policy review and interview, the facility failed to provide Resident #13 necessary supervision as per the resident's plan of care to ensure the resident maintained good nutrition and decreased risk of choking during meals. This affected one resident (#13) of three residents reviewed for nutrition. The facility census was 74. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including Type 2 diabetes mellitus with mild nonproliferation diabetic retinopathy and macular edema bilateral, epilepsy without status epilepticus, schizoaffective disorder bipolar type, major depressive disorder, chronic obstructive pulmonary disease, vascular dementia with agitation, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Alzheimer's disease with early onset, hypothyroidism, age-related nuclear cataract, bilateral myopia, bilateral unspecified sequelae of cerebral infarction, other sleep disorders, hypo-osmolality and hyponatremia ataxia following cerebral infarction; iron deficiency anemia, hypotension, unspecified, hyperlipidemia, unspecified; tobacco use, other drug-induced secondary parkinsonism; history of falling; mental disorder not otherwise specified, tachycardia, and long-term (current) use of insulin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment created on [DATE] revealed Resident #13 had a brief interview for mental status (BIMS) score of 12 indicating the resident was cognitively impaired. Resident #13 had impaired mobility and required supervision for eating. Review of the progress notes revealed on [DATE] at 6:13 P.M. the resident was in the main dining room when staff noted she was coughing/choking on her food and the nurse was called. When the nurse arrived the Heimlich was preformed and Resident #13 became unresponsive and had no pulse. Cardiopulmonary Resuscitation (CPR) was initiated until the paramedics arrived and transported the resident to the hospital. Speech therapy was ordered to conduct an evaluation when returning to the facility. Review of the care plan for Resident #13 revealed a focus on the resident eating quickly initiated on [DATE] with an intervention the resident was to eat only with supervision. Review of the dietician evaluation dated [DATE] revealed the resident could eat independently, but needed extensive supervision. Interview on [DATE] at 11:46 A.M. with the resident revealed she was switched to a mechanical soft diet due to choking and stated she hates the food and does not eat it. Interview on [DATE] at 9:41 A.M. with the speech therapist revealed she evaluated Resident #13 after her hospitalization after she choked. The hospital stated it was a behavior eating too quickly leading to choking. She stated she knows Resident #13 does not like the mechanical soft diet and the goal was to upgrade the resident to a regular diet once they figure out alternative interventions. She stated for breakfast that morning she supervised Resident #13 for breakfast with a regular diet and the resident was still eating too fast. Interview on [DATE] at 9:45 A.M. with Resident #13 revealed the speech therapist was in the room that morning but stated they did not explain their plan with the mechanical soft diet. Resident #13 stated she always eats on her own unsupervised either in her room or in the dining room. Resident #13 revealed at times she does not eat at all due to the mechanical soft diet. Observation on [DATE] from 12:11 P.M. revealed the food tray being passed out to Resident #13 for lunch. Resident #13 was observed eating on her own in her room with no staff present or with no assistance from staff. Interview on [DATE] at 12:42 P.M. with Resident #13, Resident #7 (roommate), and Resident #25 (roommate) confirmed no staff had come into their shared room to supervise/assist Resident #13 while eating. Additionally, Licensed Practical Nurse (LPN) #406 confirmed Resident #13 ate 50% of her lunch meal with no staff present to provide the needed supervision. Interview on [DATE] at 1:50 P.M. with the Interim Director of Nursing (IDON) and Registered Nurse (RN) #410 confirmed Resident #13 should be supervised while eating during every meal. Review of the meal supervision and assistance policy revealed the facility will utilize a systemic approach to ensure safety throughout the residents environment and among staff. Additionally, the facility would develop and implement an individualized care plan based on the resident assessment instrument (RAI) to address the residents needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time.

Based on record review and staff interview, the facility failed timely identify and treat urinary tract infections (UTIs) for Resident #72 and Resident #59. This affected two residents (#72 and #59) of two residents reviewed for UTIs. The facility census was 74. Findings include: 1. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), acute embolism and thrombosis of unspecified deep veins of the lower extremities (bilateral), chronic pulmonary embolism, diverticulosis of the intestine without perforation or abscess, hydrocele, nutritional anemia, essential hypertension, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms, unspecified anemia, urinary tract infection, disorders of the left external ear, age-related cataract in the left eye, enophthalmos due to trauma or surgery in the right eye, other diseases of the pharynx, dysuria, hypo-osmolality and hyponatremia, other pulmonary embolism with acute cor pulmonale, atrophy of the globe in the right eye, aspiration risk, kidney calculus, and a personal history of transient ischemic attack (TIA) without residual deficits. Review of the entry Minimum Data Set (MDS) 3.0 assessment revealed Resident #72 was cognitively intact. Review of the progress notes revealed on 11/07/24 at 6:07 A.M. Resident #72's foley catheter was leaking and the urine draining was cloudy and pale yellow. At 7:22 A.M. the primary care provider ordered a urine analysis (UA) and culture and sensitivity (C&S). At 7:12 P.M. Resident #72 had blood in his urine and the Certified Nurse Practitioner's (CNP) instructions were to send the resident to the hospital if the bleeding persists. On 11/08/24 at 8:34 A.M. the CNP was notified of the abnormal UA and was awaiting the C&S. This C&S was reported on 11/09/24 as contaminated and to contact the laboratory within 48 hours. No additional documentation was provided in the medical record related to practitioner notification, resident assessment or actions taken by the facility related to the test not being completed. Review of the progress notes revealed on 11/19/24 at 7:30 A.M. new orders for a UA and C&S were submitted. Two days later on 11/21/24 the UA, C&S sample was collected and was picked up by the laboratory. Review of the laboratory results report from revealed the specimen was collected on 11/21/24, received on 11/21/24 but not reported for 15 days, until 12/06/24. The medical record had no documented communication from the facility to the laboratory regarding the collected UA, C&S and test results. Review of the progress note dated 12/08/24 at 1:52 P.M. revealed the urine which was obtained on 12/06/24 was not picked up by the phlebotomist due to the urine being in the refrigerator since 12/06/24. New order provided by the CNP for another UA, C&S to be completed. On 12/09/24 at 6:24 A.M. a nurse obtained a urine sample for the new UA, C&S. The medical record had no laboratory results report for this sample. Progress note dated 12/13/24 at 12:32 P.M. revealed two UA samples were reported as contaminated, a new order for Pyridium (used to treat symptoms of UTI) was prescribed for two days with a start date of 12/13/24 and an end date of 12/15/24. On 12/16/24 at 6:59 P.M. Resident # 72 had another UA ordered. On 12/17/24 at 5:54 A.M. the urine sample was obtained for the UA, C&S. This UA was reported as contaminated on 12/20/24. Review of the progress notes revealed on 12/23/24 at 3:22 P.M. the laboratory was called by the Minimum Data Set nurse asking why the C&S was not completed. The laboratory informed the nurse there was a mistake on their behalf and the urine sample would have to be collected again due to the sample being too old to complete a C&S. The CNP ordered another UA and a sample was collected. On 12/27/24. A new order for Levofloxacin (antibiotic) was ordered for five days with a start date of 12/27/24 for a urinary tract infection (UTI). Review of the laboratory results report from revealed the sample was collected on 12/24/24, received on 12/24/24, and reported on 12/29/24 with the results of 70-99,000 Colony Forming Units per milliliter (CFU/mL) klebsiella pneumoniae, 70-99,000 CFU/mL proteus vulgaris and 70-99,000 CFU/mL enterococcus faecalis. The C&S revealed proteus vulgaris was resistant (R 4) to the ordered Levofloxacin. Review of the progress notes revealed on 12/29/24 at 10:39 P.M. Levofloxacin was discontinued and a new order for Bactrim (antibiotic) was ordered for UTI with a start date of 12/30/24 and an end date of 01/03/25. Additionally, Nitrofurantoin Macrocrystal (antibiotic) was ordered for UTI with a start date of 12/30/24 and an end date of 1/06/25. Interview on 01/09/25 at 10:42 A.M. with Interim Director of Nursing (IDON) revealed if the results of a specimen were contaminated the physician or the CNP would have the final say in ordering a new UA or ordering a treating medication. The IDON stated the reason for the delays with Resident #72's UA, C&S were due to the laboratory but confirmed the facility did not contact the laboratory during the delays and the final decision to change the laboratory companies would be up to the regional directors of the facility. She stated the time it takes for laboratory tests to return was dependent on what culture was ordered and stated it could take 24-72 hours for results but did not confirm which laboratory tests take longer. The IDON confirmed the physician did not order any medications for Resident #72 until 50 days had passed after the initial UA was collected for the suspected UTI. The IDON stated she recommended the facility start antibiotics sooner. Interview on 01/09/25 at 11:13 A.M. with the Medical Director revealed he initially ordered the UA due to Resident #72 having behaviors. He confirmed multiple UA laboratory tests came back contaminated and he did not order any other laboratory tests to confirm if there was an ongoing infection. He confirmed the resident had a UTI and medications were not ordered for 50 days after the initial UA was collected. 32654 2. Review of the medical record for Resident #59 revealed an initial admitted [DATE] with the latest readmission of 10/01/24. Diagnosis included but were not limited to cerebral atherosclerosis, chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, psychotic disorder with hallucinations, sleep disorders, epilepsy, dysphagia, ataxia, vascular dementia with behavioral disturbances, bilateral ocular hypertension, glaucoma, bilateral cataract, constipation, functional urinary incontinence and seasonal allergic rhinitis. Review of the resident's progress note dated 10/01/24 at 7:30 P.M. revealed the resident was admitted from the acute care hospital with a prescription for Keflex (antibiotic) 250 milligrams (mg) by mouth twice daily for seven days for infection management. Review of the progress note dated 10/02/24 at 9:13 A.M., as a late entry revealed the resident returned to the facility on [DATE] with a new order for Keflex with no diagnoses. The Certified Nurse Practitioner (CNP) was made aware and advised to stop the antibiotic and obtain a urinalysis (UA). Review of the resident's hospital discharge summary dated 10/02/24 revealed a culture and sensitivity (C&S) dated 10/01/24 revealed the resident was positive for greater than 100,000 proteus mirabilis bacteria and was ordered Keflex 250 mg by mouth twice daily for seven days. Review of the resident's urinalysis results dated 10/08/24 revealed the resident's urine was dark orange (normal yellow), clarity was extra turbid (normal clear), blood one plus (normal negative), protein one plus (normal negative), urobilinogen three plus (normal negative), leukocytes four plus (normal negative), red blood cells greater than 50 (normal less than 6), white blood cells 21-50 (normal less than six), epithelial cells few (normal negative) and bacteria to numerous to count (normal negative). The lab result indicated probable contamination. Review of the progress note dated 10/09/24 at 10:02 A.M. revealed the CNP was notified of the UA results with no new orders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder and had not been treated for an infection in the past 30 days. Review of the medical record revealed no evidence the resident's UTI was treated. On 01/08/25 at 9:52 A.M., interview with the Interim Director of Nursing (IDON) verified the lack of treatment for the UTI and lack of follow up with the 10/08/24 contaminated urinalysis.

Based on medical record review, staff interview and facility policy review, the facility failed to ensure the physician provided a rationale for the decline of a pharmacy recommended gradual dose reduction (GDR) for Resident #31 and Resident #59. This affected two residents (#31 and #59) of five residents reviewed for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admitted [DATE] with the diagnoses including but not limited to Alzheimer's disease, diabetes mellitus, bipolar disorder, hypertension, anxiety disorder, hyperlipidemia, overactive bladder, sleep disorder, dementia with mood disturbance, adjustment disorder with mixed anxiety and depressed mood, and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Resident was coded to rejected care and wander. The assessment coded diagnoses of Alzheimer's, anxiety and bipolar disorder. The assessment indicated the resident received antianxiety, antidepressant and opioid medications. Review of the resident's monthly physician orders for January 2025 identified orders dated 07/19/24 for Melatonin (medication used for sleep) 10 milligrams (mg) by mouth daily at bedtime for insomnia, 08/01/24 for Zoloft (antidepressant) 100 mg by mouth daily for depression, 12/23/24 for Hydroxyzine (antihistamine) 25 mg by mouth twice daily and Ativan (antianxiety) 0.5 mg by mouth twice daily. Review of the pharmacy recommendation dated 10/02/24 revealed the pharmacist recommended a GDR for the medication Hydroxyzine 25 mg by mouth twice daily. The physician checked the box indicating past reduction attempts have resulted in problematic behavior and/or staff inability to provide care. The physician gave no further rationale for the disagreement. On 01/08/25 at 9:52 A.M., interview with the Interview Director of Nursing (IDON) verified the physician provided no rationale for the decline in the pharmacy recommended GDR. 2. Review of the medical record for Resident #59 revealed an initial admitted [DATE] with the latest readmission of 10/01/24 with the diagnoses including but not limited to cerebral atherosclerosis, chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, psychotic disorder with hallucinations, sleep disorders, epilepsy, dysphagia, ataxia, vascular dementia with behavioral disturbances, bilateral ocular hypertension, glaucoma, bilateral cataract, constipation, functional urinary incontinence and seasonal allergic rhinitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Resident #59 was coded to display no behaviors. The assessment coded the diagnoses of dementia, anxiety disorder, depression, psychotic disorder and sleep disorder. The assessment indicated the resident received antidepressant, opioid, antiplatelet and anticonvulsant medications. Review of the resident's monthly physician orders for January 2025 identified orders dated 10/30/24 for Zoloft 100 mg by mouth daily for depression and 12/06/24 for Seroquel (antipsychotic) 25 mg by mouth twice daily for psychological disorder. Review of the pharmacy recommendation dated 11/04/24 revealed the pharmacist recommended a GDR on the medication Zoloft 100 mg daily. The physician addressed the recommendation on 11/15/24 and gave no rationale for the disagreement. On 01/08/25 at 9:52 A.M., interview with the Interview Director of Nursing (IDON) verified the physician provided no rationale for the decline in the pharmacy recommended GDR.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were properly stored to include labeling that identified the date multi-use vials were first accessed/used, and medications did not exceed the expiration date on stock medication supplies. This affected two residents (#46 and #130) of two residents admitted to the third floor after 11/14/24. The facility census was 74. Findings include: Observation with Licensed Practical Nurse (LPN) #462 on 01/08/25 at 8:22 A.M. of the medication refrigerator in the third floor medication storage room revealed an opened multi-dose vial of tuberculin skin testing solution 5TU/0.1 milliliter with a manufacturer's expiration date of January 2026. The vial was opened and undated. At the time of the observation, interview with LPN #462 confirmed the vial was opened and unlabeled with either date/time opened or date/time the vial was to expire. Interview on 01/08/25 at 10:30 A.M. with LPN #462 revealed the observed tuberculin skin testing solution vial was delivered to the facility from the pharmacy on 10/22/24 and the facility policy was opened stock medications expire 30 days after opening. Review of policy Storage of Medications last revision date April 2019 revealed medications requiring refrigeration were stored in a secured location. Discontinued or outdated medications were returned to the dispensing pharmacy or destroyed.

Based on medical record review, staff interview and facility policy review, the facility failed to provide adequate justification for the use of antibiotics for Resident #73 and Resident ##72. This affected two residents (#73 and #72) of five residents review for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the closed medical record for Resident #73 revealed an initial admitted [DATE] with the latest readmission of 06/27/24. Diagnoses included but were not limited to diabetes mellitus with diabetic retinopathy with macular edema, hypothyroidism, peripheral vascular disease, bipolar disorder, chronic kidney disease, sleep disorders, cirrhosis of liver, major depressive disorder, gastro-esophageal reflux disease, enterocolitis due to clostridium difficile (c-diff), anxiety disorder, hyperlipidemia, severe morbid obesity, hypertension, congestive heart failure, arthropathic psoriasis, lymphedema, anemia, factitious disorder imposed on self combined with psychological and physical signs and symptoms, post traumatic stress disorder, obstructive and reflux uropathy, constipation and cerebral ischemia. Review of the progress note dated 10/30/24 at 7:12 P.M. revealed the resident complained of dysuria. The Certified Nurse Practitioner (CNP) was notified and a new order for urinalysis (UA) was placed. Review of the progress note dated 10/31/24 at 4:44 P.M. revealed the urine specimen was collected and picked up by the facility's contracted laboratory company. Review of the UA results dated 11/04/24 revealed the resident's clarity was abnormal at extra turbid, glucose abnormal at three plus, blood (RBC) abnormal at 21 to 50, white blood cells (WBC) abnormal at greater than 50, epithelial cell abnormal at few, bacteria abnormal at few. Review of the progress note dated 11/05/23 at 6:48 A.M. revealed the laboratory result was received and was sent to the CNP with no new orders. Review of the progress note dated 11/06/24 at 11:55 A.M. awaiting culture and sensitivity (C&S) results. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident was not treated for an infection in the past 30 days. Review of the situational background assessment recommendation (SBAR) dated 11/07/24 revealed the resident was placed on Cipro (antibiotic) 500 milligrams (mg) by mouth twice daily for seven days for a urinary tract infection (UTI). Review of the resident's C&S results dated 11/08/24 revealed the urine was found to have 70,000 to 99,000 escherichia coli. Further review revealed the antibiotic Cipro was resistant to the identified bacteria and sensitive to the antibiotic to Keflex. Review of the progress note dated 11/08/24 at 8:40 A.M. revealed the physician reviewed the lab results. The antibiotic Cipro 500 mg was discontinued due to being resistant to the bacteria. A new order was given for Keflex 250 mg twice daily for seven days. On 01/09/25 at 4:30 P.M., interview with Registered Nurse (RN) #450 verified the antibiotic Cipro was ordered prior to the C&S result returned and the lack of follow up for the contaminated UA results. 2. Review of the medical record for Resident #72 revealed an initial admitted [DATE] with the latest readmission of 02/01/24. Diagnoses included but were not limited to chronic obstructive pulmonary disease (COPD), chronic pulmonary embolism, diverticulosis of intestine, hydrocele, anemia, hypertension, obstructive and reflux uropathy, benign prostatic hyperplasia, UTI, dysuria and calculus of kidney. Review of the plan of care dated 02/02/24 revealed the resident had occasional hematuria, dysuria and pain in urethra related to Foley catheter and was at risk for infection related to diagnoses hydrocele, BPH and kidney calculus. Interventions included administer medication as ordered, observe for side effects, notify physician of any abnormal findings, encourage fluids, observe for continued symptoms of infection and assist with routine toileting and assist with incontinent and peri-care as needed. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had an indwelling urinary catheter and was not treated for an infection in the past 30 days. Review of the progress note dated 11/10/24 at 6:34 A.M. revealed the resident reported his indwelling urinary catheter was leaking and the nurse observed the resident urinate around the catheter. The urine was noted to be blood tinged with a foul odor and a large amount of mucous. The nurse changed the resident's indwelling urinary catheter and was draining hazy colored urine with some bleeding in the tubing. Review of the progress note dated 11/11/24 at 10:02 A.M. a new order was obtained for a UA. Review of the progress note dated 11/19/24 at 12:08 A.M. revealed the urine for the UA was obtained. Review of the progress note dated 11/21/24 at 5:27 P.M. revealed the urine for the UA/S&S STAT was collected and waiting to be picked up by the lab. Review of the progress note dated 11/29/24 at 6:38 P.M. revealed the UA/C&S results were received and the CNP was notified and gave no new orders. Review of the progress note dated 12/08/24 at 3:52 P.M. revealed the resident's urine was not picked up by the facility contracted lab due to urine being in the refrigerator since 12/06/24. Review of the progress note dated 12/09/24 at 6:24 A.M. revealed the resident had no urine output for the shift and the resident's indwelling urinary catheter was changed. The urine for the UA/C&S was obtained. Review of the progress note dated 12/13/24 at 12:32 P.M. revealed the resident's urine had been obtained twice and resulted as contaminated. The resident continued to complain of dysuria. New orders were obtained for Pyridium (medication to treat UTI symptoms) three times daily for two days. Review of the SBAR dated 12/16/24 at 9:31 A.M. revealed a new order was obtained for a UA/C&S. Review of the progress note dated 12/17/24 at 5:54 A.M. revealed the urine for the UA/C&S was obtained. Review of the progress note dated 12/19/24 at 6:23 A.M. revealed the UA results were faxed to the CNP with no new orders at that time. Review of the progress note dated 12/23/24 at 3:22 P.M. revealed the facility called the facility contracted laboratory and questioned why the C&S had not been completed. The laboratory revealed it was a mistake on their part and the laboratory specimen would have to be obtained again. The CNP was notified and ordered to obtain urine for C&S. Review of the progress note dated 12/27/24 at 5:43 P.M. revealed a new order was obtained for Levaquin (antibiotic) 500 mg by mouth daily for five days for UTI. Review of the progress note dated 12/29/24 at 10:39 P.M. revealed the C&S results returned and new orders were obtained to discontinue the Levaquin and start Macrobid 1(antibiotic) 00 mg by mouth twice daily for seven days for UTI. Review of the progress note dated 12/29/24 at 10:43 P.M. revealed the CNP returned call and also ordered Bactrim Double Strength (DS) (antibiotic) 800/160 mg by mouth twice daily for five days for UTI. On 01/09/25 at 4:30 P.M., interview with Registered Nurse (RN) #450 verified the antibiotic Levaquin was ordered prior to the C&S result return. Review of the facility policy titled, Antibiotic Stewardship, dated 2001 and last revised 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. When a resident was admitted from an emergency department, acute care facility, or other facility, the admitting nurse would review discharge and transfer paperwork for current antibiotic/anti-infective orders. When a C&S was ordered lab results and the current clinical situation would be communicated to the prescribe as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued.

Based on observations, record review and interview, the facility failed to ensure an adequate water supply was maintained in case of emergency. The facility emergency water supply policy did not include provisions for how emergency water would be stored including potable and non-potable water, method for distributing water and details for how the facility shall estimate the needed volume of water. This had potential to affect all facility residents. Facility census was 74. Findings include On 01/06/25 at 11:33 A.M. interview with the Administrator revealed the facility emergency water plan was in the survey readiness binder. Review the emergency water plan revealed it included steps to take in case of a short term water shut off including boiling water and flushing water systems. A contract was later provided for Water Company (WC) #1050, the emergency water supplier. Review of the policy from WC #1050 dated 01/01/25 revealed in the event of a water emergency, WC #1050 would provide gallons of drinking water within 24 to 48 hours. The contract included, if the emergency water company was also impacted in water outage, they could not be held responsible for not fulfilling the contract timeline. It also indicated they would fulfill this timeline as long as their personnel were not placed in harms way or violated Department of Transportation rules and regulations. On 01/07/25 at 4:25 P.M. observation with Kitchen Manager #500 revealed emergency water was not stored in the kitchen and staff had to go searching for the emergency water being stored by facility. After 10 minutes of searching including management staff, maintenance, and Administrator the water supply was found in a small supply closet in the human resources office behind several boxes of paper which had to be moved to visualize the boxes of water. A total of 31 boxes with three gallons per box for a total of 93 gallons of water was noted. The amount was confirmed via interview by Kitchen Manager #500 who stated typically there should be at least 150 gallons stored or enough for a week supply. He stated some must have been destroyed when they moved the water from the therapy gym to the human resource closet. Kitchen Manager #500 stated he last ordered emergency water a few months ago. However, the facility was unable to provide evidence of when this order occurred and revealed his emergency water supplier was Food Company #1060. At the time of the interview Kitchen Manager #500 revealed the supply was way less than it should be. Review of facility policy titled, Water Supply - Disruption Due to Repairs or Emergencies, dated 02/2018 revealed the facility shall respond to contamination of water supply and prevent the spread of waterborne microorganisms. Facility estimated the water needs for the entire facility for three days shall include one to three liters per resident per day plus 50 gallons per day per 100 residents. For a census of 74 residents for one liter per resident per day revealed 74 liters divided by 3.785 liters in a gallon equaled 19.55. Three liters per resident per day equaled 74 liters times three (222) divided by 3.785 liters in a gallon equaling 58.65. In addition, the facility reported needs of 50 gallons for every 100 residents (0.5 gallon per resident calculation) daily. With a census of 74 this would add 37 gallons to the totals. Therefore, the facility estimated needs ranged from 56.55 to 95.65 gallons needed for one day. For a three day supply as the policy suggested, the facility should maintain a supply of water of 169.65 to 286.95 gallon supply. For a week long supply as the Kitchen Manager suggested, the facility should maintain a supply of water of 395.85 to 669.55 gallon supply.

Based on closed record review, review of e-mail communication, facility policy review and interview the facility failed to ensure an orderly discharge for Resident #79, when the facility did not timely inform the resident of a planned discharge and packed the resident's belongings without her knowledge or involvement. This affected one resident (#79) of three residents reviewed for discharge. The facility census was 75. Findings include Review of the closed medical record for Resident #79 revealed an admitted [DATE] with diagnoses including diabetes, anxiety, delusion disorder and paranoid schizophrenia. Record review revealed the resident was discharged from the facility on 09/26/24. Record review revealed the facility issued Resident #79 a 30-day discharge notice on 05/23/24 due to the safety of individuals in the home being endangered. The notice reflected the resident would be discharged on [DATE] and provided the resident her rights to appeal the notice. The resident refused to sign the notice. However, an appeal was generated, and a hearing was held on 06/18/24. As a result of the hearing, the facility retained the right to discharge the resident to an appropriate location. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 (out of 15) indicating the resident was cognitively intact. The assessment revealed the resident required only supervision and set up with activities of daily living and was ambulatory. Review of the resident's medical record revealed the facility had made multiple referrals to other skilled nursing facilities for the resident to transfer to following the discharge hearing. However, the resident was not accepted by these facilities due to identified behaviors she had and/or income issues. Review of email communications from the facility previous Administrator (Administrator #100) and the Ombudsman dated 09/12/24 revealed Administrator #100 informed the Ombudsman Resident #79's behaviors had continued and the facility wanted to issue an immediate (discharge) notice and discharge the resident to a shelter. The Ombudsman responded and informed Administrator #100 a shelter was not appropriate as the resident met level of care for a long-term care facility and a homeless shelter would not be an appropriate discharge. The email noted the Ombudsman provided resources and education to Administrator. A progress note dated 09/24/24 revealed Facility #500 (a skilled nursing facility) came for an onsite visit (to see Resident #79) for possible admission and had discussion with the resident at that time. There was no evidence the resident was refusing transfer to this facility at the time of the onsite visit. A second note dated 09/26/24 revealed Facility #500 accepted Resident #79 for admission. Review of email communications from previous Administrator #100 on 09/26/24 at 8:50 A.M. to the Ombudsman revealed a facility had accepted Resident #79 and pick-up was scheduled for 1:00 P.M. this date. He also confirmed Resident #79 had not yet been informed and the facility wanted a police officer present when she was notified as we cannot physically make her get on the bus, but we are certainly within our right to let her know we have fulfilled our obligation to provide a safe discharge location, and she will have to leave the property. The email stated Administrator would inform the sister as well. Review of IDT discharge planning summary dated 09/26/24 revealed Resident #79 was to be transferred to the nursing home (Facility #500) and was independent with mobility. Review of email communications on 09/26/24 at 3:00 P.M. from Resident #79's sister to the Ombudsman revealed Resident #79 was outside without her wheelchair and personal items and the facility would not allow her back in. They packed all of her stuff while she was outside her room and then told her to get on the bus. The sister stated Resident #79 declined to get on the bus as the facility had refused to tell her where she was going and about the facility she was going to. A progress note documented on 09/26/24 at 8:51 P.M. revealed Resident #79 refused to get on the transport bus, refused to leave the property, and became aggressive. Police were contacted and subsequently escorted the resident off the property and facility staff informed the resident along with police that if she returned to the property, she would be trespassing. A note dated 09/27/24 at 1:44 P.M. revealed facility social services staff contacted [NAME] County Adult Protective Services (APS) and informed them of the situation as the resident had been discharged but her whereabouts were unknown by the facility. The note indicated APS was notified the resident was her own person and the note indicated there were no safety concerns at the time of discharge. A social services note revealed the facility contacted the accepting facility (Facility #500) on 09/27/24 at 1:45 P.M. and was informed Resident #79 had just arrived at their facility. Interview on 10/01/24 at 9:28 A.M. with Ombudsman #120 revealed Resident #79 had been given a discharge notice several months ago and the facility was informed by another Ombudsman they (the facility) was still responsible to ensure a safe discharge and that did not include a shelter or the streets. Ombudsman #120 revealed the accepting facility, Facility #500 had been contacted on 09/27/24 around 1:00 P.M. and they confirmed Resident #79 had arrived and been admitted . Interview on 10/01/24 at 9:36 A.M. with Ombudsman #110 revealed Resident #79 had been given a discharge notice in 05/2024 and had a hearing that upheld the facility's ability to discharge the resident in 06/2024. Ombudsman #110 revealed the facility had sent out several referrals and the resident had been denied (admission). She revealed the facility previous Administrator (#100) wanted to discharge the resident to the shelter and was informed that was not safe or appropriate and the facility needed to find a safe discharge plan. Ombudsman #100 also revealed numerous conversations by phone and email related to the discharge of Resident #79 on 09/26/24 and 09/27/24 where staff did not keep resident updated or provide a timely notice, packed her belongings without her knowledge and placed them on a transport bus and when the resident refused to get on the bus had the police remove her off the property. The Ombudsman voiced concerns the resident's whereabouts were then unknown from 09/26/24 at about 6:00 P.M. until about 1:00 P.M. on 09/27/24. Interview on 10/01/24 at 9:52 A.M. with Director of Nursing (DON) #130 from accepting Facility #500 and Unit Manager #140 revealed Resident #79 was scheduled to arrive to their facility on 09/26/24 in the afternoon but did not show up. They revealed Resident #79 called on 09/27/24 and asked about coming to the facility, and then arrived around 1:00 P.M. Unit Manager #140 revealed the resident was dropped off in a private car. The resident's personal belongings/equipment from the facility had arrived to the receiving facility the previous day. Interview on 10/01/24 at 11:10 A.M. with Scheduler #150 revealed on 09/26/24 facility staff packed Resident #79's belongings and placed them on the transport bus. She was not aware of the resident being involved in this process. Interview on 10/01/24 at 11:27 A.M. with previous Administrator #100 revealed he believed Resident #79 had been informed of her discharge, but when asked about the email communication from the Ombudsman, the Administrator verified the resident had not been told about the planned discharge until shortly before the resident was to get on the bus to transfer at which time the resident became combative and was refusing to get on the bus. Administrator #100 revealed the bus had stayed while they tried to convince the resident to get on it, but eventually the bus had to go to. The Administrator verified the resident's belongings were sent to the new facility at that time. Administrator #100 revealed due to the resident's aggression, the police were contacted. However, they were delayed in responding for about three to four hours. When police arrived, Resident #79 was informed by Administrator #100 and police that she had to leave and could not return to the facility property. Police escorted the resident to a back road behind the facility. The resident was told if she returned, she would be charged with trespassing. Administrator #100 revealed the facility chose to not press charges but just wanted the resident to leave. Interview on 10/01/24 at 12:00 P.M. with the facility current administrator, Administrator #175 revealed she was training the day (09/26/24) this situation occurred and could not confirm who or when Resident #79 was told about the transport and plan for discharge to the receiving facility which was about 45 minutes away. She also confirmed the facility packed up Resident #79's belongings without the resident's knowledge and placed them on the bus as an attempt to get her to leave and revealed even when the resident declined to get on the bus, her belongings were not returned to her in an attempt to get her to leave the property. Administrator #175 revealed the facility was unaware of the resident's whereabouts from 09/26/24 around 6:00 P.M. to 09/27/24 around 1:00 P.M. but stated that doesn't mean she was unsafe as she had street smarts. Interview on 10/01/24 at 3:34 P.M. with Social Services (SS) #180 and Corporate Social Services #185 revealed they were not sure who informed the resident of her discharge to Facility #500, transportation time, and overall plan for discharge prior to or on 09/26/24. SS #180 revealed she believed Resident #79 was aware of the possibility of the discharge because Facility #500's liaison had come to the facility to meet with Resident #79 on 09/24/24; however, she could not confirm any conversations after the meeting about being accepted or a plan for transfer at 1:00 P.M. on 09/26/24. SS #180 and Corporate Social Services #185 revealed it was possible the previous facility administrator may have kept it quiet as he wanted police presence when they told Resident #79; however, the police did not arrive to the facility on [DATE] until around 6:00 P.M. On 10/02/24 at 2:46 P.M. a telephone interview with Resident #79 verified she left the faciity on [DATE] after being walked to the sidewalk by police and told not to come on the (facility) property. The resident had her cell phone with her. Resident #79 stated she contacted a friend where she stayed the night on 09/26/24 and then the friend drove her to the new facility about 45 minutes away on 09/27/24. During the interview, Resident #79 revealed she did not get on the (facility) bus (on 09/26/24) when facility staff asked her to because she was only told of the discharge about an hour before and also stated facility staff would not tell her where she was going or what the facility would be like. Resident #79 stated she arrived at the new facility (on 09/27/24) without any new injuries. On 10/03/24 at 4:23 P.M. a telephone interview with responding police Officer #1 and Officer #2 revealed they were called to the facility (on 09/26/24) but were delayed in responding due to other activity in the community. When they arrived at the facility, the administration provided them a copy of the legal notice to discharge Resident #79 and the resident's discharge paperwork with the new facility name on the paperwork. Officer #1 stated the facility said Resident #79 had new housing set up, she refused to get on the bus, and the bus left. The administration stated Resident #79 then attempted to re-enter the facility, was denied and became belligerent yelling and screaming about the facility evicting her. Officer #1 stated he did not observe Resident #79 or facility staff acting inappropriately while on the property. Officer #1 stated he did provide the resident the discharge paperwork from the facility which included the name of the facility she was being transferred to. The Officer also stated he put the new facility's phone number in Resident #79's personal cell phone. Officer #1 stated Resident #79 told him she was going to call her sister, and she was escorted off the property by the officers. There was no indication the resident was unsafe or in danger. Officer #2 added to the interview that he had knowledge of Resident #79 from prior interactions the police had at the facility in the past, but he had no experience of Resident #79 being belligerent in her interactions with the facility and its staff. On 10/04/24 at 10:40 A.M. a follow-up interview with DON #130 revealed their facility staff believed Resident #79 was going to arrive on 09/26/24 in the afternoon with a second resident being admitted to their facility from this transferring facility and it was the transferring facility providing the resident's transportation. However, upon arrival Resident #79 was not present and there was no additional communication from the transferring facility related to the status of the resident. DON #130 revealed the facility had been provided a transfer level of care (LOC) dated 05/31/24 that allowed for the resident's transfer from one nursing facility to the other, however a subsequent LOC following admission revealed the resident did not meet LOC and the facility was working with Home Choice to assist the resident to discharge to the community after a 60 day stay (which was required due to a break in nursing home stays). DON #130 revealed upon the resident's arrival to their facility on 09/27/24 there were no concerns with her condition or evidence of immediate harm to the resident. The resident was alert and oriented and pleasant. Review of facility policy titled, Transfer and Discharge, dated 01/02/24 revealed the facility shall ensure a safe and orderly transfer or discharge from the facility and assist in arrangement as needed for a transfer. This deficiency represents non-compliance investigated under Complaint Number OH00158325.

Based on observation, medical record review, staff interview, review of the facility smoking policy, and review of the facility therapeutic leave policy, the facility failed to develop and implement safe smoking policies and practices and comprehensive, individualized and effective smoking interventions to prevent accidents and/or resident injuries when smoking. This resulted in Immediate Jeopardy and actual harm on [DATE] when Resident #69, who had previously been identified to exhibit unsafe smoking practices was assessed to have third degree burns to his bilateral nares after being found smoking with oxygen in place. In addition, the facility failed to provide adequate supervision and the safe/secure storage of smoking materials for seven additional residents, Resident #17, #32, #48, #52, #55, #78 and #79 identified to require supervision while smoking placing these residents at risk for incidents/accidents related to smoking. This affected eight residents (#17, #32, #48, #52, #55, #69, #78 and #79) of eight residents reviewed for smoking. On [DATE] at 5:00 P.M. the Administrator, Director of Nursing (DON), Regional Nurse #260, and [NAME] President (VP) of Regulatory Operations #255, were notified Immediate Jeopardy began on [DATE] related to the facility's failure to develop and implement safe smoking policies and practices and comprehensive, individualized and effective smoking interventions to prevent accidents and/or resident injuries resulting in Resident #69 sustaining third degree burns to his bilateral nares as a result of smoking with oxygen in place. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] by 7:15 P.M., the DON and/or designee observed 34 of 34 residents who smoke to ensure adequate supervision, appropriate interventions, and that safe smoking practices were followed. Any residents who smoked who were identified to be on a leave of absence (LOA) or at the hospital would also be observed upon return to the facility by the DON and/or designee. On [DATE] by 11:00 P.M., the DON and/or designee educated 67 of 67 staff members on the facility revised smoking policy, safe smoking practices, and the storage of smoking materials. Any staff not educated during this time period, would be educated prior to their next scheduled shift. On [DATE] by 11:00 P.M., the DON assessed Resident #69, who was currently not smoking and verified the resident continued to accept smoking cessation and was still not smoking as of this date. Additionally, Resident #69 signed an updated copy of the smoking policy. On [DATE] by 11:00 P.M., the DON and/or designee reviewed 34 of 34 residents who expired a desire to smoke to ensure their safe smoking review assessment was reviewed and revised to update the resident's supervision status. Residents who were on a leave of absence (LOA) or at the hospital would be reassessed upon return to the facility by the DON and/or designee. On [DATE] by 11:00 P.M., VP of Regulatory Operations #255 and the Executive VP of Operations #303 reviewed and revised the facility smoking policy to include an evaluation of residents upon admission and routinely to determine if they were able to smoke with or without supervision. Residents who do not require supervision when smoking must store smoking materials with staff, on their person while in route to or from designated smoking areas or in a locked container. If there were observations or evidence of violation of the smoking policy then the facility reserved the right to re-educate the resident on the smoking policy, increase supervision, or issue a discharge notice. Facility staff would notify the Administrator of any violations to the smoking policy. On [DATE] by 11:00 P.M., the revised smoking policy had been added to the new hire orientation and the human resources representative was updated. On [DATE] by 11:00 P.M., the DON and/or designee educated 34 of 34 residents who smoke on the updated smoking policy, safe smoking practices, and the storage of smoking materials. Residents who were on a leave of absence (LOA) or at the hospital would be reeducated upon return to the facility by the DON and/or designee. On [DATE] by 11:00 P.M., the DON and/or designee observed 34 of 34 smokers to ensure smoking materials were kept and stored per the revised smoking policy. There were no negative findings. Residents who were on a leave of absence (LOA) or at the hospital would be observed upon return to the facility by the DON and/or designee. On [DATE] by 11:00 P.M., the receptionists were provided an updated list of which residents were deemed supervised smokers and which residents were deemed independent smokers as well as where their materials were to be stored. On [DATE] at 1:40 P.M., Social Service Designee #233 met with Resident #69 to complete a psychosocial assessment. It was determined a referral to behavioral health services was not needed at that time. On [DATE] by 11:00 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held regarding the facility smoking policy. Attendees included the Administrator, DON, Minimum Data Set (MDS) Nurse #272, SSD #233, VP of Regulatory Operations #255, Regional VP of Operations #301, and Regional Nurse #260. On [DATE] by 11:00 P.M., the Administrator or designee ensured the medical director was notified and involved with the systematic changes made to the smoking policy. Beginning on [DATE] at 9:00 A.M., the facility implemented a plan for the DON and/or designee to observe ten residents who smoke daily at random designated smoking times and shifts over thirty days to ensure adequate supervision, appropriate interventions, and safe smoking practices. Beginning on [DATE] at 9:00 A.M., the facility implemented a plan for the DON and/or designee to observe the storage of smoking material five times daily at random times and shifts over thirty days to ensure the proper storage and distribution of smoking materials. Beginning [DATE] at 1:00 P.M., the facility implemented a plan for the DON and/or designee to monitor Resident #69 daily for thirty days to ensure smoking cessation continues or compliance with the smoking policy was maintained. Interview on [DATE] from 8:33 A.M. to 12:20 P.M. with Resident #36, #57, #48 and #60, revealed they had been educated and were knowledgeable about the new smoking policy. Interview on [DATE] from 10:20 A.M. to 11:23 A.M. with State tested Nursing Assistant (STNA) #309, STNA #312, and Unit Manager #306 revealed they had been educated on the facility smoking policy. They were knowledgeable on how smoking materials were to be stored and who noncompliance should be reported to. Observation on [DATE] at 8:30 A.M. of supervised smoking revealed residents were supervised appropriately and exhibiting safe smoking practices. Observation on [DATE] from 7:45 A.M. to 12:30 P.M. revealed no independent smokers smoking in inappropriate locations or exhibiting unsafe smoking practices. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings include: 1. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), Alzheimer's disease with late onset, anxiety disorder, type two diabetes mellitus, bipolar disorder, psychotic disorder with delusions, and generalized anxiety disorder. Review of Resident #69's physician's orders, dated [DATE] to [DATE], revealed Resident #69 had an order for oxygen at two to four liters per minute (LPM) via a nasal cannula continuously. Review of Resident #69's Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had no concerns related to his cognitive patterns, communication, hearing, vision, or physical ability. The assessment indicated observation of Resident #69 revealed he was able to communicate why oxygen must be off prior to lighting a cigarette, he was able to communicate risks of smoking, he smoked safely, utilized ashtrays, and was able to extinguish cigarettes safely. The assessment did not indicate if Resident #69 was able to smoke safely. Resident #69 was noted to be unsupervised with smoking. Review of Resident #69's Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had no concerns related to his communication, hearing, vision, or physical ability. The assessment indicated there were no concerns noted when Resident #69 was observed smoking. However, for his cognitive patterns, it was noted Resident #69's decision skills were not reasonable and consistent. There was no indication if Resident #69 was to be independent or supervised for smoking as of this date. Review of the progress note, dated [DATE] revealed Resident #69 was caught smoking in his room. He stated he could not make it downstairs because he did not have a wheelchair. He was educated on the risk of smoking in his room and social services as well as the Administrator were notified. Review of the progress note, dated [DATE], revealed the nurse was notified of Resident #69 smoking in his room. Resident #69 was educated on the smoking policy and the risks of smoking in his room while wearing oxygen. The Ombudsman was to be contacted to follow up with behavior contract. Review of the progress note, dated [DATE] at 11:09 A.M., revealed Resident #69 was sitting outside next to the other smokers while wearing his oxygen. Resident #69 was educated to not take oxygen outside in the smoking area as it was a hazard. The note revealed Resident #69 verbalized understanding. Review of the progress note, dated [DATE] at 7:35 P.M., revealed Resident #69 was observed by staff smoking with oxygen on outside of the building. Staff intervened and extinguished his cigarette and ensured his safety. Resident #69 was educated on the risks of smoking with oxygen on. His lighter and cigarettes were removed and secured, and Resident #69 was educated that he could obtain the materials after removal of the oxygen. Review of the resident document, dated [DATE], revealed Resident #69 signed a copy of the smoking policy. Review of the Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had no concerns related to cognitive patterns, physical ability, or resident observation. He was noted to have inadequate hearing and was unable to communicate effectively with others. Resident #69 was deemed to be an independent smoker. Review of the Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had no concerns related to cognitive patterns, physical ability, or resident observation. He was noted to have inadequate hearing and was unable to communicate effectively with others. Resident #69 was deemed to be an independent smoker. Review of the Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had no concerns related to cognitive patterns, physical ability, or resident observation. It was noted that he had inadequate hearing and was not able to communicate effectively with others. Resident #69 was to remain an independent smoker until the next assessment. Review of Resident #69's physician's orders, dated [DATE] through [DATE] revealed Resident #69 continued to have oxygen orders for the use of continuous oxygen via nasal cannula to maintain oxygen above 90%. Review of the Safe Smoking Review Assessment, dated [DATE], revealed the assessment indicated there were no concerns related to Resident #69's cognitive patterns, communication, hearing, vision, or observation of Resident #69. The resident was noted to have a total or limited range of motion of both arms and hands. There was no summary of findings. There was no indication if Resident #69 was to be independent or supervised for smoking. Review of Resident #69's physician's orders, dated [DATE] to [DATE], revealed Resident #69 had an order for oxygen at four LPM via the nasal cannula continuously with humidification. Review of the progress note, dated [DATE], revealed the social service director and the Administrator both met with Resident #69 to discuss the safety concerns of Resident #69 smoking with his portable oxygen concentrator tank attached to his wheelchair and the safety concerns of it catching on fire and putting lives at risk. Resident #69 was advised that if he continued to break the rules then he would be issued a discharge notice. Resident #69 indicated he understood. The Ombudsman was notified. Resident #69 was offered a nicotine patch and he agreed. The note indicated nursing was to follow up. Review of the Safe Smoking Review Assessment, dated [DATE], revealed there were no concerns related to Resident #69's cognitive patterns, communication, hearing, vision, or observation of Resident #69. Resident #69 was noted to have a total or limited range of motion of both arms and hands. Resident #69 was noted to be an independent smoker. Review of the progress note, dated [DATE], revealed a staff member witnessed Resident #69 sign out and go out front and light a cigarette with his oxygen tank turned on. The staff member turned off the oxygen tank and Resident #69 refused to extinguish the cigarette or to come back inside the building. Unit Manager #306 educated the staff that Resident #69 was a supervised smoker and was to only go out during scheduled smoke times with supervision. The writer and the staff nurse educated Resident #69 on the risk of smoking with oxygen. Resident #69 verbally acknowledged his understanding and gave the writer a box of cigarettes that contained one lighter and two cigarettes. The box of cigarettes was labeled and given to activities, and Resident #69 was provided a copy of the smoke times. Review of Resident #69's plan of care, dated [DATE] revealed Resident #69 was a supervised smoker. Resident #69 had a history of smoking in his room and bathroom. Staff had reported the smell of smoke in his room and nursing staff had observed the resident smoking in his room. Resident #69 had been educated on the risks. The ombudsman was notified, and a behavior contract was initiated. The plan of care indicated Resident #69 had a history of attempting to smoke with oxygen on. The resident was educated on the risks and dangers and his lighter and cigarettes were removed from his possession. The Ombudsman was again notified. Interventions included completing a smoking assessment quarterly and as needed, instructing Resident #69 about smoking risks and hazards, instructing Resident #69 regarding the facility policy on smoking, notifying the charge nurse if it was suspected Resident #69 had violated the smoking policy, observing Resident #69's clothing and skin for signs of burns, redirecting the resident, and ensuring Resident #69 keeps smoking materials with facility staff. Review of Resident #69's physician order, dated [DATE] to [DATE], revealed Resident #69 had an order for oxygen at two to four LPM via the nasal cannula continuously with humidification. Review of Resident #69's physician order, dated [DATE], revealed Resident #69 an order for oxygen at three LPM via a nasal cannula continuously with humidification. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #69 had moderately impaired cognition and had no limitation in functional range of motion. Review of the progress note and wound assessment, dated [DATE] at 9:30 A.M., revealed Resident #69 had acquired a third degree burn to his nose. It was categorized as a chemical injury with granulation tissue present. There was scant serous drainage present. The wound had irregular edges and measured 5.5 centimeters (cm) by 3.0 cm by 0.1 cm. The plan was to apply Bactroban two percent ointment to the area. Review of the progress note, dated [DATE] at 10:53 A.M., revealed the Administrator met with Resident #69 to discuss safe smoking as he was found to have a burn across the distal surface of his nose and above his top lip. Resident #69's case manager from hospice was with him during the conversation. Resident #69 had a care plan for supervised smoking and Resident #69 stated he went out on his own to smoke. Resident #69 indicated he had his nasal cannula in place and his oxygen on while he was lighting the cigarette and it flared and burned him. He stated he did not know he needed supervision for smoking. The Administrator explained the dangers of smoking with his oxygen on and Resident #69 verbalized understanding. The case manager and Administrator spoke to Resident #69 regarding a nicotine patch, and he expressed interest in it. It was explained that he would be unable to smoke while wearing the nicotine patch and he verbalized understanding. The Administrator updated the unit manager on the conversation. The interdisciplinary team was to continue to investigate the situation and add or reinforce interventions for Resident #69. The social worker was asked to reassess his Brief Interview for Mental Status (BIMS). Review of the progress note, dated [DATE] at 11:30 A.M., revealed the social service assistant and psychiatry spoke with Resident #69. He stated he usually took the tubing off and turned off his oxygen before smoking. Resident #69 stated his nose did not hurt. Nursing staff reported the area to his nose was noted upon passing his morning medication. Resident #69's had a Brief Interview for Mental Status Score (BIMS) was a 12 (out of 15) indicating moderate cognitive impairment. Review of the progress note, dated [DATE] at 1:53 P.M., revealed Registered Nurse (RN) #280 took morning medications to Resident #69 and noted redness to his nose. Upon close inspection, Resident #69 had what appeared to be a chemical burn. Resident #69 stated he had been outside the previous evening and when he lit up his cigarette it blew up and burned my nose and my moustache. He stated he would never do it again and was done smoking. Resident #69 indicated he had not reported the incident to anybody. The nurse assessed the area and noted a third degree burn from some chemical. The nurse reinforced supervised smoking with Resident #69, and he verbalized understanding. The physician was notified, and new orders were received for an antibiotic, Doxycycline 100 milligrams (mg) twice a day, Bactroban two percent twice a day for 10 days (a topical treatment to the burn areas), and a nicotine patch 14 mg daily for smoking cessation. Review of the Safe Smoking Review Assessment, dated [DATE], revealed Resident #69 had cognitive concerns related to his short-term memory and his decision skills were not reasonable and consistent. He had total or limited range of motion of both arms and hands. No observation concerns were noted but it was indicated Resident #69 was a supervised smoker. Review of the progress note, dated [DATE], revealed the Director of Nursing (DON) went to assess and talk to Resident #69. Resident #69 denied any pain and his nostril was noted to be moist and wet. Resident #69 stated he went outside to the front area to smoke and forgot to take his oxygen off. Resident #69 stated he was outside in the front area by himself. He stated he immediately went to his room and did not report the situation until the nurse came in to give him morning medications. Resident #69 stated he did not want to smoke anymore and agreed to the nicotine patch and smoking cessation program. The physician was asked to assess Resident #69. The plan was to continue to monitor Resident #69's oxygen and pain along with his skin assessment. Review of Nurse Practitioner #270's note, dated [DATE], revealed Resident #69 was seen in his room and assessed with epistaxis (nosebleeds). The nostrils were assessed with no discomfort voiced. Resident #69's bilateral nose was noted to be patent and there was no hindrance with the use of the nasal cannula. Resident #69 was educated on smoking while on oxygen. Resident #69 stated he was no longer interested in smoking and wanted to be put on the patch. Staff were to continue to educate and redirect. Review of the Wound Nurse Practitioner #235's progress note, dated [DATE], revealed Resident #69 had a second degree burn to his bilateral nares after smoking cigarettes with oxygen in place. The wound was 100% epithelial and the area around the wound was intact, and there was no exudate. Resident #69 reported a pain level of two (on a scale of one to 10) at rest. It was recommended the resident be monitored during smoking and have his oxygen removed. Record review revealed following the incident on [DATE], the facility revised the resident's plan of care. The plan of care, was dated [DATE] and revisions included re-educating Resident #69 on not keeping smoking materials on his person, re-educating Resident #69 on safe smoking and not smoking with oxygen on and re-educating Resident #69 on the facility smoking and therapeutic leave of absence (LOA) policies. Review of the Weekly Skin Assessment, dated [DATE], revealed Resident #69's burn to his nose had healed. Interview on [DATE] at 4:40 P.M. with Receptionist #247 revealed some residents keep their smoking materials in bank bags at the front desk. She reported these residents could access the bags at any time and the residents had keys to their bags. Receptionist #247 reported she signed them out of the facility each time they did this. Receptionist #247 stated the residents were to return to her desk to be signed back in and return their smoking materials, however, she could not always verify the residents returned the items. She verified nobody went out with these residents and they could smoke independently. Interview on [DATE] at 11:00 A.M. with MDS Nurse #272 revealed Resident #69 only had one instance of noncompliance with smoking on [DATE] and the second note was the interdisciplinary team (IDT) meeting to discuss the incident. Interview on [DATE] at 11:04 A.M. with Social Service Director (SSD) #233 revealed the interventions for Resident #69's first two instances of smoking in his room included educating him on the risks and the smoking policy. SSD #233 stated her [DATE] note had been related to reports of incidents involving Resident #69 which had been reported to her by staff. Resident #69 had been going out to smoke or would sit outside with other smokers while wearing his oxygen. However, he would have problems getting back inside and would need staff assistance, so his non-compliance was noted. SSD #233 was unsure of the number of times the non-compliance occurred. She reported interventions for non-compliance with the smoking policy included notifying the Ombudsman, offering smoking cessation, re-evaluating the resident, and searching the resident's room if they suspected they were smoking in their rooms. She reported there was no set procedure for addressing non-compliance and it was addressed on a case-by-case basis. Interview on [DATE] at 12:06 P.M. with Resident #78 revealed Resident #69 had been caught smoking in their room when they were roommates and Resident #69 tried to blame it on him. Interview on [DATE] at 12:10 P.M. with Social Service Consultant (SSC) #243 and SSD #233 revealed the facility did not have a smoking agreement as mentioned in the [DATE] note. Additionally, they reported that while a behavior contract was mentioned in [DATE], they were not able to find a behavior contract for Resident #69. SSD #233 indicated Resident #69 had a smoking bag downstairs at the front desk and signed himself out at the time of the [DATE] incident. SSD #223 reported Resident #69 was able to obtain his own smoking materials during LOA's or visits with his brother. Interview on [DATE] at 12:22 P.M. with Regional Nurse #260 revealed the facility completed a quality assessment and performance improvement (QAPI) plan related to the [DATE] incident involving Resident #69. She reported Resident #69 was his own person and was able to go on LOA's. Regional Nurse #260 reported residents were not allowed to keep smoking materials on their person, however, they had residents who were noncompliant with this rule. She reported some residents were given bank bags at the front desk to keep the smoking materials out of their room and away from potentially confused residents who may enter their room. She reported all residents were encouraged to smoke at the designated smoking times with the other residents. Regional Nurse #260 indicated she believed Resident #69 was non-compliant with being supervised and he refused to follow smoking times. Regional Nurse #260 reported they found smoking materials in Resident #69's room following the incident in [DATE]. Regional Nurse #260 reported they could search rooms for smoking materials; however, residents had the right to refuse the search. Interview on [DATE] at 1:10 P.M. with the DON, SSD #233, and Regional Nurse #260 revealed they were unsure why Resident #69 was not started on Nicotine patches in [DATE] after Resident #69 agreed to them. The DON reported Resident #69 was still not smoking at the time of the interview and stated she randomly checked in on him to ensure he was still not smoking. During the interview, the staff noted upon resident reassessments in [DATE], they changed all residents to be supervised smokers as that was the facility policy. However, those residents who had locked bags (provided by the facility) at the front desk were not compliant with the facility smoking policy. The DON reported if residents were observed going out to smoke, she would remind them to go across the street, however, she verified that not all staff were doing this. All three staff verified that each instance of non-compliance (signing out to smoke independently) was not documented in Resident #69's medical record. SSD #233 reported she had been working to discharge Resident #69 since [DATE] and he was currently on a wait list. The staff members reported Resident #69 was on continuous oxygen and could never take his oxygen off. They were unable to identify what interventions were in place to prevent him from obtaining smoking materials and smoking with oxygen on aside from educating Resident #69. Interview on [DATE] at 2:28 P.M. with Ombudsman #253 revealed she had worked with the facility until December of 2023. She reported she was familiar with Resident #69 and his non-compliance with smoking. She reported she had spoken with Resident #69 about the danger of his actions. However, Ombudsman #253 reported the facility did not initiate an action plan with her. She reported they had discussed trying behavior contracts which included steps to take with each incident of non-compliance, but she did not think the facility initiated one. Ombudsman #253 reported the facility never discussed with her regarding discharging Resident #69. Interview on [DATE] at 3:02 P.M. with Ombudsman #256 revealed she began working with the facility at the beginning of [DATE]. She was unaware of Resident #69, or any concerns related to him. Interview on [DATE] at 4:14 P.M. with Regional Nurse #260, the Administrator, the DON, and VP of Regulatory Operations #255 revealed Resident #69 had been assessed as an independent smoker from his admission until [DATE]. On [DATE], Resident #69 had signed himself out and was observed smoking by facility staff and the intervention was to educate him. They had him sign the smoking policy as this was his first episode of non-compliance. At that time, Resident #69 had his smoking materials on him because he was independent. They reported he was receptive to the education and understood that his oxygen needed shut off, so he was kept an independent smoker. They verified a new assessment was not completed at that time. The staff revealed [DATE] was the next documented incident of non-compliance for Resident #69. The intervention was to provide deeper education and explain the risk of discharge. They were unable to provide information on why nicotine patches were not started although they assumed Resident #69 later refused the nicotine patches. They reported he remained an independent smoker because he was again receptive to the education. On [DATE], Resident #69 was again observed by facility staff to light a cigarette with oxygen nearby. At that time, he was changed to supervised smoking and activities was supposed to have his cigarettes. They were unable to identify when Resident #69 would have stopped having a bag of smoking materials downstairs at the front desk or how the receptionist would have known Resident #69 was not to smoke independently. The DON reported the receptionist was given a list of supervised smokers after they became aware of the incident that occurred on [DATE]. Additionally, Resident #69 was monitored for five days after the incident on [DATE] to ensure compliance with the smoking rules. There was no additional monitoring for compliance between [DATE] and [DATE]. The interview verified Resident #69 had been educated numerous times regarding not smoking while wearing oxygen, however he continued to smoke while wearing oxygen and ultimately received a third degree burn due to smoking with oxygen on. VP of Regulatory Operations #255 indicated facility staff were not aware of the burn to Resident #69's nose until [DATE], despite the injury having occurred the night of [DATE]. The facility policy indicated all residents who smoke on facility grounds were to be supervised. The Administrator reported he considered the facility grounds to include the building and six to eight feet outside the walls. He verified this would not include the parking lot and stated he could not account for what the non-compliant residents were doing there. The staff members were unable to identify how long the locked bags at the reception desk had been in place. Review of the facility policy titled Smoking, dated [DATE], revealed all residents who smoked on facility grounds were to be supervised. Residents were to only smoke during the designated times and were to be supervised during those times. All smoking materials including cigarettes and lighters were to be kept and distributed by care-team members. Operation of lighters and matches was to be done under the supervision of care team members. Residents with oxygen were to be restricted from the smoking area while oxygen was flowing. The oxygen was to be shut off and removed by care team members. Both the oxygen container as well as the nasal cannula were to be removed and left inside the building. Residents who smoked were to be assessed upon admission, quarterly, or with a significant change in condition by social services or the designee. The facility reserved the right to search resident's room, property, or person if suspected of noncompliance with the smoking policy. Residents who leave the premises and smoke, as determined by the LOA policy, must surrender their smoking materials when they have returned. Residents who were found to be noncompliant with the policy would be considered a safety risk to the facility. An immediate meeting was to occur with the resident and facility management to discuss options up to and including discharge from the facility. Review of the undated facility policy provided as their LOA policy, titled Therapeutic Leave, revealed the facility was to coordinate with the resident the length of time the resident was to be gone while on leave. Education was to be given about administration of medications, treatments, or any other pertinent information prior to therapeutic leave. The facility was to document in the medical reco [TRUNCATED]

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observations, interview with facility staff, and review of facility policy, the facility failed to appropriately implement the use of Personal Protective Equipment (PPE) and isolation procedures to prevent the spread of the SARS-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy when the facility staff failed to utilize PPE properly when coming into contact with COVID-19 positive residents. Staff members were observed to provide care and services to one COVID-19 positive resident (#101) without donning the appropriate PPE and then proceeded to provide care and services to 17 COVID-19 negative residents (#82, #83, #84, #85, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, and #103) on the 300 hall without changing their N-95 masks or cleansing their eye protection. No isolation bins were placed outside resident rooms and isolation signage from resident room doors had been removed on the 300 hall. The facility also allowed five residents (#45, #70, #80, #87, and #98) who were COVID-19 negative to remain in a room with a COVID-19 positive roommate. Additionally, the facility failed to follow proper isolation precautions for seven residents (#46, #77, #86, #88, #89, #101, and #102) who tested positive for COVID-19 from 12/30/22 to 01/02/23 but were removed from isolation precautions prior to the recommended 10 days of isolation on 01/09/23. This placed 20 residents (#45, #70, #80, #82, #83, #84, #85, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, and #103) at risk for the likelihood of serious harm, negative health outcomes/complications and/or death. The facility census was 102. On 01/11/23 at 5:28 P.M., the Administrator and Regional Nurse Consultant (RNC) #100 were notified Immediate Jeopardy began on 12/28/22 when Resident #98 who was COVID-19 negative was allowed to cohort in the same room as Resident #97 who tested positive for COVID-19 on 12/28/22. The facility allowed an additional four residents (#80, #70, #87, and #45) who tested negative for COVID-19 to cohort in the same rooms as four residents (#81, #69, #86, and #46) who tested positive for COVID-19 between 12/29/22 to 01/04/23. On 01/09/23 staff members were observed to provide care and services to one COVID-19 positive resident (#101) without donning the appropriate PPE and then proceeded to provide care and services to 17 COVID-19 negative residents (#82, #83, #84, #85, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, and #103) on the 300 hall without changing their N-95 masks or cleansing their eye protection. No isolation bins were placed outside resident rooms and isolation signage from resident room doors had been removed on the 300 hall. The Immediate Jeopardy was removed on 01/12/22, when the facility implemented the following corrective actions: On 01/09/23, Resident #87 was moved from room [ROOM NUMBER]B to room [ROOM NUMBER]B. On 01/10/23, Resident #45 was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]B. On 01/10/23, Residents #45, #70, #80, #87, #98 tested negative for COVID-19. On 01/11/23, The Director of Nursing (DON)/designee assessed Residents #45, #70, #80, #87, #98 for signs and symptoms of COVID-19. No concerns/issues were noted. On 01/11/23, the DON/designee tested all residents that have not been COVID-19 positive in the last 30 days for COVID-19. All residents were negative. On 01/11/23, the DON/designee, audited all COVID-19 positive residents to ensure isolation bins were placed outside of each COVID-19 positive room and stocked with appropriate personal protective equipment and ensured COVID-19 signage was on the door of each COVID-19 positive room. On 01/11/23, the facility's policies and procedures for Infection Control related to COVID-19 were reviewed. No revisions were made. On 01/11/23, The DON/designee started Infection Control Education related to COVID-19 including: Cohorting COVID-19 Residents, wearing appropriate PPE in COVID-19 positive rooms, what residents are COVID-19 positive, and how to identify what residents are in isolation for being COVID-19 positive. Staff members are not permitted to work a shift until education had been completed (Leave of Absence LOA's, vacations, illness, etc.). The education will be completed by 01/13/23. Starting 01/12/23, the DON/designee will audit daily for one week, two times/week for three weeks and then weekly for four weeks to ensure that staff are wearing appropriate PPE in COVID-19 positive rooms, isolation bins are outside of each COVID-19 positive room, correct COVID-19 signage is posted on the door or beside the door (as visual aid for staff), and to ensure that no COVID -19 negative resident is cohorting in a room with a COVID-19 positive resident. Results of the Audits will be forwarded to the Quality Assurance and Performance Improvement (QAPI) committee for review. Although the Immediate Jeopardy was removed on 01/12/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: During interviews on 01/09/23 with State tested Nursing Assistants (STNA's) #51 and #53 between 11:00 A.M. and 11:55 A.M. revealed the facility had no current residents in COVID-19 isolation. On 01/09/23 from 11:00 A.M. to 11:55 A.M., Licensed Practical Nurse (LPN) #75 was observed to remove isolation signage from resident room doors on the third floor. On 01/09/23 at 11:52 A.M., STNA #51 was observed to bring a food tray into Resident #101's room. STNA #51 was wearing an N-95 mask upon entering but did not put on eye protection, gown or gloves before entering the resident's room and did not change her mask after exiting the room. Interview with the Administrator on 01/09/23 at 6:00 P.M. revealed the facility was still in COVID-19 outbreak status as there were seven residents (#46, #77, #86, #88, #89, #101, and #102) who had not completed their COVID-19 isolation and should remain in isolation. Observation on 01/10/23 at approximately 9:30 A.M. revealed LPN #82 and STNA #104 responded to Resident #101's call light. The staff stopped at the isolation bin outside the door and put on gowns and gloves in addition to the N-95 mask and eye protection the staff were already wearing. The staff was observed to read the signage on the door that stated the resident was in droplet precautions. Staff entered the resident room and were observed to provide the resident with her morning medications. When staff left the room, they discarded their gowns and gloves in the trash can at the head of the resident's bed, walked across the room to the sink and washed their hands. The two staff exited the resident's room and shut the resident's door. The staff did not remove or change their N-95 mask and did not disinfect or replace their eye protection. In an interview on 01/10/23 at 9:35 A.M., LPN #82 verified the staff discarded their gowns and gloves in the trash can which was located at the head of Resident #101's bed and walked across the room to complete hand hygiene. LPN #82 also verified eye protection was not removed or disinfected when she exited Resident #101's room. LPN #82 stated she wore the same N-95 for her entire shift unless it was too soiled to continue to wear. LPN #82 verified she had COVID-19 positive residents on her assignment and COVID-19 negative residents on her assignment. LPN #82 was caring for five residents (#86, #88, #89, #101 and #102) who were COVID-19 positive and in isolation, in addition to 17 residents (#82, #83, #84, #85, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, and #103) who were COVID-19 negative. Review of the facility list of active COVID-19 positive residents as of 01/10/23 revealed seven residents (#46, #77, #86, #88, #89, #101, and #102) tested positive for COVID-19 from 12/30/22 to 01/02/23 and were removed from COVID-19 isolation on morning of 01/09/23. Review of the facility policy titled, COVID-19 Resident Policy, dated 03/20 and updated 10/22, revealed all current residents will have daily temperature monitoring. Residents will be monitored for potential symptoms of COVID-19. When residents are suspected or confirmed with COVID-19, the Charge Nurse will immediately move the resident to a private room, or a private location while waiting for a private room. Ideally the room should be as far away from other resident rooms and common areas (i.e., room at end of hall near emergency exit) and resident should have dedicated bathroom or bedside commode. If no private rooms are available, move resident as far away from others as possible, at a minimum of 6 feet, with privacy curtains pulled. Only residents with the same respiratory pathogen may be cohorted in the same room, a resident with COVID-19 should not be cohorted in the same room as a resident with an undiagnosed respiratory infection. Every shift monitoring of temperature and respiratory symptoms. The resident will be placed on Droplet Precautions. The door should remain closed at all times unless contraindicated for safety reasons. An isolation cart must remain outside of the room or in a donning and doffing area. Follow the proper procedure when removing personal protective equipment: Remove gloves, face shield/goggles, and gown, prior to leaving the patient's room ensuring not to touch any part of equipment that may have been contaminated. After leaving the room, and closing the door, remove mask carefully by using the straps and avoid touching the outside of the respirator or mask. Wash hands with soap and water after removing personal protective equipment; if hands are not visibly soiled an alcohol-based hand sanitizer may be used. Long term care facility residents with COVID-19 should remain on standard contact and droplet precaution for 10 days after symptoms first appeared or positive test results (unless severe illness and then 20 days must have passed). Must be 24 hours after resolution of fever, without use of fever reducing medication, and improvement in symptoms. Review of the online Centers for Disease Control (CDC) COVID-19 guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/22 revealed the recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection 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. Healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety & Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Five COVID-19 positive residents (#46, #69, #81, #86 and #97) were in dual occupancy rooms with roommates (#45, #70, #80, #87, and #98) who were tested and COVID-19 negative but continued to cohort with their COVID-19 positive roommate. Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to chronic obstructive pulmonary disease, diabetes type two, and vascular dementia. Resident #45's medical record lacked evidence that the resident was having his temperature taken daily and to him being observed daily for signs and symptoms of COVID-19. The medical record also did not have documented evidence of the resident or responsible party being notified of the facility COVID-19 outbreak and that the resident was cohorting with a COVID-19 positive roommate. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to malignant prostate cancer with metastases to the bone. Resident #70 was admitted to hospice services on 08/26/22 for his terminal cancer diagnosis. Resident #70's medical record lacked evidence that the resident was having his temperature taken daily and to him being observed daily for signs and symptoms of COVID-19. The medical record also did not have documented evidence of the family being notified of the facility having a COVID-19 outbreak and that the resident was cohorting with a COVID-19 positive roommate. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to heart failure, obstructive sleep apnea, and history of pulmonary embolism. Resident #80's medical record lacked evidence that the resident was having her temperature taken daily and to her being observed daily for signs and symptoms of COVID-19. Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to multiple sclerosis, generalized weakness, epilepsy, hypertension, and type two diabetes. Resident #87's medical record lacked evidence the resident was having her temperature taken daily and to her being observed daily for signs and symptoms of COVID-19. Resident #87 had a guardian over her care. The medical record also did not have documented evidence of the guardian being notified of the facility having a COVID-19 outbreak and that the resident was cohorting with a COVID-19 positive roommate. Review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to Vitamin D deficiency, type two diabetes and intellectual disabilities. Resident #98's medical record lacked evidence that the resident was having her temperature taken daily and to her being observed daily for signs and symptoms of COVID-19. Resident #98 had a guardian over her care. The medical record also lacked documented evidence of the guardian being notified of the facility having a COVID-19 outbreak and that the resident was cohorting with a COVID-19 positive roommate. Interview with the Director of Nursing (DON) on 01/10/23 at 12:30 P.M. revealed Resident #80 remained in her room when the roommate, Resident #81 tested positive for COVID-19 on 12/29/22. The DON stated Resident #80 was educated but refused to move rooms. Review of Resident #80's care plan revealed on 01/05/23 the resident was at risk for COVID-19 and educated to move rooms and the resident declined, stating she did not care. The education was documented as being provided six days after the roommate tested positive for COVID-19. Interview with RNC #100 on 01/10/23 at 4:04 P.M. confirmed COVID-19 isolation was not implemented correctly at the facility and the family and guardians were not notified of the COVID-19 outbreak. RNC #100 verified residents in isolation should have isolation signage on their door, the resident room should have isolation trash bins near the resident room door, staff should be changing their N-95 mask when they exit a COVID-19 positive room, and staff should either replace their eye protection or disinfect the eye protection they wore into the COVID-19 positive room. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of cellular phone pictures, interviews with facility staff, and review of the facility policy titled Abuse and Neglect Clinical Protocol, the facility failed to ensure residents were free from physical, verbal, and mental/emotional abuse by two facility staff members while in two resident rooms not for any apparent care or needed services. This resulted in Immediate Jeopardy and the potential for serious physical and/or psychosocial harm for two cognitively impaired residents (#95 and #98) when State tested Nursing Aide (STNA) #112 and STNA #113 engaged in acts meant to humiliate and dehumanize the residents by recording inappropriate videos and pictures on a cellular phone of explicit actions/movements towards Resident #95 and #98 which was not in accordance with facility policy. This affected two (#95 and #98) of three residents reviewed for abuse. The facility census was 102. On 01/11/23 at 5:28 P.M., the Administrator, Regional Nurse Consultant (RNC) #100 and Regional [NAME] President of Operations (RVPO) #101 were notified Immediate Jeopardy began on 12/27/22 when management staff were texted edited picture screenshots of STNA #112 engaged in inappropriate acts with Resident #95 and Resident #98 in compromising positions when both Residents #95 and #98 were cognitively impaired, while no personal care services were being provided. Review of the screenshot pictures revealed three pictures. The first edited picture was of STNA #112 lying face up on top of Resident #95 who was also lying faceup in bed with her gown open, and breasts and incontinence brief exposed with no linens/bedding on the bed. Resident #95 appeared to be in pain and appeared to be yelling out in the picture. The second edited picture was of STNA #112 sitting on Resident #95's legs facing away from the resident who was lying in bed faceup with her gown open, and breasts and incontinence brief exposed with no linens/bedding on the bed. Resident #95 appeared to be in pain and appeared to be yelling out in the picture. The third picture featured no staff and included a picture of Resident #98 lying on her left side, curled up in the fetal position, and completely naked with no linens/bedding on the resident's bed. Resident #98's face appeared to show distress. The first two pictures were edited using an application (app) editing tool which blurred or whited out sections of the picture over the staff member's face and identifiable features. A video was taken of STNA #112 abusing Residents #95 and #98 by STNA #113 and was shared in a group chat message among STNA #110, STNA #111, STNA #112 and STNA #113. On the evening of 01/03/23, STNA #110 told Housekeeping Supervisor #85 of the videos and showed the full- length unedited videos. The next morning, (01/04/23) Housekeeping Supervisor #85 informed facility management of the full context of the video and photographs and provided them the perpetrators' names. The Immediate Jeopardy was removed on 01/12/23, after the facility implemented the following corrective actions: On 12/27/22 early afternoon, Human Resources Director #56 received a picture texted to her phone of an edited-out staff member laying on Resident #95. The Administrator was immediately notified, and an investigation was initiated. On 12/27/22 late afternoon, the Administrator received a picture texted to her phone of an edited-out staff member sitting on Resident #95. This picture was sent from the same anonymous phone number and included accusations of abuse and threats of sending the photos to the resident's family and a local news channel. Resident #95's family was also contacted by the anonymous sender and was sent the photos. On 12/27/22, the text message stated the Assistant Director of Nursing (ADON) was involved in the abuse and therefore the ADON was suspended 12/27/22 to 01/03/22 pending investigation which found the ADON had no involvement in the incident. On 12/27/22, an abuse investigation was initiated, and an SRI was submitted to the Ohio Department of Health. On 12/27/22, the Director of Nursing (DON) and/or designee completed a head-to-toe skin check and pain assessment of Resident #95 with no new concerns identified, the physician and family were notified of the incident, and Physician #150 completed an assessment of the resident. On 12/27/22, the local police were notified of the first two pictures that were sent to facility management. On 12/27/22, RNC #100 notified the sister facility [NAME] Care of [NAME] they are not to hire or rehire any [NAME] Care of Columbus staff without prior approval of the RVPO #101 or RNC #100. On 12/27/22, residents with a Brief Interview of Mental Status (BIMS) of eight or above were interviewed or assessed to ensure they feel safe and if they had experienced abuse while living at the facility. No concerns were identified. On 12/27/22, the facility's abuse policy was reviewed, and no revisions were made. On 12/27/22, staff were educated regarding the identification of abuse, the abuse policy, prevention, reporting and investigation of abuse. The training started on 12/27/22 and all staff were required to complete the training before their next shift. On 12/28/22, a third picture was texted to the Administrator by a different anonymous phone number of Resident #98 lying naked and in a compromising position. On 12/28/22, Resident #98 was added to the SRI and facility investigation related to abuse. On 12/28/22 the local police department was notified of the incident involving the three text messages of resident photographs. The police came to the facility to begin an investigation. On 12/28/22, the DON and/or designee completed a head-to-toe skin check assessment of Resident #98 with no new concerns identified, the resident's family/guardian was notified of the incident, and Social Worker #58 completed a psychosocial assessment check in with the resident. On 12/28/22, nursing supervisors completed physical assessments/skin audits on residents with a BIMS of seven or below to identify any injuries of unknown origin or evidence of abuse or neglect. Residents with a BIMS of eight or above were interviewed by nursing supervisors to identify any issues or concerns. No concerns were identified through skin checks or interviews. On 12/28/22 at 2:00 P.M., Activity Director #72 held a resident council meeting in which residents were provided education on the facility's abuse policy and procedures. Resident #95 had psychosocial check ins by Social Worker #58 on 12/28/22, 12/29/22, 12/30/22, 01/03/23, and 01/11/23 and psychiatric services follow up on 01/04/23 and 01/09/23. Resident #98 had psychosocial check ins by Social Worker #58 on 12/29/22, 12/30/22, 01/03/23, and 01/11/23. On 01/03/22, the final SRI report was submitted to the Ohio Department of Health. On 01/11/23, the Administrator, Social Worker #58 and Clinical Manager team of unit managers were educated by RNC #100 on timely and thorough abuse investigations. On 01/11/23, Resident #98 had a pain assessment completed by Social Worker #58 with no new findings and Physician #155 was notified. The resident had a follow up with psychiatric services on 01/11/23. On 01/12/23 from 9:00 A.M. to 12:05 P.M., interviews were conducted with Human Resources Director #56, Admission Director #52, Social Service Director #58, Social Services Assistant #59, Maintenance Director #77, STNAs #55, #71, #61 and Licensed Practical Nurse (LPN) #80. All staff reported they had not observed any staff video recording residents on the units with their cellular phones. Additionally, they stated they had not observed any video recordings of residents on other staff members' cellular phones nor on any form of social media. They all stated they received training by reviewing the Abuse policy and procedures. Although the Immediate Jeopardy was removed on 01/12/23, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #95 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, psychotic disorder with hallucinations, depression and anxiety, and dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact with a BIMS of 15 and required supervision of one person assist for bed mobility and extensive assist of one staff for transfers. Review of the plan of care dated 04/07/21 revealed Resident #95 required assistance with activities of daily living due to weakness, psychosis and dementia. Review of the SRI dated 12/27/22 revealed on 12/27/22, Human Resources Director #56 was anonymously texted an edited picture of a video screenshot of STNA #112 laying on Resident #95. Resident #95 was lying face up in bed with her gown open with both breasts exposed and wearing an incontinence brief with no bed sheets on the bed. The resident appeared to be in pain during the interaction. The staff member was laying on the resident with the staff member's back against resident's exposed chest and legs. The picture had been altered and the staff member had been blurred out. On 12/27/22, a second photograph was texted from the same anonymous number to the Administrator showing Resident #95 lying in bed with her gown open and her breasts exposed and wearing a depends, with no linens on the bed. STNA #112 was observed to be sitting on the resident's legs facing away from the resident. Resident #95's mouth was open in a yelling motion and appeared to be in pain. The staff member was again blurred out in the picture. This text message also included threats to send pictures to the resident's family and to a local news station. The investigation included an interview with Resident #95, who had no recollection of the event. The facility's investigation was completed on 01/03/23 and substantiated the allegation of abuse for Resident #95. Interview on 01/10/23 at 5:00 P.M. with RNC #100 revealed Resident #95's daughter was texted a copy of the picture along with a text claiming abuse occurred at the facility. Review of the screenshot pictures on 01/11/23 revealed the first edited picture was of STNA #112 lying face up on top of Resident #95 who was also lying faceup in bed with her gown open, and breasts and incontinence brief exposed with no linens/bedding on the bed. Resident #95 appeared to be in pain and appeared to be yelling out in the picture. The second edited picture was of STNA #112 sitting on Resident #95's legs facing away from the resident who was lying in bed faceup with her gown open, and breasts and incontinence brief exposed with no linens/bedding on the bed. Resident #95 appeared to be in pain and appeared to be yelling out in the picture. The first two pictures were edited using an app editing tool which blurred or whited out sections of the picture over the staff member's face and identifiable features. 2) Review of the medical record for the Resident #98 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type, diabetes type two, cognitive impairment, glaucoma, anxiety, and intellectual disability. Review of the MDS assessment dated [DATE] revealed Resident #98 was cognitively impaired with a BIMS of five and required extensive assistance of two staff members for bed mobility and transfers. Review of the plan of care dated 05/13/22 revealed Resident #98 had difficulty with communication due to slurring words and cognitive deficit with interventions to ask yes or no questions, make eye contact when speaking with resident and use simple or brief words. Review of the SRI dated 12/27/22 revealed on 12/28/22, a third picture was sent to the Administrator's cell phone from a different anonymous phone number featuring Resident #98. This picture was of Resident #98 lying completely naked in bed on her left side in the fetal position with no linens/bedding on the bed. The resident appeared to look sad or distressed. The investigation included an interview with Resident #98, who had no recollection of the event. The facility's investigation was completed on 01/03/23 and substantiated the allegation of abuse for Resident #98. Review of the third screenshot picture revealed no staff in the picture, but instead was just Resident #98 lying on her left side, curled up in the fetal position, completely naked with no linens/bedding on the resident's bed. Resident #98's face appeared to show distress. Interview on 01/09/23 at 1:51 P.M. with Police Officer #200 revealed they had not closed the investigation but revealed all further information would be found by the Ohio Department of Health investigation and reviewed by the Ohio Attorney General. Police Officer #200 revealed no arrests had been made since the identities of the perpetrators were made known by the facility investigation. Interviews on 01/09/23 from 11:00 A.M. to 2:30 P.M. with Residents #95 and #98 revealed neither resident had any recollection of the videos being taken. From brief interview, neither resident was interviewable. Interview on 01/11/23 at 9:24 A.M. with Housekeeping Supervisor (HS) #85 revealed she observed the unedited images and videos on the phone of STNA #110 on 01/03/23 who was employed at the facility. HS #85 revealed she reported the identity of the staff involved in the pictures and videos to the Administrator the next day on 01/04/22. HS #85 revealed the videos were brought to her in a bragging manner and were part of a group chat involving four STNA's (#110, #111, #112 and #113). HS #85 revealed she saw the unedited videos and pictures and could tell who was laying and sitting on the residents and who was recording the video. She stated both residents could be heard screaming in the videos as staff were messing with them while taking the videos including laughing and dancing on the residents in a sexual manner. Interview on 01/11/23 with RNC #100 and the Administrator revealed all four staff members involved were no longer working at the facility. The two staff involved in the making of the videos (STNA #112 who was perpetrating the abuse by sitting and laying on Resident #95 and STNA #113 who was recording the abuse) both stopped working at the facility on 08/16/22 and transferred to a sister facility. STNA #111 was involved in the group text message and was terminated around 12/27/22 for falsifying timeclock hours and STNA #110 who was also involved in the group text of the abuse videos and pictures was terminated 01/04/23 for falsifying a COVID-19 test to get time off after being placed on probation for numerous other infractions. Due to the timeframes of when the residents were admitted to the facility and when the staff left the facility, it was estimated by RNC #100 and the Administrator that the videos were taken, and abuse occurred between 05/20/22 and 08/20/22 and were released to facility management in retaliation. Review of a written statement from HS #85 revealed she was shown the videos and photos of abuse of Residents #95 and #98 by STNA #110 in a bragging or gloating manner from his cell phone. HS #85 revealed she saw the unedited videos from a group message that contained STNAs #110, #111, #112 and #113. HS #85 was able to go into detail of the photographs and clearly describe the staff in front of and behind the camera based on viewing the picture and the audio of STNA #112 and #113 speaking in the video. HS #85 revealed STNA #112 was trying to be funny by dancing on Resident #95 in a sexual way while STNA #113 was laughing. HS #85 revealed during this interaction, Resident #95 was screaming and yelling out. HS #85 revealed Resident #95 was exposed with both breasts showing and her incontinence brief showing. HS #85 estimated the video was a few minutes long. HS #85's statement revealed Resident #98 was naked in the video and she was able to hear STNA #113 telling Resident #98 she's a pretty mermaid. HS #85 revealed in the video Resident #98 was moving in a flowing or rocking manner and was seen without any clothes on and no bedding on the bed. Review of the police report dated 12/27/22 revealed facility management received through an anonymous text message, pictures of Residents #95 and #98. The police report was able to provide a partial physical description of the perpetrator based on what was still visible. The description included an African American female about five-foot nine-inch height with a [NAME] waist and a large butt and black hair. Neither resident had a recollection of the incident. Review of the personnel file for STNA's #110, #111, #112, #113 revealed no mention in their employee file of a history of abuse and no mention of the incident. All staff had been terminated for reasons not related to the abuse of Residents #95 and #98. Review of the policy titled, Abuse and Neglect Clinical Protocol, effective 03/2018, revealed the policy stated abuse was defined as a willful infliction of pain or intimidation causing mental anguish and also includes deprivations causing mental anguish. It also includes verbal abuse, sexual abuse, physical and mental abuse including abuse facilitated or enabled through the use of technology. This deficiency represents non-compliance investigated under Complaint Number OH00139008, Complaint Number OH00139010, and Complaint Number OH00139012.

Based on observation, record review, resident interview, staff interview and policy review, the facility failed to timely implement procedures to minimize the risk for pressure ulcers for one (#59) of three residents reviewed for pressure ulcers. This resulted in actual harm when Resident #59 developed a new stage II pressure ulcer. The facility also failed to follow the wound treatment recommendations for three (#59, #55, and #58) of three residents reviewed for pressure ulcers. The facility census was 102. Findings include: 1. Review of the medical record for the Resident #59 revealed an admitted [DATE]. Diagnoses included sepsis, heart failure, respiratory failure, diverticulitis, depression, encephalopathy, and transient ischemic attack. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and required extensive assistance of two staff members for transfers and required extensive assist of one staff member for eating. The MDS revealed the resident had a greater than 5% weight loss that was unplanned and the resident had a therapeutic diet. Review of the progress notes dated 12/09/22 revealed the dietician reviewed the resident for a significant weight loss of 13 pounds and recommended the supplement Ensure twice daily. The resident had another small weight loss of 3 pounds on 12/14/22 and the dietician had continued to monitor the resident's weights. Review of the Medication Administration report (MAR) dated 12/2022 and 01/2023 revealed the resident had been getting the supplements once daily and twice daily as ordered and the percentage of intake had been documented in the MAR. Review of the plan of care dated 07/29/22 revealed Resident #59 was at risk for potential for nutritional risk related to weight loss with interventions to document food and fluid intakes, honor food preferences, serve diet as ordered provide supplements and dietician to evaluate for diet changes. Resident #59's care plans included a care plan which stated the resident had moisture associated dermatitis to the sacrum dated 10/07/22 and the care plan was updated stating the resident had an unstageable pressure ulcer (the base of the ulcer is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black and therefore the stage could not be determined) to the sacrum on 12/18/22. Interventions listed on the care plan included to provide incontinence care as needed, wound treatment as ordered, pressure reducing bed, and turning the resident. All interventions were dated 10/07/22. Review of Resident #59's physician orders at the time of the survey revealed the resident had the following wound orders in place: float heels as tolerated dated 07/29/22; air mattress ordered 11/29/22; apply heel protector boots every shift for pressure reduction ordered 11/29/22; apply triad cream (barrier cream) to sacrum two times a day for wound care dated 10/07/22; cleanse buttock ischium with soap and water and apply triad cream twice daily and as needed dated 12/23/22; cleanse left heel with mild soap and water apply triad cream and cover with border foam dressing dated 12/23/22. Review of Certified Nurse Practitioner (CNP) #300's wound documentation revealed the resident was seen weekly and had his wounds measured. The documentation included the wound's size, surface area and condition of the wounds. The documentation also included the current treatment and interventions for each wound. The resident's sacral wound was acquired on 10/06/22 and documented etiology as moisture related to urine and stool incontinence. The wound was classified as moisture associated dermatitis (MASD). Sacral wound documentation was as follows: -MASD measurement on 10/06/22: 5.42 centimeters (cm) x 3.56 cm x 0.1 cm. -MASD measurement on 10/11/22: 1.29 cm x 1.05 cm x 0.10 cm. -MASD measurements on 10/18/22: 0.91 cm x 0.30 cm x 0.1 cm. -MASD measurement on 10/28/22: 1.93 cm x 2.09 cm x 0.1 cm. -MASD measurement on 11/01/22: 3.11 cm x 3.37 cm x 0.1 cm. -MASD measurement on 11/08/22: 5.75 cm x 5.02 cm x 0.1 cm. -MASD measurement on 11/15/22: 3.26 cm x 1.50 cm x 0.1 cm. Resident #59 was in the hospital from 11/15/22 through 11/29/22 and returned to the facility on [DATE]. Review of the nursing admission/readmission evaluation from 11/29/22 revealed the resident had redness to the coccyx, and a right thigh and a left heel pressure ulcer. No wound measurements or description of the areas were included in the nursing admission/readmission evaluation or in the medical record. A MASD measurement of the sacrum revealed on 12/06/22 the area was 3.84 cm x 4.60 cm x 0.1 cm. The recommended treatment for the 12/06/22 MASD documented in CNP #300's wound documentation was to cleanse the area with normal saline and apply triad paste twice daily and as needed. CNP #300's documentation on 12/13/22 revealed the sacral area was worsening and was now classified as an unstageable pressure ulcer measuring 6.79 cm x 3.83 cm. The treatment was documented as cleanse wound with normal saline, apply hydrogel (keeps the wound moist and helps to remove slough or necrotic tissue), and cover with a border foam dressing daily. Wound care interventions were updated to include a specialty bed. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's recommended treatment starting on 12/13/22 when the facility continued to use the triad paste twice daily to the wound and apply border foam. Resident #59 was hospitalized from 12/18/22 through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization . There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The resident's wounds were re-assessed on 12/27/22 by CNP #300, six days later. CNP #300's documentation of the unstageable area to the resident's sacrum was as follows: -12/27/22 improving wound measuring 3.51 cm x 2.65 cm, continue with normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. -01/03/23 wound is stable measuring 3.67 cm x 2.60 cm, continue normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. -01/10/23 wound is stable measuring 3.13 cm x 2.37 cm, continue normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's wound treatment recommendations when the facility continued to treat the sacrum ulcer with triad paste twice daily. Resident #59's right posterior thigh skin alteration was documented in the medical record by CNP #300 as follows: -10/28/22 skin tear: 1.16 cm x 1.42 cm x 0.10 cm -11/01/22 skin tear: 1.99 cm x 2.68 cm x 0.1 cm -11/08/22 skin tear: 2.08 cm x 1.32 cm x 0.1 cm -11/15/22 skin tear: 1.35 cm 0.98 cm x 0.10 cm Wound care treatment recommendations for the above dates were documented in CNP #300's notes as cleanse with normal saline and apply triad paste twice daily and as needed. Resident #59 was in the hospital from 11/15/22 through 11/29/22 and returned to the facility on [DATE]. Review of the nursing admission/readmission evaluation documented the resident wounds as redness to the coccyx, a right thigh, and a left heel pressure ulcer. No wound measurements or description of the areas were included in nursing admission/readmission evaluation or in the medical record. The medical record had the ordered treatment for the right posterior thigh from 11/29/22 through 12/06/22 as cleanse the area with normal saline and apply triad paste twice daily and as needed. On 12/06/22 the right posterior thigh wound was assessed by CNP #300 and documented the wound to the right posterior thigh as 1.42 cm x 1.94 cm x 0.20 cm. The wound was classified as a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) with the treatment documented as cleanse with normal saline, apply hydrogel and cover with a border foam dressing change daily. On 12/13/22 CNP #300 documented the right posterior thigh stage III pressure ulcer was 1.31 cm x 1.87 cm x 0.1 cm and the treatment recommendation by CNP #300 was cleanse with normal saline, apply hydrogel, and cover with a border foam dressing change daily. Resident #59 was hospitalized from 12/18/22 through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization . There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The wounds were re-assessed on 12/27/22 by CNP #300, six says later. CNP #300's documentation of the resident's right posterior thigh was as follows: -12/27/22 stage III pressure ulcer to right posterior thigh: 1.59 cm x 1.94 cm x 0.1 cm documented as stable, treatment continued as cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. -01/03/23 right posterior wound classification changed to an unstageable area: 1.16 cm x 2.01 cm x 0.2 cm continue to cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. -01/10/22 right posterior thigh unstageable pressure ulcer: 1.15 cm x 2.12 cm x 0.2 cm documented as stable and to continue to cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. Review of Resident #59 's physician orders revealed the facility failed to follow the CNP #300's wound treatment recommendations when the facility continued to treat the right posterior thigh (buttock/ischium) ulcer with triad paste twice daily and cover with a border foam dressing. Resident #59's medical record revealed the resident acquired an unstageable pressure ulcer to the left heel on 11/14/22. CNP #300's wound documentation for the left heel was as follows: -11/15/22 unstageable: 3.14 cm x 3.99 cm cleanse with normal saline, apply hydrogel, cover with Army Battle Dressing (ABD) pad, and wrap with Kerlix/Kling. -12/06/22 unstageable: 2.79 cm x 2.64 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -12/13/22 unstageable: 3.50 cm x 3.81 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. Resident #59 was hospitalized from 12/18/22 through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization . There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The wounds were re-assessed on 12/27/22 by CNP #300, six days later. CNP #300's documentation of the resident's left heel was as follows: -12/27/22 unstageable: 2.16 cm x 2.14 cm, wound stable, continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -01/03/23 unstageable: 2.13 cm x 2.39 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -01/10/23 left heel classification was changed to a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) :1.24 cm x 1.64 cm x 2.03 cm, documented as an improving wound and to continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's wound treatment recommendations from 12/27/22 to 01/10/23 when the facility continued wound care to the left heel ulcer as cleanse left heel with mild soap and water apply triad paste and cover with border foam dressing. Interview on 01/09/23 at 12:13 P.M. with Resident #59 revealed he used the call light to get assistance and it typically took 30 to 60 minutes for staff to come to the room. He revealed he wears incontinence briefs and revealed he will be left to sit in his urine and feces for hours at times. Observation on 01/12/23 at 11:00 A.M. of Resident #59 with Unit Manager #75 revealed the resident was agreeable to have his incontinence brief checked. Upon observation of the resident's incontinence brief, it was noted to be saturated with urine and this was verified by Unit Manager #75. Resident #59 stated during the observation, he last received incontinence care on 01/12/23 at 5:00 A.M. Interview on 01/12/23 at 11:10 A.M. with STNA #55 revealed she was the staff assigned to care for Resident #59 on this day. The STNA was observed in another resident's room sitting in a resident's wheelchair and stated she was waiting to assist another staff member to get this resident ready for an appointment and then she would go to provide care to Resident #59. STNA #55 verified she had not provided any personal care to Resident #59 on this day and verified her shift started at 7:00 A.M. STNA #55 was asked how often incontinence care was to be provided and she stated twice. STNA #55 was asked to clarify what she meant by twice and she stated twice a shift. She then stated incontinence care should be provided every two hours or as needed. STNA #55 stated she checked on Resident #59 at the beginning of her shift at 7:00 A.M and he was dry and that the night shift had changed the resident prior to going off shift. STNA #55 then confirmed the present time was after 11:00 A.M. Interview on 01/12/23 at 11:11 A.M. with Unit Manager #75 confirmed STNA #55 was currently assisting get another resident ready. Unit Manager #75 was questioned if there was enough staff to complete the workload if STNA #55 had not yet provided care to a resident on her assignment and it was 11:00 A.M. and her shift had started at 7:00 A.M. Unit Manager #75 stated there should be four STNA's on the hall and revealed STNA #55 was new to the facility. Observation and interview with Resident #59 on 01/17/22 at 9:15 A.M. revealed the resident's call light was activated and the resident stated he needed to be changed. The resident stated he had last been provided incontinence care on 01/17/22 at approximately 3:00 A.M. The facility's Assistant Director of Nursing (ADON) #67 entered Resident #59's room on 01/17/22 at 9:35 A.M. The resident's incontinence care product was checked and ADON #67 verified the incontinence care product was saturated with urine. Interview with STNA #102 on 01/17/23 at 9:37 A.M. confirmed Resident #59 was on her assignment and she had not provided any care to the resident on this day. Resident #59 was provided incontinence and wound care on 01/17/23 at 9:40 A.M. When the incontinence brief was removed the resident's border foam dressing to the sacrum was only attached to the resident's skin at the top of the dressing; the other three sides of the dressing were no longer attached to the resident's skin and the border foam dressing was saturated. During the incontinence care the border foam dressing to the sacrum fell off the resident. Additionally, Resident #59's left buttock was observed to have an open area to the skin that was not documented in Resident #59's medical record. The area was red in appearance with the top layer of skin missing. Interview with Regional Nurse Consultant (RNC) #100 on 01/17/23 at 9:42 A.M. who was present during the incontinence and wound care verified Resident #59's incontinence brief was saturated with urine and the sacrum dressing to the sacral pressure ulcer was so saturated with urine the dressing fell off the resident during incontinence care. RNC #100 confirmed there was a new open area to the resident's left buttock which was observed during the incontinence and would care and the area was a stage II pressure ulcer. The new stage II pressure ulcer to the resident's left buttock was cleansed with normal saline and measured as 5.0 cm x 2.0 cm. The staff stated CNP #300 would be notified and the facility would obtain a dressing order for the area from CNP #300. The resident's right posterior thigh border foam dressing was removed, and an unidentified white cream was noted on the skin around the wound. It could not be determined if the cream was in the wound bed. The wound was observed to have an area on the top left side of the wound that was covered in slough. RNC #100 and Assistant Director of Nursing (ADON) #67, who was performing the dressing change, both verified the current dressing orders did not include the use of any cream to the resident's skin/wound as part of the ordered treatment. RNC #100 and ADON #67 verified the wound dressing which was removed from the right posterior thigh was not the correct dressing. RNC #100 verified neither the sacrum wound, nor the right thigh wound border foam dressing was dated indicating when the dressing was last changed. Observation of the left heel pressure area revealed when ADON #67 removed the Kerlix wrap from the wound the wound was covered with a border foam dressing and not the ordered ABD pad. ADON #67 and RNC #100 both verified this at that time. The border foam dressing was not the current ordered treatment and should not be in place over the resident's left heel pressure ulcer. The border foam dressing was dated of 01/16/23 on the 7:00 A.M. to 7:00 P.M. shift. ADON #67 stated she thought the dressing was to be completed once per day with hydrogel being placed in the wound bed and covered with an ABD pad and then wrapped in Kerlix. Interview with RNC #100 on 01/17/22 at 11:30 A.M. verified Resident #59 was not provided incontinence care timely and his incontinence brief was saturated with urine at the time of the incontinence and wound care on 01/17/23 at 9:40 A.M. RNC #100 verified the etiology of the sacrum wound was documented by CNP #300 as moisture related to urine and stool incontinence. RNC #100 also verified that during the observation of incontinence and wound care Resident #59 had a new stage II pressure ulcer identified to his left buttock. RNC #100 also verified the resident did not have his skin and wound assessments completed when the resident was readmitted on [DATE] and the wounds had no documented assessment in the medical record until six days later when wound CNP #300 assessed the resident's wounds on 12/27/22. During multiple observations of Resident #59 during the days of the survey there were no observed heel boots on the resident or in the resident's room for the resident as ordered on 11/29/22. During an observation of Resident #59 with RNC #100 on 01/17/23 at 1:20 P.M. it was confirmed the resident did not have heel boots in use. RNC #100 verified the treatment orders for Resident #59 were not updated to the recommended wound treatments CNP #300 had in the wound notes for Resident #59. RNC #100 verified the treatments in place during the dressing change observation on 01/17/23 at 9:40 A.M. were not the ordered treatment for the right posterior thigh and the left heel pressure ulcer, and RNC #100 verified the resident did not have the ordered heel boots in place as ordered. Interview with ADON #67 on 01/17/22 at 1:25 P.M. confirmed the resident's orders did not match the treatments CNP #300 recommended. ADON #67 also verified she had not seen the resident use heel boots in the facility. 2. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, suicidal ideations and history of traumatic brain injury. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had mild cognitive impairment, required limited assist for bed mobility, transfers, and locomotion on and off the unit. Resident #58 was occasionally incontinent with bowel and bladder, had a current pressure ulcer coded as a stage III ulcer that was present on admission or re-entry to the facility. The resident was noted to have an area to his lower spine on admission/readmission evaluation dated 10/28/22. Resident #58's medical record revealed the resident's wound was followed by CNP #300 and was regularly assessed with the area being described as a stage III pressure that was stable or improving on the weekly documentation. CNP #300's recommended treatment for the stage III pressure ulcer was cleanse wound with normal saline, apply hydrogel and border foam dressing from 11/01/22 to 01/03/23. Resident #58's physician orders for the stage III pressure ulcer were documented as open area to right upper back cleanse with saline, pat dry and apply dry dressing from 10/30/22 to 01/04/23. Open area to right upper back cleanse with saline, pat dry, apply calcium alginate (dressing used for wounds with moderate to heavy drainage) and foam dressing daily dated 01/05/23 to 01/18/23. There were no other orders present for any wound or skin alteration on the resident's back during the listed time frames. Interview on 01/17/23 at 4:55 P.M. with RNC #100 verified the facility was not following CNP #300's recommended treatment of hydrogel and border foam dressing 11/01/22 to 01/03/23. 3. Review of Resident # 55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis, contracture, dementia, pseudobulbar affect, and schizoaffective disorder. Resident #55's physician orders at the time of the survey included may use barrier cream as needed, may keep at bedside dated 04/11/17; Calmoseptine (barrier cream) to buttock after each incontinence episode dated 05/20/21; Remedy Calazime (barrier cream) skin protectant, apply to wound to left inner thigh three times daily and as needed dated 01/19/22; Cleanse inner left thigh with normal saline, apply silver alginate (moist dressing used for infected chronic wounds) and cover with ABD dated 10/07/22; Pillow between legs to help with contraction dated 10/06/22; Cleanse right posterior thigh with normal saline, pat dry, apply hydrogel and cover with border foam dressing dated 10/12/22. Review of 12/2022 treatment administration record (TAR) for Resident #55 revealed the treatment for the right posterior thigh was cleanse right posterior thigh with normal saline, pat dry, apply hydrogel and cover with a border foam dressing, and apply skin prep to right posterior thigh. Both treatments were on the same order and were to be completed daily with a start date of 10/12/22. Review of Resident #55's 01/2023 TAR revealed the treatment for the right posterior thigh was cleanse right posterior thigh with normal saline, pat dry, apply hydrogel cover with border foam dressing and apply skin prep to right posterior thigh. Both treatments were on the same order and were to be completed daily with a start date of 10/12/22. The treatments were signed off daily as completed except 01/01/23 and 01/17/23 when the resident refused the treatment. Review of CNP #300's wound documentation revealed Resident #55's right posterior thigh wound was assessed weekly and the wound was noted as either stable or improving on all notes. CNP #300's listed the treatment for the right posterior thigh wound on 10/06/22 was cleanse with normal saline and apply skin prep. CNP #300's note from 10/13/22 revealed the treatment recommendation changed to cleanse the area with normal saline, apply hydrogel and cover with border foam dressing and to place pillows between knees for offloading for stage III pressure ulcer. This dressing remained the recommended dressing for the right posterior thigh pressure ulcer until 12/13/22 when the recommended treatment was changed to triad cream to stage III pressure ulcer, complete twice daily, place pillows between knees for offloading for stage III pressure ulcer. CNP #300 documented the right posterior thigh pressure ulcer as healed on 12/20/22 and no treatment recommendation was included in the wound documentation. The facility failed to follow CNP #300's recommendations when the facility treated the right posterior thigh with normal saline, patted dry, applied hydrogel and covered with border foam dressing from 10/12/22 and continued through 01/03/23. Review of the 12/2022 treatment administration record (TAR) for Resident #55 revealed the treatment for the left inner thigh, dated 10/07/22, was cleanse left inner thigh with normal saline, apply silver alginate and cover with ABD, change daily. Review of Resident #55's 01/2023 TAR revealed the treatment for the left inner thigh was cleanse the left inner thigh, apply silver alginate cover with an ABD pad perform daily. The treatment was initialed as completed daily except on 01/01/23 and 01/17/23 where it was documented the resident refused the treatment. Review of CNP #300's wound documentation of the left inner thigh wound revealed on 10/06/22 the wound was a new pressure ulcer, called a suspected deep tissue injury with the recommended treatment of cleanse the wound with normal saline, apply silver alginate and cover with an ABD pad. CNP #300 documented the left inner thigh wound as a pressure ulcer, called a suspected deep tissue injury that was either improving or stable, with the recommended treatment of cleanse the wound with normal saline, apply silver alginate and cover with an ABD pad through 12/06/22. The wound note from 12/13/22 changed the recommended treatment to triad cream, place pillows between knees for offloading of contractions. This remained the recommended treatment through 01/03/23. Review of progress note dated 01/10/23 at 11:06 A.M. revealed the resident refused wound care from the nurse and CNP #300. No wound measurements were in the medical record for the wound from 01/03/22 through 01/10/23. Review of weekly nursing evaluation completed on 01/11/23 revealed the resident had no new skin conditions. There was no assessment of the resident's left posterior thigh in the evaluation. Review of the weekly nursing evaluation dated 01/17/23 revealed the form had the resident's vital signs but the rest of the evaluation was blank including the resident's skin evaluation and the additional comment field was also blank. Interview with RNC #100 on 01/18/22 at 9:00 A.M confirmed the facility did not follow the wound treatment recommendations from CNP #300 for Resident #55. Review of policy titled, Skin Management, dated 10/2019, revealed it is the policy of [NAME] Care to assess each resident to determine the risk of potential skin integrity impairment. Residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment. A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and no less weekly. Residents identified at risk for skin breakdown will have appropriate preventative interventions put in place. All alterations in skin integrity will be documented in the medical record. Residents admitted or readmitted with alterations in skin integrity will be documented on admission evaluation. All newly identified areas after admission will be documented on the weekly pressure/non-pressure evaluation. The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. A plan of care will be initiated to include resident specific risk factors with appropriate interventions. Review of policy titled, Wound Care, dated 2001 and revised on 10/2010, revealed staff were to verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. The following information should be recorded in the resident's medical record: The type of wound care given; the date and time the wound care was given; the position in which the resident was placed; the name and title of the individual performing the wound care; any change in the resident's condition; all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; how the resident tolerated the procedure; any problems or complaints made by the resident related to the procedure; if the resident refused the treatment and the reason(s) why; the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00139013 and OH00138817.

Based on observation, review of the medical record review, fall investigation, fall policy, hospital records and staff interviews, the facility failed to ensure Resident #98 who was at risk for falls, had care planned interventions in place, was assessed properly post fall, received timely medical treatment from falls with injury, and failed to investigate the root cause of the falls to implement appropriate falls interventions. This resulted in Immediate Jeopardy on 05/22/22 at 1:36 A.M., when Resident #98 reported to staff he had an unwitnessed fallen on 05/21/22 at 11:00 P.M., after having a [CONDITION(S)]. The resident had requested to go to the hospital, however, was not sent due to the on-call nurse at the facility did not answer the phone. There was no evidence the physician was notified of the fall and resident request to go to the hospital. The facility did not initiate neurological checks, complete a fall investigation, or initiate a new fall intervention. Actual Harm occurred when Resident #98 sustained five additional falls (05/22/22, 05/23/22, 06/04/22, 06/05/22, and 06/12/22) that were not thoroughly investigated to determine the root cause, appropriate interventions were not initiated and/or revised, or the physician notified of all falls that ultimately resulted in the resident having to be admitted to the hospital on 06/12/22 with a Level II Trauma involving malar fracture (uncommon injury involving one or more of the bones that make up the malar region of the face), rib fracture, and subsequent surgery. In addition, a concern that did not rise to the level of Immediate Jeopardy occurred when Resident #21, #37 and #61, who were at risk for falls, did not have effective fall interventions in place to prevent falls, failed to determine the root cause of falls and/or failed to ensure timely follow up of radiology results for residents following falls. This affected four residents (Resident #21, #37, #61, and #98) of four residents reviewed for falls. The facility census was 101. On 06/15/22 at 5:40 P.M. Regional Nurse #310 was notified Immediate Jeopardy began on 05/22/22 at 1:36 A.M., when Resident #98 had reported an unwitnessed fall and then had five additional falls from 05/22/22 to 06/12/22 that were not thoroughly investigated to determine the root cause, appropriate interventions were not initiated and/or revised, or the physician notified of all falls that ultimately resulted in the resident having to be admitted to the hospital on 06/12/22 with a Level II Trauma involving malar fracture, rib fracture, and subsequent surgery. The Immediate Jeopardy was removed on 06/16/22 when the facility implemented the following corrective action: · On 06/15/22 at 6:15 P.M., the Medical Director was notified by the Director of Nursing (DON). · On 6/15/22 at 6:15 P.M., AD HOC QAPI team (Regional Nurse Consultant, VP Clinical Operations, VP Operations, Regional VP of Operations, Medical Director, Director of Nursing Services, Executive Director) met to develop the abatement plan. · On 6/15/22 from 8:00 P.M. to 11:50 P.M., education in person and via phone was started with 19 of the 20 Licensed Nurses (LPN #303, LPN #304, LPN #308, LPN #309, RN #501, LPN #502, RN #503, LPN #504, RN #505, LPN #506, LPN #507, LPN #508, LPN #509, LPN #510, LPN #511, RN #512, LPN #513, LPN #514, and LPN #516) including the Director of Nursing on the fall management policy including notifications, interventions, fall risk assessments and root cause analysis with appropriate intervention. The licensed staff were also educated on the new incident and accident packet. The one Licensed Nurse (LPN #500) will be educated on or before their next scheduled shift. · On 6/15/22 at 10:15 P.M., Regional Nurse Consultant reviewed progress notes for all 101 residents in the last 60 days to ensure fall incidents have a risk management completed. No Concerns were identified. · On 6/15/22 at 11:35 P.M., Regional Nurse Consultant reviewed 101 residents to ensure that fall risk assessments have been completed in the last 90 days. Five Residents did not have a fall risk assessment completed in the last 90 days. Those residents were evaluated for fall risk condition to ensure appropriate interventions have been followed and/or implemented to reduce the risk of fall or injury related to fall. Care plans updated as needed. · On 06/15/22 at 11:45 P.M., Director of Nursing Services (DNS) reviewed all residents (8) that had a fall in the last 60 days to ensure physician/NP notification, root cause analysis with appropriate intervention(s). Care plans and fall risk assessments updated as needed. · Beginning on 06/15/22 a new incident and accident packet will be implemented to ensure a thorough investigation including root cause, appropriate intervention, post fall assessment, and notification. The packets will be reviewed by the DNS the next business day during the IDT (LPN #303, LPN #304, RN #512, LPN #513, LPN #514, LPN #516, Social Service (SS) #517, and Director of Resource (DOR) #518) meeting. · Beginning on 06/16/22 audits will be conducted weekly for four weeks and then monthly for two months, and then as needed. Results of the audit will be forwarded to QAPI for review. Although the Immediate Jeopardy was removed on 06/16/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) related to the concerns identified for Resident #21, #37 and #67 and as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings include: 1. Review of the closed medical record revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including fracture of the lower end of left tibia, seizures, [CONDITION(S)], fracture of the third thoracic vertebra, injury of the blood vessels at the lower leg level, pedestrian injured in traffic accident involving unspecified motor vehicle and personal history of traumatic brain injury. The resident was ordered [MEDICATION(S)] and [MEDICATION(S)] medications for his seizures on admission. Review of Resident #98's morse fall scales dated 05/12/22 revealed the resident was at a moderate risk for falls. Additional morse fall scale assessments completed on 05/19/22,05/24/22, 06/05/22, 06/07/22, 06/09/22, 06/12/22 revealed the resident was at high risk for falls. Record review revealed a plan of care was initiated on 05/13/22 and revised on 05/25/22 reflecting was at risk for fall related to injury due to diagnosis of fracture of the left tibia. On 05/13/22 the interventions included to keep call light and frequently used items in reach, appropriate footwear, and assist with toileting. Intervention dated 05/24/22 included staff to assist with transfers and to use a gait belt for all transfers, encourage to participate in activities, keep clear and well-lit pathway, mat on floor next to bed (resident has several mats on the floor next to his bed because he will crawl on the floor and sleep), medication review including [MEDICATION(S)]/[MEDICATION(S)] levels, and therapy to screen. On 06/09/22 an intervention to assist resident and ambulate when he becomes restless was added. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 had severe cognitive impairment and required extensive assistance from one staff member for bed mobility, transfers, walking in his room and corridor, toilet use and personal hygiene. The resident was assessed to require supervision from staff with locomotion on and off the unit and eating. The resident had unsteady balance with transition and walking, limited range of motion of lower extremities on one side and used a wheelchair. Record review revealed Resident #98 reported he had sustained an unwitnessed fall on 05/21/22 around 11:00 P.M. while having a [CONDITION(S)]. The resident reported his speech was slurred and requested to go to the hospital. The nurse attempted to call the on call nurse three times without a response. There was no evidence the physician was notified. The facility did not complete a fall investigation nor was neurological assessments or new interventions initiated. The resident was not sent to the hospital per his request. On 05/22/22 at 8:30 A.M., a progress note revealed a nurse's aide reported to the nurse that Resident #98 had a cut on his left eyebrow. The resident reported that he had an unwitnessed [CONDITION(S)] and fell to the floor from the bed after 2:00 A.M., this morning. The physician was notified, and new orders were received to send the resident to the emergency room . Neurological checks were initiated at 8:30 A.M., and completed again at 8:45 A.M. The resident returned to the facility at 2:30 P.M., with steri-strips to the left forehead, however the neurological checks were not continued. The facility had no paperwork regarding the emergency room visit prior to the survey investigation and was trying to call the hospital to obtain the records. Review of the hospital records dated 05/22/22 revealed there was discrepancies in the size of the laceration above the left eyebrow. The notes indicated the size was two centimeters to four centimeters. The physician indicated that the seizures was from missed doses of mediations. Review of Resident #98's fall investigation dated 05/22/22 indicated the resident described having a [CONDITION(S)] after 2:00 A.M. but doesn't recall the exact time. He stated that he had fallen out of bed and then climbed back into the bed after the [CONDITION(S)] had stopped. There was no evidence there was a thorough investigation completed or intervention implemented. The neurological assessment flow sheet indicated that neurological checks would be performed every 15 minutes for one hour, every hour for four hours, and then every 4 hours for 19 hours. The neurological checks were only completed on 05/22/22 at 8:30 A.M. and 8:45 A.M. On 05/23/22 the Certified Nurse Practitioner (CNP) notes revealed the staff reported the resident had been physical aggressive towards staff at times and had fallen several times since admission. There were no new labs to review. The resident had a safety screening completed and was positive for fall risk and mitigation recommendation included the use of proper footwear. The resident was admitted with [MEDICATION(S)], however the CNP wrote new orders to discontinue the [MEDICATION(S)] due to the resident was not psychotic and was a fall risk. On 05/24/22 A.M., at 12:52 A.M., there was a nursing note indicating the resident was noted to be combative with staff and [MEDICATION(S)] was reordered. On 05/24/22 at 1:00 A.M., a psych note indicated the resident was referred for assessment and management of mood related behaviors, difficulties mood, and possible cognitive issues. The resident endorsed difficulties with depression and as well as anxiety. It was noted the resident had significant swelling of his lower lip and his left eye and laceration with stitches from a fall the previous day. The resident verbalized he was worried about what would happen to him and he was sad. The resident appeared to be visible appeared depressed and had great difficulty speaking. It was unclear if it was due to hurting his mouth during the fall or if this was his normal. Review of a fall investigation dated 05/24/22 at 1:31 A.M., revealed on 05/23/22 at 10:50 P.M., Resident #98 was found sitting on the floor in his room with a bruise on the lip and both knees. The fall was not documented in the medical record. The resident was assessed and had no indication of hitting his head, patient was unable to respond to the question if he hit is head or not. As needed [MEDICATION(S)] was ordered, as well as new interventions of a mattress placed in front of the bed, low bed, repositioning, and frequent checks. The investigation indicated under the injury section that there were no injuries, even though the description indicated he had bruise on lip and both knees. The investigation was not thorough to include the root cause of the fall, if fall interventions were in-place, or the last time the resident was seen, etc. The neurological assessment flow sheet provided as part of the investigation dated 05/23/22 indicates that the neurological assessments started on 05/23/22 at 3:00 A.M., however the fall didn't occur until 10:50 P.M. Review of the paper and electronic medical records revealed no evidence Resident #98 had fallen on 05/23/22. A second fall plan of care was initiated on 05/24/22 and revised on 06/13/22 that indicated the resident was a fall risk related to history of falls related to psychoactive drug use, periods of confusion, gait/balance problems, and poor communication/comprehension. The resident was noted to crawl/sleep on the floor. Four mattresses placed on floor for safety. Intervention dated 05/24/22 included to wear appropriate footwear, call light and personal items in reach, clear and well-lit pathway, and to assist with toileting and transfers. On 05/25/22 therapy screening as needed was added, and wheelchair as an assistive device. On 06/09/22 one on one sitter as needed. An IDT note dated 05/24/22 at 10:26 P.M., revealed that the resident's medication was reviewed and [MEDICATION(S)] and [MEDICATION(S)] levels. There was no evidence in the paper or electronic medical records that the resident's [MEDICATION(S)] or [MEDICATION(S)] levels had been checked since admission. Review of the Resident #98's medication records dated 05/2022 revealed an order was entered on 05/24/22 to obtain [MEDICATION(S)] and [MEDICATION(S)] levels and notify the physician of results. Notify the unit manager if refusal of every shift for one day. There was no evidence the lab results were obtained. On 05/24/22 9:00 P.M., Resident #98's medical record revealed the resident was noted to have a temperature of 102.2 and was given ice cream, cool towel, and Tylenol. On 05/25/22 at 7:18 A.M. review of a progress note revealed there was a change of condition note indicating Resident #98 was bleeding other than GI (gastrointestinal), shortness of breath, and [CONDITION(S)]. A new intervention was to increase oral fluids. On 05/26/22 at 2:28 P.M., a nursing note revealed the resident remained in the hospital. There was no evidence when and why the resident was transferred to the hospital in the paper or electronic medical record. Review of Resident #98's hospital records dated 05/25/22 to 06/03/22 revealed the resident was admitted to the hospital with severe [CONDITION(S)] in the urine, seizures, and acute nasal bone fracture nonoperative. New orders for [MEDICATION(S)] (antibiotic) for urinary tract infection ([CONDITION(S)]) and increased [MEDICATION(S)] to 300 milligrams (mg). There was no evidence of the laboratory results. Resident #98 returned to the facility on [DATE]. The facility called the hospital during the survey on 06/16/22 and obtained the [MEDICATION(S)] and [MEDICATION(S)] levels. The resident [MEDICATION(S)] level was drawn on 05/25/22 at 8:19 A.M., and the level was 2.3 (low). The normal level was 4.0 to 12.0 micrograms per milliliter. On 06/04/22 a nursing note at 8:00 P.M., revealed the physical therapist noted Resident #98 on the floor in his room. His left forehead was cut open. The resident was instructed on the importance of staying in bed and waiting for staff to help. Currently the resident was one on one care. There was no evidence the physician was notified of the fall. Review of Resident #98's fall investigations revealed there was no evidence a fall investigation was completed on 06/04/22 to determine the root cause of the fall. Review of the fall investigation dated 06/05/22 at 6:30 P.M., revealed the resident had a fall in his room next to the bed. The site to the left eye reopened. The resident was not able to talk much but moans out his words and uses hand gestures. Instructed resident to sitting down and waiting for help to arrive before making attempts to get up. Mattress was placed on the floor to help prevent falls and additional safety due to the resident crawls onto floor. Curtains were tied up to help prevent the resident from hanging on them. There was no evidence of the root cause of the fall or evidence neurological assessments were completed. Review of the paper and electronic medical records revealed no evidence Resident #98 had fallen on 06/05/22. Review of Resident #98's 24-hour resident flow record dated 06/08/22 at 12:00 P.M. to 06/09/22 to 12:00 A.M. revealed the resident was on 15-minute checks. There was no indication to why the resident on was on 15-minute checks for those dates. Review of CNP note dated 06/06/22 revealed the resident remained a fall risk. The note indicated she had discontinued the [MEDICATION(S)] last visit due to the resident was a fall risk and not psychotic, however the physician had reordered the [MEDICATION(S)]. New orders to discontinue the [MEDICATION(S)] again due to the resident had multiple falls since admission to the facility. On 06/07/22 at 8:31 P.M., a nursing note reported the resident had a nosebleed. He was on the bed mat moaning. He could not get words out. He used his hands for gestures to point to the bleeding nose. He was administered [MEDICATION(S)] to calm him down and to stop the nosebleed. There was no evidence the physician was notified. On 06/08/22 at 3:44 P.M., Resident #98's progress note indicated a new order for one on one supervision, however there was no written ordered noted. On 06/08/22 at 8:50 P.M., a progress note revealed Resident #98 was placed in a Broda chair at the nurse's station. The doctor was notified of nosebleed and new orders for Vaseline. Resident #98 was on one on one. Review of Resident #98's medical record revealed no evidence of when one on one supervision was initiated, completed, or stopped. On 06/12/22 at 8:20 A.M., a progress note revealed a nurse aide notified the nurse Resident #98 was found on the floor with a gash in his posterior occipital. The resident was sent to the hospital. Review of the hospital notes dated 06/12/22 revealed Resident #98 arrived as a level 2 trauma. The resident was noted holding his breath and grunting in pain. The CT scan showed bilateral anterior and lateral maxillary sinus wall, left medical sinus wall fracture, left interior and lateral orbital rim fracture, and bilateral comminuted nasal bone fracture which required open reduction internal fixation surgery. New fracture of the C6 was also noted on the x-ray and a c-collar was put in-place for six weeks. Resident #98 remained at the hospital at the time of the survey. On 06/14/22 at 3:21 P.M., interview with the DON and Registered Nurse (RN) #310 revealed the facility had not identified the root cause of all six falls or completed a thorough investigation. The falls that occurred on 05/21/22 and 06/04/22 did not have any type of investigation and the falls on 05/23/22 and 06/05/22 were not documented in the medical record. Neurological assessments were not completed on 05/21/22 or 05/22/22. RN #310 confirmed there was no written documentation the physician/CNP was notified of all incidents/change of conditions. There was no order written for one on one per the nurse's notes. It was up to the staff discretion when to implement the one on one. It was concerning one doctor was discontinuing orders for [MEDICATION(S)] due there was no indication for use and the resident fall risk, and the other physician re-wrote them the same day they were discontinued. The facility was not able to determine why the resident was sent out per his request on 05/21/22. Review of facility fall policy titled Fall Management, dated October 2019, revealed a neurological assessment will be initiated on all un-witnessed fall; 15 minutes for one hour, then every hour for four hours, then every four hours for twenty hours, and then every eight hours for 48 hours. All falls would be discussed by the interdisciplinary team at the first IDT meeting after the fall to determine root cause and other possible intervention to prevent future falls. The physician would be contacted immediately, if there were injuries, and orders would be obtained. If there were no injuries, notify the physician during normal business hours. 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnosis including multiple [CONDITION(S)], [CONDITION(S)], dementia, anxiety, muscle weakness, and neuromuscular dysfunction of the bladder. Review of Resident #61's morse fall scale dated 12/31/21 revealed the resident was at high risk for falls. Review of Resident #61's quarterly MDS 3.0 dated 01/01/22 revealed the resident cognition was intact and she was unsteady during transitions and walking. Review of Resident #61's progress notes dated 03/11/22 revealed the resident was found on the floor in the lobby. The resident reported she hit her head but was feeling ok. The physician was notified and ordered neurological assessments. Review of Resident #61's fall investigation revealed no evidence a fall investigation was completed to determine the root cause of the fall. Review of Resident #61's progress notes dated 03/12/22 revealed no evidence of a fall. Review of Resident #61's fall investigation dated 03/12/22 at 2:00 P.M., revealed the nurse was called by the activities director outside and notified the nurse that the resident was laying on the floor. On arrival the resident was found laying on the pavement on her left side with her left arm behind her and her head resting on the gravel. Resident reported she felt dizzy and tripped and fell getting off the bus. The resident had a small laceration to her left upper eye that was bleeding. The resident complained of bad headaches and dizziness and demanded to be sent to the hospital. The resident was transferred to the hospital. There was no evidence of the facility investigating the root cause of the fall or new interventions being implemented as a result of the fall. Review of Resident #61's fall plan of care initiated 03/24/21 and revised 04/14/21 revealed the resident was at risk for falls due to impaired mobility, weakness, multiple [CONDITION(S)], [CONDITION(S)], and bladder dysfunction. There had been no new fall interventions implemented since 2021. On 06/14/22 at 3:16 P.M., interview with the DON and RN #310 confirmed a fall investigation was not completed to determine the root cause for Resident #61's fall that occurred on 03/11/22 and the fall investigation completed on 03/12/22 was not thorough and did not include the root cause of the fall. The fall on 03/12/22 was not documented in the medical record. 3. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnosis including diabetes, paranoid [CONDITION(S)], [CONDITION(S)], seizures, history of falling, and mental disorder. Review of Resident #21's quarterly MDS dated [DATE] revealed the resident had cognition impairment and required supervision with walking in room and toileting. The resident was not steady with balance during transitions and walking. Review of Resident #21's fall plan of care initiated 04/23/21 revealed the resident required assistance with toileting. Review of Resident #21's nursing note dated 03/09/22 at 10:00 P.M., revealed the resident reported she had an unwitnessed fall and twisted her left ankle. The left ankle and calf appeared swollen. The physician was notified and ordered x-rays. The ankle was iced and elevated awaiting x-ray. Pain medication given and will continue to monitor. Further review on 03/10/22 at 5:12 A.M., a late entry was entered that the nurse was called and updated by staff about x-ray results. The physician ordered to wait to get the confirmed fax prior to sending the resident out. The x-ray company was contacted by the primary nurse and a fax was sent. Physician confirmed with x-ray results and ordered to send resident to emergency room . At 5:30 A.M. the x-ray report indicated there was an acute comminuted spiral fracture involving the distal tibial diaphysis, with mild lateral and posterior displacement, and 15 degrees of apex anterior angulation. There was also an acute proximal fibular shaft fracture with displacement. At 6:00 A.M. the resident was transported to the hospital. Review of the x-ray reported dated 03/09/22 revealed the x-ray was reported at 12:58 A.M. on 03/10/22. The results included an acute comminuted spiral fracture involving the distal tibial diaphysis, with mild lateral and posterior displacement, and 15 degree of apex anterior angulation. There was also an acute proximal fibular shaft fracture with displacement. Review of the fall investigation report dated 03/09/22 at 8:40 P.M., revealed the resident was found sitting on bathroom floor due to a hypoglycemic episode. The resident complained of pain to left lower leg. The resident told the nurse she fell in the restroom and hurt her leg and she felt her sugar was low. A STAT (to be done right away) x-ray was ordered due to left lower extremity pain. The resident's blood sugar was checked and was low and [MEDICATION(S)] was given. Review of the medication administration record dated 03/2022 revealed the residents blood glucose was 157 at 9:00 A.M., 132 at 11:00 A.M., 207 at 4:30 P.M., and 78 and 9:00 P.M. on 03/09/22. Further review revealed the resident blood glucose for the month ranged from 70-373. There was no evidence the resident had received pain medication on 03/09/22 or [MEDICATION(S)] per the progress note and fall investigation. Interview on 06/14/22 at 2:24 P.M., with the DON and RN #310 confirmed the fall investigation was not thorough and accurate. There was no evidence the resident's blood glucose results and received [MEDICATION(S)] per the incident report. RN #310 reported she did not know why there was a delay from 12:58 A.M. to 5:12 A.M. notifying the physician of the x-ray results. The physician should have been notified at 12:58 A.M., when the results were reported. RN #310 also verified there was no evidence the resident had received pain medication on 03/09/22 per the progress note. The progress note indicated the resident reported the fall at 10:00 P.M., however the fall investigation report indicated 8:40 P.M. 4. Resident #37 was admitted to the facility on [DATE] with the diagnoses of unspecified symptoms and signs involving cognitive function and awareness, dementia in other diseases classified elsewhere without behavioral disturbances, psychotic disorder with hallucinations due to known physiological condition, muscle weakness, and [CONDITION(S)]. Review of Resident #37's quarterly MDS dated [DATE] revealed he was cognitively impaired and needed supervision with one person for physical assistance in bed mobility, transfer, eating, and toileting. The quarterly MDS also revealed he needed supervision with setup help only in walking, and dressing. Review of quarterly fall assessment dated [DATE] revealed Resident #37 was a moderate risk for falling. Review of Resident #37's progress note dated 03/26/22 at 10:57 P.M. revealed Resident #37 was found on the floor in his room in front of the bathroom sink. This was an unobserved fall, neurological checks were initiated, and the resident was presenting with signs and symptoms(s/s) of pain rated an eight on a zero to ten scale. Review of Resident #37's fall investigation for the fall on 03/26/22 at 10:36 P.M. revealed the facility did not investigate the root cause of the fall. Resident #37's progress note dated 03/26/22 at 11:00 P.M. revealed a STAT right hip x-ray was ordered due to Resident #37's s/s of pain. Review of radiology form titled, Timeframe for STAT Exams, undated, revealed a technologist would complete STAT exams as quickly as they could, and the goal was to have STAT exams completed within four hours of the order being entered into the system. Review of Resident #37's physician March 2022 orders revealed he could receive Tylenol 325 mg, two tablets every six hours as needed for pain. Review of Resident #37's March Medication Administration Record (MAR) revealed he received Tylenol 325 milligrams (mg), two tablets at 11:10 P.M. on 03/26/22 for signs and symptoms of pain. Review of the progress note dated 03/27/22 at 1:11 A.M. revealed the Tylenol was effective for his pain. Review of Resident #37's progress note dated 03/27/22 at 2:55 A.M. revealed the x-ray company was contacted regarding continued need for STAT hip x-ray. Resident #37's progress note dated 03/27/22 at 6:58 A.M. revealed Resident #37 was presenting with facial grimacing and guarding his right hip due to pain rated an eight on a zero to ten scale. The note also revealed the pain was unrelieved by the Tylenol and an order was received to send Resident #37 to the emergency room . There was no evidence Resident #37 received additional Tylenol or pain-relieving interventions since Tylenol was administered at 11:10 P.M. Resident #37's progress note dated 03/27/22 at 7:29 A.M. revealed he was sent to the emergency room via emergency services transport. Review of Resident's discharge instructions from the acute care hospital, dated 04/01/22, revealed he was admitted to the facility with a diagnosis of a closed right hip fracture and on 03/28/22 he had surgery (an open reduction cannulated screw fixation) to the right femoral neck to correct/stabilize the fracture for healing. Review of Resident #37's care plan revealed the interventions of adding colored tape to his call light and a medication review were added on 03/31/22. Resident #37 returned to the facility on [DATE]. Review of an admission fall assessment dated [DATE] at 5:15 P.M. revealed Resident #37 was a high risk for falling. Resident #37's progress note dated 04/03/22 at 12:30 A.M. revealed Resident #37 was found sitting on the floor with his back against his bed. This was also an unobserved fall and neurological checks were initiated. Review of facility fall policy titled Fall Management, dated October 2019, revealed a neurological assessment will be initiated on all un-witnessed fall; 15 minutes for one hour, then every hour for four hours, then every four hours for twenty hours, and then every eight hours for 48 hours. All falls would be discussed by the interdisciplinary team at the first IDT meeting after the fall to determine root cause and other possible intervention to prevent future falls. The physician would be contacted immediately, if there were injuries, and orders would be obtained. If there were no injuries, notify the physician during normal business hours. Review of the facility fall investigation for the fall on 04/03/22 at 12:45 A.M. revealed the investigation did not identify the root cause of the fall. Review of Resident #37's neurological check documentation dated 04/03/22 revealed Resident #37 received assessments following his fall every 15 minutes for an hour, every hour for four hours, and every four hours for twelve hours. He received neurological assessments for a total of 20 hours and 45 minutes. Review of Resident 37's care plan revealed the interventions of assisting resident with toileting every two hour and add skid strips to the bathroom floor were added on 04/04/22 and a bladder tracker was added on 04/05/22. Review of Resident #37's significant change MDS dated [DATE] revealed the resident was rarely or never understood and needed extensive assistance of two plus people for physical assistance in bed mobility, transfer, dressing, toileting, and personal hygiene. Observation on 06/16/22 at 9:00 A.M. of Resident #37 revealed the resident was lying in bed dressed and covered with blankets. Resident #37's bed was in the low position, call light was within reach, and fall mat was on the floor to the left side of the bed. There was no color tape to the call light, and there were no skid strips on the floor next to the dresser or in the bathroom. On 06/14/22 [TRUNCATED]

Based on observation, interview, record review, policy review, review of police report, and review of facility investigations, the facility failed to ensure residents were protected from abuse when actual harm was suffered by Resident #32 after Resident #105 punched Resident #32 in the face causing a laceration and a nasal fracture that required hospitalization . This affected one (Resident #32) of one resident reviewed for abuse. The facility census was 106. Findings include: 1. Review of medical record for Resident #32 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 04/16/21 revealed Resident #32 exhibited behavior symptoms of physical and verbal aggression towards staff and residents. Interventions included maintain a safe environment for resident, remove resident from situation, provide resident personal space, provide resident with diversional activity, administer medications as ordered, approach resident in a calm and friendly manner, identify behavior triggers, if resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure, re-approach as needed and fifteen-minute checks. Review of quarterly Minimum Data Set (MDS) assessment, dated 08/23/21, revealed the resident was cognitively intact. Resident #32 did not exhibit physical or verbal behavioral symptoms. Resident #32 required supervision of one person for bed mobility, transfers, walking in room and corridor and locomotion on and off the unit. 2. Review of medical record for Resident #105 revealed an admitted [DATE] and a discharge date [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 10/01/21, revealed Resident #105 was cognitively intact. Resident #105 did not exhibit any hallucinations or delusions. Resident #105 exhibited physical behavioral symptoms directed towards others on four to six days. Resident #105 did not exhibit verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. Resident #105 did not reject care or exhibit wandering. Resident #105 required limited assistance of one person for bed mobility, transfers, supervision with set up for walking in room and corridor, locomotion on and off unit, dressing, eating, personal hygiene, and bathing and supervision with one person physical assistance for toilet use. Resident #105 received seven days of an antidepressant. 3. Review of a facility Self Reported Incident (SRI), dated 09/12/21, revealed an altercation related to physical abuse, emotional and verbal abuse involving Residents #32 and #105. Resident #32 and #105 were alleged to have been arguing and Resident #105 swung his open hand around Maintenance Assistant #102 making minimal contact to Resident #32's face. Review of the facility's SRI, dated 09/27/21 with a discovery date of 09/26/21, stated at 3:45 P.M. the incident occurred at the facility's designated smoking area. Narrative summary of the incident and investigation revealed staff and resident statements indicated during the scheduled smoking time the resident-to-resident incident occurred. The actual start of the altercation was not witnessed by staff. Resident interviews indicate Resident #32 entered the smoking area and began raising his voice and going toward Resident #105 with his hand drawn like he was going to hit him. Resident #105 jumped up and Resident #105 and Resident #32 began swinging at each other. Resident #28 fell during this time and was unable to recall what made her fall. Staff intervened and separated residents while another staff member contacted 911. Resident #105 was placed on one-on-one supervision. Resident #28 and Resident #32 were transferred to the emergency room (ER) for evaluation. Resident #105 remained on one-on-one supervision while Social Services worked on the discharge plan with the resident. Resident #105 was seen by a psychosocial provider for services and medication adjustment. Resident #105 had alternative smoke breaks with one-on-one employee supervision and the breaks were independent of other residents. Upon return from the hospital, Resident #32 was placed on one-on-one supervision and moved to a different unit. The facility was working with the responsible party on alternate placement for Resident #105. The facility's plan included psychosocial needs will be monitored for other residents witnessed or involved in the incident. The facility reported they completed re-education with staff regarding behavior management and education with each resident with a brief interview for mental status score of thirteen or higher regarding resident-to-resident altercations. The facility further reported they were committed to protecting their residents from abuse which included other residents. Facility reported law enforcement was involved and the officer reported from resident interviews, Resident #32 initiated the altercation. Neither resident was detained by the police. Review of police report dated 09/26/21 at 4:05 P.M. revealed the reporting officer was dispatched to the facility for a report of a fight. There was no mention of a weapon. Upon arrival, the reporting officer made contact with Resident #32 who stated that Resident #105 assaulted him. Resident #32 stated he was outside smoking a cigarette when Resident #105 walked up to him and punched him for no reason. Resident #105 stated that he was outside about to smoke a cigarette when Resident #32 walked up to him a cocked his fist back like he was going to punch him. Resident #105 stated that he defended himself and punched Resident #32 four times in self-defense. Resident #28 and Resident #34, who were witnesses, corroborated Resident #105's version of events. While the reporting officer was speaking with Resident #28, she informed him that Resident #32 walked up to Resident #105 and swung first. After hearing this, Resident #32 stated that he was not trying to punch Resident #105 and that he was trying to punch Resident #105's friend. Resident #28 was transported to the hospital in stable condition for precautionary reasons as she was knocked down while Resident #32 and Resident #105 were fighting. Resident #32 was transported to the hospital in stable condition to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility investigation revealed resident and staff interviews were conducted on 10/01/21. Resident #100 reported Resident #32 was accusing Resident #105 of stealing cigarettes and after three times of him accusing Resident #105, Resident #32 and #105 got into it. Resident #32 was accusing Resident #100 of the same thing last week. Resident #100 reported he just ignored him and walked away. Resident #4 reported Resident #105 was hitting Resident #32. Resident #86 reported Resident #32 walked over and swung at the other guy. Resident #105 reported he and Resident #28 were sitting by the tree, Resident #32 came over, swinging at him so he stood up and protected himself and punched him back. Resident #28 reported she and Resident #105 were sitting down getting ready to smoke a cigarette, Resident #32 came over to Resident #105 and leaned down in Resident #105's face yelling with his hand drawn like he was going to hit Resident #105. Resident #105 jumped up and they both started swinging. State tested Nursing Assistant (STNA) #179 reported she heard someone screaming for help. STNA #179 ran to the smoking area. STNA #147 told her they were fighting. STNA #179 reported she saw Resident #105 on top of Resident #32, hitting him. STNA #179 reported she pulled Resident #105 off of Resident #32. Resident #28 was lying on the ground. Resident #105 stayed behind him. STNA #179 reported she had Resident #32 lay still and called 911. STNA #147 came back outside. STNA #179 reported she took Resident #105 with her, and he stayed in the chair in the lobby away from everyone. Police came and spoke to Resident #105. Emergency Medical Services (EMS) arrived, assessed Resident #32 and Resident #28, and took them to the hospital. Review of an assessment titled, eInteract Transfer Form V5, dated 09/26/21, revealed Resident #32 was sent to the hospital for a trauma injury to the face on 09/26/21 at 3:45 P.M. Review of hospital imaging report with a date of service of 09/26/21 revealed a computed tomography (CT) scan of the face for trauma and indicated assault. Imaging revealed bilateral displaced fractures of the nasal bone near the nasal maxillary sutures with the right-sided deviation of the fracture fragments. There was extensive overlying soft tissue swelling and severe s-shaped configuration of nasal septum with possible fracture of the anterior osseous part of the nasal septum. There were extensive soft tissue swelling and hematoma within the subcutaneous tissues of the left malar region. Review of hospital imaging report with a date of service 09/26/21 revealed a CT of the head for trauma and indicated assault. There were bilateral, displaced nasal bone fractures and prominent soft tissue hematomas involving the left frontal scalp as well as the left face. Maxillofacial CT is being performed for further evaluation. Review of hospital after visit summary dated 09/26/21 through 10/02/21 revealed the mechanism of injury was assault with extensive soft tissue swelling, bilateral nasal bone fractures, nasal septum fracture, left elbow laceration and left subconjunctival hemorrhage with repair left facial laceration and closed nasal reduction. Resident #32 had a left eyebrow laceration repair on 09/26/21 and a closed nasal reduction and repair of facial laceration on 09/29/21. Discharge planning included trauma clinic follow up, plastic surgery follow up in one week on 10/06/21, outpatient follow up with mental health provider of choice and outpatient follow up with primary care provider. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of assessment titled Nursing Admission/Readmission Evaluation, dated 10/02/21, revealed facial injuries. The assessment indicated Resident #32 had scattered bruises, extensive soft tissue swelling with bilateral nasal bone fractures and nasal septum fracture, left eyebrow laceration and left subconjunctival hemorrhage. Review of nurse practitioner progress note dated 10/08/21 at 4:00 P.M. revealed bruises all over face, injury from altercation with another resident and monitor for pain. Review of the weekly nursing summaries, dated 10/11/21, 10/18/21, 10/25/21 and 11/01/21 revealed Resident #32 had bruising to the face. Observation on 11/01/21 at 12:21 P.M. of Resident #32 revealed bruising and one scab on the left cheek, a cut with a scab, one scab on the bridge of the nose and three scabs above the left eyebrow. During interview on 11/01/21 at 12:21 P.M. with Resident #32 revealed another resident had a weapon, the metal knuckle device. The unidentified resident hit Resident #32 in the face. Resident #32 did not know the name of the resident who hit him and reported the resident was a lot younger than Resident #32. Resident #32 revealed the incident happened in September 2021 in the smoking area. Resident #32 reported the resident hit Resident #32 four to five times to the left-hand side of his eye, nose and cheek area. During interview on 11/03/21 at 5:55 P.M., the Director of Nursing (DON) stated Resident #155 pushed the door to go outside to the smoke area and all the resident flooded out. Resident #28 and Resident #105 went outside and sat down. The STNA have to make sure the smoke cart is locked up. Resident #32 came out and immediately started yelling at Resident #105 and raising his fist and struck Resident #105 making contact. The DON reported Resident #105 did not have any injury. Resident #32 was frail and had a lot of talk. Resident #105 was short, [NAME] and healthier. Another resident yelled that they were fighting, then STNA #147 ran out and saw they were on the ground. STNA #147 ran for help. The receptionist at the time, STNA #179, ran to them and separated them and then called 911. She had Resident #105 behind her. Resident #32 attempted to get up and she told him to stay down until the EMT and police came. STNA #179 then took Resident #105 with her one-on-one and the facility got him discharged . Resident #32 sustained fractures to the nose and the left orbital eyebrow according to Resident #32's sister who verbally told the DON. The DON reported it all happened in less than 30 seconds, approximately, and was not otherwise unsupervised as it was very quick while STNA #147 was locking up the smoking supply cart. The smoking supply cart was just inside the door to the room where they keep the cart. Resident #28 did not sustain any injuries. Resident #105 was one-on-one supervision until he discharged . When Resident #32 was readmitted , he was put on fifteen-minute checks and his room was moved to the second floor to keep them separated and reduce any interaction as much as possible. The DON confirmed Resident #32 was no longer on fifteen-minute checks. Resident #32 verbally antagonizes people and Resident #32 sees psychiatry services frequently. During interview on 11/17/21 at 12:39 P.M., STNA #147 revealed she was familiar with Resident #32 and #105 and she was familiar with the resident-to-resident altercation that occurred in the smoking area on 09/26/21 between Resident #32 and #105. STNA #147 revealed the altercation occurred during the smoke time and estimated it was around 4:00 P.M. or 5:00 P.M. STNA #147 reported she had already locked up the smoking cart and was outside with the residents lighting their cigarettes. STNA #147 denied knowledge of which specific resident she was lighting cigarettes for. STNA #147 revealed she heard residents saying stuff and she turned around to see Resident #105 hitting Resident #32 in the face. STNA #147 reported it all happened so fast. STNA #147 revealed she went to get help and called out, Help! Help! They're fighting. Get the nurse! Get the nurse! and she went back outside with the residents. STNA #147 reported again that it all happened so fast, and could not estimate a time other than under a minute that she went to get help. STNA #147 revealed she did not walk up to the receptionist desk, but called out from the hallway. STNA #147 reported she and a secretary, whom she did not recall the name and no longer works at the facility (STNA #179), broke up the fight. STNA #147 denied ever having seen Resident #32 and #105 in a verbal or physical altercation prior to this. STNA #147 confirmed she had completed a witness statement regarding this incident. STNA #147 confirmed residents are supervised during smoke times. Review of facility policy titled Abuse Prevention Program, revised March 2021, revealed our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, resident representative, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Procedures included identification of occurrences and patterns of potential mistreatment/abuse. This deficiency substantiates Complaint Numbers OH 683 and OH 829.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interviews, observation, review of the facility's Self-Reported Incident (SRI), review of the police investigation report, review of the facility's investigation, review of a personnel file, and review of the facility's policy and handbook, the facility failed to ensure a cognitively impaired resident was free from physical and mental abuse by facility staff members. This resulted in Actual Physical and Psychosocial Harm when Resident #03 was held down against his will by Registered Nurse (RN) #106 in the shower room despite verbally refusing to be showered and sustained minor physical injuries. This affected one (Resident #03) of three residents reviewed for abuse. The facility census was 114. Findings include: Review of Resident #03's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#03's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/16/21, revealed Resident #03 was moderately cognitively impaired. Resident #03 required supervision for bed mobility, transfer, dressing, eating, and toileting and he required limited assistance for personal hygiene. Review of Resident #03's care plan revealed the resident needed assistance with incontinence care and the resident exhibited refusal behaviors for medications, showers and personal care. Interventions included to allow the resident to vent feelings and needs, approach resident in a calm and friendly manor, explain the task about to initiate, give the resident as many choices as possible about care and activities, maintain a safe environment, notify the physician and psychologist services, provide the resident personal space, and remove the resident from the situation. Resident's [CONDITION(S)] medications were discontinued due to the resident continued refusals. The resident received ancillary services from Psychology Services #600. Review of the nurses' progress notes from 05/25/21 to 07/28/21 revealed Resident #03 refused to be showered multiple times, his weight, medications, refused care, treatments with multiple attempts from nurses and aides. Review of the facility's Self-Reported Incident (SRI), dated 07/28/21, revealed the facility investigated an allegation of physical abuse between Resident #03 and Registered Nurse (RN) #106. On 07/28/21 around 3:45 A.M. to 4:00 A.M., Resident #03 was incontinent, and he was wet, and his bed was wet. State tested Nursing Aide (STNA) #204 attempted to provide incontinence care and the resident refused. STNA reported to the floor nurse as the resident was saturated in urine and refused to be cleaned up. The floor nurse notified her supervisor, Registered Nurse (RN) #106. Then RN #106 went into the room, asked the resident if he could change him and the resident replied no, leave me alone. The RN then unplugged the resident's bed, pulled the resident' bed out of the room with the resident in bed, pushed the bed down the hallway and went into the shower room. As they approached the shower room door, Resident #03 then jumped out of the bed into the shower room and RN #106 followed him into the room. The shower door automatically closed when another staff member removed the bed from the shower room. The staff member had placed the bed in the hallway as it blocked the shower room door. STNA #204, LPN #104 and LPN #105 then went into the shower room. They observed RN #106 holding the resident's right wrist down, and the shower was turned on with the resident's clothes on. The resident was stating leave me alone and was trying to get out of the RN's release of his hand restraint. STNA #204, LPN #104, and LPN #015 took over the care for Resident #03. Resident #03 refused the shower but did allow them to change his clothes. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did substantiate this allegation of physical abuse. RN #106 was terminated. The Ohio Board of Nursing was notified on 07/28/21. Review of the social services (SS) progress note for Resident #03 on 07/28/21 at 4:00 P.M. revealed Resident #03 made the statement he tried to put me in the shower, he grabbed my arm and I don't know why. I don't want to talk about it. SS returned to talk to the resident at 5:26 P.M. Resident #03 showed his arms to SS and his arms appeared to be scabbed and to have bruises. Review of the Licensed Nurse Weekly Skin Assessment, dated 07/28/21, revealed Resident #03 had bruises on both arms from his elbow to his wrist and top of his right hand. The nurse described the bruises were senile purpura. The resident was also noted to have a skin tear on top of his right wrist with dimensions of 1.2 centimeter (cm.) in length by 1.0 cm. in width. Review of the local police department's investigation, dated 07/28/21, revealed that an assault had not occurred. The responding officers then cleared with no further incident. Review of the Psychology Services #500 progress note, dated 07/29/21, revealed the nurse reported the resident's behaviors were at baseline with no new or worsening behaviors since last visit (07/15/21). Resident #03 continues to decline all medications. The psychologist summary of session revealed Resident #03 was at his baseline and denied fearing for his safety or being upset about the event on 07/28/21. Review of the employee file for RN #106 revealed RN #106 was suspended through the investigation and issued a termination letter on 08/03/21 by the Director of Nursing Services (DNS). The letter informed RN #106 of his termination effective 08/03/21 as a result of violating the Company abuse policy and resident rights. This employee was not re-hirable. Interview on 08/18/21 at 9:50 A.M. with the Administrator and Regional RN #200 confirmed the facility substantiated the allegation of physical abuse when Resident #03 sustained injuries from RN #106 on 07/28/21. Interview and observation on 08/18/21 at 12:00 P.M. with Resident #03 revealed the resident could not recall the shower incident. Observation of Resident #03's arms and hands revealed they were bruised as being purple areas on his arms and hands. Interview on 08/19/21 at 12:12 P.M. with RN #105 confirmed RN #106 physically abused Resident #03 in the shower room on 07/28/21 and Resident #03 sustained a skin tear on his right wrist from the incident. Her statement was the same as her statement given to the facility on [DATE]. Interview on 08/19/21 at 12:32 P.M. with RN #106 confirmed he showered Resident #03 against his resident right to refuse and held his right wrist down in order to shower him. Interviews on 08/23/21 at 6:55 A.M with STNA #204 and at 9:26 A.M with LPN #104 verified Resident #03 was showered against his right and was physically abused by RN #106 on 07/28/21 in the shower. Both confirmed RN#106 was holding the resident's right wrist down in the shower and Resident #03 sustained a skin tear on his right wrist. Review of the facility's policy titled Abuse Prevention, revised March 2021, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. The Abuse Prevention program revealed the facility is committed to protecting their residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents. The definition of abuse in the facility's policy included the willful infliction of injury, with resulting with physical harm, and further clarified the word willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the facility's Care Team Member Handbook revealed the employees are expected to accept certain responsibilities and adhere to the organization's expectations. Degrees of corrective action are generally progressive but at times could result in further action up to and including termination. Violations such as resident physical abuse are the most serious offenses, and the team member may be placed on immediate suspension while an investigation is conducted. Pending investigation of resident physical abuse may result in a final written warning or immediate discharge of position. As a result of the incident, the facility took the following actions to correct the deficient practice by 08/13/21: · On 07/28/21, Resident #03 was assessed for injuries. Social Services followed up with the resident on the same day with no noted change in mood. · On 07/28/21 at 4:30 A.M., RN #106 was placed on suspension. On 08/03/21, RN #106 terminated and not eligible for re-hire. · On 07/28/21, the Local Police and the Ohio Board of Nursing were made aware of the physical abuse allegation involving RN #106. · On 07/28/21, Social Workers (SW) #1, #2 and #3 interviewed 31 residents to see if they had witnessed or been a victim of abuse. There were no other reports of abuse. · On 07/28/21, the DON began all management staff education, activity staff and nursing staff on the abuse policy. Dietary Manager #400 educated all dietary staff, and the Housekeeping and Laundry Supervisor #401 educated all housekeeping and laundry staff. The education was completed on 07/30/21. · On 07/29/21, Resident #03 was seen by Psychology Services #600 and the resident was noted to be at his baseline. · On 08/02/21, the facility began to monitor their staff and residents for abuse concerns weekly. On 08/03/21, 08/12/21, and 08/13/21, the facility completed weekly monitoring without any additional abuse concerns. · On 08/18/21, interviews with STNAs #200, #201 and #203 and LPN #100, #101 and #102, and RN #103 confirmed they received re-education of the facility's abuse policy. · On 08/19/21, two additional residents (#01 and #02) were sampled and reviewed for abuse. No concerns regarding abuse were identified. · On 08/19/21, review of the facilities SRI's revealed there were no further concerns identified regarding abuse. This deficiency substantiates Control Number OH 678.

Based on medical record reviews, review of a Self-Reported Incident (SRI), staff interviews, resident interviews, review of video camera footage, review of employee time clock punch reports, review of the local police report, review of the facility investigation, and policy review, the facility failed to ensure two Residents (#75 and #76) were free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical and psychosocial harm for Resident #75 and Resident #76 when on 11/01/20, Licensed Practical Nurse (LPN) #300 approached Resident #75 in an aggressive and intimidating posture causing her to back up against a wall and then used his forearm and elbow to forcefully push Resident #75 out of the common area into the hallway. LPN #300 was then observed kicking the back of Resident #76's wheelchair. This resulted in Resident #75 and Resident #76 being fearful for their safety and well-being. This affected two residents (#75 and #76) of six reviewed for abuse. The facility census was 108. On 11/13/20 at 3:12 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Nurse #222, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/01/20 at approximately 10:22 P.M. when LPN #300 was observed on video to have approached Resident #75 in an intimidating and aggressive posture and used his forearm and elbow to forcefully push Resident #75 out of the common area. LPN #300 was then observed kicking the back of the wheelchair of Resident #76. State tested Nursing Assistant (STNA) #305 was notified of the allegation of abuse by Resident #76 and failed to immediately report the allegations of abuse to administrative staff per facility policy. Resident #76 then notified the local police department at 10:28 P.M. of the allegations of abuse. The DON verified she was not notified of the incident until 11:20 P.M. when LPN #300 contacted her and stated the residents called the police and accused him of abuse. LPN #300 remained in the facility unsupervised from 10:22 P.M., when the alleged abuse occurred, until 11/02/20 at 12:07 A.M. when he clocked out at the end of his shift. The Immediate Jeopardy was removed on 11/06/20 when the facility implemented the following corrective actions: · On 11/01/20 at approximately 11:20 P.M., Resident #75 and Resident #76 were interviewed by the local Police Department. · On 11/01/20 at approximately 11:30 P.M., the DON spoke with the local Police Department regarding the abuse allegation. · On 11/01/20 at approximately 11:38 P.M., LPN #300 was suspended by the DON by telephone and LPN was subsequently terminated from employment on 11/06/20. · On 11/01/20 at approximately 11:40 P.M., the DON began an investigation and spoke with STNA #305 on the telephone. · On 11/02/20 at 6:00 A.M., Resident #75 and Resident #76 were assessed by Wound Nurse #215 with no injuries identified. · On 11/02/20 at approximately 8:00 A.M., the allegation of abuse was reported to the Ohio Department of Health (ODH) by the DON. · On 11/02/20 at 12:51 P.M., Director of Social Services (DSS) #203 met with Resident #76 regarding the incident on 11/01/20 and no psychosocial issues or other concerns were identified. · On 11/05/20 at 8:00 A.M., Regional Nurse #222 completed re-education with the DON and Executive Director (ED) on the center's Abuse Prevention Policy and Abuse Critical Pathway. · On 11/05/20 at 9:15 A.M., the DON completed re-education on the center's Abuse Prevention Policy with department managers including Wound Nurse #215, Director of Laundry #217, Transportation Employee #221, Unit Manager #213, the Administrator, Unit Manager #212, Director of Dietary #214, Behavioral Service Employee #204, Activities Director #250, Assistant Minimum Data Set Coordinator #211, Director of Rehabilitation #223, Business Office Manager #201, Admission Director #207, DSS #203, Minimum Data Set Coordinator #210, and Dietitian #810. · On 11/05/20 beginning at 10:30 A.M and ending at 9:30 P.M., the DON completed re-education for all staff members employed at the facility regarding the center's Abuse Prevention Policy. Staff unable to attend the training (LPN #314, LPN #319, LPN #321, LPN #323, and STNA #373) will receive the education by the DON prior to returning from leave. A return to work date has not been established at this time due to approved extended leave for these employees. · On 11/06/20 beginning at approximately 10:00 A.M., and ending at approximately 2:00 P.M., interviews were conducted by Registered Nurse (RN) #331 for Residents #65, #94, #86, #100, #103, #73, #42, #53, #23, #39, #43, #45, #48, #44, #49, #59, #38, #57, #35, #63, #11, #28 with a Brief Interview for Mental Status (BIMS) of 13 or higher with no concerns identified regarding abuse or allegations of abuse. · On 11/06/20 beginning at approximately 10:00 A.M., and ending at approximately 3:00 P.M., visual checks were conducted by Assistant MDS Coordinator #211 on Residents #10, #12, #13, #14, #15, #16,#17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #29, #30, #31, #32, #33, #34, #36, #37, #40, #41, ##46, #47, #50, #51, #52, #54, #55, #56, #58, #60, #61, #62, #64, #66, #67, #68, #69, #70, #71, #72, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #87, #88, # 89, #90, #91, #92, #93, #95, #96, #97, #98, #99, #100, #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, # 113, #115, #116, and #117 with a BIMS of 12 and lower with no concerns identified. · On 11/06/20 at approximately 10:00 A.M., the DON followed up with Resident #43 who had witnessed the incident on 11/01/20. She reported no effects related to the incident. · On 11/06/20 at 12:55 P.M., DSS #203 met with Resident #75 regarding the incident on 11/01/20 and no psychosocial issues or other issues were identified. · On 11/06/20 at 3:00 P.M., a Quality Assurance meeting was held by the Executive Director. Staff members in attendance included the DON, Wound Nurse #215, Dietitian #810, Director of Laundry #217, DSS #203, Unit Manager #213, the Administrator, Unit Manager #212, Director of Dietary #214, Behavioral Services Employee #204, Director of Rehabilitation #223, Business Office Manager #201, Admission Director #207, MDS Coordinator #210, Assistant Director of Maintenance #219, and Medical Director #800. · Beginning the week of 11/09/20 and ending on 12/28/20, resident interviews or visual inspections will be completed with five residents, three times a week for four weeks, then once a week for four weeks. Interviews will be completed by a Department Manager, Executive Director, or designee. Visual checks will be completed by a Licensed Nurse. · Beginning the week of 11/09/20 and ending on 12/28/20, interviews will be conducted by the Executive Director or designee regarding types of abuse and reporting requirements. These will be conducted with five staff members three times a week across all shifts for four weeks, then five staff members once a week for four weeks. · On 11/19/20, STNA #305 was terminated related to not acting on an allegation of abuse. · Beginning on 11/23/20 and ending in January 2021, resident and staff interviews will be reviewed during monthly Quality Assurance meetings held by the Executive Director and further action will be taken if indicated. Although the Immediate Jeopardy was removed on 11/06/20, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #75's care plan dated 07/21/20 revealed the resident exhibited signs of cognitive impairment due to her score of 10 on the BIMS and history of [MEDICAL CONDITION]. Interventions included: allow extra time for the resident to respond, allow the resident to make daily decisions regarding care, and always approach the resident in a gentle and friendly manner. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/14/20, revealed Resident #75 had moderately impaired cognition. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, revised on 09/29/20, revealed the resident exhibits signs of cognitive impairment. Interventions included: allow extra time for resident to respond, allow resident to make decisions regarding daily care, give one direction or ask one question at a time, and always approach resident in a gentle and friendly manner. Review of Resident #76's quarterly MDS assessment, dated 11/06/20, revealed Resident #76 had intact cognition having scored a 15 on the BIMS. Review of the SRI dated 11/02/20 revealed the DON was notified by LPN #300 the police were at the facility due to an allegation of abuse against him. LPN #300 denied the allegations and stated STNA #305 was present and witnessed the incident. STNA #305 was interviewed by the DON and stated she was present and did not witness any abuse. The facility suspended LPN #300 on 11/01/20 and terminated LPN #300 on 11/06/20. The facility interviewed all residents on unit three to determine if they had any concerns with a male nurse or any concerns with a male nurse spitting or striking out at them with no findings noted. The SRI was originally unsubstantiated due to lack of evidence. On 11/10/20, an addendum was added to the SRI indicating the facility considered the allegation of abuse substantiated. Review of the facility investigation revealed all residents residing on the 300 unit of the facility were interviewed on 11/04/20 using a questionnaire to determine if they had any concerns with a male nurse or if facility staff had ever struck out or spat at them. On 11/05/20, seven residents (#43, #65, #75, #76, #77, #78, and #86) were interviewed by the DON regarding the incident on 11/01/20. Resident #43 revealed during her interview LPN #300 came into the lounge on 11/01/20 and told residents they had to go to their room. Resident #43 stated she went into the hallway and witnessed LPN #300 elbow Resident #75 in the back and kick the wheelchairs of other residents to get them to move faster. Resident #43 stated Resident #76 then called the police. Resident #75 revealed during her interview that on 11/01/20, LPN #300 told everyone to get out of the dining room and when she refused, he became angry and elbowed her in the middle of her back, pushed her into a corner, and spit on her. Resident #75 stated Resident #76 then phoned the police on her cell phone and reported the incident. Resident #76 revealed during her interview, LPN #300 came in the dining room on 11/01/20 and told the residents to leave and the next thing she knew, he elbowed Resident #75 in the back. Resident #76 stated LPN #300 began yelling and cursing at her and spit in her face and that was when she left the room and called the police. Resident #65 revealed during her interview LPN #300 was arguing with Resident #76 to leave the dining room and she saw LPN #300 have Resident #75 against a wall telling her to move. Resident #86 revealed during her interview a nurse gave the finger to a resident who did not want to leave the dining room. Residents #77 and #78 revealed in their interviews they denied witnessing anything on 11/01/20. Interview on 11/13/20 at 8:35 A.M., Resident #86 revealed a male nurse was yelling at residents to get out of the dining room and was sticking up his middle finger at them. Resident #86 was unable to provide a date this occurred, but stated it was a few nights ago. Interview on 11/13/20 at 11:20 A.M., LPN #300 revealed he had attained the services of an attorney related to the alleged incident on 11/01/20 and any questions could be directed to the attorney. Interview on 11/13/20 at 11:30 A.M., Resident #75 revealed a man who worked at the facility pushed her out of the dining room, spit in her face, and slapped her the other night. She stated she was very afraid of him when the incident occurred. Interview on 11/13/20 at 12:00 P.M., Resident #43 revealed LPN #300 snapped the other night. She stated she observed LPN #300 man-handle, curse at, and push Resident #75. Resident #43 stated LPN #300 then began kicking at Resident #76's wheelchair to get her out of the dining room faster. She stated Resident #76 called the police and reported the incident after getting back to her room. Interview on 11/13/20 at 12:15 P.M., Resident #76 revealed she was in the dining room on 11/01/20 when LPN #300 entered and told the residents they needed to go to their rooms. She stated she told him he was not her boss and could not tell her what to do and he began yelling and cursing at her. She stated she observed LPN #300 push Resident #75 out of the dining room and she was afraid he was going to harm her. Resident #76 stated she exited the dining room and called the police to report what had occurred. Interview on 11/13/20 at 1:40 P.M., STNA #305 revealed she was working on the night of 11/01/20 and witnessed LPN #300 asking residents to leave the common area and go to their rooms but did not witness any form of abuse. She stated Resident #76 informed her LPN #300 was hitting, kicking, and spitting on residents. STNA #305 replied to Resident #76's accusations by telling her she did not witness any of those things. STNA #305 stated she did not report the accusations to any other staff members or administration, but believed other staff working the unit heard the resident's accusations as they were yelling in the hallway. On 11/13/20 at 12:45 P.M., review of the facility video camera footage with the DON and Regional Nurse #222 present revealed on 11/01/20 at 10:20 P.M., LPN #300 was observed to approach Resident #75 in an aggressive and intimidating posture causing her to back up against a wall. At 10:22 P.M., LPN #300 was observed to be using his forearm and elbow to push Resident #75 out of the common room into the hallway and was then observed kicking the back of Resident #76's wheelchair. Review of employee timeclock punches for LPN #300 revealed he clocked out on 11/02/20 at 12:07 A.M. after being suspended by the DON for allegations of resident abuse. Review of the local police report revealed on 11/01/20 at 10:28 P.M., the local police department received a report alleging LPN #300 had struck Resident #75 in the back with his elbow when she would not leave the common area. Resident #43 corroborated Resident #75's statement. LPN #300 denied the use of physical violence. STNA #305 corroborated LPN #300 statement. Review of the facility policy titled Abuse Prevention Program, undated, revealed the Administrator must be immediately notified of alleged abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or paged and informed of such incident. Employees of the facility who have been accused of resident abuse shall be suspended from duty immediately until the results of the investigation have been reviewed by the Administrator. Any staff member or person affiliated with the facility who has witnessed or believes a resident has been a victim of abuse shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individuals withholding such information. This deficiency substantiates Complaint Number OH 183.

Based on medical record review, observation, staff and resident interviews, the facility failed to prevent a resident from developing a pressure ulcer and failed to put in appropriate interventions to promote the healing of the developed pressure ulcer. This resulted in harm when the resident's pressure ulcer went from a stage one to a stage three. This affected one of three sampled residents (Resident # 200) with pressure ulcers. This had the potential to affect all eight facility identified residents with pressure ulcers. The facility census was 86. Findings include: Medical record review revealed Resident #200 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #200's quarterly comprehensive assessment dated [DATE] documented the resident understood others, made himself understood and was cognitively intact for daily decision making skills. The assessment revealed he was not a risk for skin breakdown, did not have a pressure ulcer on prior assessment and did not currently have a pressure ulcer. Review of Resident #200's care plans revealed a care plan for potential for skin integrity related to urinary incontinence and diabetes, dated 09/11/15. All the interventions were dated 09/11/15. The care plan had not been revised. The medical record lacked a care plan for pressure ulcers. Review of a podiatry exam dated 12/30/15 revealed a stage one pressure ulcer was found on his right lateral (pinky) toe which measured 0.5 centimeters (cm) by 0.5 cm. The podiatrist notes recommended the resident not wear his shoes for 24 hours, lotion to be applied to both feet after bathing and a treatment order for the toe. Review of the treatment order revealed to wash the right fifth toe with normal saline, apply [MEDICATION NAME] (anti-biotic) ointment, cover with a dry dressing every day until healed. The order also revealed that pressure relief to the lateral right toe was required. The order did not include to apply lotion to both feet and for the resident not to wear shoes for 24 hours. Review of Resident #200's skin grid dated 01/06/16 documented the resident developed an in-house pressure wound to the right pinky toe that was found on 01/06/16 as a stage two pressure ulcer measuring 1.3 cm by 0.4 cm with 0.1 cm depth. Current measurements on 02/04/16 were 1.2 cm long by 1.9 cm wide with 0.1 cm depth. The skin grid revealed the pressure ulcer was now a stage three. Interview with the wound nurse, Licensed Practical Nurse (LPN) #7 on 02/03/16 at 4:50 PM stated the pressure ulcer on Resident #200's toe was caused from his tennis shoes. She denied the shoes were too small, however stated they have an overlapped area of fabric on the inside that is pressing against his toe. She stated they ordered him diabetic shoes and asked him not to wear tennis shoes until the diabetic shoes arrive. However, the resident refused and continued to wear the tennis shoes. Interview with Nurse Practitioner (NP) #3 on 02/04/16 at 10:30 AM stated the diabetic shoes were ordered because the resident was an insulin dependent diabetic with a food wound. NP #3 stated she had never seen the resident's wound. She also stated the Medical Director had not seen the wound. She stated it was a long tedious process to get diabetic shoes, however, the process had been started and he had been fitted for the shoes. Observation on 02/04/16 at 11:00 AM revealed LPN #7 performed Resident #200's pressure ulcer treatment per the physician order [REDACTED]. When she removed the bandage the resident stated the wound looked worse. LPN #7 agreed with the resident and stated she would call the physician to get a new treatment order. LPN #7 described the wound as pink, overly moist, clean wound bed, and 10% slough around the wound edges. She stated the measurements were 1.2 cm long by 1.9 cm wide with 0.1 cm depth. She stated the pressure ulcer was now a stage three. Interview with the resident following the treatment revealed the resident stated he could not wear the slipper socks the facility had provided because they do not provide traction and he can't propel himself in the wheelchair. He stated he was paralyzed on his left side and could not move his left foot. He stated he can only be independent in propelling the wheelchair with his right foot (with shoes) to propel the wheelchair. He stated wearing a non-skid sock without shoes would not work for him because it would be cold outside and he goes downstairs to the main dining room to eat and the sock would get dirty or he could injure that foot without a shoe for protection. He stated he would wear the diabetic shoes instead of his tennis shoes when they arrive. He denied the facility had offered him a different pair of shoes or house shoes. Interview with LPN #7 on 02/04/16 at 4:40 PM stated she received an incident report dated 12/30/15 that noted Resident #200 had a pressure ulcer on his right pinky toe. She stated she looked at the toe and started a skin grid on 01/06/16 and the ulcer was a stage two. She stated she was not aware the podiatrist had evaluated the ulcer on 12/30/15 as a stage one and wrote a treatment order. She stated that if a treatment is in place and the stage increases, she calls the doctor for a change in treatment. She stated this did not happen on 01/06/16 because she was not aware it was a stage one on 12/30/15. LPN #7 stated Resident #200 was an insulin dependent diabetic and a care plan for pressure ulcers should have been started and/or the potential for impaired skin integrity care plan should have been revised to include an existing pressure ulcer and it had not been done. LPN #7 could not find documentation in the medical record where the resident was advised not to wear tennis shoes. She admitted it was not on any of his plans of care. She admitted the resident's pressure ulcer had increased from a stage one to a stage three, in five weeks and had not had a change in treatment, nor was the resident seen by the physician or nurse practitioner. This deficiency substantiates complaint number OH 514.

Based on medical record review and staff interview, the facility failed to put fall interventions in place for a resident identified as a high fall risk. This resulted in harm when a resident fell out of bed and fractured a vertebrae. This affected one of three sampled residents sampled for falls. (Resident #100). This had the potential to affect all 30 facility identified residents at risk for falls. The facility census was 86. Findings include: Medical record review revealed Resident #100 was re-admitted to the facility on [DATE], from the hospital after falling at the facility. [DIAGNOSES REDACTED]. Review of Resident #100's prior nursing admission screening dated 01/15/16 at 10:24 PM documented the resident was alert to person only. She had difficulty understanding others, difficulty making herself understood and was confused. A fall risk assessment from the previous admission, dated 01/15/16 at 11:08 PM revealed a score of 10, meaning high risk for falls. The medical record also contained a form titled interim care plan dated 01/15/16 which revealed the resident was totally dependent on staff with bed mobility, transferring, ambulation, locomotion, dressing, personal hygiene, eating, toileting and bathing. The medical record did not contain a care plan. Interview with Registered Nurse (RN) #22 on 02/04/16 at 4:15 PM stated the nurse at admission should put into place a temporary admission care plan for triggered areas. However, after medical record review she stated there was not a temporary admission care plan for Resident #100 on 01/15/16. Review of Resident #100's nurses note dated 01/15/16 documented by Licensed Practical Nurse (LPN) #60 revealed the resident arrived at the facility and the Nurse Practitioner (NP) was notified and orders received. A nurses note dated 01/16/16 at 10:30 AM by RN #22 documented she was called to the resident's room and found Resident #100 on the floor. There was blood on the floor and blood coming out of the resident's nose. The resident was alert and oriented and stated she fell out of bed. Emergency services (911) was called and the resident was sent to the emergency room (ER). Review of the resident's hospital record dated 01/16/16 revealed the resident was seen status [REDACTED]. The resident stated she was reaching for some cookies on her night stand and fell out of bed. A cat scan of the head showed a C2 (neck) vertebral body fracture with displacement. The resident was admitted to the hospital for acute gastrointestinal bleed (likely upper), hypotension, and acute blood loss with a secondary vertebral fracture. Review of Resident #100's medical record did not contain documentation of fall interventions in place. The fall investigation dated 01/16/16 revealed no fall interventions were in place and the resident was a new admission. Resident #100 was re-admitted to the facility on [DATE] and a nursing home history and physical dated 01/26/16 documented the resident had a witnessed fall at the facility. The emergency room head x-ray showed a non-displaced fracture of vertebrae C2 and a C-collar was placed for the fracture. Interview with Resident #100 on 02/03/16 at 2:50 PM stated she remembered falling out of bed, however could not give any specific information related to the fall. She denied she was able to activate the call light then or now. She appeared to be tired and fell asleep a couple of times during the interview. Interview with the Administrator (ADM) on 02/03/16 at 6:00 PM stated LPN #60 was Resident #100's nurse the night she was readmitted . The ADM stated he interviewed LPN #60 after the resident 's fall. LPN #60 stated the resident was readmitted to the facility late in the evening. He admitted to the ADM the resident was scored a high risk for falls, however he did not put any interventions into place because it was late at night and he knew the resident could not get out of bed. The ADM stated LPN #60 used bad nursing judgement and did not put any fall interventions into place. He stated the resident had a fractured vertebra in her neck. The ADM stated the nurse should have put the bed in low position and placed mats on the floor beside the bed, however it was not done. Interview with RN #22 at 1:52 PM on 02/04/16 stated on admission when a resident is identified as high risk for falls they should put interventions into place immediately. She stated a low bed and floor mats were the expected interventions. Several attempts to interview LPN #60 on 02/04/16 and 02/05/16 were made without success. This deficiency substantiates complaint number OH 514.

Based on medical record review, incident log review, policy review, observation, and staff interview, the facility failed to provide adequate supervision to prevent Resident #13 from eloping from the facility. This resulted in Immediate Jeopardy for one resident (Resident #13) of 16 residents at risk for elopement. The facility also failed to implement safety interventions to prevent elopement for six additional residents (Residents #3, #42, #54, #55, #65 and #82). The facility census was 93. On 01/03/14 at 12:10 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 12/13/13 when Resident #13 was admitted to the facility at risk for elopement. Resident #13 exhibited exit seeking behaviors and wandering between 12/13/13 and 12/26/13 without interventions being implemented to prevent elopement from the facility. On 12/26/13 between 10:00 A.M. and 10:30 A.M., Resident #13 was observed by Licensed Practical Nurse (LPN) #11 in the foyer between the exit doors. LPN #11 was unable to redirect the resident and therefore left the resident alone and unsupervised to go to the second floor to notify Registered Nurse (RN) #120 that she was unable to remove Resident #13 from the exit doors. When RN#120 arrived at the foyer, Resident #13 was gone. RN#120 failed to initiate a search for Resident #13. One hour later at 11:30 A.M., a transport arrived to take Resident #13 to a medical appointment. As the resident could not be located, a search was then initiated. On 12/26/13 at 12:30 P.M., Resident #13 was found at a hospital emergency room approximately 500 feet from the facility. The hospital was located one block from a major state route and four blocks from an interstate highway. On 01/03/14 at 12:38 P.M., Resident #82 was observed attempting to exit the facility on the east side of the building. Resident #82 entered the foyer, opened the exit door and then turned around once the cold air entered the foyer. The resident had been identified by the facility as an elopement risk. A Wander Alert (an electronic device to notify the facility a resident at risk was attempting to exit the facility unsupervised) was not in use. The Immediate Jeopardy was removed on 01/03/14 at 7:45 P.M.; when the facility implemented the following corrective actions: ? On 01/03/14 at 2:44 P.M., the facility only had three wander alerts available and they were applied to three of six residents (Residents #42, #54 and #82) at risk for elopement. Eight other residents at risk for elopement had wander alerts in place (Residents #8, #13, #27, #36, #44, #86, #90 and #93). ? On 01/03/14 at 3:00 P.M., Regional Director of Operations #121 stated additional wander alerts were ordered for residents at risk for elopement and were to be delivered to the facility on [DATE]. ? On 01/03/14 at 3:05 P.M., additional staff were posted at all exits and the elevator to prevent Residents #3, #55 and #65 from exiting the building unsupervised until wander alerts were available for residents at risk for elopement. ? On 01/03/14 by 4:30 P.M., all residents had been reassessed for the risk of elopement by RN #9, RN #10 and RN #234. ? On 01/03/14 at 7:45 P.M., the facility applied wander alerts to Residents #3, #55, and #65. ? On 01/03/14 at 7:45 P.M., all residents at risk for elopement had wander alerts applied. Ten extra wander alerts were available for use in the event a wander alert malfunctioned or a new resident was assessed at risk. * On 01/06/14, the Resident Care Director completed in-service training on elopement for 104 of 130 employees. Regional Director of Clinical Operations #122 stated those employees that had not been in-serviced on elopement would be taken off the schedule until elopement training was completed. ? On 01/06/14 between 11:10 A.M. and 11:25 A.M., Residents #3, #42, #54, #55, #65 and #82 were observed with wander alerts in place and functioning. The wander alert system was also observed functioning at the exit doors. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity Level 2, (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as not all staff had received the in-service training on elopement. Findings include: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Nursing Comprehensive Admission Data Collection and assessment dated [DATE] revealed the resident was at risk for elopement related to exit-seeking behavior and independently mobile with cognitively impairment. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #13 was moderately impaired for daily decision-making, required supervision for walking, had continuously present disorganized thinking, and had no wandering behavior. Review of the Elopement Plan of Care: Assessment, Prevention and Management dated 12/13/13 and revised 12/26/13 included an expressed desire to leave and return home, was confused and disoriented, had a psychiatric history, was restless/irritable, eloped from the facility on 12/26/13, and had exit seeking behaviors of wandering, trying to get out doors and packing belongings. Review of the resident ' s goals included to remain free of elopement. Interventions (undated) included to initiate a wander alert system, photograph of resident with a description, allow for safe wandering, encourage movement and exercise, reassure if the resident felt lost, abandoned or disoriented, and remove objects that were reminders of leaving. Review of the physician orders [REDACTED].#13 from eloping from the facility. Review of Resident #13's progress notes revealed the following: On 12/13/13 at 11:00 P.M., had periods of confusion and wandering the hall. On 12/14/13 at 9:00 P.M., confused, wandering the hallway and redirected as needed with short term results. On 12/16/13 at 9:00 P.M., agitated, pacing halls and moving furniture in room. Wandering into other residents ' rooms and arguing with them. On 12/18/13 at 2:30 A.M., resident was resting intermittently and then ambulating in the hallway. On 12/18/13 at 11:00 A.M., resident was extremely confused, disoriented and ambulating. Resident was redirected and reoriented. On 12/18/13 at 9:00 P.M., resident was ambulating in the halls pulling a suitcase behind him. Attempts to re-orient the resident were ineffective. On 12/20/13 at 2:00 A.M., resident was up ambulating in hallway, going into other residents' rooms and the staff restroom. Attempts to reorient resulted in short term positive results. On 12/20/13 at 11:00 A.M., resident ambulating, continue to monitor. On 12/25/13 at 10:00 A.M., resident remained extremely confused and disoriented, family at facility to take home for Christmas; resident returned at 10:00 P.M. On 12/26/13, transportation was unable to locate Resident #13 inside the facility to transport him to dialysis. At approximately 11:30 A.M., "Code Amber" (missing resident) was announced and the facility elopement protocol was initiated. The search expanded to the area outside the facility with staff driving around the neighborhood. The resident's physician, family and the police were notified. Staff began calling hospital emergency room s and Resident #13 was found at the hospital emergency room across the street. Review of the facility incident report dated 12/26/13 at 11:30 A.M. revealed Resident #13 was not in his room when transportation arrived to take the resident to an appointment. The facility was searched and Resident #13 was not found. The resident ' s physician and family were notified. The resident was at risk for elopement, high-risk precautions and elopement precautions were in place. However, the resident did not have a wander alert in place. The investigation summary included the resident wandered out of the facility at 10:30 A.M. to the hospital across the street and was found unharmed. Summary of corrective actions included an interdisciplinary review, 15 minute checks for 24 hours, application of a wander alert and the elopement care plan was updated. The administrator was not notified of the elopement. Review of the facility investigation revealed no documented evidence of facility staff interviews, no evidence of emergency room staff interviews, and no evidence of an investigation into the events between 10:00 A.M. and 12:30 P.M. when the resident was missing from the facility. Review of the medical record revealed the last documented evidence of staff awareness of Resident #13 ' s location in the facility was at the time of the administration of medications at 9:00 A.M. Review of the medical record revealed no documented evidence Resident #13 ' s family was notified when the resident was found and returned to the facility. There was no revision of the Elopement care plan to reflect the resident was to be monitored hourly and in a common area when out of bed. Resident #13 ' s wander alert to the right ankle was initiated on 12/30/13. Review of Resident #13 ' s Missing Resident Action Plan, dated 12/26/13 revealed the following suggested interventions were not completed: verify family and physician contact, initiate accident/incident process, conduct an emergency team meeting to determine the next step, interview the resident, assess the resident ' s electronic monitoring device (wander alert) and modify the interdisciplinary plan of care. Review of the Incident and Accident Log dated December 2013 revealed no documentation Resident #13 eloped from the facility on 12/26/13. On 01/02/14 at 9:25 A.M., interview with the Administrator revealed the facility had no elopements in the past six months even though Resident #13 had eloped 12/26/13. On 01/02/14 at 10:30 A.M., interview with RN #5 verified Resident #13 was at risk for elopement, had been packing and unpacking his suitcase, and eloped from the facility on 12/26/13. RN #5 stated safety interventions prior to the resident eloping from the facility was hourly checks. On 01/02/14 at 11:56 A.M., interview with the DON stated residents were to be assessed upon admission and interventions implemented if identified at risk for elopement. On 01/02/14 at 2:37 P.M., interview with LPN #11 revealed Resident #13 was observed on 12/26/13 on the east side of the building on the first floor in the foyer of the exit doors. LPN #11 stated staff tried to encourage him to come in and the resident refused stating someone just killed his brother. LPN #11 left the resident unattended in the foyer, returned to the second floor via the elevator, and informed Resident #13's nurse (RN #120) of the situation. LPN #11 stated within five to 10 minutes, RN #120 went downstairs to the foyer between the exit doors and the resident was gone. There was no search conducted to determine if Resident #13 wandered out of the facility. On 01/02/14 at 2:39 P.M., interview with RN #10 verified Resident #13 was assessed as an elopement risk upon admission on 12/13/13. RN #10 stated interventions implemented at admission to prevent elopement included to be kept in common areas, only to be outside with staff or transport for appointments and hourly rounds. These interventions were supposed to be on the elopement care plan and nurse aide Kardex. At 2:41 P.M., RN #10 verified Resident #13 ' s elopement care plan and nurse aide Kardex did not include the above interventions. At 2:46 P.M., RN #10 verified the medical record revealed Resident #13 had exit-seeking behaviors since admission, staff failed to notify her, the DON and the physician, there was no documented evidence interventions were implemented to prevent the resident from eloping and if she had been aware of the exit-seeking behavior, she would have initiated a wander alert. On 01/02/14 beginning at 2:56 P.M., interview with the DON verified Resident #13 was assessed at risk for elopement on admission, the only interventions implement on admission to prevent elopement was hourly checks and monitoring in a common area when out of bed. A wander alert was not initiated for wandering behaviors until the resident eloped from the facility, and there was no documented evidence of wander alert function or placement in the medical record until 12/30/13. The DON stated a wander alert was placed on residents that were known to actively exit-seek. The DON verified packing and unpacking a suitcase and walking on the unit pulling a suitcase would be considered active exit-seeking. The DON verified the Missing Resident Action Plan was incomplete and there was no documented evidence a thorough investigation was completed or the family was notified when Resident #13 was found until 12/27/13. The DON stated no staff education was conducted after Resident #13 eloped from the facility. The DON verified high-risk precautions included hourly rounds and to ensure the resident was in a common area when up. The DON verified these high-risk precautions were not documented. The DON verified Resident #13 had eloped from the facility and his whereabouts were unknown for approximately two hours. The resident was located after RN #10 called the hospital emergency room located across the street from the facility and emergency room staff stated the resident was there to be evaluated. At that time, RN #120 went to the hospital where the resident was in a room to be evaluated. RN #120 told the emergency room physician the resident was from the facility across the street and took the resident back to the facility without an evaluation. On 01/03/14 at 10:45 A.M., Resident #42 was observed self-propelling in a wheelchair independently with no wander alert observed. At the time of the observation, RN #10 verified the resident was at risk for elopement and a wander alert was not in use. On 01/03/14 at 10:46 A.M., Resident #55 was observed lying in bed with eyes closed with no wander alert observed. At the time of the observation, RN #10 verified the resident was at risk for elopement and a wander alert was not in use. On 01/03/14 at 10:49 A.M., Resident #3 was observed sitting on the edge of her bed ripping up paper with no wander alert device observed in place. At the time of the observation, RN #10 verified the resident was at risk for elopement and a wander alert was not in use. On 01/03/14 at 10:50 A.M., Resident #82 was observed in the lounge of the nurses ' station lying on a couch with no wander alert observed. At the time of the observation, RN #10 verified the resident was at risk for elopement and a wander alert was not in use. On 01/03/14 at 10:51 A.M., Resident #65 was observed lying in bed with no wander alert. At the time of the observation, RN #10 verified the resident was at risk for elopement and a wander alert was not in use. On 01/03/14 at 11:11 A.M., phone interview with RN #120 stated on 12/26/13 she had visualized Resident #13 between 10:00 A.M. and 10:30 A.M. in his room lying in bed. RN #120 stated she was aware Resident #13 was an elopement risk, and was notified Resident #13 could not be located in the facility when transportation arrived to take him to dialysis. RN #120 stated she was not told Resident #13 was in the foyer between the exit doors prior to the resident ' s elopement. On 01/03/14 at 11:56 A.M., interview with LPN #276 revealed staff would be aware of a resident being at risk for elopement if the resident had a wander alert in use. However, during the investigation, it was determined that not all residents who were at risk for elopement had a wander alert in place. On 01/03/14 at 12:38 P.M., Resident #82 was observed attempting to exit the facility through the east side exit doors with no wander alert. No staff members were observed in the immediate area at this time or accompanying the resident. Resident #82 entered the foyer, opened the exit door and then turned around once the cold air entered the foyer. As the resident began to return into the facility, the DON was observed to walk from her office, which was located near the exit door, saw and approached the resident. The resident had been identified by the facility as an elopement risk. The DON stated it was the first time Resident #82 had attempted to exit the doors. The DON verified Resident #82 did not have a wander alert. Review of the medical record revealed Resident #82 had a wander alert between 11/05/13 and 11/07/13. There was no documented evidence of the wander alert after 11/07/13, no monitoring of Resident #82 ' s risk of elopement or interventions implemented when the wander alert was discontinued. It was unknown when the facility discontinued Resident #82 ' s wander alert. On 01/06/14 at 1:50 P.M., interview with Regional Director of Clinical Operations #122 verified there was no documented evidence of Resident #82's wander alert function or placement since admission, no nursing documentation of the elopement attempt on 01/03/14, no documented evidence of the wander alert after 11/07/13, and no documentation when or why the wander alert was discontinued. This deficiency substantiates Complaint Number OH 100.