Every finding on record at Maple Gardens Rehabilitiation and Nursing Center

Based on record review, review of Self-Reported Incidents (SRI), interviews and facility policy review, the facility failed to ensure supervision was provided during smoke break which resulted in resident to resident abuse. This affected one resident (Resident #30) of three reviewed for abuse. The facility census was 63. Review of the medical record revealed Resident #3 had an admission date of 08/31/21 with diagnoses of alcohol induced persisting dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 did not exhibit physical or verbal behaviors. Review of the Smoking Safety Screen dated 05/05/26 revealed Resident #3 was safe to smoke with supervision. Review of the care plan revealed Resident #3 had behavior problem related to being verbally abusive to roommate and others and loud w/ staff at times. Interventions include education on successful coping and interaction strategies. Resident #3 had a care plan which documented the resident had the potential to be verbally aggressive related to dementia dated 09/03/24. The goal was for the resident to verbalixe understanding of need to control verbally abusive behavior. Interventions included when the resident becomes agitated to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. Resident #3 had a care plan dated 06/15/26 that documented the resident had the potential to be physically aggressive to peers related to dementia and poor impulse control, the goal was for the resident not to harm others, interventions included when the resident becomes agitated to intervene before agitation escalates, guide away from the source of distress and engage calmly in conversation. Further review revealed Resident #3 is a smoker with interventions including supervision while smoking. Review of the medical record for Resident #30 revealed an admissions date of 11/26/25 with the most recent readmission date of 05/20/26. Diagnoses included bipolar II, borderline personality disorder, muscle weakness and repeated falls. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 did not exhibit physical or verbal behaviors. Review of the Smoking Safety Screen completed on 05/20/26 revealed Resident #30 was safe to smoke with supervision. Review of the care plan revealed Resident #30 revealed a care plan dated 02/09/26 which documented the resident exhibits verbal aggression including yelling, threatening language, insults or hostile tone towards staff and peers. Interventions include using calm non-confrontational communication. Further review revealed Resident #30 was a smoker with interventions including supervision while smoking. Review of Resident #30's progress note dated 06/14/26 at 9:00 A.M. revealed the resident was out in the designated smoking area with Laundry Aide #75. Resident #30 was asked by another Resident (#3) if she could borrow her lighter and Resident #30 stated no. The other resident called Resident #30 profane names and Resident #30 stood up and pointed at the other resident and stated that is the last time you will call me that, you call me that all the time and I'm sick of it. At this point Laundry Aide #75 came into the building to find a nurse. As reported by both residents the other resident grabbed onto Resident #30's arm and pushed her to the ground. Resident #30 had a bruise on her left knee and left inner arm. Resident #30 was helped up off her knee by Licensed Practical Nurse (LPN) #1 who was the nurse who arrived on the scene and assisted Resident #30 back into the building. Review of the Self-Reported Incident dated 06/14/26 revealed on the morning of 06/14/26, two female residents (#3 and #30) were involved in an altercation in the main courtyard. An argument started during a supervised smoke break. The supervising attendant reported both residents began arguing intensely and name calling. The attendant repeatedly requested for them to calm down when Resident #30 stood from her wheelchair and walked towards Resident #3 who was in her wheelchair. Shortly after, Resident #3 grabbed Resident #30 and allegedly knocked Resident #30 to the ground. When a nurse arrived to assist, Resident #30 was on one knee on the ground near Resident #3 who remained in her wheelchair. Resident #3 and #30 were the only two in the courtyard. The residents were separated and taken to their halls/units. Resident #30 stated she stood up from her wheelchair because she was not going to tolerate being called horrible names. She reported once she stood next to Resident #3 she was grabbed by the left arm and then shoved to the ground. Resident #30 described landing on her back, but given the evidence that seems unlikely. Resident #3 stated that Resident #30 had punched her in the face, however, no evidence (no redness or bruising) to indicate that occurred. No charges were filed or arrests made. Resident #30 complained of back pain so X-rays were obtained. The results of those X-rays revealed no damage or fractures. The allegation was unsubstantiated. Interview with the Administrator on 06/23/26 at 3:13 P.M. confirmed the altercation between Resident #3 and Resident #30 occurred towards the end of the smoke break and the two had gotten into a name calling event. The Administrator verified there was a laundry aide supervising the smoke break, but stated at the time of the incident between the two residents, the laundry aide had gone inside to get help from the nurse. Observation of smoking on 06/24/26 at 8:43 A.M. revealed two residents did not have their smoking products in the lock box. Housekeeping #80 who was supervising smoking was observed to walk away from the smoking area, around the corner, and out of sight of the smoking area to see if activities staff had the resident's smoking products. Interview with Housekeeping #80 on 06/24/26 at 9:17 A.M. revealed housekeeping staff usually supervise the first two smoke breaks of the day. Housekeeping #80 verified during smoke break the staff supervising the smoking should not leave the smoking area. Housekeeping #80 stated she thinks the facility should have a walkie in the smoking area so they can call for help when needed. Housekeeping #80 verified on this day she did have to walk away from the smoke break to retrieve smoking materials, confirming she did not have eyes on all residents during the smoke break. Interview on 06/24/26 at 9:52 A.M. with Laundry Aide #75 verified she was supervising the smoke break on 06/14/26 when Resident #30 and Resident #3 began to argue and call each other names. Laundry Aide #75 revealed she attempted to get Resident #3 to go back back in the facility, but Resident #30 began to stand up, and she (laundry Aide #75) panicked because she could not help the residents. Laundry Aide #75 stated she went inside to the front to get LPN #1 but had to go back to the living room and LPN #1 told her to get LPN #10. Laundry Aide stated LPN #10 told her to get LPN #26. Laundry Aide #75 stated at most the residents were outside alone for two minutes while she ran for help. Interview with the Director of Nursing on 06/24/26 at 11:40 A.M. verified the Resident #30's fall on 06/14/26 was not on the incident log due to it being a physical altercation incident. Interview on 06/24/26 at 1:57 P.M. with Resident #3 revealed she did not remember what exactly happened on 06/14/26, but she was satisfied the facility was keeping Resident #30 away from her. She stated her and Resident #30 now have separate smoke breaks and verified smoke breaks are always supervised. Interview on 06/24/26 at 2:44 P.M. with Certified Nursing Assistant # 43 revealed she was working the day of the altercation, and stated she has supervised smoke breaks before and never seen an altercation. CNA # 43 stated staff are supposed to have a walkie on them when they go to supervise smoke break to call for help if needed, but the facility will run low on them. Interview on 06/24/26 at 3:22 P.M. with Resident #30 revealed during the smoke break on 06/14/26, she was outside with Resident #3 and Laundry Aide #75 who was supervising the smoke break. Resident #30 stated Resident #3 had asked to use her lighter and when she refused, Resident #3 began calling her names. Resident #30 stated Laundry Aide #75 did not intervene and went inside. Resident #30 stated she and Resident #3 were the only ones outside, and she told Resident #3 she was not going to let her keep talking to her like that. Resident #30 confirmed she stood up and was pulled to the ground by Resident #3. Resident #30 stated that she had bruising on her arm and pain in her back since the incident. Resident #30 stated that an X-ray of her back was completed with no findings. Resident #30 verified that now she had separate smoke breaks and can sign herself out to smoke as wanted. Review of the undated facility policy titled, Safe Smoking Policy revealed smoke breaks will always be supervised. This deficiency represents non-compliance investigated under Complaint Number 3050549.

Based on medical record review, interview, and policy review, the facility failed to maintain complete and accurate documentation. This affected one (#64) out of three residents reviewed for documentation. The facility census was 61.Findings include:Review of the closed medical record for Resident #64 revealed an admission date of 11/07/25 and a discharge date of 05/27/26. Diagnoses included acute pyelonephritis, Type Two Diabetes Mellitus with diabetic neuropathy, primary lateral sclerosis, hypertension, functional quadriplegia, chronic hepatitis, factitious disorder imposed on self, major depressive disorder, myoneural disorder, generalized anxiety disorder, bipolar disorder, personality disorder, other chronic pain, chronic kidney disease stage three, and chronic respiratory failure with hypoxia.Review of the significant change Minimum Data Set (MDS) assessment, dated 02/27/26, revealed this resident was cognitively intact. This resident was assessed to require setup assistance for eating, supervision for oral hygiene, and was dependent for toileting, bathing, dressing, personal hygiene, and bed mobility.Review of the physician orders for Resident #64 revealed orders for Ativan (antianxiety) with a dosage of 0.25 milliliters (ML) four times a day for anxiety/restlessness, Lorazepam (antianxiety) with the dosage of 0.5 ML every six hours for nausea and vomiting, and Morphine (opioid) with a dosage of 0.5 ML every six hours for chronic pain.Review of the Medication Administration Record (MAR) for Resident #64 from 05/01/26 to 05/27/26 revealed blank spaces for Morphine on 05/02/26, 05/03/26, 05/05/26, and 05/23/26, Lorazepam on 05/02/26, 05/03/26, and 05/05/26, and Ativan on 05/23/26.Interview on 06/10/26 at 12:15 P.M. with Regional Director of Clinical Services (RDCS) #600 verified the medications had not been signed off as refused on the MAR.Review of the facility policy titled Administering Medications, revised 12/2012 revealed if a medication is refused, the individual administering the medication should initial and circle the MAR space provided for that drug and dose.This deficiency represents non-compliance investigated under Complaint Number 2967767.

Based on medical record review, observation, interview, review of training competency records, review of the manufacturers guidelines, facility record review, policy review, and review of current Occupational Safety and Health Administration (OSHA) guidance, the facility failed to ensure glucometers were cleaned after use. This affected one (Resident #60) out of two residents observed for glucometer use. In addition, the facility failed to maintain documentation of annual fit testing for staff for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. This had the potential to affect all 64 residents who resided in the facility. The facility census was 64.Findings included:1. Review of the medical record revealed the facility admitted Resident #60 on 03/07/25. Diagnoses included type two diabetes mellitus. Review of Resident #60's Care Plan Report, included a focus area initiated 03/11/25, that indicated the resident had diabetes mellitus. Interventions directed staff to monitor blood sugar levels. During an observation of medication pass for Resident #60 on 02/25/26 at 6:16 A.M., Licensed Practical Nurse (LPN) #02 performed a blood glucose test with a result of 144 milligrams per deciliter (mg/dL). The LPN #02 placed the used glucometer on the top of the medication cart, removed their gloves, performed hand hygiene, and documented the results of the test. LPN #02 then placed the glucometer into the top drawer of the medication cart. LPN #02 had not cleaned the glucometer prior to placing in the top drawer of the medication cart. Interview at the time of the observation LPN #02 stated she was not told she had to clean the glucometer.During an interview on 02/27/26 at 11:19 A.M., the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist (IP), stated she expected that multiuse equipment, including glucometers, were cleaned and disinfected after each use. During an interview on 02/27/26 at 11:33 A.M., LPN #03 stated she worked with and trained LPN #02 on how to complete a fingerstick glucose check, clean the glucometer, and then reviewed the cleaning procedure. She stated LPN #02 had demonstrated competency during their training.During an interview on 02/27/26 at 1:05 P.M., the Director of Nursing (DON) stated she expected the glucometers were cleaned per the manufacturer's instructions. The DON stated she had immediately provided re-education to LPN #02 on the morning of 02/25/2026 following the medication pass observation.Review of a Competency Assessment Obtaining a Fingerstick Glucose Level for LPN #02, specified, Always ensure that the blood glucose meters intended for reuse are cleaned and disinfected between resident uses. The document further specified, Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The competency was checked as demonstrated and signed by the Observer/Trainer, LPN #03 on 02/23/26.Review of a facility policy titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, specified, 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.Review of the manufacturer guideline revealed The [name of manufacturer] Multi Blood Glucose Monitoring System instructions for use, undated, specified, The meter should be cleaned and disinfected after use on each patient. The [name of manufacturer] Multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The policy also specified, The cleaning procedure is needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens.2. Review of an undated Nursing Phone Roster revealed a list of 80 current employees from all departments.During interviews on 02/27/26 between 6:30 PM. and 7:00 P.M., four nurses, Registered Nurse (RN) #07, Licensed Practical Nurse (LPN) #03, #08, and #09, four Certified Nurse Aides (CNA) #10, #11, #12, and #13, the Dietary Manager [DM], two Dietary Aides (DA) #14, and DA #15, the Admissions Director, and Housekeeper #16, all stated they had been fit tested in 2025.During an interview on 02/27/26 at 5:00 P.M., the DON stated they would look for the fit testing documentation. During an interview on 02/27/26 at 6:34 P.M., the ADON/IP stated she and Central Supply Medical Records (CS/MR) #05 were responsible for performing fit testing for staff. She stated that fit testing was performed upon hire, annually, and with any significant changes. The ADON/IP stated that the fit documentation should be maintained, but she found no documentation for 2025.During a follow-up interview on 02/27/26 at 6:50 P.M., the DON stated the Nursing Phone Roster provided at the start of the survey was a current list of employees. The DON stated she expected fit testing documentation for employees to be maintained and readily available.Review of a facility policy titled, Mask Fitting Policy and Procedure, revised 05/28/2020, indicated, The purpose of this policy is to follow OSHA Standards 1910.134 for mask fit testing for those employees that may come in contact with an airborne pathogen in home or facility settings. This testing will be conducted at the time of hire then annually moving forward.Review of the 1910 Occupational and Safety Health Standards Subpart: 1910 Subpart 1 Personal Protective Equipment - Standard Number: 1910.134, titled, Respiratory protection, indicated the following:- 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter.- 1910.134(m)(2)(ii) - Fit test records shall be retained for respirator users until the next fit test is administered.This deficiency represents noncompliance investigated under Complaint Number 2725949.

Based on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure foods were served per resident preference. This affected one (Resident #44) out of five residents reviewed for food preferences. The facility census was 64. Findings included:Review of the medical record revealed the facility admitted Resident #44 on 01/19/26. Diagnoses included hyperlipidemia, gastro-esophageal reflux disease (GERD), adult failure to thrive (FTT), atherosclerotic heart disease (AHD), ascites, and depression. Review of a Diagnosis Report indicated Resident #44 also had diagnoses that included protein calorie malnutrition (PCM), cirrhosis of the liver, type 2 diabetes mellitus (DM2), and hyperlipidemia. Review of Resident #44's Care Plan Report included a problem statement that indicated the resident had nutritional problems related to severe PCM, cirrhosis of the liver, DM2, hyperlipidemia, GERD, adult FTT, and AHD. Interventions directed staff to provide and serve diet as ordered and monitor/record intake for each meal. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2026, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also indicated Resident #44 ate independently after the tray was set up by staff. During an interview on 02/23/26 at 11:36 A.M., Resident #44 stated they were served beans sometimes, which was a food the resident disliked, was recorded as a food the resident did not like and populated on the tray tickets from dietary services. Resident #44 stated that when beans were received, the resident ate around the beans. During a concurrent observation and interview on 02/24/26 at 12:15 P.M., Resident #44 was observed with their lunch meal, which included a bowl of baked beans. Resident #44 did not eat the baked beans and stated, I don't like beans and they know it. Interview on 02/24/26 at 12:22 P.M. with Certified Nurse Aide (CNA) #04 revealed she provided a lunch tray to Resident #44 that day and that she looked at the tray ticket to make sure the resident received the correct diet. CNA #04 stated she did not see on the tray ticket that the resident did not like beans, but she should have noticed that and offered Resident #44 an alternative to the baked beans. During an interview on 02/25/2026 at 8:20 A.M., the Dietary Manager (DM) stated that on admission to the facility, Resident #44 provided a list of foods the resident did not like, including beans, and Resident #44 was consistent in that the resident did not like beans. The DM stated that when beans were on the menu, Resident #44 should receive a different vegetable. The DM further stated that Resident #44 should have received double carrots instead of beans for lunch on 02/24/26, and if beans were provided it was because staff may not have paid attention to the tray ticket.During a telephone interview on 02/25/26 at 10:20 A.M., the Registered Dietitian (RD) revealed that if a resident expressed food preferences, those preferences should be communicated to the DM, who would update the tray ticket. The RD stated food preferences should be listed on the tray ticket and honored. During an interview on 02/27/26 at 11:20 A.M., the Administrator stated that during admission and throughout the resident's stay, the staff asked residents about preferences. That information was entered into the facility's tray ticket system, and any likes/dislikes were printed on the tray ticket. The Administrator stated that if the tray ticket listed a dislike, staff should not serve it but should serve the resident something comparable. The Administrator stated that he expected dietary staff to honor resident requests. During an interview on 02/27/26 at 11:45 A.M., the Regional Director of Clinical Operations stated she expected the facility to follow what the patient wanted to eat and provide an alternative for items expressed as a dislike.Review of a facility policy titled, Resident Food Preferences, revised July 2017, indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The policy further indicated, 1. Upon the resident's admission (or within forty eight (48) hours after his/her admission) the Dietician or dietary staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. The Dietician and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. The policy continued, 7. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. and 9. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. This deficiency represents noncompliance investigated under Complaint Number 2718114.

Based on observation, interview, and facility policy review, the facility failed to ensure two of four medication carts were locked when not within the line of sight of facility staff. This had the potential to affect all 64 residents who resided in the facility. The facility census was 64.Findings Included:During an observation and concurrent interview on 02/25/26 at 6:01 A.M., at the nurse's station on the 300 Hall, a medication cart and a treatment cart, located between the Minimum Data Set (MDS) office and the nursing station, were observed unlocked. There were no staff members in the hallway where the carts were located. Three staff were observed in an adjacent hallway walking away from the carts. At 6:08 A.M., Licensed Practical Nurse (LPN) #01 returned to the nursing station. LPN #01 stated the carts should have been locked when not in use. Medications in the medication cart included lisinopril (used to treat high blood pressure), Amlodipine (used to treat high blood pressure and coronary artery disease), and glipizide (used to treat type two diabetes).During an interview on 02/27/26 at 11:19 A.M., the Assistant Director of Nursing, who also served as the Infection Preventionist, stated she expected medication carts to always be locked when not in use.During an interview on 02/27/26 at 1:05 P.M., the Director of Nursing stated she expected medication carts to be locked if the nurse could not see the drawers and supervise the cart.Review of a facility policy titled, Storage of Medications, revised April 2007, specified, 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes. [sic]) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Any malfunctioning medication storage, especially secure/locked carts or containers must be reported immediately to prevent medications diversion and provide safety for patient's medications.

Based on observations, staff interviews, policy review and review of a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 53 residents residing in the facility. Facility census was 53. Findings include: Tour of the facility kitchen with Dietary Supervisor #10 on 01/15/25 at 9:19 A.M. revealed the emergency food supply consisted of six cans (24 servings per can) of tuna; six cans (12 servings per can) of ravioli; 48 individual serving cans of a variety of soups; 72 orange juice, four ounces (oz) each; 12 packs of lemonade powder, each pack makes three gallons of lemonade; four five pound bags of dry milk; a box of crackers; and 150 gallons of water. Interview on 01/15/25 at 9:32 A.M. with Dietary Supervisor #10 confirmed, during the facility tour, the kitchen has a shelf with emergency food available that contains the items observed. Interview on 01/15/25 at 12:42 P.M. with Maintenance Director (MD) #32 confirmed he is responsible for the emergency water supply and there is currently 150 gallons of drinking water available. MD #32 confirmed Food Supplier #12 will supply water in an emergency, but recommends the facility has 1.5 gallons available for each resident on hand with a three-day supply, in case an emergency deliver is delayed. MD #32 also confirmed the facility has 53 residents, which would require 238.5 gallons to be on hand and the current supply is not enough to last three days. Interview on 01/15/25 at 1:30 P.M. with the Administrator confirmed the kitchen has an order placed for additional emergency food supplies coming on 01/16/25 from Food Supplier #12. Interview on 01/15/25 at 3:40 P.M. with Dietary Supervisor #10 confirmed the emergency food available at this time is not enough to last three days in the event of an emergency. Dietary Supervisor #10 confirmed the food currently available in the emergency stock would not last three days for the 51 residents in house, who eat food from the kitchen. Interview on 01/16/25 at 10:43 A.M. with Dietary Supervisor #10 confirmed the Disaster Plan, undated states the facility will have a three-day supply of staple goods on hand at all times and that disposable eating ware in ample supply will be available. Dietary Supervisor #10 confirmed the facility does not have the three-day supply of staple goods on hand and does not have enough disposable eating ware. Dietary Supervisor #10 also confirmed an order for the disposable eating ware has been place and would arrive next week. Review of the Disaster Plan, undated revealed in the event of a disaster, the facility wound keep a 3-day supply of staple goods is on hand at all times, a 2-day supply of perishable goods is on hand at all times, and disposable eating ware in ample supply are maintained. Review of Food Supplier #12's, Emergency Preparedness Plan, dated 10/15/23 revealed the facility should have contingency plans to include a backup supplier for the following: Food and supplies (please see state guidelines for quantities to have on-hand), water (industry standards suggest up to 1.5 gallons per person per day), and refrigeration. This deficiency represents non-compliance investigated under Complaint Number OH00161442.

Based on medical record review, staff and resident interviews, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to ensure a comprehensive person-centered care plan was updated with current interventions. This affected one (#51) out of the three residents reviewed. The facility census was 53. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, congestive heart failure, schizoaffective disorder, and chronic ischemic heart disease. Review of the medical record for Resident #51 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #51 was cognitively intact and was independent with all ADL's except required supervision with bathing. Review of the medical record for Resident #51 revealed no documentation to support a comprehensive person-centered care plan was developed for behavioral concerns with the interventions of 15-minute checks or one on one supervision. Review of the facility document titled 15-minute check sheet, dated 11/06/24, revealed Resident #51 was started on 15-minute staff checks on 11/06/24 at 7:45 P.M. until 11/07/24 at 5:45 P.M. Review the facility staffing from 11/06/24 to 11/12/24 revealed staff had been scheduled to provide Resident #51 with one-on-one supervision 24 hours per day. Interview on 11/13/24 at 8:38 A.M. with State tested Nursing Assistant (STNA) #147 stated Resident #51 had been put on one-on-one supervision after an allegation that Resident #51 had inappropriately touched a female resident. STNA #147 stated she had worked 11/07/24, 11/09/24 and 11/12/24 and provided the one-on-one supervision for Resident #51 for day shifts. Interview on 11/13/24 at 8:45 A.M. with Licensed Practical Nurse (LPN) #134 confirmed Resident #51 was put on 15-minute checks on 11/06/24 and then was put on one-on-one supervision on 11/07/24. LPN #134 stated Resident #51 was put on one-on-one supervision to ensure he did not enter any female resident rooms. Interview on 11/13/24 at 8:47 A.M. with Resident #51 confirmed he was found in a female resident's room on 11/06/24 and had been under staff supervision she that incident. Resident #51 denied any allegation of abuse. Interview on 11/13/24 at 10:50 A.M. with Administrator stated he was notified on 11/06/24 by the Director of Nursing (DON) of a concern for possible sexual abuse of Resident #12 by Resident #51. Administrator stated he went to the facility and interviewed Resident #12 who denied any sexual assault. Administrator stated he interviewed STNA #115 who stated he found Resident #51 in Resident #12's room with his knee up on Resident #12's bed and that Resident #51 told STNA #115 not to say anything. Administrator stated STNA #115 immediately left and went to get the nurse. Administrator confirmed he initiated a Self-Reported Incident (SRI) and an investigation into the allegation. Administrator stated Resident #51 was put on 15-minute staff checks on 11/06/24 and was changed to one-on-one supervision on 11/07/24 and had remained on one-on-one supervision since 11/07/24. Interview on 11/13/24 at 10:55 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #51 did not contain documentation to support Resident #51's comprehensive person-centered care plan included the one-on-one supervision by staff effective 11/07/24. Review of the RAI 3.0 manual, dated October 2023, page 4-8 stated the comprehensive care plan is an interdisciplinary (IDT) communication tool which must include measurable objectives and time frames. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI manual stated the care plan must be reviewed, and revised, periodically, and the services provided or arranged must be consistent with each resident's written plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00159734.

Based on medical record reviews, review of a facility self-reported incident (SRI), staff interview, and policy review, the facility failed to ensure staff intervened when a concern was identified regarding potential resident to resident sexual abuse. The affected one (#12) out of three residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of the medical record for the Resident #12 revealed an admitted [DATE] with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident #12 was non-ambulatory. Review of the medical record for Resident #12 revealed no documentation related to Resident #51 being found in her room and allegation of possible sexual abuse. 2. Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of COPD, anxiety, congestive heart failure, schizoaffective disorder, and chronic ischemic heart disease. Review of the medical record for Resident #51 revealed a quarterly MDS, dated [DATE], which indicated Resident #51 was cognitively intact and was independent with all ADL's except required supervision with bathing. Review of the medical record for Resident #51 revealed a nurses' note dated 11/07/24 at 11:08 A.M. stated Resident #51 continued 15-minute checks due to being in a female room unsupervised. The resident has stayed in room thus far today. Review of a facility SRI dated 11/11/24 revealed on 11/06/24 there was an allegation of potential sexual abuse by Resident #51 towards Resident #12. Review of the SRI revealed the investigation was ongoing and a conclusion had not been made. Review of the statement written by State tested Nursing Assistant (STNA) #115 stated when he walked into Resident #12's room he witnessed Resident #51 on top of Resident #12's bed leaning over with one leg on her bed and his pants halfway off his bottom. The statement by STNA #115 continued to state when Resident #51 noticed STNA #115 he told the STNA not to tell anybody that he saw him in the room. The statement concluded that STNA ran out of the room to get two nurses to redirect Resident #51 back out. Interview on 11/13/24 at 10:19 A.M. interview with Registered Nurse (RN) #166 confirmed she worked on 11/06/24 and during report around 7:10 P.M. STNA #115 came to the nurses' station and informed her Resident #51 was found in Resident #12's room and STNA #115 had concerns that something inappropriate had occurred. RN #166 stated when she entered Resident #12's room she observed Resident #51 sitting in his wheelchair and he was observed pulling Resident #12's sheet up to cover her abdominal region. RN #166 stated she had Resident #51 leave Resident #12's room immediately. RN #166 stated she asked Resident #12 if Resident #51 had touched her inappropriately and Resident #12 denied being touched by Resident #51 and stated she felt safe in the facility but also stated she did not want Resident #51 to enter her room again. RN #166 stated she asked permission from Resident #12 to look underneath her sheet and was given authorization to do so. RN #166 stated she observed Resident #12's brief to be loose and slightly opened. RN #166 stated she again asked Resident #12 if she had been sexually assaulted to which Resident #12 denied. RN #166 stated the incident was very suspicious to her, so she called the Director of Nursing (DON) around 7:25 P.M. and notified her concern for possible sexual abuse. RN #166 stated the Administrator arrived at the facility between 8:00 P.M. and 8:30 P.M. and both the Administrator and RN #166 interviewed Resident #12 who repeated that she had not been sexually assaulted and stated she felt safe in the facility. RN #166 confirmed STNA #115 left Resident #12 alone in her room with Resident #51 while he went to get staff assistance. Interview on 11/13/24 at 10:50 A.M. with Administrator stated he was notified on 11/06/24 by the DON of a concern for possible sexual abuse of Resident #12 by Resident #51. Administrator stated he went to the facility and interviewed Resident #12 who denied any sexual assault. Administrator stated he interviewed STNA #115 who stated he found Resident #51 in Resident #12's room with his knee up on Resident #12's bed and that Resident #51 told STNA #115 not to say anything. Administrator stated STNA #115 immediately left and went to get the nurse. Administrator confirmed the incident occurred on 11/06/24 but confirmed the SRI was not reported until 11/11/24. Administrator confirmed an investigation began immediately and the investigation into the SRI was still in progress. Administrator stated Resident #51 was put on 15-minute staff checks on 11/06/24 and was changed to one-on-one supervision on 11/07/24 and had remained on one-on-one supervision since 11/07/24. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated revised 11/01/19, stated the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident property, including injuries of unknown sources. The policy stated if a third party is accused or suspected (not a staff member) the facility would take action to protect the resident including, but not limited to, contacting the third party and addressing the issue directly with him/her, preventing access to resident during the investigation and /or referring the matter to the appropriate authorities. This deficiency represents non-compliance investigated under Complaint Number OH00159734.

Based on review of the medical record reviews, review of a facility self-reported incident (SRI), staff interviews, and policy review, the facility failed to report an allegation of potential sexual abuse to the Ohio Department of Health in a timely manner. This affected one (12) out of the three residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of the medical record for the Resident #12 revealed an admitted [DATE] with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident #12 was non-ambulatory. Review of the medical record for Resident #12 revealed no documentation related to Resident #51 being found in her room and allegation of possible sexual abuse. 2. Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of COPD, anxiety, congestive heart failure, schizoaffective disorder, and chronic ischemic heart disease. Review of the medical record for Resident #51 revealed a quarterly MDS, dated [DATE], which indicated Resident #51 was cognitively intact and was independent with all ADL's except required supervision with bathing. Review of the medical record for Resident #51 revealed a nurses' note dated 11/07/24 at 11:08 A.M. stated Resident #51 continued 15-minute checks due to being in a female room unsupervised. The resident has stayed in room thus far today. Review of a facility SRI dated 11/11/24 revealed on 11/06/24 there was an allegation of potential sexual abuse by Resident #51 towards Resident #12. Review of the SRI revealed the investigation was ongoing and a conclusion had not been made. Review of the statement written by State tested Nursing Assistant (STNA) #115 stated when he walked into Resident #12's room he witnessed Resident #51 on top of Resident #12's bed leaning over with one leg on her bed and his pants halfway off his bottom. The statement by STNA #115 continued to state when Resident #51 noticed STNA #115 he told the STNA not to tell anybody that he saw him in the room. The statement concluded that STNA ran out of the room to get two nurses to redirect Resident #51 back out. Interview on 11/13/24 at 10:19 A.M. interview with Registered Nurse (RN) #166 confirmed she worked on 11/06/24 and during report around 7:10 P.M. STNA #115 came to the nurses' station and informed her Resident #51 was found in Resident #12 ' s room and STNA #115 had concerns that something inappropriate had occurred. RN #166 stated when she entered Resident #12 ' s room she observed Resident #51 sitting in his wheelchair and he was observed pulling Resident #12 ' s sheet up to cover her abdominal region. RN #166 stated she had Resident #51 leave Resident #12 ' s room immediately. RN #166 stated she asked Resident #12 if Resident #51 had touched her inappropriately and Resident #12 denied being touched by Resident #51 and stated she felt safe in the facility but also stated she did not want Resident #51 to enter her room again. RN #166 stated she asked permission from Resident #12 to look underneath her sheet and was given authorization to do so. RN #166 stated she observed Resident #12 ' s brief to be loose and slightly opened. RN #166 stated she again asked Resident #12 if she had been sexually assaulted to which Resident #12 denied. RN #166 stated the incident was very suspicious to her, so she called the Director of Nursing (DON) around 7:25 P.M. and notified her concern for possible sexual abuse. RN #166 stated the Administrator arrived at the facility between 8:00 P.M. and 8:30 P.M. and both the Administrator and RN #166 interviewed Resident #12 who repeated that she had not been sexually assaulted and stated she felt safe in the facility. Interview on 11/13/24 at 10:50 A.M. with Administrator stated he was notified on 11/06/24 by the DON of a concern for possible sexual abuse of Resident #12 by Resident #51. Administrator stated he went to the facility and interviewed Resident #12 who denied any sexual assault. Administrator stated he interviewed STNA #115 who stated he found Resident #51 in Resident #12's room with his knee up on Resident #12's bed and that Resident #51 told STNA #115 not to say anything. Administrator stated STNA #115 immediately left and went to get the nurse. Administrator confirmed the incident occurred on 11/06/24 but confirmed the SRI was not reported until 11/11/24. Administrator confirmed an investigation began immediately and the investigation into the SRI was still in progress. Administrator stated Resident #51 was put on 15-minute staff checks on 11/06/24 and was changed to one-on-one supervision on 11/07/24 and had remained on one-on-one supervision since 11/07/24. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated revised 11/01/19, stated if the event that caused the allegation involved an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health immediately, but no longer than 24 hours from the time the incident/allegation was made know to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00159734.

Based on medical record reviews, review of a facility self-reported incident (SRI), staff and legal guardian interviews, and policy review, the facility failed to implement their abuse policy by ensuring a resident's legal guardian and physician were notified of an allegation of potential sexual abuse. This affected one (#12) out of the three residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of the medical record for the Resident #12 revealed an admitted [DATE] with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident #12 was non-ambulatory. Review of the medical record for Resident #12 revealed no documentation related to Resident #51 being found in her room and allegation of possible sexual abuse. Review of the medical record for Resident #12 revealed no documentation to support the legal guardians or physician were notified of the allegation of sexual assault. 2. Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of COPD, anxiety, congestive heart failure, schizoaffective disorder, and chronic ischemic heart disease. Review of the medical record for Resident #51 revealed a quarterly MDS, dated [DATE], which indicated Resident #51 was cognitively intact and was independent with all ADL's except required supervision with bathing. Review of the medical record for Resident #51 revealed a nurses' note dated 11/07/24 at 11:08 A.M. stated Resident #51 continued 15-minute checks due to being in a female room unsupervised. The resident has stayed in room thus far today. Review of a facility SRI dated 11/11/24 revealed on 11/06/24 there was an allegation of potential sexual abuse by Resident #51 towards Resident #12. Review of the SRI revealed the investigation was ongoing and a conclusion had not been made. Review of the statement written by State tested Nursing Assistant (STNA) #115 stated when he walked into Resident #12's room he witnessed Resident #51 on top of Resident #12's bed leaning over with one leg on her bed and his pants halfway off his bottom. The statement by STNA #115 continued to state when Resident #51 noticed STNA #115 he told the STNA not to tell anybody that he saw him in the room. The statement concluded that STNA ran out of the room to get two nurses to redirect Resident #51 back out. Interview on 11/13/24 at 10:19 A.M. interview with Registered Nurse (RN) #166 confirmed she worked on 11/06/24 and during report around 7:10 P.M. State tested Nursing Assistant (STNA) #115 came to the nurses' station and informed her Resident #51 was found in Resident #12's room and STNA #115 had concerns that something inappropriate had occurred. RN #166 stated when she entered Resident #12's room she observed Resident #51 sitting in his wheelchair and he was observed pulling Resident #12's sheet up to cover her abdominal region. RN #166 stated she had Resident #51 leave Resident #12's room immediately. RN #166 stated she asked Resident #12 if Resident #51 had touched her inappropriately and Resident #12 denied being touched by Resident #51 and stated she felt safe in the facility but also stated she did not want Resident #51 to enter her room again. RN #166 stated she asked permission from Resident #12 to look underneath her sheet and was given authorization to do so. RN #166 stated she observed Resident #12's brief to be loose and slightly opened. RN #166 stated she again asked Resident #12 if she had been sexually assaulted to which Resident #12 denied. RN #166 stated the incident was very suspicious to her, so she called the Director of Nursing (DON) around 7:25 P.M. and notified her concern for possible sexual abuse. RN #166 stated the Administrator arrived at the facility between 8:00 P.M. and 8:30 P.M. and both the Administrator and RN #166 interviewed Resident #12 who repeated that she had not been sexually assaulted and stated she felt safe in the facility. RN #166 confirmed she did not notify Resident #12's Legal Guardian or physician of the concern of possible sexual assault. Interview on 11/13/24 at 10:50 A.M. with Administrator stated he was notified on 11/06/24 by the DON of a concern for possible sexual abuse of Resident #12 by Resident #51. Administrator stated he went to the facility and interviewed Resident #12 who denied any sexual assault. Administrator stated he interviewed STNA #115 who stated he found Resident #51 in Resident #12's room with his knee up on Resident #12's bed and that Resident #51 told STNA #115 not to say anything. Administrator stated STNA #115 immediately left and went to get the nurse. Administrator confirmed the incident occurred on 11/06/24 but confirmed the SRI was not reported until 11/11/24. Administrator confirmed an investigation began immediately and the investigation into the SRI was still in progress. Administrator stated Resident #51 was put on 15-minute staff checks on 11/06/24 and was changed to one-on-one supervision on 11/07/24 and had remained on one-on-one supervision since 11/07/24. Interview on 11/13/24 at 10:55 A.M. with DON confirmed the medical record for Resident #12 revealed no documentation related to concern for possible sexual abuse or that Resident #12's legal guardian or physician were notified of the incident. Interview on 11/13/24 at 11:35 A.M. with Resident #12's legal guardian stated the facility notified both he and Resident #12's mother of the concern for possible sexual assault involving the resident on 11/11/24. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated revised 11/01/19, stated the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident property, including injuries of unknown sources. The policy stated if a third party is accused or suspected (not a staff member) the facility would take action to protect the resident including, but not limited to, contacting the third party and addressing the issue directly with him/her, preventing access to resident during the investigation and /or referring the matter to the appropriate authorities. The policy stated the Resident Representative, and the attending physician should be notified of the incident. The policy stated documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and Resident Representative, and any treatment provided. This deficiency represents non-compliance investigated under Complaint Number OH00159734.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff followed infection control procedures during medication administration. This affected one (#51) out of the two residents observed for medication administration. The facility census was 52. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of Parkinson's disease, arthritis, hypertension, anxiety, heart failure, and depression. Review of the medical record for Resident #51 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/24/24, which indicated Resident #51 had moderate cognitive impairment and was independent with eating and bed mobility, required supervision with toileting and transfers, and required partial/moderate staff assistance with bathing. Review of the medical record for Resident #51 revealed a physician order dated 02/27/23 for Carbidopa-Levodopa 25-100 milligram (mg) one tablet by mouth four times per day, an order dated 02/28/23 for glucosamine 400 mg one tablet by mouth daily and Primidone 50 mg one tablet by mouth three times per day, an order dated 10/11/24 for Buspar 5 mg one tablet by mouth three times per day, an order dated 01/07/24 for hydroxyzine 25 mg one tablet by mouth two times per day, and an order dated 02/06/24 for Coreg 3.125 mg one tablet by mouth two times per day. Observation on 11/05/24 at 8:25 A.M. revealed Registered Nurse (RN) # 202 prepare Resident #51 medications for administration. The observation revealed RN #202 place carbidopa-levodopa, glucosamine, Primidone, Buspar, hydroxyzine, and Coreg tablets into his bare hands prior to placing medications into a medication cup. The observation revealed RN #202 observed Resident #51 consume the medications. Interview on 11/05/24 at 9:06 A.M. with RN #202 confirmed he had not performed hand hygiene before or after medication administration and that he placed Resident #51's medications into his bare hands prior to administration. Review of the facility policy titled, Medication Administration, stated only persons licensed by the State to prepare, administer and document the administration of medications may do so. The policy stated the medications must be administered in accordance with the orders, including any required time frame. The policy also stated staff shall follow established facility infection control procedures (i.e. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. The deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to ensure money from a resident fund account (RFA) was returned in a timely manner following the resident's discharge. This affected one (#60) out of the three residents reviewed for resident fund accounts. The facility census was 52. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE] with medical diagnoses of schizophrenia, chronic obstructive pulmonary disease, asthma, hypertension, and anemia. Review of the medical record for Resident #60 revealed a discharge date of [DATE]. Review of the medical record for Resident #60 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/07/23, which indicated Resident #60 had moderate cognitive impairment and required supervision with toileting, bathing, bed mobility and transfers. Review of the RFA statement for Resident #60 revealed a balance of $50.87 on 12/01/23. Review of the RFA statement revealed the balance was refunded to Resident #60 on 02/09/24 and the RFA was closed. Interview on 11/05/24 at 1:08 P.M. with Business Office Manager (BOM) #215 confirmed Resident #60 was discharged from the facility on 11/20/23 and the resident's RFA remaining balance was not disbursed until 02/09/24. BOM #215 confirmed Resident #60 had transferred to another facility where she remained as a resident for at least six weeks after discharge. BOM #215 stated the facility did not have a policy for RFA. This deficiency represents non-compliance investigated under Complaint Number OH00158172.

Based on medical record review, review of a Self-Reported Incident (SRI), interviews with staff, residents, the law enforcement detective, and Sexual Assault Nurse Examiner (SANE), review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility investigation, review of the SANE report, and policy review, the facility failed to ensure one resident (#49) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial harm on 02/26/23 at approximately 6:00 P.M., when Resident #25 entered Resident's 49's room and forcefully penetrated Resident #49's vagina with his fingers causing Resident #49 to have pain and bleeding while the resident yelled for help. This affected one resident (#49) of three residents (#25, #49, and #59) reviewed for abuse. There was a total of eight residents (#14, #24, #25, #28, #43, #44, #49, and #59) screened for abuse during the annual survey. The facility census was 66. On 03/09/23 at 3:50 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #125, and Regional Director of Clinical Services (RDCS) #400 were notified Immediate Jeopardy began on 02/26/23 at 6:00 P.M. when Resident #25 entered Resident #49's room and forcefully penetrated Resident #49's vagina with his fingers causing pain and bleeding. Resident #49 told Resident #25 to quit as the resident yelled for help. Resident #49, who was cognitively intact but had a guardian due to significant psychiatric disorders, held onto this information until approximately 11:00 P.M., when she tearfully reported the incident to Hospitality Aide (HA) #79. Subsequently, Resident #49 was transported to the Emergency Department (ED) where the resident reported she was inappropriately touched by another resident causing vaginal pain and right sided abdominal pain. Additionally, Resident #49 was examined by the SANE nurse and according to the examination report, Resident #49 was noted to have significant abrasions on areas of her vagina and the resident was frightened about returning to the facility. The Immediate Jeopardy was removed on 03/10/23 when the facility implemented the following corrective actions: On 02/26/23 at 6:00 P.M., Resident #25 touched Resident #49's vagina in Resident #49's room. On 02/26/23 at 11:00 P.M., Resident #49 reported that Resident #25 inserted his fingers into her vagina, and she had discomfort. The residents were already separated as Resident #25 was asleep in his bed. On 02/26/23 from 11:00 P.M. to 12:40 A.M., the staff were sitting with Resident #49 to ensure the resident's psychiatric needs were met. On 02/26/23 at 11:01 P.M., Resident #25 was placed immediately on one-to-one (1:1) monitoring. On 02/26/23 at 11:05 P.M., a message was left for Resident #49's guardian by Registered Nurse (RN) #130. A message was left for Resident #25's Power-of-Attorney (POA) by RN #130. On 02/27/23 at 12:10 A.M., Medical Director/Physician #500 was contacted related to the incident and made aware of Resident #49 needing to go to the ED. On 02/27/23 at 12:40 A.M., Resident #49 was sent to the local hospital ED for an assessment. The local police responded with EMS due to the nature of the call. On 02/27/23 at 7:45 A.M., Resident #25's POA was made aware of the incident after a returned phone call. On 02/27/23 at 8:00 A.M., Resident #25 was moved to the Meadows unit to separate the distance between the residents to ensure no contact. On 02/27/23 at 8:00 A.M., referrals to transfer Resident #25 were sent to other facilities to transfer the resident. On 02/27/23 at 8:42 A.M., the Administrator initiated an SRI noting the category of allegation as sexual abuse. On 02/27/23 at 9:30 A.M., Detective #230 arrived at the facility and interviewed Resident #25. On 02/27/23 from 10:00 A.M. to 12:00 P.M., Social Services Designee (SSD) #115 interviewed other residents. No further incidents were identified. On 02/27/23 at 11:00 A.M., RDCS #400 educated the DON, ADON #125, and the Administrator on abuse, documentation on resident relationships and notification to responsible parties, and care planning of relationships if there is approval from guardian or if there is not, proper interventions for when incidents occur that may be sexual in nature. On 02/27/23 at 11:03 A.M., Resident #49's Guardian was notified by the DON. On 02/27/23 at 12:00 P.M., the DON and ADON #125 reviewed other residents that were in a relationship. The facility identified two residents (#15 and #39) being in a relationship status and there were no identified concerns related to abuse. On 02/27/23 at 1:25 P.M., Resident #49 returned to the facility from the hospital. Resident #49 was placed on 15-minute checks for psychiatric signs and symptoms. On 02/27/23 at 2:00 P.M., GuideStar Eldercare psychiatric services were notified of the sexual abuse incident and that Resident #49 needed further psychosocial services. On 02/27/23 at 2:09 P.M., the DON, ADON #125 and the Administrator completed education to all facility staff regarding abuse. On 02/27/23 at 2:30 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was completed to review the incident with all department heads and the Administrator. Attendees included: Administrator, DON, ADON #125, Minimum Data Set (MDS)/RN #119, Staff Scheduler/Licensed Practical Nurse (LPN) #124, SSD #115, Business Office Manager (BOM) #122, Activities Director (AD) #68, Dietary Manager (DM) #76, Maintenance Director #116, Housekeeping Supervisor #114, Medical Records Supervisor #123, and Admissions Staff #126. On 02/27/23, the DON, ADON #125 and LPN #124 initiated skin assessments for all residents. This was completed by 02/28/23 with no concerns being identified. On 02/28/23 at 1:17 P.M., Licensed Professional Clinical Counselor (LPCC) #900 was notified to provide extra counseling for Resident #49. On 03/01/23 at 8:30 A.M., GuideStar Eldercare assessed residents (#49 and #25). The plan was for Resident #49 to have weekly counseling sessions. On 03/06/23 at 10:27 A.M., the DON and ADON #125 reviewed the facilities abuse policy, and no changes were made. On 03/06/23 at 12:30 P.M., Resident #25 was transferred to another Skilled Nursing Facility (SNF). On 03/07/23 at 4:59 P.M., the facility Administrator initiated another SRI (unrelated to the incident involving Residents (#25 and #49) noting the category of allegation as staff to resident emotional/verbal abuse and completed the SRI on 03/09/23. The facility unsubstantiated the allegations of abuse; however, the facility completed additional abuse education on 03/09/23 related to the verbal abuse allegations. On 03/08/23 at 2:00 P.M., SSD #115 updated Resident #49's care plan. On 03/09/23 at 5:00 P.M., the DON notified Medical Director/Physician #500 of the Immediate Jeopardy (IJ) notification. On 03/09/23, MDS/RN #119 initiated weekly audits on psychosocial care plans for four weeks. On 03/09/23, SSD #115 initiated weekly audits on grievances and concerns for four weeks. On 03/13/23, review of the medical records for residents (#14, #24, #25, #28, #43, #44, and #59), reviewed for abuse, revealed no concerns related to abuse of a resident. Proper assessments, care plans and appropriate interventions were noted in the medical records of the residents. On 03/13/23, interviews with LPNs #135 and #136, RN #128, State tested Nursing Assistants (STNAs) #64, #90, #94, #95, and #101, Housekeeper #108, Dietary Staff #69, #73, #75, and #76, and Activities Aid #66, verified they were educated on resident abuse. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on 03/10/23, 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: Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, psychosis, suicidal ideations, obsessive compulsive disorder (OCD), anxiety disorder, delusional disorder, and panic disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had intact cognition. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed the resident was assessed as a 14, which indicated the resident was cognitively intact. Further review of the assessment revealed resident had no hallucinations, delusions, rejection of care and no behaviors were identified. Further review of the assessment revealed Resident #49 required extensive assistance for toileting, hygiene and dressing and supervision for all other activities of daily living (ADLs). Review of the plan of care for Resident #49 dated 02/15/23, revealed the resident had behavioral problems related to suicidal ideations. Interventions included GuideStar psychiatric services as needed, praising any indication of progress/improvement in resident behavior, and a medication review. Further review of the care plan for Resident #49 revealed no care plan related to the resident being in a relationship or involved in sexual activities with other residents. Review of psychiatric notes dated 02/15/23 and 03/01/23 for Resident #49, revealed resident lacked judgement regarding everyday activities and lacked insight concerning matters of self. Review of the progress notes dated 02/18/23 at 6:26 P.M for Resident #49, revealed the resident was in her room visiting with her boyfriend. Review of the medical record of Resident #25, revealed an admitted [DATE]. Diagnoses included history of traumatic brain injury (TBI), major depressive disorder, hypotension, and legal blindness. Review of the quarterly MDS assessment dated [DATE], revealed Resident #25 had an intact cognition. Review of the BIMS assessment dated [DATE], revealed the resident was assessed as a 14. Further review of the assessment revealed resident had no hallucinations, delusions, rejection of care and no behaviors were identified. Further review of the assessment revealed Resident #25 required extensive from staff for locomotion on/off the unit, dressing toileting, hygiene and supervision. Review of the plan of care dated 04/25/22 revealed Resident #25 required medications and psychiatric services as needed from Eldercare Psych Services related to behavioral management. Further review of the care plan for Resident #25 revealed no care plan related to the resident being in a relationship or involved in sexual activities with other residents. Review of the psychiatric notes dated 02/15/23 and 03/01/23 for Resident #25, revealed the resident lacked judgement regarding everyday activities and lacked insight concerning matters of self. Review of the progress notes from 02/26/23 through 03/06/23 for Resident #25, revealed the resident was placed on 1:1 supervision at all times due to the incident with Resident #49. Review of the SRI created on 02/27/23 at 8:42 A.M., revealed around midnight on 02/27/23, an aide (identified as Hospitality Aide [HA] #79) notified the LPN Unit/Charge Nurse (who was later identified and clarified to be RN #130) that Resident #49 was alleging Resident #25 had touched her inappropriately. Resident #49 stated to HA #79 and RN #130 that Resident #25 touched her vagina with his fingers and his fingers were inserted inside her. According to Resident #25's statements, the incident occurred on 02/26/23 between 5:30 P.M. and 7:30 P.M. Resident #49 stated to HA #79 that her vaginal area hurt, and she experienced some bleeding. The SRI indicated certain factors made the investigation challenging such as Resident #49 had diagnoses of paranoid schizophrenia, unspecified psychosis, delusional disorders, suicidal ideations, and obsessive-compulsive disorder. On several occasions when the facility had been unable to provide her proper care, the resident was transferred to the hospital for psychological and behavioral services. Resident #49 was care planned for making false accusations. Further review of the SRI revealed Resident #25 was noted to be legally blind and suffered a traumatic brain injury. Resident #25 used a wheelchair to ambulate throughout the building. The SRI indicated it was tough to discern if Resident #25 had the capability to fully grasp the gravity of different situations. Resident #25 appears to be easily swayed or manipulated. Review of the progress notes dated 02/27/23 at 12:40 A.M. for Resident #49, revealed the resident requested to go to the hospital for an evaluation. The nurse practitioner was made aware of the events and gave the order to send the resident to the hospital for evaluation. Review of the E-Interact Change in Condition assessment dated [DATE] at 12:40 A.M., revealed the client made an allegation against another resident and wanted to go to the hospital for evaluation. Review of the EMS run report dated 02/27/23 at 12:59 A.M., revealed the patient (Resident #49) was located conscious/breathing, seated on bed, talking with the police department. Patient stated about 5:30 P.M., another resident who resides at facility sexually assaulted her by ramming his fingers up my vagina. Patient stated there was bleeding at the time, and stated she did not know if there was any bleeding now. Patient stated she was having pain in her vaginal area, and reported the pain was a ten out of a ten on the pain scale (0 = none and 10 = severe pain) with no radiation. Workers at the facility stated they changed patient's sheets two times prior to EMS arrival. Patient states she was not assaulted anywhere else and stated she was sitting on her bed eating dinner at time of assault. Review of the SANE report dated 02/27/23 at 3:34 A.M. revealed the patient (Resident #49) reported being touched by a fell ow resident (Resident #25) at the nursing home. The two residents were in Resident #49's room and they had just finished supper. Resident #25 was noted to hang out in Resident #49's room and talk. Resident #49's roommate was in the room, but asleep. Resident #49 reported she was crocheting, when Resident #25 who was seated in a wheelchair and next to her bed, pulled her covers back. Resident #49 reported that Resident #25 was always telling her he loved her and stuff. Review of the report indicated Resident #25 put his hands in Resident #49's Depends (incontinent briefs) and then put his fingers in her vagina. Resident #25 was scratching her with his nails and Resident #49 told him to get off of her and quit. Resident #49 could not find her call light. Resident #49 jerked his hand to get him to stop. Resident #49 tried to get the nurses attention, but she could not. Resident #49 had to wait to tell them and after she told them, they called the police. Further review of the report revealed Resident #49 reported she could not sleep there, I am scared. Resident #49 was noted by the examiner to be anxious and guarded. Resident #49 was asked about the vaginal penetration, and she stated that he put his fingers in my vagina, it hurt. Further review of the report indicated Resident #49 had significant abrasions of her labia minora, majora, and clitoris. Resident #49 was frightened about going back to nursing home if the perpetrator was still there. The hospital was holding patient until a decision has been made about where perpetrator is to go. The report indicated all specimens collected were being sent off for analysis. Review of the progress notes dated 02/27/23 at 1:40 P.M. for Resident #49, revealed the resident returned to the facility from the hospital at about 1:25 P.M. that afternoon. Review of the progress notes dated 02/27/23 at 3:50 P.M. for Resident #49, revealed social services went in to check on the resident. Resident #49 stated that she was not in the mood to talk. The resident was noted to be in her bed knitting. Review of the progress notes dated 02/27/23 at 10:56 P.M. for Resident #49, revealed the resident was very tearful and having episodes of paranoia this shift. The resident refused a shower and a skin assessment. Resident #49 stated she did not want a shower or for anyone to see her naked body. Review of the hospital records dated 02/27/23 for Resident #49, revealed the resident arrived at the hospital at 1:39 A.M. The resident stated that she was inappropriately touched by another resident at the facility endorsing mild vaginal pain and right-sided abdominal pain. The resident was seen by the SANE nurse at the hospital. Resident #49 was diagnosed with an alleged assault and abdominal pain. Resident #49 was discharged back to the facility on [DATE] at 12:58 P.M. Review of the progress notes dated 02/28/23 at 12:37 A.M. for Resident #49, revealed the resident spent most of the shift in her room. Resident #49 had some brief episodes of crying this shift. Review of the progress notes dated 02/28/23 at 2:01 P.M for Resident #49, revealed the resident spent most of the day in bed resting and resident's appetite was fair. Resident #49 had episodes of tearfulness, however, did not want to talk about anything at that moment with the nurse. Review of the progress notes dated 02/28/23 at 2:17 P.M for Resident #49, revealed the writer reached out to a counseling resource to see if they could see the resident soon due to her experiencing a recent trauma. Review of the psychiatric notes for Resident #49 dated 03/01/23, revealed the resident did not wish to talk about the incident on 02/26/23, but the staff were great in helping her through the process. Review of the progress notes dated 03/02/23 at 12:17 A.M. for Resident #49, revealed the resident continued to have episodes of crying. Review of the progress notes dated 03/02/23 at 10:25 A.M. for Resident #49 revealed Social Services Designee (SSD) #115 was given a note from a staff member which was written by Resident #49. The note stated, no one cared for the resident anymore and she had an empty spot in her life, so it's like being empty in my heart now and Resident #25 do not like me anymore. SSD #115 entered the room, and the resident was sobbing. Resident #49 also stated the television was talking to her and telling her about Resident #25 and his new girlfriend. SSD #115 explained to the resident that because of the circumstances, she was unable to talk with Resident #25 at this time. Review of the progress notes dated 03/02/23 at 11:33 P.M., for Resident #49, revealed the resident remained on 15-minute checks this shift and remained in her room all shift. The resident was noted to have several episodes of crying this shift. Review of the progress notes dated 03/03/23 at 3:32 P.M. for Resident #49, revealed SSD #115 was in to visit with the resident. The resident was tearful at times. Review of the progress notes dated 03/04/23 at 12:04 A.M. for Resident #49, revealed she had episodes of crying throughout the shift. Interview on 03/06/23 at 9:11 A.M. with Resident #49, revealed that she and Resident #25 would regularly eat meals together. On 02/26/23, Resident #25 told Resident #49 that he was going to get into her pants. Resident #49 stated Resident #25 scratched the inside of her vagina when he inserted his fingers. Resident #49 stated that she tried to get the attention of her roommate, but she was sleeping. Resident #49 stated that she had asked Resident #25 to stop but he kept going with his fingers. Resident #49 stated that she pulled his arm to make him stop. Resident #49 stated she notified staff of her injuries later that evening, went to the hospital later in the evening where they took pictures of her injuries. The resident also stated that she was in a relationship with Resident #25, and they were engaged. Resident #49 stated that her guardian is aware and told her it was not a good idea since she had been married three times prior. Interview on 03/06/23 at 10:40 A.M. with Resident #25, revealed that he used to eat with Resident #49, and it stopped because he was leaving today. Resident #25 stated that he is going to another nursing home closer to his sisters. The resident confirmed penetrating the vagina of Resident #49 on the evening of 02/26/23. Resident #25 stated I was stupid and dumb. I should have never did it. The resident denied doing that to any other women before. Resident #25 stated that the roommate of Resident #49 was not in the room at the time. Resident #25 classified the relationship with Resident #49 as somewhat girlfriend and boyfriend and went on to say that they kissed before, and he loved her. Resident #25 stated that Resident #49 still comes around and tells him hello and confirmed that he still loves her, and she knows it. Subsequent interview with Resident #49 on 03/08/23 at 9:30 A.M. revealed the resident had three husbands who were abusive to her. The resident stated that she still wanted to press charges on Resident #25 even though she loved him because he hurt her and made her bleed. Phone interview on 03/08/23 at 9:48 A.M. with SANE Nurse #01 revealed the resident was upset when she examined her. Resident #49 stated that she was in bed and was eating when Resident #25 came into her room and sat next to her, and the roommate fell asleep. Resident #25 lifted her bedding and stuck his hands under the blanket. SANE Nurse #01 stated Resident #49 had some significant scratches on her vagina. One was up the left side and blood was seeping significantly on the right side of the vagina. The scratch on the right side of the vagina was wider than on the left and could have been sutured. Resident #49 was consistent with her story and very upset. SANE Nurse #01 reported the two residents were involved in some type of relationship but Resident #49 did not say Resident #25 was her boyfriend. Resident #49 was worried about going back and did not want to go back to the facility. The resident appeared afraid. Interview on 03/08/23 at 2:10 P.M. with the DON, revealed the facility was aware of the relationship between both residents and always kept the door open to keep an eye on the couple. The DON reported Resident #49's guardian was aware of the relationship. Interview on 03/08/23 at 2:16 P.M. with HA #79 confirmed that she worked on 02/26/23 from 11:00 P.M. to 7:00 A.M. HA #79 reported when she started her shift, the door to Resident #49's room was open and when she walked into the room, Resident #49 was in the bathroom and another Aide was changing her linens due to an incontinence episode. HA #79 noted the resident would become more incontinent when she was more emotional. The resident hit her call light a little later and told HA #79 that she was not good. Resident #49 reported that Resident #25 hurt her really bad. HA #79 told the resident to tell the nurse. The nurse on the floor (RN #130) went into Resident #49's room and the resident was crying and said she was sore and wanted someone to call her daughter. Resident #49 had another incontinence episode in the bed. HA #79 stated she changed her sheets when the resident was in the bathroom getting cleaned up. HA #79 stated that she checked the trash can and there was no blood on her depends and there were traces of blood on the sheet. HA #79 reported the facility was aware of a relationship between Residents #49 and #25. HA #79 reported Resident #49 had an engagement ring on, and the resident took it off and stated she was done with Resident #25. Resident #49 had mentioned that she had been raped before and did not want that. Resident #49 stated that she was yelling for her roommate, but she was sleeping. HA #79 reported Resident #49 was obsessed with Resident #25 and asked about him all the time. HA #79 stated the facility was aware of what went on with Resident #49 and Resident #25, but they have free will, our job was to provide safety, and try to make sure it does not get to this point. HA #79 mentioned another couple in the facility. Review of the progress notes dated 03/08/23 at 2:48 P.M for Resident #49, revealed the resident had episodes of tearfulness this shift. Interview on 03/08/23 at 3:25 P.M. with STNA #83 revealed that she was the aide taking care of Resident #49 on 02/26/23 from 3:00 P.M. to 11:00 P.M. STNA #83 reported Resident #25 was put on 1:1 monitoring after the 8:00 P.M. smoke break. STNA #83 never witnessed Resident #25 inside Resident #49's room. STNA #83 denied hearing Resident #49 calling out for help and stated the resident never reported the sexual abuse during her shift. STNA #83 stated Resident #49 was not incontinent during the evening and was resting in her bed after the evening medications were administered. Interview on 03/08/23 at 4:00 P.M. with RN #130, revealed she was the nurse assigned to care for Resident #49 on 02/26/23 from 7:00 P.M. to 7:00 A.M. RN #130 stated that sometime between 11:00 P.M. and 12:00 A.M., Resident #49 informed her that another resident had touched her inappropriately in the vaginal area. RN #130 stated that Resident #49 was unable to give many details about the incident. Resident #49 was able to give a time frame of between 5:30 P.M. and 7:30 P.M. of when the incident with Resident #25 occurred. The resident was unable to provide how long it occurred and did not provide a lot of details. RN #130 asked Resident #49 if she wanted to go to the hospital, and when the resident stated yes, RN #130 called EMS. RN #130 stated that she did not notice any blood on the sheets or on the resident's brief. Follow up interview on 03/08/23 at 5:25 P.M. with RN #130 reported she examined the outside area of Resident #49's vaginal area and there was no blood or bruising noted. Interview on 03/09/23 at 9:05 A.M. with Detective #230 revealed that he did investigate the alleged sexual abuse against Resident #25 on 02/26/23. Detective #230 stated that he could not comment on the incident as the investigation was still ongoing. The police report was finished, and the incident was being sent up for charges. Detective #230 stated the alleged perpetrator (Resident #25) had not been officially charged with anything. Review of the progress notes dated 03/09/23 at 2:13 P.M for Resident #49, revealed the resident was having incontinence episodes. Resident #49 was noted having tearful episodes where the resident stated, she wants to be left alone. Review of Centers for Medicare and Medicaid Services (CMS) interpretive guidance on sexual abuse indicated generally, sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. CMS addresses the facility's responsibility to determine whether sexual activity was consensual on the part of the resident. CMS indicates a resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion, or fear, whether it is expressed by the resident or suspected by staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered sexual abuse. A facility is required to investigate and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. A resident's voluntary engagement in sexual activity may appear to mean consent to the activity, in these instances, if the facility has reason to suspect that the resident may not have the capacity to consent, the facility must protect the resident from potential sexual abuse while the investigation is in progress. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/01/19, revealed that sexual abuse was defined as Non-consensual sexual contact of any kind with a resident. This deficiency represents non-compliance investigated under Complaint Number OH00140737.

Based on observation, interview, and review of facility policy, the facility failed to ensure staff wore hairnets and gloves while serving meals. This affected all residents except Resident #46 who was nothing by mouth (NPO) and did not receive food from the kitchen. Census was 66. Findings include: During the initial tour of the kitchen on 03/06/23 at 8:05 A.M., Dietary Aide (DA) #71 was observed with facial hair while serving breakfast. Further observation revealed DA #71 was not wearing a beard protector nor gloves while serving breakfast meals on the tray line. Additionally, DA #75 was observed placing bread in a toaster without gloves in place. During continued observations, revealed DA #75 touched her arms and continued to place bread in the toaster without washing her hands. Interview on 03/06/23 at 8:15 A.M., revealed Dietary Supervisor (DS) #76 verified findings and reported staff are to always cover beard and hands while serving meals on the tray line. DS #76 verified DA #75 touched her arms and failed to wash her hands before loading more bread in the toaster. Review of the undated facility policy titled, Hair Covering Policy, reported all dietary staff are required to wear effective hair restraints that cover all exposed body hair including facial hair and head hair. Review of an undated and untitled facility document, revealed the dietary department were to use single use gloves to protect both patrons and employees from contagious and food borne illnesses. Employees will wash their hands thoroughly before and after wearing or changing gloves.

Based on medical record review, staff interview, and review of facility policy, the facility failed to create a comprehensive care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (#215) out of twenty-one residents reviewed for care plans. The facility census was 66. Findings included: Review of the medical record for Resident #215 revealed an admitted [DATE]. Diagnoses included, but not limited to, PTSD, Parkinson's Disease, chronic obstructive pulmonary disease (COPD), vascular dementia, history of Coronavirus (COVID-19), and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #215, revealed the resident had an intact cognition. The resident had a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Assessment indicated the resident had no hallucinations, delusions, behaviors or concerns with his mood and /or rejection of care. Review of the progress note dated 02/08/23 at 6:50 P.M. for Resident #215, revealed the resident was in his room on the phone. The nurse entered the resident's room, and the resident handed the nurse the phone. Resident #215 had called the Veteran Crisis Center. The Crisis Center stated that the resident had called them and stated he wanted to commit suicide and planned to hang himself. Resident #215 was sent to the hospital for evaluation and treatment. Review of the progress note dated 02/28/23 at 2:31 P.M for Resident #215, revealed a referral was sent to the facility counseling service after a consent was received from the resident. Review of the care plans for Resident #215 revealed no care plan was implemented for the resident's diagnosis of PTSD. Interview on 03/08/23 at 9:37 A.M. with the Director of Nursing (DON), confirmed Resident #215 did not have a care plan for his diagnosis of PTSD. The DON stated that the resident had a long-standing history of suicidal and homicidal ideations. Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 12/01/16 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's Coronavirus (COVID-19) policy and procedure, review of the facility's COVID-19 resident and employee positive test results, review of the facility's daily COVID-19 employee screening log, review of e-mail communications, review of timecards, review of text communications, review of audits and in-service records, staff and Local Health Department (LHD) staff interviews, the facility failed to implement effective and recommended infection control practices, including following CDC guidelines for excluding health care personnel, who have had contact with someone with suspected or confirmed COVID-19 infection during the prior 14 days, from working to prevent the potential spread of COVID-19 within the facility. This resulted in Immediate Jeopardy and potential serious negative health outcomes and/or life-threatening harm on [DATE], when the Director of Nursing (DON) permitted Licensed Practical Nurse (LPN) #330 to work her 12-hour weekend shifts beginning on [DATE] at 7:00 P.M., after LPN #330 notified the DON that her son, who lived with her, had tested positive for COVID-19. LPN #330 tested positive for COVID-19 on [DATE]. Between [DATE] and [DATE], 44 residents tested positive for COVID-19 while residing in the facility, 37 residents recovered, and seven residents expired who had a [DIAGNOSES REDACTED].#330 had cared for 34 (#06, #07, #09, #10, #13, #14, #17, #21, #22, #23, #24, #27, #28, #30, #31, #32, #33, #34, #36, #38, #42, #45, #46, #47, #49, #50, #52, #54, #55, #70, #71, #72, #73, and #74) of the residents. In addition, between [DATE] and [DATE], 18 staff members tested positive for COVID-19. There have been no resident or staff positive cases since [DATE]. The facility census was 57 residents. The Administrator was notified on [DATE] at 2:52 P.M., that Immediate Jeopardy began on [DATE] when the DON allowed LPN #330 to work her 12-hour weekend shifts beginning on [DATE] at 7:00 P.M., after LPN #330 notified the DON that her son, who lived with her, had tested positive for COVID-19. LPN #330 tested positive for COVID-19 on [DATE] and following LPN #330's positive test results, 34 (#06, #07, #9, #10, #13, #14, #17, #21, #22, #23, #24, #27, #28, #30, #31, #32, #33, #34, #36, #38, #42, #45, #46, #47, #49, #50, #52, #54, #55, #70, #71, #72, #73, and #74) residents that resided on the unit she worked tested positive for COVID-19. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · All residents will continue to have their temperature and pulse oximetry assessed at minimum each shift. Any abnormalities will be reported to the physician for follow-up and recommendations. If a resident has a temperature greater than 100 degrees Fahrenheit (F) or a pulse oximetry less than 93, they will be assessed further, and the physician and the DON will be notified of the change in condition. Residents were assessed on [DATE] with no negative findings. · On [DATE], the DON implemented a new screening tool for staff, to include contact with anyone who is under investigation for COVID-19 or exposure to COVID-19. If the staff member has positive answers, they are to be assessed by nursing to determine if they can work or need to be sent home. Additionally, the Administrator, DON, Assistant Director of Nursing (ADON) or a Unit Manager are to be notified. · On [DATE] from 4:05 P.M. until 5:37 P.M., the DON, Registered Nurse (RN) Infection Control Preventionist (ICP) #400, Business Office Manager (BOM) #410, Social Worker (SW) #420 and Administrative Assistant (AA) #420 educated all staff regarding the new screening tool, COVID testing, signs and symptoms of COVID, and exposure and quarantine procedures. · On [DATE], an audit tool was implemented to include Nursing Management to review the screening tool to ensure staff were screened correctly. This will be completed daily for 30 days. · On [DATE], the DON notified the Medical Director of the Immediate Jeopardy situation. · On [DATE], between 8:00 A.M. and 11:00 A.M., interviews with LPN #338 and #510; Certified Nurse Aide (CNA) #325, #505, and #515; and Maintenance Director (MD) #500 verified receiving education and were able to verbalize the education they received. · On [DATE], review of the facility audits from [DATE] to [DATE] revealed all residents were having their temperature and pulse oximetry assessed daily, every shift, by a nurse. · On [DATE], review of the screening logs and audits from [DATE] to [DATE] revealed the staff are being screened according to the new screening tool. · On [DATE], review of the in-service records revealed all staff were trained on the new screening tool, COVID testing, signs, and symptoms of COVID, exposure and quarantine. Although the Immediate Jeopardy was removed on [DATE], 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) until it was corrected on [DATE]. Findings include: Review of a facility e-mail communication dated [DATE], revealed the DON sent an e-mail to LHD Nurse #335. The DON indicated there was an employee (LPN #330) who was placed on quarantine for having a child who was possibly exposed to COVID-19. The DON indicated the employee had tested negative twice and had no symptoms. Additionally, the employee had informed the DON that her son's physician instructed the LPN's family to quarantine. The DON indicated she explained to the employee that she could still work since the employee had no symptoms and was screened and tested upon entry to the facility. The DON indicated N-95 masks were being utilized in the facility and the employee did not want to miss work but wanted confirmation that it was okay to work. LHD Nurse #335 replied, indicating the DON was correct. Review of the facility screening tools used for all staff revealed staff were screened via body temperature and two screening questions: Have you traveled out of the country in the last 14 days? and Been sick in the last 14 days? Staff entered the date and time of entry, signed, and an assessor entered their initials. Review of the facility staff screening log dated [DATE], revealed LPN #330 underwent the screening process at 7:00 P.M., with a body temperature of 94.0 degrees Fahrenheit (F) and answered the two screening questions negatively. Review of the facility staff screening log dated [DATE] revealed LPN #330 underwent the screening process at 7:00 P.M., with a body temperature of 96.4 degrees F and answered the two screening questions negatively. The assessor on LPN #330's screenings on [DATE] and [DATE], was LPN #340. Review of daily timecard dated [DATE] to [DATE], revealed LPN #330 clocked in on [DATE] at 7:01 P.M. and clocked out on [DATE] at 7:31 A.M. On [DATE], LPN #330 clocked in at 7:00 P.M. and clocked out on [DATE] at 7:25 A.M. Review of a facility e-mail communication dated [DATE] revealed the DON notified LHD Nurse #335 that LPN #330 had tested positive for COVID-19 and was instructed to isolate. The DON indicated LPN #330 tested negative for COVID-19 on [DATE] (her last day worked) but was displaying general symptoms. The DON further indicated all staff were wearing KN-95 masks and full Personal Protective Equipment (PPE) when they went into isolation rooms. Review of the resident COVID-19 positive reports from [DATE] to [DATE], revealed 44 facility residents (#01, #03, #06, #07, #09, #10, #13, #14, #15, #17, #18, #21, #22, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #42, #45, #46, #47, #49, #50 #52, #54, #55, #70, #71, #72, #73, #74, #75, and #76) tested positive for COVID-19. Review of resident status as of [DATE] revealed seven (#70, #71, #72, #73, #74, #75, and #76) of the 44 residents who tested positive for COVID-19, had expired between [DATE] and [DATE]. Further review revealed LPN #330 had cared for 34 (#06, #07, #09, #10, #13, #14, #17, #21, #22, #23, #24, #27, #28, #30, #31, #32, #33, #34, #36, #38, #42, #45, #46, #47, #49, #50, #52, #54, #55, #70, #71, #72, #73, and #74) of the 44 residents from [DATE] to [DATE] and five (#70, #71, #72, #73, and #74) of the 34 residents LPN #330 cared for between [DATE] and [DATE] had expired between [DATE] and [DATE]. Review of the facility employee COVID-19 testing reports revealed 18 staff members tested positive for COVID-19 between [DATE] and [DATE]. Review of a screen shot of text communication from LPN #330's phone with the DON revealed an undated text from LPN #330 to the DON at 12:43 P.M. which indicated So (son's name)'s test is positive .I can still come in this weekend ??. The DON replied at 12:44 P.M., Yes according to health department wear n95 and screen in. On [DATE], the DON asked LPN #330, Can you help on 2nd today? Interview on [DATE] at 1:28 P.M., the DON indicated she was aware LPN #330's son had tested positive for COVID-19. The DON indicated that LPN #330 had tested negative and LHD Nurse #335 told her it was okay for LPN #330 to continue to work. The DON further revealed, when employees were known to have direct exposure, the facility would consult LHD Nurse #335 for guidance. Interview on [DATE] at 1:57 P.M., with LHD Nurse #335 verified the facility had contacted her when LPN #330's son was exposed; however, the facility did not contact her regarding LPN #330's son testing positive for COVID-19. LHD Nurse #335 stated, once LPN #330's son was known to be positive, her recommendations would have been for LPN #330 to quarantine and stay home. Follow-up interview on [DATE] at 2:35 P.M., the DON verified the [DATE] e-mail with LHD Nurse #335 indicated LPN #330's son was exposed to COVID-19 and the next written communication with LHD Nurse #335 was on [DATE]. The DON indicated she had spoken with LHD Nurse #335 on the phone when LPN #330 notified her that her son was positive for COVID-19. The DON did not have any evidence of phone calls occurring at that time. Interview on [DATE] at 3:39 P.M. with LPN #330 revealed, she took her son, who lived with her, to the doctor on [DATE] to get tested for COVID-19 because he had been exposed. LPN #330 stated she spoke with the DON to inform her of her son's exposure and the DON informed her she had talked with the LHD and they said it was okay for LPN #330 to continue to work. LPN #330 revealed on the afternoon of [DATE], she was notified that her son had tested positive for COVID-19. LPN #330 stated she immediately texted the DON and notified her that her son had tested positive for COVID-19. LPN #330 asked if she was still able to work the upcoming weekend ([DATE] and [DATE]). LPN #330 stated the DON texted her back immediately and indicated it was okay for her to continue to work. The DON instructed LPN #330 to take a rapid COVID-19 test at the facility prior to starting her shift. LPN #330 denied having any symptoms of COVID-19 on [DATE], when she worked. LPN #330 reported she worked 12 hour night shifts on [DATE] and [DATE]. Review of facility policy titled, Coronavirus (COVID-19) Policy and Procedure, revised [DATE], revealed, if there was any indication from an employee of exposure to COVID-19, a nurse will evaluate if the employee should be able to enter the building. Review of the CDC Interim Infection and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) updated [DATE], revealed healthcare personnel who have had contact with someone with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection during the prior 14 days should be excluded from work. This is an example of continued non-compliance from survey dated [DATE]. This deficiency substantiates Complaint Number OH 930.

Based on review of facility screen logs, observations, staff interview, policy review and review of guidance from the Centers for Medicare and Medicaid Services (CMS) and Guidance from the Centers for Disease Control (CDC), the facility failed to ensure all employees or visitors were screened for Coronavirus Disease 2019 (COVID-19) prior to entrance into the facility, failed to clean/disinfect resident care equipment between resident use and failed to ensure a doffing location was appropriately set up with a trash receptacle for disposal of used personal protective equipment (PPE) and for individuals leaving the area to perform hand hygiene to potentially prevent the spread of COVID-19. This had the potential to affect all 60 residents residing in the facility. Facility census was 60. Findings include: 1. Review of the COVID-19 screening log dated 01/26/21 revealed corporate staff members who had not been screened at the time of entry to the facility. Interview with the Social Services Director on 01/26/21 at 1:34 P.M. verified there was no evidence the corporate staff member was screened for COVID-19 prior to entering the building at this time. 2. Review of the COVID 19 screening log dated 01/27/21 at 5:45 A.M. revealed a visitor from the State Surveying Agency entered the unlocked designated entrance at the front of the building after ringing doorbell and waiting for facility staff to come to the door. Two staff members sitting behind the desk were observed. Licensed Practical Nurse (LPN) #61 walked to the second internal door and questioned surveyor. A photo identification was provided. LPN #61 opened the door allowing the surveyor to entry the facility and the staff did not screen the surveyor. LPN #61 did not instruct surveyor to complete the screening document at the entrance. Surveyor had self-screened at home prior to entrance into the facility. Interview with Director of Nursing (DON) on 01/27/21 at 8:13 verified LPN #61 should have conducted a screening before allowing the surveyor into the facility. 3. Observation on 01/26/21 at 5:50 P.M. of State tested Nursing Assistant (STNA) #30 working on the COVID-19 unit, entering Resident #32's rooms to obtain vital signs. STNA #30 placed thermometer, blood pressure cuff and oximeter on the top of the container used to store clean PPE, donned the appropriate PPE entered the residents' room and completed task. STNA #30 moved to the doorway of the room set the blood pressure cuff, the thermometer, and the oximeter on a folding chair just inside room, removed PPE and completed hand hygiene with hand sanitizer. STNA #30 picked up thermometer, automatic blood pressure cuff and oximeter from the chair and exited room. STNA #30 walked to Resident #104's room and set the thermometer, oximeter, and the blood pressure cuff on top of the three drawer container outside of the room. STNA #30 then donned PPE, picked up the thermometer, blood pressure cuff and oximeter went to enter another resident's room without cleaning or disinfecting the equipment. Interview immediately after observation on 01/26/21 with STNA #30 and before STNA #30 entered Resident #104's room, STNA #30 verified the equipment was not cleaned before re-entering another resident's room. Additionally, stated he had taken eight sets of vitals without cleaning or disinfecting the equipment between each resident. Interview with DON on 01/27/21 at 9:09 A.M. verified STNA #30 should be cleaning and disinfecting equipment after each set of vitals with disinfecting wipes. 4. Observation on 01/27/21 at 3:25 P.M. surveyor exited COVID-19 unit #1 thru zippered plastic walls to a small area in front of the exit door of the building. Surveyor doffed PPE and was unable to find a trash receptacle for the used PPE. Further observation revealed there was no alcohol based hand rub available for hand hygiene. Housekeeper #70 was standing on the other side of the plastic wall and alerted to missing items. Housekeeper #70 verified trash receptacle and hand sanitizer was not present as it should have been. Interview on 01/27/21 at 3:31 P.M. with Administrator verified the area for doffing used PPE should have had a trash receptacle and appropriate hand sanitization for staff. Review of the CMS Quality Safety and Oversight Group Memo (QSO-20-39-NH), dated 09/17/2020 revealed under the Core Principles of COVID-19 Infection Prevention included screening of all who entered the facility for signs and symptoms of COVID-19 (e.g. temperature checks, questions or observations about signs and symptoms). Review of the facility titled Coronavirus (COVID-19) Policy and Procedure undated revealed the facility will screen all visitors, ancillary staff and vendors by questionnaire, temperatures and pulse oximetry prior to entrance to the facility. This deficiency substantiates Complaint Number OH 461 and Complaint Number OH 429.

Based on review of training documentation and staff interview, the facility failed to have a designated infection preventionist employed in the facility at least part-time that had completed specialized training in infection prevention and control. This had the potential to affect all 60 residents residing in the facility. The facility census was 60. Findings include: Review of the Centers of Disease Control (CDC) training website for the Director of Nursing's (DON) training profile revealed all training modules had been successfully completed on May 19, 2019; however, further review revealed the training was not completed as the test was not successfully passed. Interview with the Director of Nursing (DON) on 01/27/21 at 12:30 P.M. stated the facility had an employee certified in the infection control and prevention training but she resigned on 12/22/20. The DON unable to provide documentation of full completion for the infection control training for her facility at this time. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation and staff interview, the facility failed to ensure fall interventions were in place in accordance with a residents care plan. This affected one (#12) out of three resident reviewed for falls. The facility census was 60. Findings include: Medical record review for Resident #12 revealed an admitted d of 11/24/18. [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment for Resident #12 dated 11/12/20 revealed the resident was cognitively impaired. Resident #12 required supervision for bed mobility, transfers and eating. Extensive assist was required for toileting. No falls were coded. Review of the plan of care for Resident #12 revealed the resident was at risk for falls related to impaired mobility, impaired coordination, and impaired memory. Interventions include: check room at intervals for wet floors drinks spills, encourage resident to keep non skin socks on at night too, encourage resident to use adaptive devices, ensure nonskid footwear, frequent cheeks throughout night for toileting needs, keep call light within reach, keep room free of clutter, refer to physical and occupational therapy (PT/OT), resident has history of stating got self-off floor after falling and not notifying staff encouraged resident to notify falls at time of occurrence. Scoop mattress, and staff to offer frequent assistance with transferring. Review of fall assessment for Resident #12 dated 10/4/20 documented resident was at high risk for falls. Review of fall assessment for Resident #12 dated 12/28/20 documented resident was at high risk for falls. Review of fall assessment for Resident #12 dated 1/10/21 documented resident was at high risk for falls. Observation on 01/26/21 at 5:15 P.M. revealed no scoop mattress was on the resident #12's bed as stated on the plan of care. Interview on 01/26/21 at 5:45 P.M. with State tested Nursing Assistant #17 verified a scoop mattress was not in place for Resident #12. Interview on 01/27/21 at 11:45 A.M. with Director of Nursing verified the scoop mattress was not in place as it should have been. This deficiency substantiates Complaint Number OH .

Based on observation and staff interview, the facility failed to ensure five bathroom floors were clean. This has the potential to affect five (#11, #19, #45, #37 and #14) out of 24 residents reviewed during the annual survey. The census was 61. Findings included: Observation of Resident #11's bathroom on 12/09/19 at 10:17 [NAME]M. revealed the floor was badly stained and around the bottom of the toilet there was a dark thick substance and the floor was sticky. Observation on 12/09/19 at 11:25 [NAME]M. of Resident #19's bathroom revealed the tile was discolored. Observation of Resident #45's bathroom floor on 12/09/19 at 12:06 P.M. revealed it was badly stained under the sink and around and behind the toilet. Observation on 12/09/19 at 2:27 P.M. of Resident #37's and #14's shared bathroom revealed under the sink there were dark stains. Observation with the Administrator and Housekeeping Supervisor (HS) #41 on 12/12/19 at 1:55 P.M. verified the conditions of the above mentioned bathrooms for Resident #11, #19, #45, #37 and #14. Interview with the Administrator on 12/12/19 at 2:00 P.M. verified he thought it was an issue of the bathroom floors but more of a scrubbing and a waxing that was needed and said the facility just got remodeled in the front of the facility and had plans to remodel the rest of the rooms, but didn't have a date. Interview with HS #41 on 12/12/19 P.M. verified the bathroom floors in the above mentioned rooms needed scrubbed and waxed. He stated the census was low and he haven't been able to get to them in quite a while now. He denied he had documentation of the last time the bathrooms had been scrubbed and waxed.

Based on record review, review of hospital documentation, nurse practitioner interview, staff interview and review of information from Medscape, the facility failed to ensure the staff administered Resident #1's physician ordered enema (rectal medication) resulting in a significant medication error. This resulted in actual harm when staff failed to administer Resident #1's physician ordered enema and the resident was subsequently hospitalized for [REDACTED]. This affected one (#1) of seven reviewed for medication administration. Facility census was 68. Findings include: Review of Resident #1 medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission orders [REDACTED].M. Review of Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #1's progress notes for the resident verified the medical record was silent to the resident refusing the enema. Further review revealed the physician, or nurse practitioner was not notified of the enema not being administered. Review of Resident #1's progress notes from admission on 10/09/17 through his hospitalization on [DATE] revealed the resident is noted to be monitored and treated for [REDACTED]. Progress notes revealed Resident #1 had a loose dark red tinged stool on the afternoon of 10/20/17 and Nurse Practitioner #88 was made aware, with orders to monitor for any more blood tinged stool. Resident #1 had another note on 10/20/17 at 11:06 P.M. that revealed the resident had bright red blood in his brief and blood clots with each bowel movement. Abdomen was hard distended and the resident was complaining of stomach pain to the point of not eating or lying down. The physician was called and an order received to send the resident to the hospital for evaluation. Prior to this day the progress notes had been silent to the resident stool containing any resemblance to blood. The resident was admitted to the hospital 10/20/17. Review of telephone orders revealed Resident #1 was sent to the hospital for bloody stools on 10/20/17. The resident returned to the facility on [DATE] and orders did not include enemas, but did include hyperbaric treatment for [REDACTED]. Review of the hospital documentation revealed Resident #1 was admitted to the hospital on [DATE] due to hematuria, right lower quadrant pain, and bloody stool. CT of abdomen/pelvis revealed circumferential wall thickening of the urinary bladder with some pericystic fat stranding, [MEDICATION NAME] favored, some mild circumferential wall thickening and vague [MEDICAL CONDITION] of the distal sigmoid colon, low grade diverticulitis. The Assessment/Plan documentation from the resident's hospital emergency room stay dated 10/20/17 at 9:21 PM revealed the resident has probable urosepsis secondary to prostatic rectal fistula. The plan included antibiotics and to consider hyperbaric oxygen treatment- due to the resident's non-operative status. During an interview on 11/07/17 at 11:03 A.M. with Nurse Practitioner #99, who is one of the two nurse practitioners who provide services to Resident #1, it was revealed that she had seen the resident twice in the facility and the first time was the morning after admission and the Nurse Practitioner stated the resident appeared uncomfortable. Nurse Practitioner #99 stated the next time she saw the resident a few days later he looked much better and he was up in a chair. The nurse practitioner revealed she was not made aware that Resident #1 was not receiving his scheduled enemas. The nurse practitioner explained that she had seen this enema used three times in her [AGE] years of practice and it is specifically used to decrease the inflammation in rectal colon area, and the enema is quite soothing for the resident. The nurse practitioner stated the enema was to be used to assist the resident with the extreme inflammation in the colon/rectal area decreasing the inflammation and making the resident more comfortable. Nurse Practitioner #99 stated the enema is a very specialized treatment and the resident would not refuse the enema, she compared it to a steroid cream on a rash and how applying the cream to the rash improves the rash and makes the resident feel better, the enema would have the same feel good response for the resident. She stated had she known the resident was not receiving the treatment as ordered she would have flipped out out because the resident needed the medication as part of his plan of care. During an interview with Registered Nurse (RN) #50 on 11/07/17 at 12:00 P.M. the RN stated she did an investigation into Resident #1 not receiving his enema that was ordered. The RN stated the investigation was completed around the 18th or 19th of October. RN #50 stated as she was reviewing Resident #1's chart regarding his [MEDICAL CONDITION] and she noted that the resident was supposed to be receiving an enema for his fistula to assist with his inflammation and she noticed that he had not received his enema, and the MAR indicated [REDACTED]. RN #50 stated there were a couple blanks spaces on the MAR, and a few days were initialed indicating the resident had received the medication. RN #50 stated through her course of investigation it was revealed there was only one enema in the medication cart with the ship date of 10/11/17. RN #50 stated she called the pharmacy and it was verified only one enema had been sent to the facility from the pharmacy since the resident was admitted . The pharmacy stated not having an enema for each day was their mistake. The enema the pharmacy had sent to be administered on the day after admission was still in the medication drawer and the staff had never administered it to the resident. RN #50 stated the enema was re-ordered and the pharmacy sent one more enema. RN #50 stated the resident was sent to the hospital on [DATE]. After the resident was admitted to the hospital, RN #50 checked the medication cart and both of the enema's pharmacy had sent to the facility remained in the medication cart. RN #50 stated she called the pharmacy again to verify only two enemas had been sent to the facility and the pharmacy verified there were only two enemas for Resident #1 sent to the facility. RN #50 stated the MAR indicated [REDACTED]. RN #50 stated the doses were signed off as given were on 10/16/17, 10/17/17 and 10/18/17. During an interview with the Director of Nursing (DON) on 11/07/17 at 12:37 P.M. it was verified there was only one enema sent from the pharmacy and the pharmacy stated it just got overlooked on their side. The DON stated she did not know if Resident #1 received any enemas at the facility. The DON stated there was no excuse for why the resident did not receive the medication that was sent from the pharmacy. The DON lastly stated she has been out of the building and her and the ADON are still working on investigating the situation. Review of Medscape revealed [MEDICATION NAME] can be given rectally to treat active ulcerative [MEDICAL CONDITION], ulcerative proctitis and/or [MEDICAL CONDITION]'s disease. [MEDICATION NAME] is an anti-[MEDICAL CONDITION] agent. This deficiency substantiates Complaint Number OH 327.

Based on record review, staff and resident interview, the facility failed to protect one (#34) of three residents reviewed for falls. This resulted in harm when the resident's wheelchair was pushed out the door to the smoking area, the brakes were not properly applied causing the chair to roll forward off the cement walk into the grass ejecting the resident from the chair. The resident sustained [REDACTED]. The facility census was 76. Findings included: Record review for the Resident #34 revealed she was originally admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 8/1/14, revealed the resident was cognitively intact. She required total care of two or more staff for transfers, and toileting. She required total care and the assistance of one staff for locomotion. She required extensive assistance of two or more staff for bed mobility and dressing. The Nursing Note, dated 9/22/14 at 11:16 P.M., revealed residents called out from the smoke break door saying that Resident #34 had fallen out of the wheelchair. The nurse reported that Resident #34 was laying supine with right leg bent under her and left leg out in front of her when she fell . When the nurse arrived the resident's legs were out in front of her. The resident's left leg was in a splint and the right leg was rotated outward. A second nurse started assessing the resident while the first nurse went inside to call the doctor, family and emergency squad. The resident complained of significant pain in the right knee. The History and Physical dated 9/23/14 noted Resident #34 had an accident involving her wheelchair. Resident #34 stated that she was assisted outside of her ECF ( Extended Care Facility) and the wheelchair rolled down an incline ejecting her from the wheelchair and she sustained a comminuted left femur fracture. An interview with Resident #34 on 10/20/14 at 11:22 A.M. revealed that she was alert and oriented. She stated that her right leg was hurting. She said her left leg was recently healed and now the right leg was broken. She stated that an aide was pushing her outside and let go of the chair on the hill and she went down the hill and her leg went under the chair breaking it. An interview with the Director of Nursing (DON) and the Administrator on 10/20/14 at 2:30 P.M. revealed per the accident investigation for the fall, the staff member locked one brake. The chair rolled into the grass where it tipped. The state tested nurse aide (STNA) was educated on locking wheelchair brakes and wheelchair safety. The STNA stated that he did not have time to lock both brakes because he wanted to stop the door from hitting another resident who was exiting the door. An interview on 10/20/14 at 2:45 P.M. with STNA #100 revealed that he was the staff member who took Resident #34 out to smoke. He stated that he was taking the resident out to her smoke break. He opened the door and was pushing her out. He reached down to apply the left brake when he noted the door was closing on another resident. He released the resident's chair and it rolled straight ahead off the cement onto the grass where it tipped causing the resident to fall from the chair. He stated that he did engage one brake. He stated he was attempting to do two things at once, push Resident #34 out while protecting the second resident coming out the door. This deficiency substantiates Complaint Number OH 624.

The following deficiency represents an incident of Past Non Compliance that was subsequently corrected prior to this survey. Based on record review and staff interview the facility failed to ensure adequate supervision was provided to one resident (# 49 ) of four sampled residents to prevent a fall from bed that resulted in a cervical fracture and facial lacerations that required sutures and hospitalization . The census was 89 . Findings include: Review of the September 2010 physician's orders [REDACTED]. The physician's orders [REDACTED]. A quarterly assessment dated [DATE] assessed Resident #49 with long and short term memory problems and required cues and supervision for daily decision-making. She required total assistance of one person for dressing, hygiene, locomotion; the assistance of two staff persons for bathing and transferring and total assistance of two persons for bed mobility. The resident was capable of feeding herself and was incontinent of both bladder and bowel. The assessment also identified the resident was unable to maintain her balance while sitting or standing without physical help. The assessment did not identify any history of falls within the past 6 months and indicated the resident did not use any bed rails for assistance with turning or repositioning. Review of the Activities of Daily Living plan of care, initiated 03/01/07 and current at the time of the fall, identified the resident needed extensive to total assistance of staff for all activities of daily living, including bed mobility. The Resident Information Sheet, used by the nurse aides to identify the individual needs of the resident, also documented the resident required total assistance of staff for Activities of Daily Living, including bed mobility and was incontinent. The resident was to be transferred using a mechanical lift. Review of an emergency room report from a local hospital dated 09/05/10 revealed Resident #49 was seen in the emergency room secondary to a fall from the bed. The emergency room report documented Resident #49 had a fracture of the second cervical vertebrae as well as a laceration of the right facial scalp which required sutures. The emergency room report noted the resident knew she fell but did not recall why she fell . The report documented Resident #49 was subsequently transferred to another hospital for neurosurgical interventions. Interview with the Director of Nursing on 09/10/10 at 8:40 A.M. confirmed Resident #49 was unable to assist in her own repositioning in bed and required the assistance of two persons for bed mobility/repositioning. The DON also confirmed the the resident required physical assistance for sitting and standing balance. During this interview, the DON stated she was notified of the resident's fall on 09/05/10 and interviewed Nurse Aide (NA) #1 who was responsible for providing care to Resident #49 at the time of the fall. NA #1 informed the DON she was providing incontinence care to the resident and rolled the resident to her left side. When NA #1 reached for some incontinence care products, the resident started to roll off the bed and the nurse aide could not prevent her from falling. Interview with Nurse Aide #1 on 09/09/10 at 3:20 P.M. revealed she had prepared the resident for incontinence care and had rolled the resident on her left side. NA #1 stated she kept her left hand on the resident's hip and reached with her right hand for a washcloth that was on her right side. When she did this, the resident began to roll out of bed and NA #1 was unable to stop the resident's fall. The aide stated the resident landed on her right side on the floor. NA #1 immediately called for help. NA #1 stated Resident #49 was not agitated or moving when she began care. No other staff were present at the time of the resident's fall. Interview with the Director of Nursing on 09/09/10 at 9:20 A.M. revealed the facility began immediate mandatory in-service training for staff on resident safety during incontinence care and positioning. The in-service training was conducted between 09/05/10 and 09/07/10 and included all nurse aides and licensed nurses. The Director of Nursing stated additional residents were identified who were required extensive to total staff assistance for bed mobility and were unable to assist in their own repositioning. The care plans for these residents were revised to include using two staff persons when care was being provided for repositioning and bed mobility. Interview with Nurse Aides #2, #3, & #4 on 09/09/10 between 1:00 P.M. and 3:00 P.M. confirmed they attended the mandatory in-service training on providing incontinence care and re-positioning of residents who require two staff members for this care. The Nurse Aides voiced understanding of which residents currently required two staff persons for turning, repositioning, bed mobility and incontinence care. On 09/10/10 between 8:42 A.M. and 9:55 A.M., 4 residents were observed during bed mobility and transfers. Resident #52 was assessed a needing extensive assistance of two persons for transfers and total assistance of two persons for bed mobility on the quarterly assessment of 06/24/10. He was observed being transferred appropriately with 2 persons using a stand up lift. Residents #44 & #2 were assessed on the annual assessment of 08/13/10 and the quarterly assessment of 07/16/10 respectively as needing total assistance of two persons for transfers and bed mobility. Both of these resident were observed being transferred appropriately using a mechanical lift and two persons. Resident #71 was assessed as needing extensive assistance of two persons for transfers and bed mobility. The resident was observed being transferred with two persons using a gait belt and a stand and pivot transfer. Interview with the DON on 09/09/10 at 3:30 P.M. revealed the facility had instituted a monitoring program to observed randomly chosen staff while providing any care to residents while they were in bed. This included bed mobility and transfers. Two observations were to be completed two times a week for one month and then two times a month for two months. The first random observation was performed on 09/08/10 and determined care was being provided according to the resident's individualized plan of care for transfers and bed mobility. Interview with five alert and oriented residents (#51, #23, #27, #20 & #35) on 09/09/10 between 12:45 P.M. and 2:30 P.M. did not reveal any complaints of the residents being fearful of staff transferring them. The residents stated they felt safe during transfers and were complementary to the facility. This citation substantiates Complaint #OH 293