Every finding on record at Marion Nursing & Rehab

Based on record review, staff interviews, and review of facility policy, the facility failed to ensure the bed hold included pricing information and also failed to provide a reason for transfer/discharge notices to the resident/representative and the Ombudsman. This affected three Residents (#77, #78, and #79) of three reviewed for discharge planning.Findings include:1. Review of the medical record for Resident #77 revealed an admission date of 03/22/26. Diagnoses included toxic effect of metals, diabetes, acute kidney failure, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively impaired and required staff assistance for activities of daily living. Review progress notes dated 03/17/26 revealed the resident was being transferred by staff and had seizure like activity. He was lowered to the ground and labs were obtained and identified a lithium toxicity level. The physician ordered intravenous (IV) fluids to be started and to recheck labs in six hours. The staff were unable to get labs drawn and after two attempts, made the decision to send the resident to the hospital for emergency care. Review of the bed hold notice dated 03/17/26 revealed the residents family gave verbal authorization for the bed to be held. The form did not include any pricing information and the price was left blank. The form did not indicate if the residents spouse was informed of the cost for holding the bed. Review of the ombudsman notification dated 03/17/26 revealed the form instructions stated to send this completed form along with a copy of the discharge notice to the Ombudsman. The ombudsman notification form also stated, this form does not replace a written discharge notice used to meet discharge notification requirements to the residents nor does it serve as evidence a discharge notice was sent to the Ombudsman. The form only stated the resident was sent to the hospital and included the name and contact information for the Administrator. There was no documented evidence that a discharge notice was provided to the resident/representative and the Ombudsman. Interview on 05/14/26 at 1:42 P.M. with Social Services Representative #44 confirmed the bed hold notice did not give pricing information. She reported she took over the task of the bed hold notices and was instructed to not fill in the pricing information. She also confirmed she had never provided the reason for the transfer/discharge notice to the resident/representative and/or Ombudsman. 2. Review of the medical record for Resident #79 revealed an admission date of 03/04/26. Diagnoses included major depressive disorder, end stage renal disease, diabetes, and pain in her joints. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact and required moderate assistance from staff members for activities of daily living. Review progress notes dated 03/16/26 reveled the resident was assessed for a change in condition (nausea and vomiting) and requested transfer to the hospital. Review of the bed hold notice dated 03/16/26 revealed the residents family gave verbal authorization for the bed to be held. The form did not include any pricing information, and the price was left blank. The form did not indicate if the resident's spouse was informed of the cost for holding the bed. Review of the ombudsman notification dated 03/18/26 revealed the form instructions stated to send this completed form along with a copy of the discharge notice to the Ombudsman. The ombudsman notification form also stated, this form does not replace a written discharge notice used to meet discharge notification requirements to the residents nor does it serve as evidence a discharge notice was sent to the Ombudsman. The form only stated the resident was sent to the hospital and included the name and contact information for the Administrator. There was no documented evidence that a discharge notice was provided to the resident/representative and the Ombudsman. Interview on 05/14/26 at 1:42 P.M. with Social Services Representative #44 confirmed the bed hold notice did not give pricing information. She reported she took over the task of the bed hold notices and was instructed to not fill in the pricing information. She also confirmed she had never provided the reason for the transfer/discharge notice to the resident/representative and/or Ombudsman. Interview on 05/14/26 at 3:00 P.M. with the Administrator confirmed the bed hold notice did not contain any information on pricing for the bed hold process and also confirmed facility did not have any additional record for the reason for transfer notification documents. 3. Review of the medical record for Former Resident #78 revealed the resident was admitted to the facility on [DATE] and had diagnosis that included dementia, psychotic disturbance, and congestive heart failure. Resident #78 was discharged on 02/24/26 due to an emergent health condition. Review of the medical record for Resident #78 found a bed hold notice dated 02/24/26 that listed hospital stay as the reason for leaving. The bed hold notice did not contain prices for the room and board rate. The bed hold notice was documented as consented by the Resident Representative of Resident #78. There was also no documented evidence that a discharge notice was provided to the resident/representative and the Ombudsman. Interview on 05/14/26 between 1:41 P.M. and 2:01 P.M with Social Services Representative (SSR) #44 confirmed there were no prices on the bed hold form. SSR #44 also stated that it was not believed a discharge notice was necessary because Resident #78 left due to an emergent health condition. Interview on 05/14/26 at 2:40 P.M. with the Administrator confirmed the facility did not have evidence of a transfer notice or bed hold notice with prices. Review of the facility policy titled Transfer or Discharge Notice (revised December 2016) states the facility shall provide a resident or resident's representative notice of a transfer or discharge as soon as practicable if an immediate transfer or discharge is required (due to) resident medical needs. The policy states a copy of this notice will be sent to the Office of the State Long-Term Care Ombudsman. Review of the facility policy titled Bed Holds and Returns (revised May 2025) states the facility will provide written information prior to transfers and therapeutic leaves to the resident and the resident's representative that explains the per diem rate required to hold a bed. This deficiency represents noncompliance investigated under Complaint Number 2804250.

Based on observation, record review, review of the Minimum Data Set (MDS) Resident Assessment Instrument, review of facility policy, and interview, the facility failed to ensure all resident assessments were accurate and coded correctly in the MDS database. This affected six residents (#3, #21, #28, #44, #53, and #62) out of 24 residents reviewed for MDS assessments. The census was 67.Findings include:1.Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 included congestive heart failure, chronic obstructive pulmonary disease, obesity, depression, diabetes type two, and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition, required two staff assistance with Activities of Daily Living (ADLs) and was receiving supplemental oxygen therapy, but was not coded for any type of mechanical ventilation. Review of the MDS quarterly assessment dated [DATE] revealed the resident was coded for an invasive mechanical ventilator. Review of Resident #3's physician orders dated 08/29/25 revealed the resident was ordered to receive mechanical ventilator via Average Volume Assured Pressure Support (AVAP) for morbid obesity and alveolar hypoventilation primary central sleep apnea. Review of Resident #3's care plans dated 10/15/25 revealed a focus for ventilator dependence related to nocturnal vent (AVAP) at bedtime and as needed. Interventions included to allow resident to express feelings about ventilator, educate resident on need for the treatments, elevate head of bed, keep call light within reach, and maintain AVAP ventilator settings as ordered. Observation on 02/09/26 at 8:33 P.M. revealed the resident was lying in bed with a nasal cannula in place. Resident #3 was observed with his eyes closed and respirations unlabored. At the time of the observation Resident #3 did not appear to be in any distress and was not using the mechanical ventilator. Interview on 02/10/26 at 11:00 A.M. with Resident #3 revealed the resident stated he did not like to use the AVAP and refused to use the mask. Resident #3 verified he had not had any endotracheal tubes or a tracheostomy tubes to assist his breathing. Resident #3 verified he was to use a face mask at night during sleep which was connected to the ventilator. Interview on 02/10/26 at 3:51 P.M. with the Administrator revealed the facility MDS nurse and the Administrator were instructed by the facility's corporate MDS nurse to have the Resident #3's MDS code changed to invasive mechanical ventilator due the Resident Assessment Tool stating the APAV ventilator could be used as an 'invasive' ventilating machine. At the time of the interview the Administrator verified there were no residents in the facility who had endotracheal or tracheostomy tubes connected to the ventilators provided respiratory support. Interview on 02/17/26 at 8:00 A.M. with MDS Nurse/Licensed Practical Nurse (LPN) #241 verified there were no residents in the facility using endotracheal or tracheostomy tubes for mechanical ventilation. LPN #241 verified she was instructed by the corporate MDS nurse to code Resident #3 as using an invasive mechanical ventilator in the MDS assessment dated [DATE]. Interview on 02/18/26 at 10:30 A.M. with Respiratory Therapist (RT) #400 and Respiratory Therapy Manager (RTM) #401 via the telephone verified all residents in the facility ordered to use the AVAP machines were using the facial masks at night and as needed per the physician's order. Per RTM #401 and RT #400 the residents were not being provided an invasive ventilator by the AVAP machines. RT #400 and RTM #401 verified the AVAP machines were being used by the residents as a non-invasive machines. 2. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 included chronic obstructive pulmonary disease, sleep apnea, myocardial infarction, heart disease, and hypertension. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was using invasive mechanical ventilation. Review of Resident #53's care plans dated 09/19/25 revealed a focus for the resident being ventilator (AVAP) dependent related to chronic obstructive pulmonary disease. Interventions included to maintain APAV machine setting as ordered. Review of Resident #53's physician orders dated 09/19/25 the resident was ordered to receive mechanical ventilator via Average Volume Assured Pressure Support (AVAP) for chronic obstructive pulmonary disease and primary central sleep apnea at night and as needed. Interview on 02/10/26 at 3:30 P.M. with Resident #53 revealed the resident stated he did not use the mechanical ventilator all the time and used it sometimes at night for short periods of time. Resident #53 verified he only used the ventilator with the facial mask and had not had any endotracheal or tracheostomy tubes. Resident #53 stated he had refused to use the APAV machine many times and was educated by staff on why he should wear the mask at night while he sleeps. Interview on 02/18/26 at 10:30 A.M. with RT #400 verified Resident #53 had refused to use the APAV ventilator at times while he sleeps. RT #400 verified when Resident #53 was using the APAV ventilator, it was in a non-invasive way. Interview on 02/18/26 at 10:35 A.M. with MDS LPN #241 verified Resident #53 was coded in the 09/2025 MDS assessment as using an invasive mechanical ventilator. LPN #241 verified Resident #53 used the facial mask when he agreed to use the APAV ventilator. 3. Review of the medical record for Resident #28 revealed an admission date of 07/18/24 with diagnoses of dementia, dependence on respirator status, [NAME] cardia, central sleep apnea and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and was receiving invasive mechanical ventilation. Review of the physician order dated 11/10/25 revealed orders for a ventilator/Average volume-assured pressure support (AVAPS AE) nightly and during naps. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and was receiving invasive mechanical ventilation. Review of the certificate for continued medical necessity dated 02/03/26 revealed due to Resident #28's chronic respiratory condition, they would continue with the AVAPS as currently ordered to reduce risk of significant adverse medical outcomes and to reduce rehospitalization risk. Observation on 02/12/26 at 8:09 A.M. revealed Resident #28 was asleep in bed, supine, resting comfortably and the AVAPS machine was not on. Interview on 02/12/26 at 9:16 A.M. with Certified Nursing Assistant (CNA) #166 and CNA #165 confirmed Resident #28 had orders to wear the AVAPS machine at night, they reported they were unsure if he wore it often, but they heard he typically took it off after 10 to 15 minutes of usage. Interview on 02/18/26 at 10:31 A.M. with MDS Nurse/Licensed Practical Nurse (LPN) #241 reported the AVAPS machine was a non-invasive machine however she was informed by corporate to code it as invasive, MDS LPN #241 was unaware of the point system of MDS and was unaware if the facility received a higher payment for the residents for invasive versus non-invasive. Interview on 02/18/26 at 10:33 A.M. with Respiratory Therapist #400 confirmed the AVAPS machine was a non-invasive machine. Interview on 02/18/26 at 10:42 A.M. with Respiratory Therapy Manager (RTM) #401 confirmed the AVAPS machine was a non-invasive machine. Interview on 02/18/26 at 11:57 A.M. with Corporate Nurse #402 confirmed coding for invasive ventilation machine would result in higher point and would receive a higher payment, they coded this based on their interpretation of the MDS manual. 4. Record review for Resident #62 revealed the resident admitted to the facility on [DATE]. Diagnoses for Resident #62 included dementia, non-traumatic brain injury, and chronic obstructive pulmonary disease with respiratory failure. Review of Resident #62's Minimum Data Set (MDS) quarterly assessment dated 10/2025 revealed the resident was coded as using an invasive mechanical ventilator. Review of Resident #62's care plans dated 10/10/25 revealed a focus for the resident being dependent on a ventilator (AVAP) due to respiratory failure. Interventions included to maintain ventilator settings as ordered. Interview on 02/18/26 at 10:30 A.M. with Respiratory Therapist (RT) #400 verified Resident #62 was on room air during the day and used the APAV ventilator at night via a face mask. RT #400 verified the use of the APAV with a facial mask was non-invasive. Interview on 02/18/26 at 10:35 A.M. with MDS Nurse/Licensed Practical Nurse (LPN) #241 revealed Resident #62 was compliant with using the facial mask with the APAV ventilator at night while she slept. LPN #241 verified during the day the resident was on room air. LPN #241 verified Resident #62 was coded in the MDS assessments as using an invasive mechanical ventilator. Review of the undated facility policy titled, 'Policy and Procedure: AVAPS (Average Volume Assured Pressure Support) Therapy revealed the procedure was for the safe use of monitoring residents using the AVAPs as a non-invasive ventilation therapy in the facility. Review of the Minimum Data Set 3.0 Resident Assessment Instrument dated 10/2025 revealed the facility may code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become unable to support their own respiration. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents receiving ventilation via an endotracheal tube or tracheostomy. Do not code this item when the ventilator or respirator is used as a substitute for BiPAP or CPAP. 5. Review of the record for Resident #21 revealed the resident was admitted on [DATE] and had diagnoses including encephalopathy, chronic obstructive pulmonary disorder (COPD), and chronic embolism and thrombosis of deep veins of lower extremity. Review of the Minimum Data Set (MDS) assessment for Resident #21 completed 01/22/26 documented the resident was not using an anticoagulant medication. Review of the Medication Administration Record (MAR) for Resident #21 for January 2026 documented daily administration of Rivaroxaban 20 milligrams (mg) (an anticoagulant medication). Interview with Director of Nursing (DON) #272 on 02/17/26 at 9:30 A.M. confirmed the residents MDS was incorrectly coded. 6. Review of the record for Resident #44 revealed the resident was admitted on [DATE] and had diagnoses including metabolic encephalopathy, hypertensive heart disease, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment for Resident #44 completed 01/22/26 documented the resident was not using a diuretic medication. Review of the Medication Administration Record (MAR) for Resident #44 for January 2026 documented daily administration of Hydrochlorothiazide 25 milligrams (mg) (a diuretic medication). Interview with Director of Nursing (DON) #272 on 02/17/26 at 9:31 A.M. confirmed the residents MDS was incorrectly coded.

Based on record review, interview, and review of facility policies, the facility failed to ensure a residents advanced directives status were addressed timely and accurate in the medical record. This affected one (Resident #59) out of 27 residents reviewed for advanced directives. The facility census was 67.Findings include: Review of the medical record for Resident #59 revealed an admission date of 08/22/25 with diagnoses including chronic obstructive pulmonary disease, emphysema, encephalopathy, malignant neoplasm, fibromyalgia and dementia.Review of Resident #59's physician orders dated 08/22/25 through 02/10/26 showed a Full Code status.Review of Resident #59's quarterly Minimum Data Set (MDS) 3.0 assessment completed on 11/12/25 showed the resident was cognitively intact.Review of Resident #59's care conference notes dated 12/04/25 showed the resident requested to change her code status from Full Code to Do Not Resuscitate Comfort Care (DNRCC).Review of Resident #59's signed DNRCC form dated 02/03/26 showed the resident elected DNRCC Arrest (A) which directs providers to treat the patient as usual until cardiac or respiratory arrest at which point all interventions stop.Review of Resident #59's physician orders dated 02/10/26 showed a code status of DNRCC-A.Review of Resident #59's care plan dated 02/10/26 showed a code status of DNRCC-A with interventions to provide comfort measures and verify resident choice quarterly.Interview on 02/17/26 at 11:55 A.M. with the Director of Nursing confirmed Resident #59 requested to be DNRCC during the care conference on 12/04/25 however the request was not implemented until 02/03/26 when a new code status form was completed.Interview on 02/17/26 at 12:49 P.M. with Social Services #119 confirmed the resident request for a code status change was not followed up on 12/04/25 and was only addressed on 02/03/26.Review of code status policy dated December 2016 revealed the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. In addition, inquiries concerning advanced directives should be referred to the administrator, director of nursing and/or the social services director.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's splint noncompliance was recorded in their care plan. This affected one (Resident #57) out of 17 residents records reviewed for comprehensive care plans. The facility census was 67. Findings include:Review of the medical record for Resident #57 revealed an admission date of 02/08/19 with diagnoses of cerebral infarction, muscle weakness, cognitive communication deficit, reduced mobility, contracture of the right hand, hemiparesis and hemiplegia following cerebral infarction.Review of the care plan dated 11/14/25 revealed the resident had a need for a splint or brace program and was dependent on staff for application and removal. Interventions included assessing for pain, assessing for progress and need, explaining the procedure before performing it and applying a soft splint to the right hand to be worn daily as tolerated. The care plan noted no documentation regarding the residents refusal of the splint or brace.Review of physician orders dated 01/01/26 revealed an order for a right hand splint as tolerated and to assess skin with each application and removal.Review of the occupational therapy evaluation and plan of treatment dated 01/09/26 revealed the resident exhibited impaired range of motion in the right extremity including wrist, hand and fingers and included interventions for splint management.Review of splint application documentation dated 01/19/26 through 02/16/26 revealed the resident refused the splint a total of 20 times.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired, had an upper extremity impairment on one side, required substantial to maximal assistance with upper body dressing and receives splint or brace assistance.Observations on 02/11/26 at 8:35 A.M., 3:21 P.M. and 4:20 P.M. revealed the resident lying in bed with no splint placed on the right hand.Observation on 02/17/26 at 9:20 A.M. revealed the resident lying in bed with no splint placed on the right hand.Observation and interview on 02/17/26 at 10:33 A.M. with Resident #57 revealed the resident reported noncompliance with wearing the splint because it was uncomfortable. The resident stated he occasionally allowed staff to place the splint, but not often, and reported wearing the device a couple of days ago.Interview on 02/17/26 at 10:37 A.M. with Licensed Practical Nurse (LPN) #268 confirmed the resident was noncompliant with wearing the right-hand splint and LPN #268 was unaware if this was currently care planned.Interview on 02/17/26 at 11:55 A.M. with the Director of Nursing confirmed the resident's noncompliance with wearing the splinting device should be documented in the care plan.Interview on 02/17/26 at 12:43 P.M. with the Director of Nursing confirmed that from 01/19/26 through 02/16/26 the resident refused the splint a total of 20 times.Review of the splinting and bracing policy dated October 2023 revealed the care plan will be updated as necessary based on changes in the resident.

Based on observation, record review, review of hospital notes, review of facility timeline, interview, and review of facility policies and procedures, the facility failed to follow interventions to prevent a fall. This affected one resident (#3) out of three residents reviewed for falls. The facility also failed to ensure the safety and security of Resident #75 who was admitted to the memory care unit and was an elopement risk. This affected one resident (#75) of three reviewed for elopement. The facility census was 67.Findings include: 1. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 included congestive heart failure, chronic obstructive pulmonary disease, obesity, depression, diabetes type two, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required two person assistance with Activities of Daily Living (ADLs) and was a fall risk. Review of Resident #3's care plan dated 09/25/21 revealed a focus identifying a risk of falls. Interventions included bedside table to be within reach at all times, maintain call light within reach, resident prefers the call light to be wrapped around the transfer handle on bed, initiated on 11/26/25 and revised on 02/12/26. Review of the facility's incident log dating from October 2025 to February 2026 revealed Resident #3 had an unwitnessed fall in his room on 11/26/25. Review of the fall investigation dated 11/26/25 revealed the Director of Nursing (DON) documented Resident #3 was observed lying on the floor on his left side. The resident's bed was noted to be in a raised position. Resident #3 stated he was reaching for his call light and fell out of bed. Emergency services were called and the resident was assessed by the emergency squad and refused to go to the hospital. Resident #3 was placed back in bed and was provided as-needed pain medication. Per the investigation the care plan was updated to keep call light within reach by wrapping it around the transfer handle. Observation on 02/10/26 at 11:00 A.M. revealed Resident #3 was resting in bed, the bed was raised to an elevated height and the resident's call light was clipped to the bed sheet at the head of the bed. Interview on 02/10/26 at 11:00 A.M. with Resident #3 revealed the resident reported he had received a new bed at the facility and it did not have the two transfer bars attached for the first few days he was using the bed. Resident #3 stated he had raised the bed up to high level and he was attempting to get his call light that was out of his reach on the table, which was also out of his reach, and he rolled out of the bed onto the floor. Resident #3 stated he had been educated to not raise the bed to the highest level, but he preferred to have the bed raised up despite the fall risk. Resident #3 stated he would not have rolled out of the bed and fallen had the call light been within his reach or if the grab bars had been in place for him to use. Resident #3 stated he believed the fall was both his fault for raising the bed so high and the fault of the facility staff for not placing his call light within his reach and not applying the grab bars on his new bed. Interview on 02/12/26 at 11:00 A.M. with Licensed Practical Nurse (LPN) #285 revealed Resident #3 was non-compliant with not raising his bed to a high level by himself. LPN #285 stated at the time of the fall on 11/26/25 the resident had been provided care by the staff, and the bed was at a low position when the LPN last visited the room, but the resident raised the bed after the staff left his room. LPN #285 stated she could not recall if the call light was placed within the reach of the resident when she left the room. LPN #285 stated when the resident was found he was alert and stated his call light was out of reach and he was attempting to get it when he rolled out of bed. LPN #285 stated the resident has not fallen since the 11/26/25 incident. Interview on 02/17/26 at 11:50 A.M. with the DON revealed at the time of the fall Resident #3 had received a new bariatric bed and there was no grab bars attached to the bed. DON verified the new bed had not been assessed and there had not been a bed rail assessment completed for Resident #3 in the new bed until 12/08/25. DON stated she had discussed with the resident having the call light clipped to his person, but he preferred to have the call light wrapped around the transfer bar above his bed so he could reach up and push it. DON verified per the investigation the call light was not within reach of the resident when he rolled out of bed on 11/26/25. 2. Review of the medical record for Resident #75 revealed an admission date of 02/05/26. Diagnoses included Alzheimer's disease, diabetes, hypertension, and dementia. Review of the admission elopement assessment dated [DATE] revealed Resident #75 scored a three and was found to be a low risk for elopement. The only items marked off included his cognition, diagnosis and physical ability to ambulate. This was the only elopement assessment completed from admission until 02/23/26. Review of the plan of care dated 02/06/26 revealed Resident #75 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia. It was updated on 02/23/26 (after surveyor intervention) and changed to also state the resident was at risk for elopement due to poor cognition. Resident resided in the secured unit for a structured environment. Interventions included the secured unit and to communicate with the resident, family and caregiver regarding the residents' capabilities and needs. The care plan dated 02/12/26 revealed the resident was a long-term resident. The resident's wife was not allowed to take the resident out of the facility and the daughter/POA (power of attorney) was to be contacted if this occurred. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 08 indicating impaired cognition and identified the resident required supervision or touching assistance with activities of daily living. Review of the progress notes dated 02/11/26 revealed the resident's daughter/POA requested the residents cell phone be taken away due to calling the police and continually calling about getting out of here. A note dated 02/12/26 from the unit manager at 10:30 A.M. revealed the resident went LOA (leave of absence) with his wife and stated the resident's daughter was notified. A progress note dated 02/12/26 at 12:00 P.M. stated this writer spoke with Resident #75's secondary POA (wife) regarding her taking resident on a LOA. Resident #75's wife stated they would return after lunch. The notes also stated although staff knew the resident was leaving with her, she needed to follow the LOA procedure and sign him out. A progress note dated 02/12/26 at 8:15 P.M. revealed the nurse was notified the resident was on his way to the hospital due to aggressive behaviors. A follow up progress note on 02/12/26 at 10:20 P.M. revealed the hospital informed the facility that the resident would be returning around 11:30 P.M. to the facility. A progress note dated 02/12/26 at 11:50 P.M. revealed the resident returned to the facility. The POA (daughter) informed staff that resident was not to leave the facility with anyone and the male visitor (who he had left with) was not to visit with the resident at all. The POA would come in on 02/13/26 to discuss concerns with management. The progress note dated 02/13/26 at 1:01 P.M. revealed a care conference was held with the POA (daughter). The progress notes revealed no documented evidence that Resident #75 left the facility with an unknown male on 02/12/26. Review of the hospital record dated 02/12/26 revealed the resident came to the emergency department due to aggression. It stated Resident #75 was removed from a locked Alzheimer's unit with a friend against the POA (power of attorney)'s wishes and taken home. Upon arrival he became increasingly agitated and once family stated they would take him back, Resident stated I'll just kill myself. The hospital record stated he remained agitated upon arrival to the hospital and was cleared to return to the facility around 11:00 P.M. Review of the medical record found a special instruction dated 02/13/26 at 12:32 P.M. stating must get authorization from daughter for any visitor other than his wife and daughter was the only person authorized to take the resident off the unit. Review of the undated facility timeline of events revealed a friend visited and asked to accompany the resident outside to assist in gathering laundry, and the Unit Manager (UM) agreed. Resident #75 got into the friend's vehicle without notifying staff. Staff spoke with Resident #75's wife who was with him at lunch and also spoke with the daughter who reported he had left town and she requested the facility make a wellness check with the police department to get resident to return to the facility. Interview on 02/23/26 at 10:07 A.M. with Licensed Practical Nurse (LPN) #285 revealed the memory care unit had a dedicated nurse and two aides on day shift. The LPN revealed Resident #75 had recently admitted and had been observed to walk the hallways and press on the locked exit doors. The LPN revealed the resident had eloped on 02/12/26 when a male visitor took him out of the facility without the resident's daughter/POA's knowledge. The LPN revealed facility staff should be checking in the medical record to determine who the main contact person was and if they were not listed, they were not allowed to take resident off the memory care unit without approval from the POA. The LPN confirmed Resident #75 left with an unapproved person with a plan to go to the parking lot and they ended up leaving the facility parking lot and driving away without memory care staff knowing the whereabouts of Resident #75. The LPN was concerned as the resident had packed up his belongings and went outside without staff supervision. The LPN also revealed the documentation in the medical record did not give an accurate portrayal of the incident and downplays that the resident had been missing. Observation on 02/23/26 at 10:40 A.M. found a sign/note taped to the nursing station desk stating staff must check in the residents medical record and get approval from the POA. Interview on 02/23/26 at 10:25 A.M. with Resident #75 revealed he had been at the facility for a while and stated he had called a friend to get him out of here. He confirmed his friend came and said this place was horrible and agreed to sneak me out. He reported they packed up his belongings and just walked out and was unsure if the friend spoke with staff prior to them leaving. He stated he left [NAME] and went and visited some friends. Resident #75 reported he did not remember returning to the facility or going to the hospital and reported he was admitted for his dementia diagnosis and memory issues. Interviews on 02/23/26 from 11:04 A.M. to 11:20 A.M. with Certified Nursing Aide (CNA) #166 and Registered Nurse (RN) #237 revealed the assigned nurse took a break and Unit Manager (UM) #244 was covering for her when Resident #75 exited the memory care unit. They reported the friend asked UM #244 about taking Resident #75 to the parking lot to exchange some clothing items and resident was allowed by UM #244 to go outside with a duffle bag of belongings. When staff later went to gather residents for lunch they were unable to find Resident #75. Staff started looking for the resident and informed the nurse and unit manager that he never returned from being outside with the friend. Staff also checked the parking lot and found the friends vehicle was also gone. They started looking for resident and calling family. They found the resident had been gone for about 30 to 60 minutes before they started looking for him. They revealed staff reached out to Resident #75's POA (daughter) to let her know a male visitor had taken the resident out of the facility and the daughter reached out and found Resident #75 was at lunch with his wife. They reported the resident should not have been allowed outside the facility with a male visitor without approval from the POA. They reported Resident #75's wife was not in the facility and was not seen by these staff members on 02/12/26 prior to Resident #75 leaving the facility property. Interview on 02/23/26 at 11:47 A.M. with CNA #165 revealed she heard the friend ask UM #244 about taking the resident to the parking lot to exchange some items at his vehicle. She reported the UM confirmed the resident would be brought back from the parking lot and the friend agreed the resident would be back once items were exchanged. The CNA revealed the UM approved and instructed her to use the door code and let them off unit and the CNA reported if a member of the management team said it was okay she thought it was fine. The CNA reported it had been some time (estimated at 30 minutes) without seeing Resident #75 and he did not return, so she informed the nurse and UM who stated, Oh crap. CNA #165 reported residents should not be allowed off the unit unless they had approval from the POA. Interview on 02/23/26 at 12:05 P.M. with LPN #124 revealed Residents daughter had informed staff prior to the incident on 02/12/26 that resident was not to leave the unit without anyone but her. LPN reported she was unsure if this was documented in the record but stated it was known to several staff members. LPN revealed she would consider this an elopement due to the staff not knowing where resident had gone for a period of time and he had made it clear he wanted to leave and get out of facility. The LPN revealed residents POA (daughter) informed her the facility called and asked her who resident had left with, and at the time she was not aware of the friend visiting or taking him out of the facility. LPN confirmed their were also issues with the resident having a phone and calling friends and family to get him out of the facility. LPN confirmed the incident documentation in the medical record was not accurate as a male visitor came in and took resident off property without the memory care staff knowledge and the facility management documented his wife took him on a LOA. Interview on 02/23/26 at 12:20 P.M. with Unit Manager (UM) #244 reported the resident's friend had asked to take him to his vehicle to exchange some items and was supposed to return to the facility. She stated she was informed shortly after that resident had not returned to the memory care unit and they searched the parking lot and found the resident and visitor had left. They called the residents wife and she had reported she was at lunch with the resident and they would return him to the facility. The UM revealed the facility completed staff education and added a special instruction in Resident #75's medical record that he was not to leave with anyone but the POA (daughter) and the only visitors were to be the wife and daughter, unless approved by family. Interviews on 02/23/26 from 12:35 P.M. to 3:20 P.M. with Administrator #188, Unit Manager #244 and Director of Nursing #272 revealed Resident #75 went on a leave of absence with his wife. They would not acknowledge the concern of the resident leaving with a visitor without memory care staffs knowing he was leaving and without contacting the POA. The UM reported it was about 10 to 15 minutes later when resident did not come back inside, staff alerted the bosses who also looked at the parking lot and did not see Resident #75 or the male visitor. At that time they contacted Resident #75's wife who reported the resident was with her at a restaurant. The Unit Manager revealed when she left around 7:00 P.M., Resident #75 still had not returned. The Administrator reported she entered the special instructions in the medical record when the resident returned to the facility and after speaking with the residents POA (daughter). They stated facility management staff knew the resident's wife was in the car and stated he was not missing but acknowledged if they knew, the facility would not have needed to call and find him, and staff on the memory care unit should have known the resident's wife was present prior to him leaving. They reported the resident left with a capable adult, but also acknowledged that the individual asked for the resident to come out to exchange belongings and would return, and instead took off with the resident without informing staff. The Administrator also stated the facility contacted the police for a wellness check to get the resident back to the facility. They confirmed the resident was out of the facility for about 12 hours. The Administrator and Director of Nursing (DON) confirmed the facility had completed an elopement assessment upon admission and they would update it quarterly. They reported they did not expect staff to repeat the assessment when changes to resident's conditions occurred and/or changes in behavior. They reported they would not have completed an updated assessment even after the resident stated pressing on doors, pacing the halls and calling family and friends to get him out of here. They also confirmed the care plan was not updated about his elopement risk until the state survey 02/23/26 brought up concerns and also confirmed changes in interventions were not initiated when the resident started showing risky behaviors for elopement but were initiated after the incident occurred. The Administrator acknowledged the elopement risk assessment and care plan were not timely updated. Interview on 02/23/26 at 2:44 P.M. with Ombudsman #600 revealed they were completing an investigation related to elopement concerns of Resident #75. They reported being onsite 02/18/26 and were waiting for the facility to provide a timeline/investigation related to the incident where Resident #75 was allowed to leave the locked memory care with a friend/unknown individual without the POA (daughter) approval. Interview on 02/23/26 at 2:52 P.M. with Social Services (SS) #640 revealed she saw Resident #75 leaving the facility and getting in a car with a male visitor. She stated the residents wife was seen in the car and she observed them drive out of the parking lot. SS #640 revealed knew Resident #75 was from the memory care unit and did not inform staff of this when resident left. She also revealed she was not aware staff did not see Resident #75's wife on the memory care unit when he left. Review of facility policy titled Signing Residents Out, dated 08/2024, revealed all resident leaving the premises must be signed out. This deficiency represents non-compliance investigated under Master Complaint Number 2748011.

Based on interview, record review, and review of facility policy, the facility failed to ensure weight measurements were verified after a significant weight change. This affected one (Resident #22) out of four residents reviewed for weight loss. The facility census was 67. Findings include:Review of the medical record for Resident #22 revealed an admission date of 10/06/23 with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease and shortness of breath.Review of the care plan dated 12/17/24 revealed the resident was at risk for altered nutritional and hydration status with interventions to administer medications as ordered, monitor for malnutrition, obtain laboratory (lab) and diagnostic work as ordered, provide prescribed diet and have the dietitian evaluate and make recommendations.Review of the annual Minimum Data Set 3.0 assessment completed 12/18/25 revealed the resident was cognitively intact, noted with significant weight loss without a prescribed weight loss regimen and was not receiving nutritional supplements.Review of the nutritional assessment dated [DATE] revealed the resident was at risk for nutritional and fluid imbalance due to obesity, COPD and sepsis. Interventions included monitoring weights, oral intake, skin and labs.Review of hospital records from 01/05/26 through 01/22/26 revealed the resident weighed 372 pounds on 01/22/26.Review of the weight summary revealed the resident weighed 372.2 pounds on 01/02/26 and 356 pounds on 02/01/26, a loss of 16.2 pounds or 4.35 percent in one month.Review of physician orders dated 02/03/26 revealed orders for weekly weights.Review of the weight report revealed the resident weighed 360.8 pounds on 02/10/26.Review of the dietary note revealed orders for weekly weights in place, weight loss was beneficial, and there were no new recommendations. Interview on 02/18/26 at 8:39 A.M. with the Director of Nursing confirmed the resident had a significant weight change after readmission from the hospital, triggered on 02/01/26.Interview on 02/18/26 at 11:52 A.M. with the Director of Nursing confirmed staff were expected to verify the weighing method and obtain a reweigh for a change of three to five pounds and confirmed that a reweigh was not completed after the 16.2 pound loss noted on 02/01/26. She stated weekly weights began on 02/03/26.Interview on 02/18/26 at 12:19 P.M. with Unit Manager #244 confirmed a reweigh was not obtained on 02/01/26. The Unit Manager stated the weight change was attributed to fluid overload resolved during hospitalization and believed medications contributed to the loss, so a reweigh was not requested. The Unit Manager confirmed the facility policy required a reweigh for changes of 3 to 5 pounds and confirmed the most recent hospital weight was 371 to 372 pounds on 01/22/26, and confirmed the dietitian assessed the resident six days later and implemented weekly weights on 02/03/26. Review of the weight management guidelines policy revealed a reweigh will be obtained when there is a weight variance of plus or minus five pounds.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure supplemental oxygen was administered per physician order. This affected one (Resident #22) out of five residents identified as receiving oxygen administration. The facility census was 67.Findings include:Review of the medical record for Resident #22 revealed an admission date of 10/06/23 with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease and shortness of breath. Review of the annual Minimum Data Set 3.0 assessment completed 12/18/25 revealed the resident was cognitively intact and was receiving oxygen therapy. Review of the physician order dated 12/31/25 revealed the resident was ordered oxygen at 3 liters per minute by nasal cannula continuous inhalation. Review of care plan dated 02/03/26 revealed the resident had oxygen therapy related to COPD. Interventions included to give medications as ordered and monitor signs or symptoms of respiratory distress. Observation and interview on 02/10/26 at 9:20 A.M. of Resident #22 revealed the oxygen concentration administration level was at 4 liters nasal cannula, the resident denied any complaints of shortness of breath. Observation on 02/11/26 at 8:36 A.M. and 3:15 P.M. of Resident #22 revealed the oxygen concentration administration level was at 4 liters nasal cannula. Interview on 02/11/26 at 3:17 P.M. with Certified Nursing Assistant #287 confirmed Resident #22 was currently receiving oxygen at 4 liters. Interview on 02/11/26 at 3:21 P.M. with Licensed Practical Nurse #283 confirmed Resident #22 was currently receiving oxygen at 4 liters nasal cannula and denied having a physician order to increase oxygen as needed, however confirmed the physician was notified. Review of progress note dated 02/11/26 at 3:32 P.M. revealed the resident reported not feeling good, vitals were taken and an assessment was completed. The residents oxygen was increased to four liters via nasal cannula with oxygen [saturation] at 95%. Review of oxygen administration policy dated October 2022 revealed nursing should verify that there is a physician order, and review the physician order or facility protocol for oxygen administration.

Based on record review and interview, the facility failed to execute timely laboratory orders. This affected one resident (Resident #48) of two residents reviewed for laboratory services. The facility census was 67.Findings include:Review of the medical record for Resident #48 revealed the resident was admitted on [DATE] and had diagnoses including Huntington's disease, overactive bladder, and spinal stenosis of the lumbar region.Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment submitted 01/22/26 revealed the resident had severe cognitive impairment.Review of Resident #48's progress notes written by Licensed Practical Nurse (LPN) #239 on 12/19/25 at 6:04 P.M. stated that Resident #48 was engaging in unusual behaviors. Examples included cleaning walls with tissue paper and attempting to put lotion on a sandwich. The progress note stated LPN #239 contacted Certified Nurse Practitioner (CNP) #616 and orders were received to check for a urinary tract infection (UTI).Review of Resident #48's medical record found that no order was placed for urine collection, analysis, or culture and sensitivity/susceptibility of pathogens isolated. Review of Resident #48's progress notes written by Licensed Practical Nurse (LPN) #239 on 12/25/25 at 10:19 A.M. stated that urine was collected for analysis and culture and sensitivity/susceptibility of pathogens. The laboratory reported receiving the urine specimen for analysis on 12/26/26 at 4:05 A.M.Review of Resident #48's laboratory results reported urinalysis results on 12/26/25 at 12:17 P.M. and urine culture and susceptibility results on 12/29/25 at 10:47 A.M. The urine culture report included Escherichia coli (a bacteria) isolated from the sample.Review of Resident #48's care conference note from 01/02/26 at 3:00 P.M. by Social Worker #119 stated the resident had a slight urinary tract infection and that the doctor was aware.Review of Resident #48's progress notes written by Registered Nurse (RN) #621 on 01/05/26 at 11:20 A.M. stated the RN contacted Certified Nurse Practitioner (CNP) #616 regarding the culture and sensitivity/susceptibility results. Later in the afternoon on 01/05/26 at 3:12 P.M., orders from Physician #634 were entered into the medical record by Registered Nurse (RN) #621 for cephalexin (an antibiotic) tablet 500 milligrams (mg) to be taken twice daily for seven days to treat a UTI.Interview with LPN #239 on 02/17/26 at 10:18 A.M. confirmed the collection of Resident #48's urine sample on 12/25/25, was not timely.Interview with the Director of Nursing (DON) #272 on 02/17/26 at 1:52 P.M. confirmed there were no orders placed in the medical record for Resident 48's urine collection, analysis, or culture and sensitivity.

Based on observation, staff interview, and review of a job description, the facility failed to ensure the doorbell to the front entrance of the facility was functional. This had the potential to affect all 77 residents residing in the facility. The facility census was 77. Findings include: Observation on 04/21/25 at 8:32 A.M. revealed the doorbell to the front door of the facility was missing a cover plate. The button on the doorbell was pushed twice and the doorbell would not ring and made no sound. There was no sign posted with the facility telephone number to obtain assistance to enter the building. Interview on 04/21/25 at 8:52 A.M., the Administrator revealed on 04/16/25 a nurse notified her the facility telephones and internet were not working and were out for a few hours until fixed. The Administrator revealed she was unaware if the doorbell to the facility was functioning. The Administrator revealed she had been at the facility for about six months and never checked to see if the doorbell was functioning. Observation and interview on 04/21/25 at 9:02 A.M. with the Administrator and the Director of Nursing (DON) revealed the doorbell to the facility front entrance door would not ring when the buttons were pushed. The DON revealed the doorbell was used to enter the facility at night and should sound at the nurse's station. The Administrator and the DON verified the doorbell was not working. Interview on 04/21/25 at 9:17 A.M., with Licensed Practical Nurse (LPN) #206 was unaware the facility doorbell was not working. Interview on 04/21/25 at 10:53 A.M., with LPN #210 was unaware the facility doorbell was not working. Interview on 04/21/25 at 1:35 P.M., with Director of Maintenance (DOM) #400 revealed he had never checked the doorbell to see if it was functioning and was not part of his routine checks. DOM #400 revealed he found out about a week ago the doorbell was not working but the staff member who reported it had never filled out a maintenance work order. Interview on 04/21/25 at 2:17 P.M., with LPN #265 revealed an outside provider was at the facility on 04/16/25 and told her the telephones and the front entrance doorbell were not working. LPN #265 revealed she reported to the Administrator about the telephones, internet, and doorbell not working. LPN #265 revealed she had not notified maintenance staff about the doorbell not working because another nurse told her maintenance was already aware. Interview on 04/21/25 at 3:57 P.M., with the Administrator revealed facility staff were trained during new hire orientation to enter maintenance requests in the computer system. Interview on 04/21/25 at 4:05 P.M., with the DON revealed some staff locked the front entrance door at night and some staff did not. The DON revealed the facility had no policy requiring the door to be locked at night. The DON revealed some staff locked the front entrance between 9:00 P.M. and 10:00 P.M. and unlocked the door between 6:00 A.M. and 6:30 A.M. Review of the job description titled, Plant Operations Manager, dated 08/31/20, revealed maintenance would maintain the facility equipment in proper working order, repair or replace any equipment not functioning properly, conduct facility rounds and repair any areas needing attention, and contact outside contractors to get quotes to complete work as required. This deficiency represents non-compliance investigated under Master Complaint Number OH00164950.

Based on observation, resident and staff interview, review of a job description, and policy review, the facility failed to ensure the call light system was functioning for all residents and timely repairs were made to the system. This affected 23 of 77 facility residents including nine (#1, #11, #16, #28, #40, #50, #55, #62, and #71) residents with no functioning call light and an additional 14 (#18, #22, #26, #34, #37, #47, #53, #56, #58, #60, #63, #70, #75, and #76) residents with intermittent functioning call lights. The facility census was 77. Findings include: Interview on 04/21/25 at 8:52 A.M., with the Administrator revealed there were a few rooms on the north end of the facility where the call lights were not working and would have to check how long they had not been working. The Administrator revealed the residents were given hand bells and revealed she had gotten a couple of quotes for repair and replacement of the call light system. The Administrator revealed the staff had increased the frequency of rounding for the rooms with hand bells, but could not say how often the rounding was done. During the interview, the Administrator was asked to provide the documentation of service provider quotes to repair or replace the call light system. Interview on 04/21/25 at 9:17 A.M., with Licensed Practical Nurse (LPN) #206 revealed the call lights on the north unit were not working and the residents had hand bells. LPN #206 revealed if she was at the nurse's station she would leave the door open so the hand bells could be heard. Interview on 04/21/25 at 9:29 A.M., with Resident #50 revealed her call light had not been working for months. Resident #50 stated the call light would stay on for a few minutes then would just shut off. Resident #50 revealed she called the facility via telephone when she needed assistance. Interview on 04/21/25 at 9:33 A.M., with Resident #28 revealed her call light was not working since her admission on 04/04/25. Resident #28 had a hand bell but stated her roommate would call the facility for her via telephone when she needed help. Interview on 04/21/25 at 9:35 A.M., with Resident #58 revealed her call light had not been working for a couple of weeks. Resident #58 had a hand bell and stated it took forever for the staff to answer it. Interview on 04/21/25 at 9:37 A.M., with Resident #62 revealed her call light and her roommate's (#71) call light had not been working for a week or two. Resident #62 and Resident #71 had hand bells. Interview on 04/21/25 at 9:42 A.M., with Resident #75 revealed his call light had not been working for about a week and had a hand bell. Interview on 04/21/25 at 9:43 A.M., with Resident #40 revealed his call light was not working but was unsure for how long it was not working. The resident had a hand bell. Interview on 04/21/25 at 9:56 A.M., with LPN #210 revealed the call lights on the north end had not been working for a few weeks and thought the facility was supposed to replace the call light system. Interview on 04/21/25 at 10:53 A.M., with Certified Nurse Aide (CNA) #230 revealed the residents had hand bells and she was rounding on the residents every 30 minutes. CNA #230 revealed the call lights had not been working for a couple of weeks. Interview on 04/21/25 at 10:55 A.M., with CNA #242 revealed she was completing checks on the residents with hand bells about every 30 minutes. CNA #242 revealed the call lights had not been working for at least two weeks. Interview on 04/21/25 at 11:01 A.M., with the Administrator revealed the call lights on the north end had not been working correctly since 03/31/25. The Administrator revealed she had been getting service pricing quotes, but the repair providers indicated the system could not be fixed. Further interview on 04/21/25 at 1:48 P.M., the Administrator revealed she was unable to provide documentation of service provider quotes to repair or replace the call light system. The Administrator revealed the vendors stated the call light system was an old system and would not put anything in writing. Observations on 04/21/25 beginning at 11:13 A.M., with the Director of Nursing (DON) revealed the call lights were not working in the rooms of nine (#50, #28, #71, #62, #16, #40, #1, #11, and #55) residents. Concurrent interview with the DON revealed the call lights worked intermittently in the rooms of 14 (#56, #70, #18, #22, #76, #60, #75, #53, #63, #47, #26, #58, #34, and #37) additional residents. The DON revealed the 23 total residents all had hand bells or service bells. Interview on 04/21/25 at 1:35 P.M., with Director of Maintenance (DOM) #400 revealed the call lights had not been working on the north end of the building for about two and a half weeks. DOM #400 revealed it was an old system and there was a power problem with the voltage. DOM #400 revealed some rooms worked intermittently. Review of the job description titled, Plant Operations Manager, dated 08/31/20, revealed maintenance staff would maintain the facility equipment in proper working order, repair or replace any equipment not functioning properly, conduct facility rounds and repair any areas needing attention, and contact outside contractor to get quotes to complete work as required. Review of the facility policy titled, Answering the Call Light, dated 09/2022, revealed no guidelines for maintaining the call light system. Further review of the policy revealed no guidelines for when the call lights were not functioning. Review of an undated facility policy titled, Call Lights-Answering, revealed if the call light system was not functioning properly, residents would be provided call bells, and the assigned staff would make ongoing rounds until the call light system was working properly. There were no guidelines for maintaining and fixing the call light system when not functioning. This deficiency represents non-compliance investigated under Master Complaint Number OH00164950 and Complaint Number OH00164825.

Based on observation, staff interview, and review of policy, the facility failed to ensure the crash carts (emergency use) were stocked with non-expired medical devices. This had the potential to affect all 69 residents residing in the facility. The census was 69. Findings include: Observation, along with Licensed Practical Nurse (LPN) #171, on [DATE] at 9:30 A.M., revealed the crash cart(located in the nurses station on the skilled nursing side) contained four 10 milliliter syringes with expiration date of [DATE]. The cart contained three 22 gauge angiocaths with expiration date of [DATE], two 20 gauge angiocaths with expiration date of [DATE], five intravenous start kits with expiration dates of (3) [DATE] and (2) [DATE], and an unopened, sealed bottle of blood glucose test strips dated [DATE]. The cart in the locked dementia unit contained three suction catheter kits dated [DATE] and a sealed providone swab stick expired ,d+[DATE]. Interview at the time of the observation, with LPN #171 verified all of the findings at the time of the observations. Review of the undated policy titled, Emergency Crash Cart and Automated External Defibrillators revealed expired items are replaced when applicable. This deficiency represents non-compliance investigated under Complaint Number OH00157697.

Based on observation, staff interview, and review of the policy, the facility failed to ensure the glucose monitor device was cleaned after use. This directly affected three residents (#26, #67 and #68) and had the potential to affect 15 residents (#16, #18, #21, #23, #32, #36, #37, #39, #44, #48, #50, #52, #56, #61, and #63), identified by the facility as having blood glucose monitored using the blood glucose device. The facility census was 69. Findings include: Observation on 09/27/24 at 5:35 A.M., revealed Licensed Practical Nurse (LPN) #100 used a blood glucose monitor device to obtain a blood glucose result on Resident #26. After obtaining the result, LPN #100 used an alcohol swab to cleanse the monitor device. Interview directly following, with LPN #100 provided verification the alcohol swab was not the correct substance to clean the device. Observation on 09/27/24 at 5:53 A.M., revealed LPN #103 to obtain a blood glucose reading using a blood glucose device for Resident #67. LPN #103 did not clean the device before proceeding to use the device to obtain a blood glucose result on Resident #68. Interview immediately following the second test, with LPN #103 provided verification she had not cleaned the device between residents #67 and #68. Review of the undated policy titled Glucometer Disinfection, revealed the glucometer is to cleaned and disinfected after each use. The glucometer is to be disinfected with a wipe pre-saturated with an Environmental Protection Agency registered healthcare disinfectant This deficiency represents non-compliance investigated under Complaint Number OH00157697.

Based on medical record review, staff interview, and policy review, the facility failed to properly assess and treat a resident's rash. This affected one (#1) out of three residents reviewed for a change in condition. The facility census was 69. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, depression, hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set assessment, dated 07/19/24, revealed Resident #1 was identified as cognitively impaired. The resident required assistance from staff for all activities of daily living. Review of Resident #1's medical record for 09/06/24 and 09/07/24 revealed no other information, documentation, or assessment regarding a rash. Review of the shower sheet dated 09/07/24, revealed Resident #1 had a rash on their left thigh. Review of the nursing progress notes dated 09/08/24 and timed 10:00 A.M., revealed the nurse on duty noted a red rash on the top of Resident #1's left thigh and lower back. A State tested Nurse Aide (STNA) reported the rash was reported to the unit managers on 09/06/24. The nurse on duty notified the on-call provider who ordered Acyclovir (anti-viral) medication. The provider on call and the family were notified via phone. Review of the skin assessment dated [DATE] indicated Resident #1 had a rash on the front of their left thigh and on their lower back, extending from the left flank to the right flank. Interview on 09/26/24 at approximately 10:42 A.M., with the Director of Nursing, revealed Resident #1's rash was reported to Licensed Practical Nurse (LPN) #167 on 09/06/24. LPN #167 reported the rash to LPN Supervisor #171. LPN #171 then reported the rash to the DON. The DON verified there was no documentation to support the facility had identified, assessed, or obtained treatment orders for the rash until 09/08/24. Review of the policy titled Notification of Changes, dated February 2023, revealed the need to alter treatment significantly was defined as needing to stop a form of treatment due to adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem. The facility would inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there was a change requiring such notification. Circumstances requiring notification included new treatment of discontinuation of a current treatment. Review of the policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the facility would notify the resident's attending physician or physician on call when there has been including but not limited to an adverse reaction to medication or a need to alter the resident's medical treatment significantly. The policy also stated the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00157697.

Based on observation, staff interview, and policy review, the facility failed to ensure food was served at safe holding food temperatures. The deficient practice had the potential to affect all 63 residents that receive food from the kitchen. The facility census was 63. Findings include: Observation on 04/02/24 at 12:19 P.M., with Dietary Manager #35 and District Manager #95, of the tray line revealed the lunch menu consisted of meatballs, capris vegetables, and white rice. Dietary Manager #35 gave a thermometer and santizer wipes to Cook #40. Cook #40 then temperature tested the food on tray line being served on the test tray. The meatballs were 150 degrees Fahrenheit, the capris vegetables were 127 degrees Fahrenheit, and the white rice was 130 degrees Fahrenheit coming out of hot holding to be placed on the test tray. The test tray left the kitchen at 12:21 P.M. Observation of tray distribution in the Reflections unit started on 04/02/25 at 12:24 P.M. Interview on 04/02/24 at 12:26 P.M., with Dietary Manager #35 revealed she was not aware what temperature the food should be during hot holding and that she was going to have to ask. Interview on 04/02/24 at 12:29 P.M., with District Manager #95 revealed they want food to be at least 135 degrees Fahrenheit coming out of the kitchen. When asked if the facility does test trays, District Manager #95 said they haven't gotten to train Dietary Manager #35 to do test trays yet. Observation of the test tray that left the kitchen at 12:21 P.M., was opened at 12:41 P.M., Dietary Manager #35 temperature tested the food on the tray and confirmed the food temperatures. The meatballs were 127 degrees Fahrenheit, the capris vegetables were 129 degrees Fahrenheit, and the white rice was 132 degrees Fahrenheit. Review of the policy titled, Food Preparation Policy dated February 2023, stated all foods will be held at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding and less than 41 F for cold holding. This deficiency represents non-compliance investigated under Complaint Number OH00152371.

Based on Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observation, interview with residents, interview with facility staff, and review of facility policy, the facility failed to appropriately implement the isolation procedures and use of Personal Protective Equipment (PPE) to prevent the spread of the SARS-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when the facility staff failed to require 13 residents (#19, #21, #42, #46, #47, #51, #55, #56, #59, #61, #62, #64, and #65) who were positive for COVID-19 to remain in isolation from the onset of the outbreak on 11/25/23. As of 12/12/23, 20 residents were identified as COVID-19 positive (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62). These 20 residents are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The facility also allowed six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative to remain in a room with a COVID-19 positive roommate. Licensed Practical Nurse (LPN) #215 was observed not to change her mask when exiting a COVID-19 positive resident's room (#50) and State tested Nursing Assistant (STNA) #275 failed to utilize proper PPE when coming into contact with a COVID-19 positive resident (#45) when the staff member was observed to not utilize a gown, gloves, or eye protection when in the resident's room. STNA #275 also did not change her face mask when exiting the room. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. Additionally, the facility failed to implement staff COVID-19 testing strategies when the COVID-19 outbreak occurred on 11/25/23. Failure of the facility to have systems in place to prevent the transmission and spread of COVID-19 to the vulnerable population of the facility placed all 64 residents at potential risk for contracting the virus. The total facility census was 64. On 12/13/23 at 1:11 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Operations (RDO) #530 were notified Immediate Jeopardy began on 11/25/23 when the facility did not implement isolation procedures and COVID-19 positive residents were allowed to be out of their rooms if they wore source control. The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate. LPN #215 exited a COVID-19 positive room and did not change her mask when exiting the room, STNA #275 did not use proper PPE when coming into contact with a COVID-19 positive resident, and the facility had no formal staff COVID-19 testing occurring since the COVID-19 outbreak. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. As of 12/12/23, 20 residents were identified as COVID-19 positive and are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective actions: On 12/07/23 at 3:00 P.M., RDO #530 educated the Administrator on COVID policies. On 12/13/23 at 2:30 P.M., the Administrator educated all department heads including the DON, Human Resource Director (HRD) #535, Maintenance #520, Receptionist #540, Dietary Manager #515, Housekeeping Manager #505, Unit Manager #550, MDS Nurse #260, Therapy Director #500, Business Office Manager #510, Activities Director #570, Admissions Director #580, and Social Service Director #230 on the COVID policies. Education of floor staff (Nurse, STNA, Dietary, Laundry, housekeeping, receptionist, Maintenance, Activities, SS, therapy) by the DON, MDS Nurse #260, Unit Manager #550, Dietary Manager #515, Housekeeping Manager #505, Therapy Director #500, and/or HRD #535 on COVID policy, proper PPE (don/doff) on 12/13/23 on Carefeed via Read & Sign, or prior to the start of their next scheduled shift completed by 12/14/23 at 4:30 P.M. On 12/13/23 by 4:30 P.M., audits of rooms were completed by Housekeeping Manager #505 for proper trash bins in COVID positive rooms. Scheduled staff testing for COVID-twice a week on Tuesdays and Fridays or when symptomatic by DON/Infection Preventionist (IP)/Designee. Positive staff will be removed from the schedule, removed from the facility, and will follow isolation precautions/rules for their symptoms. Employees will follow Return to Work Guidelines per Centers for Medicare & Medicaid Services (CMS), CDC, State and local guidelines, and company policy, 12/12/23 at 5:10 P.M. (For healthcare personnel (HCP) who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. Either antigen test (ex, Binax Now, Quidel, BD Veritor) or NAAT (PCR) testing can be utilized. It is not recommended to test staff who are COVID-19 recovered in the past 30 days. Inform the staff member to self-monitor for fever and symptoms consistent with COVID-19 and not to report to work when ill or testing positive for COVID-19. Confer with the staff member to work restrict if: The staff member is unable to wear source control for 10 days following exposure. They are personally moderately to severely immunocompromised. They work solely on units with residents who are moderately or severely compromised and are unable to be reassigned or they are assigned to a unit that is currently in outbreak and the transmission is not controlled with initial interventions and they are unable to be re-assigned). We will either follow Table 1 Return to Work Criteria, Confirmed Infection, Conventional Staffing or Table 2 Return to work Criteria, Confirmed Infection, Contingency and Crisis Staffing. Residents are educated on COVID-19 policies and in room isolation requirement on COVID -19 positive date by DON/IP/Designee, at time of event. Re-testing of all negative residents-twice a week on Tuesdays and Fridays or when symptomatic by DON/IP/Designee, initiated 12/07/23. If a resident is COVID-19 positive they will be immediately provided a private room as available and will be cohorted with residents with the same pathogen as able. On 12/13/23 by 5:15 P.M., the DON/IP/Designee re-located all non-COVID-19 positive residents. On 12/13/23, the DON/IP/Designee ensured all residents are cohorted with like status, and documented, educated, and will monitor (signs and symptoms) those who refused room moves. Starting on 12/15/23, the Administrator/DON/designee to monitor the education through completion. Any staff on paid time off (PTO) will be educated prior to working, and any new hires will be educated during orientation. This monitoring will be conducted weekly for four weeks, then monthly times two. Starting on 12/15/23, the DON/designee to monitor resident testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two. Starting on 12/15/23, the DON/Human Resources (HR)/Designee to monitor staff testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two. Although the Immediate Jeopardy was removed on 12/15/23, 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 in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Interview with the Administrator and the DON on 12/12/23 at 9:25 A.M. confirmed the facility is in COVID-19 outbreak status and the facility had their first COVID-19 positive resident on 11/25/23. The Administrator and DON confirmed there were currently 20 residents (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62) who were COVID-19 positive and there was not a dedicated COVID-19 unit. The Administrator confirmed at the beginning of the COVID-19 outbreak, COVID-19 positive residents were allowed to be out of their rooms if they wore source control and maintained social distance. Interview with LPN #200, LPN #260, Housekeeper #235 and Social Services #230 on 12/12/23 from 11:32 A.M. to 1:12 P.M. all confirmed the facility did allow COVID-19 residents to be out of their rooms and in common areas until last week. Observation on 12/12/23 at 11:32 A.M. revealed LPN #215 took medication into a resident (#50) in an isolation room, and the LPN donned gloves and gown and had on a surgical mask and glasses. The resident was heard to refuse the medications and the nurse was observed to remove the gown and place it in a small, resident room sized trash can by the door, dump the medication in the sharp's container, remove her gloves with the medication cup in the gloves, exit the room, complete hand hygiene with hand sanitizer and discard her gloves in the medication cart trash can. The nurse continued to wear the same surgical mask she had on prior to entering the isolation room. The nurse verified the facility staff were wearing surgical masks and verified she should have removed her mask prior to exiting the isolation room but she had not. Observation of State tested Nursing Assistant (STNA) #275 on 12/13/23 at 10:10 A.M. revealed the STNA was observed in a COVID-19 positive resident's (#45) room, with a face mask in place as the only PPE in use. There was PPE outside the door and signage on the door indicating staff were to wear a gown, gloves, mask, and eye protection if entering the room. The STNA was observed to exit the room carrying a large Styrofoam cup and walk down the hallway. Interview with STNA #275 on 12/13/23 at 10:12 A.M. confirmed she had exited the resident's room with a large cup. The STNA stated yea I didn't have any PPE on. I was just getting this cup. She verified she did not remove her mask and was wearing the same surgical mask she had on while she was in the room. She stated she had performed hand hygiene and then obtained more large Styrofoam cups from the kitchen. Interview with the DON on 12/12/23 at 11:40 A.M. confirmed the staff are not being tested by the facility for COVID-19 but have been told if they feel sick, they need to test and if they are positive, they come to the facility to test and have their result verified. The DON stated the staff are allowed to test anytime they want but it is not tracked at the facility. The DON verified the residents are currently being tested on Tuesdays and Fridays. Observation of all isolation rooms on 12/12/23 at 4:15 P.M. revealed there were no trash receptacles close to the door for staff to discard used PPE upon exit from the room. Interviews with LPN #200, LPN #210, and LPN #215 on 12/13/23 at 7:45 A.M. confirmed there were no trash receptacles near the doors to discard their PPE and it made it difficult to properly remove their PPE and exit the isolation rooms. The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate. Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. Review of the CDC guidance for transmission-based precautions regarding COVID -19 revealed: Patient Placement Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multidrug-resistant organisms (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Flong-term-care.html#:%7E:text=Top%20of%20Page-,2.%20Recommended%20infection%20prevention%20and%20control%20(IPC)%20practices%20when%20caring%20for%20a%20patient%20with%20suspected%20or%20confirmed%20SARS%2DCoV%2D2%20infection,-The%20IPC%20recommendations This deficiency represents non-compliance investigated under Complaint Number OH00148969 and OH00148956.

Based on record review, facility staff interview, and policy review, the facility failed to notify the responsible party for two residents (#21 and #57) of four reviewed for COVID-19 that they were positive for SARS-CoV-2 virus (COVID-19), and the facility failed to notify the responsible party of six (#01, #04, #08, #20, #32, and # 63) of six residents reviewed who were COVID-19 negative that the resident remained in a room with a COVID-19 positive roommate. The total facility census was 64. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression. Resident #21 was documented to have a guardian over her care at the facility. Review of the state optional minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating. Resident #21 had order for isolation and observation due to testing positive for COVID-19 for 10 days dated 12/04/23. Review of the facility's COVID -19 tracking revealed Resident #21 tested positive for COVID-19 on 12/03/23. Resident #21's record had no documentation that the responsible party was notified of the resident's change in condition, testing positive for COVID-19, or requiring isolation in the facility. 2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including infection to skin and subcutaneous tissue, venous insufficiency, need for assistance with personal care, hypertension, chest pain, and weakness. Review of the state other MDS 3.0 assessment dated [DATE] revealed the resident is cognitively intact and had no behaviors. Resident #57 required no help from staff for bed mobility, transfers, eating and personal hygiene. Review of Resident #57's orders revealed the resident had an order dated 12/11/23 for vital signs due to diagnosis of COVID-19 and to isolate the resident for 10 days. Review of the facility's COVID -19 tracking revealed Resident #57 tested positive for COVID-19 on 12/10/23. Resident #57's record had no documentation that the responsible party was notified of the resident's change in condition, testing positive for COVID-19, or requiring isolation in the facility. 3. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur. Resident #01 had family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19. 4. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit. Resident #04 had a family listed as her responsible party over her care. The medical record also not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #04 was negative for COVID-19. 5. Review of Resident #08's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes. Resident #08 had a family listed as responsible party over his care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19. 6. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociative and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity. Resident #20 had a family over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID-19 tracking revealed Resident #20 was negative for COVID-19. 7. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, unspecified psychosis. Resident #32 had a guardian over his care. The medical record did not have documented evidence that the guardian was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19. 8. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression, and weakness. Resident #63 had a family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate. Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19. Interview with the Director of Nursing on 12/13/23 at 4:00 P.M. confirmed the findings. Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room.

Based on record review and facility staff interview, the facility failed to monitor six (#01, #04, #08, #20, #32, and #63) of six residents who were COVID-19 negative and remained in a room with a COVID-19 positive roommate for signs and symptoms of COVID-19. The total facility census was 64. Findings include: 1. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur. Resident #01's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit. Resident #04's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID-19 tracking revealed Resident #04 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 3. Review of Resident #08's medical record revealed the resident was admitted to 11/10/23 with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes. Resident #08's medical record lacked evidence that the resident had his temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 4. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociate and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity. Resident #20's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #20 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 5. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, and unspecified psychosis. Resident #32's medical record lacked evidence the resident was having his temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 6. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression and weakness. Resident #63's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. Interview with the Director of Nursing on 12/14/23 at 4:00 P.M. confirmed Resident #01, #04, #08, #20, #32, and #63 remained in a room with a COVID-19 positive roommate and the facility was not monitoring the residents daily for signs or symptoms of COVID-19.

Based on record review, facility staff interview, and policy review, the facility failed to update care plans for three (#21, #57 and #61) of four residents reviewed for being COVID-19 positive. The total facility census was 64. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression. Review of the 10/12/23 state optional Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating. The resident had order for isolation and observation due to positive COVID status for 10 days dated 12/04/23. Care plans reviewed revealed the resident is long term care at the facility. That she likes to spend most of her time outside her room in communal areas and will watch tv and will participate regularly in bingo and group discussions. The care plan included a plan that she has demonstrated a refusal or inability to wear a mask when outside her room. The care plan had no documentation regarding the resident being positive for COVID-19, or being in isolation. 2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including infection to skin and subcutaneous tissue, venous insufficiency, need for assistance with personal care, hypertension, chest pain, and weakness. Review of the state other MDS 3.0 dated 10/06/23 revealed the resident is cognitively intact and had no behaviors. Resident #57 required no help from staff for bed mobility, transfers, eating and personal hygiene. Review of Resident #57's orders revealed the resident had order for vital signs due to COVID positive results and for isolation for 10 days due to COVID positive status dated 12/11/23. Review of facility COVID -19 tracking revealed the resident tested positive for COVID-19 on 12/10/23. Review of care plans revealed the resident had a care plan dated 12/10/23 that stated she had the potential for or required an actual isolation related to COVID -19 if she developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that she required isolation due to being COVID-19 positive. 3. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes, anxiety, heart failure, asthma, chest pain, weakness, obesity, depression and need for assistance with personal cares. Review of the 11/21/23 state other MDS 3.0 assessment revealed the resident is cognitively intact, had no behaviors, required supervision for bed mobility, transfers, eating and personal hygiene. Review of facility COVID-19 documentation revealed the resident tested positive for COVID-19 on 12/04/23. Review of care plans revealed the resident had a care plan dated 12/04/23 that stated he had the potential for or require an actual isolation related to COVID -19 if he developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that he required isolation due to being COVID-19 positive. Interview with the Director of Nursing on 12/13/23 at 4:00 P,M. confirmed the residents' care plans were not updated to reflect the residents' diagnosis of COVID-19 or their being in isolation. Review of the policy titled, F656, F657, F658 Comprehensive Care Plans, dated 09/2012 last revised 09/2023 revealed the facility's care planning/Interdisciplinary team in coordination with the resident, his/her family or representative(sponsor), develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician's orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on observations, staff and resident interviews, the facility failed to ensure a safe environment for residents, staff, and visitors. This had the potential to affect all 62 residents residing in the facility. Findings include: The initial tour was conducted on 08/21/23 from 8:30 A. M. to 9:00 A.M. and revealed the entry way into the facility contained two glass doors. The first entry door (from the outside, door number one) from the bottom of the glass door closest to the floor extending up three quarters of the door and the entire width of the door, the glass was shattered. It appeared to have a shattered circle of glass in the center of the door with extending cracked glass to forming sharp lines of cracked glass extending in every direction. The area resembled a sun beam design or a spider web effect. Four feet in front of the first entry glass door was another glass door into the lobby of the facility. Door number two was shattered at the bottom right side about 24 inches wide and extended up to the middle of the door, the shattered glass was covered with a two-inch tape on both sides. There were no particles of glass in the area. The shattered glass remained inside the two door frames. Interview with the Administrator on 08/21/23 at 2:48 P. M. revealed on 07/27/23, a resident was attempting to exit the building, and hit the glass with his wheelchair causing the door number two's glass to break. Two days later on 07/29/23, after business hours, the first entry door (door number one) was locked. An unidentified person who appeared to be intoxicated attempted to enter the locked facility. The person kicked the glass door and cracked the glass. Per the direction of the corporate office, Maintenance Director #165 was instructed to place tape over each crack on the doors. The Administrator explained they had a company come and give an estimate to replace the doors. The process continues as the facility was in the process of obtaining additional bids for replacement of the doors. Observation on 08/24/23, at 2:00 P. M. revealed there was a sign on the entry door and door number two that stated, Close door gently to prevent slamming. Thank you. Interview on 08/24/34 at 2:13 P.M. with the Maintenance Director #165 confirmed the outside door was covered with duct tape while the inside door has some special glass tape to prevent further breakage. The additional areas of cracked glass were covered with a generic clear tape. Observation of the doors accompanied by Maintenance Director #165 confirmed the outside glass door had a new area of cracked glass that was not covered with tape. Interview on 08/24/23 at 2:15 P.M. with Resident #9 stated the doors have been shattered since July. The facility has many residents who go outside to sit, and they must be careful when exiting the building to prevent the shattered doors from further cracking. Interview on 08/24/23 at 2:30 P.M. with Licensed Practical Nurse (LPN) #182 stated the facility has 40 residents who use a wheelchair to enter and exit the building. LPN #182 stated several residents liked to sit outside this time of year.

Based on medical record review, resident and staff interview, review of the facility's self-reported incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of physical abuse of a resident to the State Survey Agency. This affected one (Resident #66) of two residents reviewed for abuse. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included chronic obstruction pulmonary disease, schizophrenia, depressive disorder, pain in shoulder, cognitive communication deficit, psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact and required limited to extensive assistance of one staff member for mobility and transfers. Interview on 08/22/23 at 9:00 A.M. with Resident #66 revealed she had an allegation of abuse with State tested Nursing Aide (STNA) #126 smacking her during care. Resident #66 revealed she had reported the allegation of physical abuse by STNA #126 to the Director of Nursing (DON) previously. Resident #66 stated this alleged incident occurred about one month ago but could not recall the exact date. Interview on 08/22/23 at 3:42 P.M. with the DON revealed she was not aware of Resident #66 having concerns related to abuse and revealed she did not recall Resident #66 reporting concern of STNA #126 had smacked her. The DON stated she would begin an investigation related to the abuse allegation. Subsequent interview on 08/24/23 at 9:22 A.M. with the DON confirmed the physical abuse allegation reported by the State Survey Agency on 08/22/23 had not yet been reported as an SRI. Review of the facility's SRI revealed there were no allegation of physical abuse of Resident #66 reported to the State Survey Agency from 07/01/23 to 08/25/23. The DON was informed on 08/22/23 at 3:42 P.M. that the allegation of physical abuse was not reported as an SRI yet. Review of the facility policy titled Abuse Prevention Program, dated 08/2022, revealed residents had the right to be free from abuse. The policy revealed the facility had policy and procedures which included reporting and filing documents relative to abuse. This deficiency represents non-compliance investigated under Complaint Number OH00145738.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, staff interviews, review of facility witness statements, review of the facility's policies for Cardio-Pulmonary Resuscitation (CPR) and Advance Directives, the facility failed to initiate CPR or contact Emergency Medical Services (EMS) or Nurse Practitioner (NP) #500 for Resident #15 who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. This resulted in Immediate Jeopardy when Resident #15 did not receive CPR, and neither EMS nor NP #500 were contacted for assistance. This affected one (Resident #15) of three residents reviewed for death in the facility. The facility identified 40 residents designated as having a Full Code status. The facility census was 78. On [DATE] at 1:05 P.M., the Administrator, the Director of Nursing (DON), and NP #500 were notified Immediate Jeopardy began on [DATE] at 4:45 A.M. when Resident #15, who was a Full Code status, was found by State tested Nursing Assistant (STNA) #33 unresponsive and lifeless in her chair. STNA #33 left Resident #15 and went to get Registered Nurse (RN) #44 to help with Resident #15. RN #44 could not find respirations, pulse, or blood pressure upon his arrival to assess Resident #15. RN #56, who was assigned to Resident #15 that night shift, followed right behind RN #44 and made everyone aware that Resident #15 was a Full Code status; however, neither RN #44 nor RN #56 immediately initiated CPR or called emergency nine-one-one (911) and did not immediately call the NP (#500) or the Physician. Although the Immediate Jeopardy was removed on [DATE] at 7:00 P.M., 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 the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 7:00 A.M., the DON started education with all nursing staff in person or via phone on the CPR policy and performing a code with emphasis on what their role would be during a code. All newly hired staff will be educated on the process during orientation. · On [DATE] starting at 7:45 A.M., the DON completed a whole house audit on the code status for residents to ensure the code statuses were current and correct. There was a total of 40 residents identified as having a Full Code status. · On [DATE] at 7:45 A.M., the facility began an audit of the report sheets for accuracy to ensure on-going compliance. The report sheets are utilized by the nurses on their shift. The report sheet includes a part to identify each resident's code status. This audit will continue to be completed twice weekly for four weeks, then as needed thereafter. It will be completed by the DON or designee and will be overseen by the Administrator or designee. The results of the audit will be reported to the Quality Assurance Performance Improvement committee as needed. · On [DATE] at 9:30 A.M., Human Resource Staff #600 audited all licensed nurses to verify they had current CPR cards. Human Resource Staff #600 checked CPR certifications on all applicable employees on [DATE]. A CPR refresher course has been scheduled for the facility's next all staff meeting on [DATE]. · Review of the staff education sign-in-sheets and documentation of phone calls with times, dated [DATE], revealed all nurses were educated regarding the emergency response procedures as of [DATE] at 7:00 P.M. The sign-in-sheet included a roster of all nurses working in the facility. · Review of the Resident Listing Report audits for code status for the weeks of [DATE] through [DATE] revealed 40 residents were reviewed for code status and verified with the physician orders. · On [DATE], interviews with Licensed Practical Nurse (LPN) #220, LPN #240, RN #56, RN #230, and RN #44 revealed they were in-serviced on the CPR policy and performing a code with emphasis on what their role would be during a code. Findings include: Review of Resident #15's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #15 was severely cognitively impaired. Resident #15 required extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. Review of the physician order, dated [DATE], revealed Resident #15 was a Full Code resuscitation status. Review of the care plan, dated [DATE], revealed Resident #15's code status was Full Code resuscitation status. Review of a nursing progress note dated [DATE] at 5:00 A.M. revealed STNA #33 went to transfer Resident #15 from a chair to her bed and noticed Resident #15's hands were cool and mottled. RN #56 and RN #44 came to check on Resident #15 and Resident #15's vitals were checked. Resident #15 was absent of pulse, blood pressure and oxygen were unable to be read, body temperature was 95.9 degrees Fahrenheit (F), and no respirations were noted. Resident #15's nail beds were blue and without capillary refill. Pupils were dilated with eyes open and unblinking. Time of death was documented at 4:45 A.M. as agreed by RN #44 and RN #56. The family, DON, Administrator, and NP #500 were notified. Review of RN #44's statement, dated [DATE], revealed on [DATE] at 4:45 A.M., STNA #33 from north hall came to get RN #44 to assist with a resident (Resident #15) stating STNA #33 thought Resident #15 might have expired. Upon arrival to the resident's room, RN #44 noticed Resident #15 was slumped in her wheelchair, hands were cool to the touch and her skin was ashen in color. A sternal rub and calling out Resident #15's name produced no response. RN #56 attempted to get vitals while RN #44 auscultated for heart and lung sounds. There were no heart sounds heard, no radial or pedal pulses, and no respirations detected. No lung sounds could be auscultated. Resident's nail beds were blue and without capillary refill. Oxygen meter did not have any reading. Temporal scan temperature was 95.9 F. Pupils were dilated with eyes open and unblinking. Time of death was documented at 4:45 A.M. RN #44 called and notified the daughter and emergency contact with a voice message to call back. RN #56 called and notified the Administrator and NP #500. Review of RN #56's statement, dated [DATE], revealed on [DATE] at 4:45 A.M., RN #56 was notified by STNA #33 that Resident #15 showed no evidence of clinical life. RN #56 and RN #44 went to assess Resident #15 and CPR was not initiated due to no signs of life and Resident #15 being lifeless. Resident #15 had no pulse, no vital signs, was cool to the touch, mottled, and there were no reflex responses. Interview on [DATE] at 10:50 A.M. with Administrator revealed that early morning on [DATE] he received a telephone message, around 5:00 A.M., that Resident #15 had passed. The Administrator confirmed RN #44 and RN #56 did not initiate CPR or immediately call 911 or call the NP (#500) on Resident #15 who was identified as a Full Code status. Telephone interview on [DATE] at 11:04 A.M. and a second conversation on the phone at 5:00 P.M. with RN #56 confirmed Resident #15 was found lifeless at 4:45 A.M. on [DATE] by STNA #33 when doing her rounds. STNA #33 asked RN #56 to come quickly to check on Resident #15. RN #56 entered the room of Resident #15 and RN #44 had already started checking all vital signs on Resident #15. RN #56 stated RN #44 asked her to find out Resident #15's code status. Upon her return to the room, RN #56 notified RN #44 and STNA #33 of Resident #15 being a Full Code status. RN #56 then proceeded with RN #44 to obtain any signs of life. RN #44 and RN #56 found no signs of life and determined together Resident #15 was clinically dead. RN #56 confirmed there was no CPR initiated on Resident #15 and there were no immediate calls out to 911 nor NP #500 or the Physician. RN #44 and RN #56 called the time of death for Resident #15 to be 4:45 A.M. RN #56 confirmed she did not immediately notify NP #500 of Resident #15's death. RN #56 confirmed she was educated on [DATE] regarding CPR, code status and facility policies on CPR and code status. Telephone interview on [DATE] at 11:17 A.M. with RN #44 confirmed he was the first nurse to be summoned to Resident #15's room by STNA #33. RN #44 stated when he entered the room, Resident #15 looked pale, ashen in color, felt cool to the touch, and he attempted to take vital signs, but Resident #15 had no pulse, no blood pressure, no respirations, and no reflex and pupil responses. RN #44 did a sternal rub and no response occurred from Resident #15. Resident #15 was lifeless and had no clinical signs of life. Upon RN #56's entry to the room and notification of Resident #15 being a Full Code status, RN #44 proceeded along with RN #56 to find any life signs but Resident #15 was determined at that point from RN #44 and RN #56 that Resident #15 was clinically dead and pronounced dead at 4:45 A.M. RN #44 confirmed there was no CPR initiated on Resident #15 and there were no immediate calls out to 911 nor the NP (#500) or the Physician. RN #44 stated he made phone calls at around 5:00 A.M. to notify the family and DON. RN #56 notified NP #500 and the Administrator of Resident #15's death. Interview on [DATE] at 2:00 P.M. with the DON and Assistant Director of Nursing (ADON) #800 revealed the nurses could determine if a resident was showing obvious clinical signs of death. The DON and ADON #800 confirmed that it was the facility's policy to initiate CPR on a resident with a Full Code status and call 911. In addition, the DON and ADON #800 confirmed Resident #15 was a Full Code status and RN #44 and RN #56 did not complete CPR on Resident #15 on [DATE]. Interview on [DATE] at 2:05 P.M. with NP #500 confirmed she did not receive a phone call from the facility on the early morning of [DATE] regarding Resident #15. NP #500 stated she received a phone text from the facility at 6:14 A.M. on [DATE] of Resident #15 passing at 4:45 A.M. NP #500 stated she was not made aware of the nurses not initiating CPR on Resident #15 who was a Full Code status. NP #500 verified the expectation for all residents with a Full Code status who experience cardiac arrest would be the nurses need to initiate CPR, call 911, and continue to try to resuscitate the resident until the ambulance arrives. NP #500 verified RN #44 and RN #56 should have completed CPR on Resident #15 because she was a Full Code status. Telephone interview on [DATE] at 3:43 P.M. with STNA #33 revealed STNA #33 was assigned on [DATE] to care for Resident #15. STNA #33 provided incontinence care on Resident #15 at approximately 2:30 A.M. on [DATE]. On [DATE] at 4:45 A.M., STNA #33 was checking on Resident #15 and Resident #15 was found to be lifeless, cool to the touch, mottled, and looked pale. STNA #33 wheeled Resident #15 back to her room and immediately went to get RN #44, as RN #44 was the closest to her. STNA #33 asked RN #44 to check on Resident #15 as she thought Resident #15 had expired. While RN #44 was checking on Resident #15, STNA #33 went to get RN #56 in the breakroom to go check on Resident #15 too. STNA #33 confirmed RN #44 and RN #56 did not initiate CPR, or immediately call 911 or call the NP (#500) or the Physician. Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed the facility is to adhere to resident's rights to formulate advance directives. In accordance with these rights, the facility will implement guidelines regarding CPR. The facility will follow current American Heart Association guidelines regarding CPR. If a resident experiences a cardiac arrest, the facility will provide basic life support, including CPR, prior to the arrival of emergency medical services and, in; a) accordance with the residents advance directives or b) in the absence of advance directives or a Do Not Resuscitate order, and c) if the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection or decomposition). There will always be CPR certified staff available. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. Review of the facility's policy titled Advance Care Planning, revised [DATE], revealed the new admitted resident will meet shortly upon admission to the facility with the healthcare team and will review Advanced Directives with the resident, family, friends, and caregivers to make them familiar with resident's wishes about the care they wish to receive, especially related to end of life care. This deficiency substantiates Complaint Number OH 567.

Based on observations, medical record review, staff interviews, review of personnel files, review of Self-Reported Incidents (SRI's) and review of the facility's policies on abuse and social media, the facility failed to ensure a cognitively impaired resident was free from verbal, mental and emotional abuse by facility staff members. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#30) when State tested Nursing Assistant (STNA) #202 engaged in an act meant to humiliate and dehumanize the resident by taking video recordings of the resident, without permission and not in accordance with facility policy, who was restrained with two gait transfer belts in a geriatric chair while demonstrating signs of distress and anxiety as he pleaded with staff for help. The video recording was then posted on a social media website, Facebook Messenger, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment. This affected one (#30) of three residents reviewed for abuse. The facility census was 84. On [DATE] at 5:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] during third shift when STNA #202 took a video recording of Resident #30 in a reclined geriatric chair with gait belts strapped around his upper chest and shoulder area. The resident was observed in the videos pleading for help stating, I'll be careful, Oh .Please, I'll be careful and Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . STNA #202 then shared the video recording with four other employees (#206, #208, #210 and #212) by sending the video on social media website via Facebook Messenger. The video recording potentially could have been viewed by others via sharing of the video from cellular telephones (cell phone) or Facebook. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 [NAME]M., the DON received a report from Licensed Practical Nurse (LPN) #302 of an alleged video recording taken of Resident #30 and began an investigation. · On [DATE] at 11:00 [NAME]M., the DON began to re-educate the staff on the facility's social media policy. All employees interviewed by the DON denied knowledge of the alleged video, except LPN #302. · On [DATE] at 9:00 [NAME]M., the Administrator continued the social media education and the investigation. No employee was permitted to work in the facility until they received re-education on the social media policy. · On [DATE] at 3:15 P.M., STNA #204 reported to the Administrator that STNA #206 stated STNA #202 sent her a video of a resident. STNA #204 stated she had viewed the video on STNA #206's cellular phone. · On [DATE] at 8:30 [NAME]M., the Administrator spoke with STNA #202 via telephone and the STNA denied any knowledge regarding a video recording of a resident. · On [DATE] at 8:40 P.M., the Administrator spoke with STNA #206 via telephone and STNA #206 denied any knowledge of a video recording of a resident. · On [DATE] at 7:30 [NAME]M., STNA #202 called the Administrator and admitted to taking a video recording of a resident. STNA #202 denied sharing the video recording on social media. No further information was obtained. · On [DATE] at 10:19 [NAME]M., STNA #202 was terminated from her employment with the facility for posting information about a resident on social media. · On [DATE] at 10:40 [NAME]M., STNA #206 received disciplinary action via telephone for failure to perform job duties. · On [DATE] at 2:00 P.M., LPN #304 was given disciplinary action for demonstrating unsatisfactory job performance, work quality, or productivity. A statement was obtained from LPN #304 who indicated she utilized a gait belt in a reclining chair to deter the resident from getting up. · On [DATE] at 6:00 P.M., education regarding the abuse policy was initiated for all staff and would be completed by the end of the day on [DATE]. · On [DATE] at 1:00 P.M., all residents were assessed for abuse through a questionnaire. The residents were asked the following questions: How has the staff been treating you?; and, Has anything occurred recently that you want to bring to our attention? Residents unable to complete the questionnaire had a skin assessment completed. All the residents interviewed and or assessed had no concerns related to abuse. · On [DATE] at 3:10 P.M., additional restraint training specific to not using a gait belt as a restraint was initiated and was to be completed by midnight. No staff members were permitted to work until they had been educated. · Interviews on [DATE] from 3:15 P.M. to 4:20 P.M. were conducted with Cook #501, Housekeeping staff #601, Admissions personnel #701, STNA ' s #220, #221, #218, and #224, RN #404, and LPN ' s #312 and #314 regarding the facilities abuse and social media policies. All staff were knowledgeable of the policies and indicated they would immediately report social media allegations to the Administrator and or DON. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision and one-person physical assist with locomotion between locations as the resident was ambulatory. Review of Resident #30's care plan revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia. Interventions included to promote dignity, converse with the resident, and ensure privacy while providing care. Review of Resident #30's nurse's note dated [DATE] at 3:54 P.M. revealed the resident was pacing and had an unsteady gait. Review of Resident #30's late entry nurse's note dated [DATE] at 3:53 [NAME]M. revealed the resident had been restless and moaning on [DATE]. Family was advised the resident was actively dying. The hospice nurse arrived on [DATE] at 7:30 P.M. and requested as needed [MEDICATION NAME] be given. Resident #30 expired on [DATE] at 11:54 P.M. Interviews on [DATE] at 5:55 [NAME]M. were conducted with STNA #206 and STNA #214 and they both denied knowledge of a resident being video recorded. During an interview on [DATE] at 6:20 [NAME]M. with STNA #208 she stated she had heard of a video being taken of Resident #30 but never saw the video. She stated STNA #202 reported to her she had taken a video recording of Resident #30 in a geriatric chair using gait transfer belts as a restraint. STNA #202 told her that LPN #304 had restrained the resident in the chair. STNA #208 stated she believed STNA #218 viewed the video recording. During an interview on [DATE] at 7:30 [NAME]M., the Administrator stated an alleged video was taken of Resident #30 by STNA #202 and sent via Facebook Messenger. She stated STNA #206 and RN #402 denied any knowledge of a video. Additionally, the Administrator verified that an SRI was not completed regarding the allegation that a video recording had been taken of Resident #30. Telephone interview on [DATE] at 8:05 [NAME]M. with STNA #202 revealed LPN #304 restrained Resident #30 in a reclining geriatric chair using two gait transfer belts. STNA #202 stated she took a video recording on [DATE], using her cellular device, of Resident #30 sitting in the geriatric chair and being restrained with the gait belts. STNA #202 stated she sent the video of the resident via Facebook Messenger to STNA's #206, #208, #210 and #212. STNA #202 stated she still has the video recording on her cellular device. STNA #202 stated she was the only staff member terminated. Observation on [DATE] at 8:25 [NAME]M. of a video recording of Resident #30 revealed the resident reclined in a geriatric chair with a gait transfer belt up around his chest, one side under his right axilla area and the other side on his left shoulder. The gait transfer belt was attached behind the chair. The resident was observed to be restless and can be heard repeating, I'll be careful, Oh .Please, I'll be careful. A second video was observed on [DATE] at 11:55 [NAME]M. and revealed the resident verbalizing to staff Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident, while recording the video, Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . During a telephone interview on [DATE] at 9:20 [NAME]M., STNA #212 denied receiving a video of Resident #30 but had knowledge of Resident #30 being restrained in the reclining geriatric chair. During a telephone interview on [DATE] at 9:30 [NAME]M., STNA #218 stated she had heard there was a video of Resident #30 being restrained but had not seen it. Telephone interview on [DATE] at 9:40 [NAME]M. with LPN #302 revealed STNA #208 reported that on break, STNA #202 was bragging about a resident being restrained and taking a video. LPN #302 stated it occurred a few days before the resident had expired. LPN #302 further stated she reported it to her supervisor, RN #402. She stated STNA #206 had the video on her cell phone and was told by RN #402 to delete the video. LPN #302 denied seeing the video. An interview on [DATE] at 9:50 [NAME]M. with the DON and the Administrator revealed on [DATE], the DON was called in by LPN #302 who had reported STNA #202 was trying to send her a video via Facebook Messenger but LPN #302 had the STNA blocked so she did not see a video. On [DATE], the DON stated she started to ask the staff questions regarding a video and all the staff denied knowledge of a video. The DON indicated STNA #208 reported a video of Resident #30 and all staff interviewed denied a video. On [DATE], STNA #204 spoke with the Administrator and reported on [DATE], she viewed a video from STNA #206's cell phone which revealed Resident #30 in a geriatric chair with gait transfer belts around his chest. They stated STNA #204 did not report the video until [DATE]. The Administrator stated LPN #304 was unaware STNA #202 took a video. The Administrator denied an allegation of abuse. On [DATE], STNA #202 admitted she took a video recording of Resident #30 in a geriatric chair that occurred on [DATE]. STNA #202 reported she sent the video via Facebook to four other employees but would not provide names or the video. Telephone interview on [DATE] at 9:40 [NAME]M. with STNA #204 revealed she had spoken with the Administrator on [DATE], and was educated on the social media and restraint policy. At that time, she reported to the Administrator that STNA #202 had sent a video recording of Resident #30 to STNA #206's cell phone and STNA #204 viewed the video from STNA #206's cell phone. During a telephone interview on [DATE] at 12:25 P.M., STNA #206 denied she had been sent a video recording of Resident #30. During a telephone interview on [DATE] at 1:20 P.M., STNA #210 stated STNA #202 took a video recording of Resident #30 in a geriatric chair with two gait belts and shared it with her via Facebook Messenger on [DATE]. STNA #210 stated the video was very disturbing to her and informed STNA #202 to remove the restraints. Review of facility submitted SRIs from [DATE] through [DATE] revealed no SRI had been submitted to the state agency regarding an abuse allegation. Review of employee personnel files revealed LPN #304 received a written warning on [DATE] for demonstrating unsatisfactory job performance. STNA #202 was terminated effective [DATE]. STNA #206 received a written disciplinary action on [DATE] for extreme failure to perform job duties in relation to reporting a violation of company protocol. RN #402 received a written disciplinary warning on [DATE] for failing to report a suspected violation of standard of conduct and corporate compliance. Review of the facility policy titled, E-Mail, Internet and Social Media Use, dated (MONTH) (YEAR), revealed improper use of internet services was strictly prohibited and included posting or sharing any unauthorized images of the facility, residents, family or events on social media or public forum. Employees who were aware of or exposed to email, internet, or social media content that violated this policy were required to report such violations to their supervisor as soon as possible. Review of the facility policy titled, Abuse Prevention Program, dated (MONTH) (YEAR), revealed the administration will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within timeframes as required by federal requirements. This deficiency substantiates Complaint Numbers OH 442 and OH 428.

Based on observations, medical record review, staff interviews, review of personnel files, review of Self-Reported Incidents (SRI's) and review of the facility policies on restraints, the facility failed to ensure a cognitively impaired resident was not physically restrained by staff who restricted the voluntary movement of the resident by using a gait transfer belt to tie the resident down in a geriatric chair for staff convenience. This resulted in Immediate Jeopardy when one resident (#30) was placed at potential risk for life-threatening injuries due to choking and strangulation as a result of the improper use of a gait belt being used as a restraint. This affected one (#30) of three residents reviewed for assistive devices. The facility census was 84. On [DATE] at 5:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] when State tested Nursing Assistant (STNA) #202 took a video recording of Resident #30 being restrained to a geriatric chair using a gait belt around his upper chest, shoulder area and below his neck. The resident appeared distressed and anxious, was thrashing his arms and legs about while running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt, and was pleading for help stating, I'll be careful, Oh .Please, I'll be careful and Help me .Honey. STNA #202 replied to the resident, Nobody is going to help you we've done everything we can to help you and you still won't do what you're supposed to do you are a Hot Fricken Fracken Mess while she continued video recording the resident. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 10:19 [NAME]M., STNA #202 was terminated from her employment with the facility. · On ,[DATE] at 10:40 [NAME]M., STNA #206 received disciplinary action via telephone for failure to perform job duties. · On [DATE] at 11:00 [NAME]M., the Administrator initiated restraint education to Licensed Practical Nurses (LPN's) and Registered Nurses (RN)'s. · On [DATE] at 2:00 P.M., LPN #304 was given disciplinary action for demonstrating unsatisfactory job performance, work quality, or productivity. A statement was obtained from LPN #304 who indicated she utilized a gait belt in a reclining chair to deter the resident from getting up. · On [DATE] at 6:00 P.M., education regarding restraint use and the abuse policy was initiated for all staff and would be completed by the end of the day on [DATE]. · On [DATE] at 1:00 P.M., all residents were assessed for restraints and abuse through a questionnaire. The residents were asked the following questions: How has the staff been treating you?; and, Has anything occurred recently that you want to bring to our attention? Residents unable to complete the questionnaire had a skin assessment completed. All the residents interviewed and/or assessed had no identified concerns related to abuse and/or restraint use. On [DATE] at 3:10 P.M., additional restraint training specific to not using a gait belt as a restraint was initiated and was to be completed by midnight. No staff members were permitted to work until they had been educated. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. The resident required supervision and one-person physical assist with locomotion between locations as the resident was ambulatory. Review of Resident #30's care plan revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia. Interventions included to promote dignity, converse with the resident, and ensure privacy while providing care. Review of Resident #30's monthly physician orders dated (MONTH) 2019 revealed no orders for physical restraints. Review of Resident #30's nurse's note dated [DATE] at 3:54 P.M. revealed the resident was pacing and had an unsteady gait. Review of Resident #30's late entry nurse's note dated [DATE] at 3:53 [NAME]M. revealed the resident had been restless and moaning on [DATE]. The family was advised the resident was actively dying. The hospice nurse arrived on [DATE] at 7:30 P.M. and requested as needed [MEDICATION NAME] be given. Resident #30 expired on [DATE] at 11:54 P.M. Further review of the nurse's notes revealed no evidence of any restraint assessment and/or the justification for the use of a restraint. Review of the facility SRIs from [DATE] through [DATE] revealed no SRI had been submitted regarding an abuse allegation or misuse of restraints. During an interview on [DATE] at 6:20 [NAME]M. with STNA #208 she stated she had heard of a video being taken of Resident #30 through text messages but never saw the video. STNA #202 had reported to STNA #208 she had taken a video recording of Resident #30 in a geriatric chair using gait transfer belts as a restraint. STNA #202 told STNA #208 that LPN #304 had restrained the resident in the chair. Telephone interview on [DATE] at 8:05 [NAME]M. with STNA #202 revealed LPN #304 restrained Resident #30 in a reclining geriatric chair using two gait transfer belts. STNA #202 stated she took a video recording on [DATE], using her cellular telephone (cell phone), of Resident #30 sitting in the geriatric chair and restrained. STNA #202 stated she sent the video of the resident via Facebook Messenger to STNA's #206, #208, #210 and #212. STNA #202 stated she still has the video recording on her cell phone. STNA #202 stated she was the only staff member terminated. Observation on [DATE] at 8:25 [NAME]M. of a video recording of Resident #30 revealed the resident reclined in a geriatric chair with a gait transfer belt up around his chest, one side under his right axilla area and the other side on his left shoulder. The gait transfer belt was attached behind the chair. The resident was observed to be restless and can be heard repeating, I ll be careful, Oh .Please, I'll be careful. A second video was observed on [DATE] at 11:55 [NAME]M. and revealed the resident verbalizing to staff Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident, while recording the video, Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . Telephone interview on [DATE] at 9:40 [NAME]M. with LPN #302 revealed STNA #208 reported that on break, STNA #202 was bragging about a resident being restrained and taking a video. LPN #302 stated it occurred a few days before the resident had expired. LPN #302 further stated she reported it to her supervisor, RN #402. She stated STNA #206 had the video on her cell phone and was told by RN #402 to delete the video. LPN #302 denied seeing the video. An interview on [DATE] at 9:50 [NAME]M. with the DON and the Administrator revealed on [DATE], STNA #204 came and spoke with her and reported on [DATE], she viewed a video from STNA #206's cell phone which showed Resident #30 in a geriatric chair with gait transfer belts around his chest which were used as a restraint. The Administrator stated LPN #304 did inquire about restraints to RN #402, who informed LPN #304 that restraints were not allowed. The Administrator stated on [DATE], staff were educated on restraints due to LPN #304 inquiring about restraints. The Administrator denied an allegation of abuse or use of physical restraints. They stated on [DATE], STNA #202 admitted she took a video recording of Resident #30 in a geriatric chair that occurred on [DATE]. STNA #202 reported she sent the video via Facebook Messenger to four other employees but would not provide names or the video. Telephone interview on [DATE] at 9:40 [NAME]M. with STNA #204 revealed she had spoken with the Administrator on [DATE], and was educated on the social media and restraint policy. At that time, she reported to the Administrator that STNA #202 had sent a video recording of Resident #30 to STNA #206's cell phone and STNA #204 viewed the video from STNA #206's cell phone. During a telephone interview on [DATE] at 12:25 P.M., STNA #206 denied she had been sent a video recording of Resident #30 restrained in a chair. During a telephone interview on [DATE] at 1:20 P.M., STNA #210 stated STNA #202 took a video recording of Resident #30 in a geriatric chair with restraints on and shared it with her via Facebook Messenger on [DATE]. STNA #210 stated the video was very disturbing to her and informed STNA #202 to remove the restraints. Review of employee personnel files revealed LPN #304 received a written warning on [DATE] for demonstrating unsatisfactory job performance. STNA #202 was terminated effective [DATE]. STNA #206 received a written disciplinary action on [DATE] for extreme failure to perform job duties in relation to reporting a violation of company protocol. RN #402 received a written disciplinary warning on [DATE] for failing to report a suspected violation of standard of conduct and corporate compliance. Review of the facility policy titled, Use of Restraints, dated (MONTH) 2007, revealed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. This deficiency substantiates Complaint Numbers OH 442 and OH 428.

Based on observations, medical record review, staff interviews, review of personnel files, review of Self-Reported Incidents (SRI's) and review of the facility's policies on abuse and social media, the facility failed to implement the abuse and social media policies prohibiting resident abuse and the improper use of internet services including posting images of residents on social media sites to ensure a cognitively impaired resident was free from verbal, mental and emotional abuse by facility staff members. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#30) when State tested Nursing Assistant (STNA) #202 engaged in an act meant to humiliate and dehumanize the resident by taking video recordings of the resident, without permission and not in accordance with facility policy, who was restrained with two gait transfer belts in a geriatric chair while demonstrating signs of distress and anxiety as he pleaded with staff for help. The video recording was then posted on a social media website, Facebook Messenger, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment. This affected one (#30) of three residents reviewed for abuse. The facility census was 84. On [DATE] at 5:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] during third shift when STNA #202 took a video recording of Resident #30 in a reclined geriatric chair with gait belts strapped around his upper chest and shoulder area. The resident was observed in the videos pleading for help stating, I'll be careful, Oh .Please, I'll be careful and Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident Nobody is going to help you .we've done everything we can to help you and you still won ' t do what you ' re supposed to do .you are a Hot Fricken Fracken Mess . STNA #202 then shared the video recording with four other employees (#206, #208, #210 and #212) by sending the video on social media website via Facebook Messenger. The video recording potentially could have been viewed by others via sharing of the video from cellular telephones (cell phone) or Facebook. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 [NAME]M., the DON received a report from Licensed Practical Nurse (LPN) #302 of an alleged video recording taken of Resident #30 and began an investigation. · On [DATE] at 11:00 [NAME]M., the DON began to re-educate the staff on the facility's social media policy. All employees interviewed by the DON denied knowledge of the alleged video, except LPN #302. · On [DATE] at 9:00 [NAME]M., the Administrator continued the social media education and the investigation. No employee was permitted to work in the facility until they received re-education on the social media policy. · On [DATE] at 3:15 P.M., STNA #204 reported to the Administrator that STNA #206 stated STNA #202 sent her a video of a resident. STNA #204 stated she had viewed the video on STNA #206's cellular phone. · On [DATE] at 8:30 [NAME]M., the Administrator spoke with STNA #202 via telephone and the STNA denied any knowledge regarding a video recording of a resident. · On [DATE] at 8:40 P.M., the Administrator spoke with STNA #206 via telephone and STNA #206 denied any knowledge of a video recording of a resident. · On [DATE] at 7:30 [NAME]M., STNA #202 called the Administrator and admitted to taking a video recording of a resident. STNA #202 denied sharing the video recording on social media. No further information was obtained. · On [DATE] at 10:19 [NAME]M., STNA #202 was terminated from her employment with the facility for posting information about a resident on social media. · On [DATE] at 10:40 [NAME]M., STNA #206 received disciplinary action via telephone for failure to perform job duties. · On [DATE] at 2:00 P.M., LPN #304 was given disciplinary action for demonstrating unsatisfactory job performance, work quality, or productivity. A statement was obtained from LPN #304 who indicated she utilized a gait belt in a reclining chair to deter the resident from getting up. · On [DATE] at 6:00 P.M., education regarding the abuse policy was initiated for all staff and would be completed by the end of the day on [DATE]. · On [DATE] at 1:00 P.M., all residents were assessed for abuse through a questionnaire. The residents were asked the following questions: How has the staff been treating you?; and, Has anything occurred recently that you want to bring to our attention? Residents unable to complete the questionnaire had a skin assessment completed. All the residents interviewed and or assessed had no concerns related to abuse. · On [DATE] at 3:10 P.M., additional restraint training specific to not using a gait belt as a restraint was initiated and was to be completed by midnight. No staff members were permitted to work until they had been educated. · Interviews on [DATE] from 3:15 P.M. to 4:20 P.M. were conducted with Cook #501, Housekeeping staff #601, Admissions personnel #701, STNA's #220, #221, #218, and #224, RN #404, and LPN's #312 and #314 regarding the facilities abuse and social media policies. All staff were knowledgeable of the policies and indicated they would immediately report social media allegations to the Administrator and or DON. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision and one-person physical assist with locomotion between locations as the resident was ambulatory. Review of Resident #30's care plan revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia. Interventions included to promote dignity, converse with the resident, and ensure privacy while providing care. Review of Resident #30's nurse's note dated [DATE] at 3:54 P.M. revealed the resident was pacing and had an unsteady gait. Review of Resident #30's late entry nurse's note dated [DATE] at 3:53 [NAME]M. revealed the resident had been restless and moaning on [DATE]. Family was advised the resident was actively dying. The hospice nurse arrived on [DATE] at 7:30 P.M. and requested as needed [MEDICATION NAME] be given. Resident #30 expired on [DATE] at 11:54 P.M. Interviews on [DATE] at 5:55 [NAME]M. were conducted with STNA #206 and STNA #214 and they both denied knowledge of a resident being video recorded. During an interview on [DATE] at 6:20 [NAME]M. with STNA #208 she stated she had heard of a video being taken of Resident #30 but never saw the video. She stated STNA #202 reported to her she had taken a video recording of Resident #30 in a geriatric chair using gait transfer belts as a restraint. STNA #202 told her that LPN #304 had restrained the resident in the chair. STNA #208 stated she believed STNA #218 viewed the video recording. During an interview on [DATE] at 7:30 [NAME]M., the Administrator stated an alleged video was taken of Resident #30 by STNA #202 and sent via Facebook Messenger. She stated STNA #206 and RN #402 denied any knowledge of a video. Additionally, the Administrator verified that an SRI was not completed regarding the allegation that a video recording had been taken of Resident #30. Telephone interview on [DATE] at 8:05 [NAME]M. with STNA #202 revealed LPN #304 restrained Resident #30 in a reclining geriatric chair using two gait transfer belts. STNA #202 stated she took a video recording on [DATE], using her cellular device, of Resident #30 sitting in the geriatric chair and being restrained with the gait belts. STNA #202 stated she sent the video of the resident via Facebook Messenger to STNA's #206, #208, #210 and #212. STNA #202 stated she still has the video recording on her cellular device. STNA #202 stated she was the only staff member terminated. Observation on [DATE] at 8:25 [NAME]M. of a video recording of Resident #30 revealed the resident reclined in a geriatric chair with a gait transfer belt up around his chest, one side under his right axilla area and the other side on his left shoulder. The gait transfer belt was attached behind the chair. The resident was observed to be restless and can be heard repeating, I'll be careful, Oh .Please, I'll be careful. A second video was observed on [DATE] at 11:55 [NAME]M. and revealed the resident verbalizing to staff Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident, while recording the video, Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . During a telephone interview on [DATE] at 9:20 [NAME]M., STNA #212 denied receiving a video of Resident #30 but had knowledge of Resident #30 being restrained in the reclining geriatric chair. During a telephone interview on [DATE] at 9:30 [NAME]M., STNA #218 stated she had heard there was a video of Resident #30 being restrained but had not seen it. Telephone interview on [DATE] at 9:40 [NAME]M. with LPN #302 revealed STNA #208 reported that on break, STNA #202 was bragging about a resident being restrained and taking a video. LPN #302 stated it occurred a few days before the resident had expired. LPN #302 further stated she reported it to her supervisor, RN #402. She stated STNA #206 had the video on her cell phone and was told by RN #402 to delete the video. LPN #302 denied seeing the video. An interview on [DATE] at 9:50 [NAME]M. with the DON and the Administrator revealed on [DATE], the DON was called in by LPN #302 who had reported STNA #202 was trying to send her a video via Facebook Messenger but LPN #302 had the STNA blocked so she did not see a video. On [DATE], the DON stated she started to ask the staff questions regarding a video and all the staff denied knowledge of a video. The DON indicated STNA #208 reported a video of Resident #30 and all staff interviewed denied a video. On [DATE], STNA #204 spoke with the Administrator and reported on [DATE], she viewed a video from STNA #206's cell phone which revealed Resident #30 in a geriatric chair with gait transfer belts around his chest. They stated STNA #204 did not report the video until [DATE]. The Administrator stated LPN #304 was unaware STNA #202 took a video. The Administrator denied an allegation of abuse. On [DATE], STNA #202 admitted she took a video recording of Resident #30 in a geriatric chair that occurred on [DATE]. STNA #202 reported she sent the video via Facebook to four other employees but would not provide names or the video. Telephone interview on [DATE] at 9:40 [NAME]M. with STNA #204 revealed she had spoken with the Administrator on [DATE], and was educated on the social media and restraint policy. At that time, she reported to the Administrator that STNA #202 had sent a video recording of Resident #30 to STNA #206's cell phone and STNA #204 viewed the video from STNA #206's cell phone. During a telephone interview on [DATE] at 12:25 P.M., STNA #206 denied she had been sent a video recording of Resident #30. During a telephone interview on [DATE] at 1:20 P.M., STNA #210 stated STNA #202 took a video recording of Resident #30 in a geriatric chair with two gait belts and shared it with her via Facebook Messenger on [DATE]. STNA #210 stated the video was very disturbing to her and informed STNA #202 to remove the restraints. Review of facility submitted SRIs from [DATE] through [DATE] revealed no SRI had been submitted to the state agency regarding an abuse allegation. Review of employee personnel files revealed LPN #304 received a written warning on [DATE] for demonstrating unsatisfactory job performance. STNA #202 was terminated effective [DATE]. STNA #206 received a written disciplinary action on [DATE] for extreme failure to perform job duties in relation to reporting a violation of company protocol. RN #402 received a written disciplinary warning on [DATE] for failing to report a suspected violation of standard of conduct and corporate compliance. Review of the facility policy titled, E-Mail, Internet and Social Media Use, dated (MONTH) (YEAR), revealed improper use of internet services was strictly prohibited and included posting or sharing any unauthorized images of the facility, residents, family or events on social media or public forum. Employees who were aware of or exposed to email, internet, or social media content that violated this policy were required to report such violations to their supervisor as soon as possible. Review of the facility policy titled, Abuse Prevention Program, dated (MONTH) (YEAR), revealed the administration will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within timeframes as required by federal requirements. This deficiency is an incidental finding discovered during the course of the complaint investigations for Complaint Numbers OH 442 and OH 428.

Based on observations, medical record review, staff interviews, review of personnel files, review of Self-Reported Incidents (SRI's) and review of the facility's policies on abuse and social media, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator of the facility and the State Agency, but not later than two hours after the allegation was made. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#30) when State tested Nursing Assistant (STNA) #202 engaged in an act meant to humiliate and dehumanize the resident by taking video recordings of the resident, without permission and not in accordance with facility policy, who was restrained with two gait transfer belts in a geriatric chair while demonstrating signs of distress and anxiety as he pleaded with staff for help. The video recording was then posted on a social media website, Facebook Messenger, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment. This affected one (#30) of three residents reviewed for abuse. The facility census was 84. On [DATE] at 5:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] during third shift when STNA #202 took a video recording of Resident #30 in a reclined geriatric chair with gait belts strapped around his upper chest and shoulder area. The resident was observed in the videos pleading for help stating, I'll be careful, Oh .Please, I'll be careful and Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . STNA #202 then shared the video recording with four other employees (#206, #208, #210 and #212) by sending the video on social media website via Facebook Messenger. The video recording potentially could have been viewed by others via sharing of the video from cellular telephones (cell phone) or Facebook. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 [NAME]M., the DON received a report from Licensed Practical Nurse (LPN) #302 of an alleged video recording taken of Resident #30 and began an investigation. · On [DATE] at 11:00 [NAME]M., the DON began to re-educate the staff on the facility's social media policy. All employees interviewed by the DON denied knowledge of the alleged video, except LPN #302. · On [DATE] at 9:00 [NAME]M., the Administrator continued the social media education and the investigation. No employee was permitted to work in the facility until they received re-education on the social media policy. · On [DATE] at 3:15 P.M., STNA #204 reported to the Administrator that STNA #206 stated STNA #202 sent her a video of a resident. STNA #204 stated she had viewed the video on STNA #206's cellular phone. · On [DATE] at 8:30 [NAME]M., the Administrator spoke with STNA #202 via telephone and the STNA denied any knowledge regarding a video recording of a resident. · On [DATE] at 8:40 P.M., the Administrator spoke with STNA #206 via telephone and STNA #206 denied any knowledge of a video recording of a resident. · On [DATE] at 7:30 [NAME]M., STNA #202 called the Administrator and admitted to taking a video recording of a resident. STNA #202 denied sharing the video recording on social media. No further information was obtained. · On [DATE] at 10:19 [NAME]M., STNA #202 was terminated from her employment with the facility for posting information about a resident on social media. · On [DATE] at 10:40 [NAME]M., STNA #206 received disciplinary action via telephone for failure to perform job duties. · On [DATE] at 2:00 P.M., LPN #304 was given disciplinary action for demonstrating unsatisfactory job performance, work quality, or productivity. A statement was obtained from LPN #304 who indicated she utilized a gait belt in a reclining chair to deter the resident from getting up. · On [DATE] at 6:00 P.M., education regarding the abuse policy was initiated for all staff and would be completed by the end of the day on [DATE]. · On [DATE] at 1:00 P.M., all residents were assessed for abuse through a questionnaire. The residents were asked the following questions: How has the staff been treating you?; and, Has anything occurred recently that you want to bring to our attention? Residents unable to complete the questionnaire had a skin assessment completed. All the residents interviewed and or assessed had no concerns related to abuse. · On [DATE] at 3:10 P.M., additional restraint training specific to not using a gait belt as a restraint was initiated and was to be completed by midnight. No staff members were permitted to work until they had been educated. · Interviews on [DATE] from 3:15 P.M. to 4:20 P.M. were conducted with Cook #501, Housekeeping staff #601, Admissions personnel #701, STNA's #220, #221, #218, and #224, RN #404, and LPN's #312 and #314 regarding the facilities abuse and social media policies. All staff were knowledgeable of the policies and indicated they would immediately report social media allegations to the Administrator and or DON. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision and one-person physical assist with locomotion between locations as the resident was ambulatory. Review of Resident #30's care plan revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia. Interventions included to promote dignity, converse with the resident, and ensure privacy while providing care. Review of Resident #30's nurse's note dated [DATE] at 3:54 P.M. revealed the resident was pacing and had an unsteady gait. Review of Resident #30's late entry nurse's note dated [DATE] at 3:53 [NAME]M. revealed the resident had been restless and moaning when, on [DATE]. Family was advised the resident was actively dying. The hospice nurse arrived on [DATE] at 7:30 P.M. and requested as needed [MEDICATION NAME] be given. Resident #30 expired on [DATE] at 11:54 P.M. Interviews on [DATE] at 5:55 [NAME]M. were conducted with STNA #206 and STNA #214 and they both denied knowledge of a resident being video recorded. During an interview on [DATE] at 6:20 [NAME]M. with STNA #208 she stated she had heard of a video being taken of Resident #30 but never saw the video. She stated STNA #202 reported to her she had taken a video recording of Resident #30 in a geriatric chair using gait transfer belts as a restraint. STNA #202 told her that LPN #304 had restrained the resident in the chair. STNA #208 stated she believed STNA #218 viewed the video recording. During an interview on [DATE] at 7:30 [NAME]M., the Administrator stated an alleged video was taken of Resident #30 by STNA #202 and sent via Facebook Messenger. She stated STNA #206 and RN #402 denied any knowledge of a video. Additionally, the Administrator verified that an SRI was not completed regarding the allegation that a video recording had been taken of Resident #30. Telephone interview on [DATE] at 8:05 [NAME]M. with STNA #202 revealed LPN #304 restrained Resident #30 in a reclining geriatric chair using two gait transfer belts. STNA #202 stated she took a video recording on [DATE], using her cellular device, of Resident #30 sitting in the geriatric chair and being restrained with the gait belts. STNA #202 stated she sent the video of the resident via Facebook Messenger to STNA's #206, #208, #210 and #212. STNA #202 stated she still has the video recording on her cellular device. STNA #202 stated she was the only staff member terminated. Observation on [DATE] at 8:25 [NAME]M. of a video recording of Resident #30 revealed the resident reclined in a geriatric chair with a gait transfer belt up around his chest, one side under his right axilla area and the other side on his left shoulder. The gait transfer belt was attached behind the chair. The resident was observed to be restless and can be heard repeating, I'll be careful, Oh .Please, I'll be careful. A second video was observed on [DATE] at 11:55 [NAME]M. and revealed the resident verbalizing to staff Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident, while recording the video, Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . During a telephone interview on [DATE] at 9:20 [NAME]M., STNA #212 denied receiving a video of Resident #30 but had knowledge of Resident #30 being restrained in the reclining geriatric chair. During a telephone interview on [DATE] at 9:30 [NAME]M., STNA #218 stated she had heard there was a video of Resident #30 being restrained but had not seen it. Telephone interview on [DATE] at 9:40 [NAME]M. with LPN #302 revealed STNA #208 reported that on break, STNA #202 was bragging about a resident being restrained and taking a video. LPN #302 stated it occurred a few days before the resident had expired. LPN #302 further stated she reported it to her supervisor, RN #402. She stated STNA #206 had the video on her cell phone and was told by RN #402 to delete the video. LPN #302 denied seeing the video. An interview on [DATE] at 9:50 [NAME]M. with the DON and the Administrator revealed on [DATE], the DON was called in by LPN #302 who had reported STNA #202 was trying to send her a video via Facebook Messenger but LPN #302 had the STNA blocked so she did not see a video. On [DATE], the DON stated she started to ask the staff questions regarding a video and all the staff denied knowledge of a video. The DON indicated STNA #208 reported a video of Resident #30 and all staff interviewed denied a video. On [DATE], STNA #204 spoke with the Administrator and reported on [DATE], she viewed a video from STNA #206's cell phone which revealed Resident #30 in a geriatric chair with gait transfer belts around his chest. They stated STNA #204 did not report the video until [DATE]. The Administrator stated LPN #304 was unaware STNA #202 took a video. The Administrator denied an allegation of abuse. On [DATE], STNA #202 admitted she took a video recording of Resident #30 in a geriatric chair that occurred on [DATE]. STNA #202 reported she sent the video via Facebook to four other employees but would not provide names or the video. Telephone interview on [DATE] at 9:40 [NAME]M. with STNA #204 revealed she had spoken with the Administrator on [DATE], and was educated on the social media and restraint policy. At that time, she reported to the Administrator that STNA #202 had sent a video recording of Resident #30 to STNA #206's cell phone and STNA #204 viewed the video from STNA #206's cell phone. During a telephone interview on [DATE] at 12:25 P.M., STNA #206 denied she had been sent a video recording of Resident #30. During a telephone interview on [DATE] at 1:20 P.M., STNA #210 stated STNA #202 took a video recording of Resident #30 in a geriatric chair with two gait belts and shared it with her via Facebook Messenger on [DATE]. STNA #210 stated the video was very disturbing to her and informed STNA #202 to remove the restraints. Review of facility submitted SRIs from [DATE] through [DATE] revealed no SRI had been submitted to the state agency regarding an abuse allegation. Review of employee personnel files revealed LPN #304 received a written warning on [DATE] for demonstrating unsatisfactory job performance. STNA #202 was terminated effective [DATE]. STNA #206 received a written disciplinary action on [DATE] for extreme failure to perform job duties in relation to reporting a violation of company protocol. RN #402 received a written disciplinary warning on [DATE] for failing to report a suspected violation of standard of conduct and corporate compliance. Review of the facility policy titled, E-Mail, Internet and Social Media Use, dated (MONTH) (YEAR), revealed improper use of internet services was strictly prohibited and included posting or sharing any unauthorized images of the facility, residents, family or events on social media or public forum. Employees who were aware of or exposed to email, internet, or social media content that violated this policy were required to report such violations to their supervisor as soon as possible. Review of the facility policy titled, Abuse Prevention Program, dated (MONTH) (YEAR), revealed the administration will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within timeframes as required by federal requirements. This deficiency is an incidental finding discovered during the course of the complaint investigations for Complaint Numbers OH 442 and OH 428.

Based on observations, medical record review, staff interviews, review of personnel files, review of Self-Reported Incidents (SRI's) and review of the facility's policies on abuse and social media, the facility failed to ensure an allegation of abuse had been thoroughly investigated and appropriate corrective action taken as a result of the investigations findings. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#30) when State tested Nursing Assistant (STNA) #202 engaged in an act meant to humiliate and dehumanize the resident by taking video recordings of the resident, without permission and not in accordance with facility policy, who was restrained with two gait transfer belts in a geriatric chair while demonstrating signs of distress and anxiety as he pleaded with staff for help. The video recording was then posted on a social media website, Facebook Messenger, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment. This affected one (#30) of three residents reviewed for abuse. The facility census was 84. On [DATE] at 5:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] during third shift when STNA #202 took a video recording of Resident #30 in a reclined geriatric chair with gait belts strapped around his upper chest and shoulder area. The resident was observed in the videos pleading for help stating, I'll be careful, Oh .Please, I'll be careful and Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . STNA #202 then shared the video recording with four other employees (#206, #208, #210 and #212) by sending the video on social media website via Facebook Messenger. The video recording potentially could have been viewed by others via sharing of the video from cellular telephones (cell phone) or Facebook. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 [NAME]M., the DON received a report from Licensed Practical Nurse (LPN) #302 of an alleged video recording taken of Resident #30 and began an investigation. · On [DATE] at 11:00 [NAME]M., the DON began to re-educate the staff on the facility's social media policy. All employees interviewed by the DON denied knowledge of the alleged video, except LPN #302. · On [DATE] at 9:00 [NAME]M., the Administrator continued the social media education and the investigation. No employee was permitted to work in the facility until they received re-education on the social media policy. · On [DATE] at 3:15 P.M., STNA #204 reported to the Administrator that STNA #206 stated STNA #202 sent her a video of a resident. STNA #204 stated she had viewed the video on STNA #206's cellular phone. · On [DATE] at 8:30 [NAME]M., the Administrator spoke with STNA #202 via telephone and the STNA denied any knowledge regarding a video recording of a resident. · On [DATE] at 8:40 P.M., the Administrator spoke with STNA #206 via telephone and STNA #206 denied any knowledge of a video recording of a resident. · On [DATE] at 7:30 [NAME]M., STNA #202 called the Administrator and admitted to taking a video recording of a resident. STNA #202 denied sharing the video recording on social media. No further information was obtained. · On [DATE] at 10:19 [NAME]M., STNA #202 was terminated from her employment with the facility for posting information about a resident on social media. · On [DATE] at 10:40 [NAME]M., STNA #206 received disciplinary action via telephone for failure to perform job duties. · On [DATE] at 2:00 P.M., LPN #304 was given disciplinary action for demonstrating unsatisfactory job performance, work quality, or productivity. A statement was obtained from LPN #304 who indicated she utilized a gait belt in a reclining chair to deter the resident from getting up. · On [DATE] at 6:00 P.M., education regarding the abuse policy was initiated for all staff and would be completed by the end of the day on [DATE]. · On [DATE] at 1:00 P.M., all residents were assessed for abuse through a questionnaire. The residents were asked the following questions: How has the staff been treating you?; and, Has anything occurred recently that you want to bring to our attention? Residents unable to complete the questionnaire had a skin assessment completed. All the residents interviewed and or assessed had no concerns related to abuse. · On [DATE] at 3:10 P.M., additional restraint training specific to not using a gait belt as a restraint was initiated and was to be completed by midnight. No staff members were permitted to work until they had been educated. · Interviews on [DATE] from 3:15 P.M. to 4:20 P.M. were conducted with Cook #501, Housekeeping staff #601, Admissions personnel #701, STNA's #220, #221, #218, and #224, RN #404, and LPN's #312 and #314 regarding the facilities abuse and social media policies. All staff were knowledgeable of the policies and indicated they would immediately report social media allegations to the Administrator and or DON. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision and one-person physical assist with locomotion between locations as the resident was ambulatory. Review of Resident #30's care plan revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia. Interventions included to promote dignity, converse with the resident, and ensure privacy while providing care. Review of Resident #30's nurse's note dated [DATE] at 3:54 P.M. revealed the resident was pacing and had an unsteady gait. Review of Resident #30's late entry nurse's note dated [DATE] at 3:53 [NAME]M. revealed the resident had been restless and moaning on [DATE]. Family was advised the resident was actively dying. The hospice nurse arrived on [DATE] at 7:30 P.M. and requested as needed [MEDICATION NAME] be given. Resident #30 expired on [DATE] at 11:54 P.M. Interviews on [DATE] at 5:55 [NAME]M. were conducted with STNA #206 and STNA #214 and they both denied knowledge of a resident being video recorded. During an interview on [DATE] at 6:20 [NAME]M. with STNA #208 she stated she had heard of a video being taken of Resident #30 but never saw the video. She stated STNA #202 reported to her she had taken a video recording of Resident #30 in a geriatric chair using gait transfer belts as a restraint. STNA #202 told her that LPN #304 had restrained the resident in the chair. STNA #208 stated she believed STNA #218 viewed the video recording. During an interview on [DATE] at 7:30 [NAME]M., the Administrator stated an alleged video was taken of Resident #30 by STNA #202 and sent via Facebook Messenger. She stated STNA #206 and RN #402 denied any knowledge of a video. Additionally, the Administrator verified that an SRI was not completed regarding the allegation that a video recording had been taken of Resident #30. Telephone interview on [DATE] at 8:05 [NAME]M. with STNA #202 revealed LPN #304 restrained Resident #30 in a reclining geriatric chair using two gait transfer belts. STNA #202 stated she took a video recording on [DATE], using her cellular device, of Resident #30 sitting in the geriatric chair and being restrained with the gait belts. STNA #202 stated she sent the video of the resident via Facebook Messenger to STNA's #206, #208, #210 and #212. STNA #202 stated she still has the video recording on her cellular device. STNA #202 stated she was the only staff member terminated. Observation on [DATE] at 8:25 [NAME]M. of a video recording of Resident #30 revealed the resident reclined in a geriatric chair with a gait transfer belt up around his chest, one side under his right axilla area and the other side on his left shoulder. The gait transfer belt was attached behind the chair. The resident was observed to be restless and can be heard repeating, I'll be careful, Oh, I'll be careful. A second video was observed on [DATE] at 11:55 [NAME]M. and revealed the resident verbalizing to staff Help me Honey while thrashing his arms and legs around and running his fingers underneath the gait belt and pulling at it in an attempt to remove the belt. STNA #202 replied to the resident, while recording the video, Nobody is going to help you .we've done everything we can to help you and you still won't do what you're supposed to do .you are a Hot Fricken Fracken Mess . During a telephone interview on [DATE] at 9:20 [NAME]M., STNA #212 denied receiving a video of Resident #30 but had knowledge of Resident #30 being restrained in the reclining geriatric chair. During a telephone interview on [DATE] at 9:30 [NAME]M., STNA #218 stated she had heard there was a video of Resident #30 being restrained but had not seen it. Telephone interview on [DATE] at 9:40 [NAME]M. with LPN #302 revealed STNA #208 reported that on break, STNA #202 was bragging about a resident being restrained and taking a video. LPN #302 stated it occurred a few days before the resident had expired. LPN #302 further stated she reported it to her supervisor, RN #402. She stated STNA #206 had the video on her cell phone and was told by RN #402 to delete the video. LPN #302 denied seeing the video. An interview on [DATE] at 9:50 [NAME]M. with the DON and the Administrator revealed on [DATE], the DON was called in by LPN #302 who had reported STNA #202 was trying to send her a video via Facebook Messenger but LPN #302 had the STNA blocked so she did not see a video. On [DATE], the DON stated she started to ask the staff questions regarding a video and all the staff denied knowledge of a video. The DON indicated STNA #208 reported a video of Resident #30 and all staff interviewed denied a video. On [DATE], STNA #204 spoke with the Administrator and reported on [DATE], she viewed a video from STNA #206's cell phone which revealed Resident #30 in a geriatric chair with gait transfer belts around his chest. They stated STNA #204 did not report the video until [DATE]. The Administrator stated LPN #304 was unaware STNA #202 took a video. The Administrator denied an allegation of abuse. On [DATE], STNA #202 admitted she took a video recording of Resident #30 in a geriatric chair that occurred on [DATE]. STNA #202 reported she sent the video via Facebook to four other employees but would not provide names or the video. Telephone interview on [DATE] at 9:40 [NAME]M. with STNA #204 revealed she had spoken with the Administrator on [DATE], and was educated on the social media and restraint policy. At that time, she reported to the Administrator that STNA #202 had sent a video recording of Resident #30 to STNA #206's cell phone and STNA #204 viewed the video from STNA #206's cell phone. During a telephone interview on [DATE] at 12:25 P.M., STNA #206 denied she had been sent a video recording of Resident #30. During a telephone interview on [DATE] at 1:20 P.M., STNA #210 stated STNA #202 took a video recording of Resident #30 in a geriatric chair with two gait belts and shared it with her via Facebook Messenger on [DATE]. STNA #210 stated the video was very disturbing to her and informed STNA #202 to remove the restraints. Review of facility submitted SRIs from [DATE] through [DATE] revealed no SRI had been submitted to the state agency regarding an abuse allegation. Review of employee personnel files revealed LPN #304 received a written warning on [DATE] for demonstrating unsatisfactory job performance. STNA #202 was terminated effective [DATE]. STNA #206 received a written disciplinary action on [DATE] for extreme failure to perform job duties in relation to reporting a violation of company protocol. RN #402 received a written disciplinary warning on [DATE] for failing to report a suspected violation of standard of conduct and corporate compliance. Review of the facility policy titled, E-Mail, Internet and Social Media Use, dated (MONTH) (YEAR), revealed improper use of internet services was strictly prohibited and included posting or sharing any unauthorized images of the facility, residents, family or events on social media or public forum. Employees who were aware of or exposed to email, internet, or social media content that violated this policy were required to report such violations to their supervisor as soon as possible. Review of the facility policy titled, Abuse Prevention Program, dated (MONTH) (YEAR), revealed the administration will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within timeframes as required by federal requirements. This deficiency is an incidental finding discovered during the course of the complaint investigations for Complaint Numbers OH 442 and OH 428.

Based on observation, medical record review, facility event report review, policy review, in-service documentation review, physician and staff interviews, the facility failed to provide adequate supervision for one cognitively impaired resident (#102) who was assessed to display behaviors of unsafe wandering placing the resident at risk for physical harm. This resulted in Immediate Jeopardy when Resident #102 was found in bed with Resident #82 engaged in inappropriate touching. This affected one of six cognitively impaired residents reviewed who displayed inappropriate behaviors. The facility census was 91. On 07/29/16 at 4:27 P.M., the Administrator, the Regional Vice President of Operations, the District Director of Clinical Operations, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 05/15/16 at 5:00 P.M., when the facility failed to provide adequate supervision for female Resident #102 who was found in the bed of male Resident #82 engaging in inappropriate physical contact. The Immediate Jeopardy was removed on 07/29/16 at 7:00 A.M., when the facility implemented the following corrective actions: · From 07/26/16 through 07/29/16, Resident #102's cognitive level was evaluated by occupational therapy and a personalized activity box was developed and put in her room. · On 07/29/16 at 7:00 A.M., Resident #102 was placed on one to one supervision until further notice. A dedicated State tested Nurse Aide (STNA) will be assigned solely to Resident #102 to provide one to one supervision, per staff in-service guidelines. · On 07/29/16 at 7:00 A.M., staffing schedules were developed for one to one supervision of Resident #102 by the Administrator and the DON. · On 07/29/16 at 10:20 A.M., all staff was in-serviced on the abuse policy by Staff Development Coordinator #1. Education was documented on attendance records. Non-working staff will be educated by phone and asked to come in as soon as possible to sign the attendance record. · On 7/29/16 at 1:59 P.M., Unit Manager #10 discussed behaviors, history and medications with a local psychiatric hospital and discussed the need for further evaluation. · On 07/29/16 at 6:10 P.M., the primary physician evaluated Resident #102 for appropriate medications, pain control and any necessary lab orders. New orders were received. · On 07/29/16 at 6:27 P.M., the family of Resident #102 was notified of one to one supervision. · On 07/29/16 at 6:40 P.M., Resident #102 was provided a private room. · On 07/29/16 beginning at 7:30 P.M., staff was educated on one to one supervision, expectations and behavior management by Staff Development Coordinator #1. · On 07/29/16, the nursing staff was in-serviced by Staff Development Coordinator #1, to notify the Director of Nursing Services or Executive Director and physician if unable to deescalate behaviors. · On 07/29/16, Resident #102's plan of care was updated with a behavior management plan including specific behaviors and specific interventions. · On 7/30/16 at 9:20 A.M., the facility action plan was reviewed with the Medical Director and approved. · On 07/30/16 beginning at 10:30 A.M., all staff was in-serviced regarding recognizing threatening and intrusive behaviors; and appropriate measures to handle and report such behavior. Education was documented on attendance records. Non-working staff will be educated by phone and asked to come in as soon as possible to sign the attendance record. · On 07/30/16, all residents in the dementia unit having behaviors that may be affecting others in a negative way were identified by the Interdisciplinary Team (IDT). All interventions were reviewed to determine if appropriate interventions were in place. Any resident identified to have ineffective interventions will be discussed and evaluated for more appropriate interventions, at the time of identification. Residents will be referred to the Rehabilitation Cognitive Program as necessary. · On 07/30/16, monitoring of progress notes and behavior monitoring tracking will be reviewed on a bi-weekly basis by the unit manager/designee to ensure that all resident behaviors are appropriately addressed. Although the Immediate Jeopardy was removed on 07/29/16 at 7:00 A.M., 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 action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #102's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed Resident #102 was cognitively impaired and had physical behavioral symptoms toward others which placed the resident and other residents at significant risk for physical harm. Review of the behavior assessment dated [DATE] revealed Resident #102 exhibited no wandering behavior. However, review of the wandering assessment dated [DATE] revealed Resident #102 was at risk for wandering. Review of the plan of care for Resident #102's wandering behavior revealed interventions dated 10/28/14 that included identify the pattern of wandering and intervene as appropriate, provide structured activities including toileting, walking inside and outside and reorientation strategies including signs, pictures and memory boxes. Review of the care plan for Resident #102 for the behavior of shoving, hitting and kicking when other residents were in her personal space dated 12/15/15 and revised 02/15/16 revealed one intervention of redirecting Resident #102 away from other residents when agitated. Review of all of Resident #102's other care plans revealed no other care plans to address the resident's additional behaviors. Review of Resident #102's nursing progress note dated 10/05/16 through 05/14/16 revealed Resident #102 had a history of [REDACTED]. Review of a nursing progress note dated 05/15/16 at 5:00 P.M., revealed when staff went to get the resident up and ready for supper, Resident #102 was found in a male resident's (Resident #82) bed and the male resident had his hands in her pajama bottoms and top. Resident #102 was immediately removed from the male resident's bed and taken to her room. Resident #102 had a full skin assessment completed with no apparent injury or trauma. Review of the event report dated 05/15/16 revealed Resident #102 was found in Resident #82's bed at 5:00 P.M., New interventions included Resident #102 was placed on one to one supervision and keep away from male residents. Review of nursing progress notes dated 05/19/16 through 06/22/16 revealed numerous events of Resident #102 wandering in other residents ' rooms, rummaging, attempting to wake up other residents through the night, disrobing and upsetting other residents. On one occasion Resident #102 picked up a resident's television and dropped it, breaking it. Review of the Resident #102's medical record revealed from 05/15/16 through 07/25/16 there was no documented evidence of one to one supervision being provided. Resident #102 continued to wander throughout the dementia unit and display behaviors that potentially exposed herself or others to harm. Observations of Resident #102 on 07/28/16 at 9:13 A.M., 2:15 P.M., 3:14 P.M., and 5:48 P.M., revealed the resident was by herself or with other residents. There was no staff observed providing one to one supervision. Additional observation on 07/28/16 at 3:14 P.M., revealed staff was caring for other residents while Resident #102 repeatedly touched the hair of another resident. No staff was observed at this time providing one to one supervision. Interview on 07/27/16 at 11:38 A.M. with Unit Manager Licensed Practical Nurse (LPN) #200 revealed on 05/15/16, LPN #201 notified her Resident #102 was found in Resident #82's bed. LPN #200 revealed LPN #201 informed her Resident #82's hands were down Resident #102's pants. LPN #200 revealed to prevent reoccurrence of the incident, the plan was to keep the residents separated. LPN #200 stated Resident #102 was placed on one to one supervision. Interview on 07/27/16 at 12:00 P.M., with the Administrator revealed wandering behavior interventions for Resident #102 included redirection and one to one supervision as needed. Interview on 07/27/16 at 12:08 P.M., revealed the Administrator and DON could not remember what interventions were added to Resident #102's care plan. Interview on 07/27/16 at 5:50 P.M., with LPN #201 revealed State tested Nursing Assistant (STNA) #300 found Resident #102 in Resident #82's bed and immediately removed her. LPN #201 further stated Resident #102 had a history of [REDACTED]. LPN #201 stated the immediate intervention was to separate Resident #102 and Resident #82. Resident #102 and Resident #82 were fully clothed. LPN #201 stated staff checked on Resident #102 frequently in the day. Interview on 07/27/16 at 5:56 P.M., with STNA #300 revealed Resident #102 was lying in Resident #82's bed. STNA #300 stated she had Resident #102 get out of the bed and leave the room with her. STNA #300 further revealed Resident #82's hands were on the outside of Resident #102's pants. STNA #300 stated she informed LPN #201 what she observed and the actions she took. Interview on 07/28/16 at 2:17 P.M., with LPN #200 revealed the staff will let the physician know if a resident has increased behaviors. Resident #102 had increased behaviors on second and third shift. LPN #200 stated Resident #102's behaviors included occasional exit seeking, sitting in people's laps and getting in people's personal space and rummaging. LPN #200 stated one time Resident #102 picked up her roommate's television and staff had to intervene. LPN #200 could not recall any harm to another resident from Resident #102's behaviors. LPN #200 further revealed the physician was updated on Resident #102's behaviors but it was not always documented. LPN #200 stated Resident #200's physician did not want to change any of resident #102's medications right now. LPN #200 additionally revealed Resident #102 does not have behaviors every day and some days a she has a lot of behavior activity. LPN #200 stated staff do one to ones when the behaviors increase. Interview on 07/28/16 at 2:36 P.M., with LPN #202 revealed sometimes staff has to redirect Resident #102 from other resident's rooms. Resident #102 pushes chairs around, and is sometimes combative with care and eating. LPN #202 stated Resident #102 was redirected when she got up in people's faces and would wake her roommate up at night. Interview on 07/28/16 at 3:08 P.M., with LPN #201 revealed she thought STNA #300 may have told her Resident #82's hands were on the pants and shirt but she heard it wrong and typed in the pants and shirt. Interview on 07/28/16 at 4:25 P.M., via telephone with Medical Director (MD) #1 revealed Resident #102 was pretty well controlled with her behaviors. MD #1 stated the facility protocol for increased behaviors is one to one supervision and keep separated from other residents. MD #1 stated the initial step is monitoring. MD #1 stated Resident #102 is a good person and has acclimated well to the facility. MD #1 stated he did not feel Resident #102's behaviors would result in harm to anyone. MD#1 stated psychiatry handled Resident #102's routine psychotropic medications. MD #1 stated he would order a calming dose for example for something like dropping the television set and stated he has not had to order anything lately. MD #1 stated the facility always notifies him or the physiatrist about Resident's #102'sbehaviors. He stated he has seen her for about the last ten years and Resident #102's behaviors maybe be related to she just gets bored, not harmful. MD #1 stated the television incident could have done something but he has not felt she is harmful. Resident #102 blames MD #1 for her being in the nursing home but she would never harm him. MD #1 stated disease processes cause behaviors and unless you use medications like Haldol there are going to be behaviors. MD #1 stated Resident #102 will still have behaviors and feels the staff are able to control Resident #102's behaviors 99% of the time but there will be episodes unless we knock the residents out . Interview on 07/29/16 at 8:50 A.M with STNA #305 revealed one to one supervision is completed when Resident #102 has aggressive behaviors. Interview on 07/29/16 at 9:10 A.M. with STNA #306 revealed she had not completed any one to one supervision with Resident #102 since her admission day. Interview on 07/29/16 at 9:15 A.M. with LPN #203 revealed when Resident #102 had increased behaviors the staff attempt to provide a one on one activity with her. Interview on 07/29/16 at 10:06 A.M. with the Administrator revealed if a resident has increased behaviors a nurse on duty can initiate one to one supervision with whomever is available or someone is called in. The Administrator further revealed the staff may complete a quick one to one supervision intervention or longer until the behavior calms down. Interview on 07/29/16 at 9:45 A.M. with Psychiatrist #500 revealed he assesses and reviews Resident #102 every two months. He stated on his last visit to the facility he did not recall nursing staff reporting to him about Resident #102's behaviors. He stated he did not recall staff informing him of the incident on 05/15/16 involving possible sexual abuse. Review of the facility policy Resident Exhibiting Challenging Behaviors dated 06/30/06 revealed implement processes to monitor a resident exhibiting extreme/serious behavior symptoms until resident condition is stable or as determined by the Interdisciplinary Team, as appropriate. Further policy review revealed to wean the resident from close staff monitoring such as every 15-minute, 30-minute or one to one, before discontinuing. Additional policy review revealed to assign a staff member to remain with the resident at all times, if necessary.

Based on surveyor observation, medical record review, resident and staff interview, review of facility policy and interview with the physician, it was determined that the facility failed to maintain the nutritional status for one (#46) of three residents reviewed for nutritional status. This resulted in actual harm when Resident #46 sustained a 12.7 pound weight loss equaling 7.8 percent of body weight over three months. The facility identified two residents with unplanned significant weight changes. The total facility census was 86. Findings include: Review of Resident #46's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED].#46's short and long term memory were intact, had no behaviors and required supervision with set-up assistance for eating. The MDS identified Resident #46's height as 74 inches with a weight of 150 pounds. Resident #46's documented monthly weights were as follows; on 01/05/10 he weighed 163.1 pounds, on 02/08/10 he weighed 159 pounds, on 03/09/10 he weighed 153.5 pounds and on 04/06/10 he weighed 150.4 pounds. Review of the 04/14/10 "Medical Nutrition Therapy Review", completed by Dietician #4, identified Resident #46 as having a 12.7 pound weight loss over three months resulting in a 7.8 percent body weight loss. At this time, Dietician #4 recommended to increase Resident #46's juices to eight ounces every meal. Review of the "Medical Nutrition Therapy Assessment", completed by Diet Tech #2, dated 04/22/10 identified Resident #46 as receiving a regular diet with no supplements. The assessment again identified significant weight loss and indicated this weight loss was not desirable. No recommendations were made at this time. Review of the nutrition plan of care dated 05/29/09 identified Resident #46 was at nutritional risk related to severe visceral protein depletion, medical diagnoses, variable oral intake, diuretic use, and a history of being a picky eater and refusing supplements. One goal was no significant weight changes. Interventions included; encourage oral intake and fluids, notify the dietician and physician of significant weight changes, abnormal labs, skin breakdown, or dehydration, continue to monitor weights, labs, oral intake and other nutritional parameters with each nutritional review, diet as ordered: regular, labs as ordered, honor food preferences as able, weigh every week until stable then monthly, adapt refreshments during activities, monitor percentage of food/fluids consumed and offer substitute as needed, offer evening snack, provide assistance as needed with meals to ensure adequate oral intake, alter meal plan and whole milk three times a day with meals. All care planned interventions were dated 05/29/09. Surveyor observation on 05/12/10 at 12:00 P.M. revealed Resident #46 seated in his wheelchair in his room. Resident #46 was independently eating a regular diet and was served eight ounces of juice and eight ounces of whole milk. At 12:13 P.M., Resident #46 indicated he would not eat the macaroni salad because he did not like it. Resident #46 stated that if he does not like the food, he does not eat it. Interview with Dietician #2 on 05/13/10 at 10:11 A.M. verified increasing Resident #46's juice to eight ounces a meal would not increase caloric intake substantially. During interview with Licensed Practical Nurse (LPN) #17 on 05/13/10 at 10:25 A.M., she identified Resident #46 as finicky and getting worse. LPN #17 indicated Resident #46 tells staff he does not eat as much as he used to. Interview with Registered Nurse (RN) #14 on 05/13/10 at 10:40 A.M. revealed the interdisciplinary team discusses residents with significant weight concerns at weekly risk meetings. RN #14 indicated weights are obtained by the nursing assistants and entered into a computer system. RN #14 stated weekly weight reports are then generated and used during the risk meeting. However, RN #14 did not recall discussing Resident #46 at those meetings. RN #14 indicated if there were any changes in dietary orders, there would be a change in condition form completed. However, RN #14 verified there were no change of condition forms completed for Resident #46. RN #14 also confirmed the last dietary intervention change for Resident #46 was in 2008. During further interview with RN #14 on 05/13/10 at 11:15 A.M., she verified the interdisciplinary team had not discussed Resident #46's weight loss. On 05/13/10 at 11:20 A.M., the Director of Nursing (DON) again verified Resident #46 has not been reviewed by the interdisciplinary team. The DON also verified Resident #46 had a significant weight loss from January 2010 to April 2010. During interview with Dietician #4 on 05/13/10 at 1:30 P.M., she identified she had spoken with Resident #46 regarding his weight loss. Dietician #4 indicated she informed Resident #46 of his need to increase caloric intake and recommended to increase his juice from four ounces to eight ounces at meals. Dietician #4 identified this would provide approximately 150 to 200 additional calories per day. Dietician #4 verified she had not recommended a nutritional supplement, increased portions, or fortified foods, however, indicated these interventions would be appropriate if Resident #46 was agreeable. Dietician #4 indicated she had discussed Resident #46's weight loss with RN #14. Additional interview with RN #14 on 05/13/10 at 1:53 P.M. revealed Dietician #4 did not speak with her regarding Resident #46's weight loss. RN #14 indicated a dietician typically attends the risk meeting; however, no dietician has been present for approximately three weeks. Interview with Dietary Manager #7 on 05/14/10 at 9:10 A.M. indicated Resident #46 receives only four ounces of orange juice at breakfast and eight ounces of cranberry juice at lunch and supper. Dietary Manager #7 stated Resident #46 has been receiving a total of eight additional ounces of cranberry juice per day. Surveyor observation of the cranberry juice packaging at this time revealed eight ounces of cranberry juice totals 120 calories. During further interview with Resident #46 on 05/14/10 at 9:30 A.M., he indicated as an adult he consistently weighed 225 pounds. Resident #46 stated he does not like all of the food the facility prepares. Resident #46 indicated if he does not consume all of his meal, he is offered a substitute only some of the time. Resident #46 additionally indicated he does not like to drink "Ensure" (a nutritional supplement). However, after explaining there are more ways to supplement a diet than just drinking Ensure, Resident #46 stated "He is willing to try anything within reason because he is skin and bones." A final interview with the DON on 05/14/10 at 9:48 A.M. verified Resident #46's weight should have been addressed at the time of the significant weight change on 04/06/10. Additionally, the DON stated weekly weights should have been completed since that time to closely monitor Resident #46's weight and verified this had not been completed. The DON identified Resident #46 was re-weighed on 05/13/10 and remains 150.7 pounds. Interview with Resident #46's primary care physician (#1) on 05/14/10 at 10:40 A.M. identified Resident #46's weight loss as substantial. Physician #1 indicated Resident #46's weight loss would not be expected based on his medical [DIAGNOSES REDACTED].#46 to decide on a plan of care; however, indicated he may suggest a nutritional supplement or appetite stimulant for Resident #46.