Every finding on record at Meadowbrook Manor

Based on interview, and review of staffing schedules, the staffing tool and the facility assessment, the facility failed to ensure a registered nurse (RN) was in the facility at least eight consecutive hours a day, seven days a week. This had the potential to affect all 50 residents residing at the facility.Findings include: Review of staffing schedules from 01/01/26 to 04/21/26 revealed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool from 04/05/26 to 04/11/26 completed on 04/21/26 at 12:00 P.M. with Administrator, Human Resource (HR) #624, and Scheduler/HR Assistant #623 revealed there was no RN coverage for at least eight consecutive hours on 04/05/26. Interview on 04/21/26 at 12:00 P.M. and 1:47 P.M. with Administrator, HR #624, and Scheduler/HR Assistant #623 verified per the staffing schedules from 01/01/26 to 04/21/26 and the staffing tool completed from 04/05/26 to 04/11/26, there was no RN coverage for at least eight consecutive hours for two days on 01/24/26 and 04/05/26.Review of the Facility assessment dated [DATE] revealed under the staffing plan there would be two RNs and/or Licensed Practical Nurses (LPN) for each shift. There was nothing per the assessment regarding ensuring there was a RN at least eight consecutive hours a day, seven days a week. This deficiency represents non-compliance investigated under Complaint Numbers 2966092, 2667528 and 2650567.

Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the state survey agency database for SRI reporting, the facility investigation and facility policy, the facility failed to ensure residents were free from sexual abuse. This affected three residents (Resident #22, #53 and #54) out of six residents reviewed for abuse. The facility census was 50.Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed Resident #22's Brief Interview for Mental Status (BIMS) was zero indicating severe cognitive impairment. She required partial to moderate staff assistance with dressing. She was independent with transfers and required supervision with ambulation. Review of the care plan dated 06/30/25 revealed Resident #22 had impaired cognition and impaired thought processes related to Alzheimer's disease. Interventions included asking her yes or no questions to determine needs; cue, reorient and supervise as needed; and keeping her routine consistent. Additional review of the care plan dated 06/30/25 revealed Resident #22 had tearful episodes and was crying out. On 07/25/25 Resident #22 was observed in an inappropriate situation with a male resident. On 12/12/25 Resident #22 was observed in an inappropriate situation with a male resident. There was nothing in her care plan regarding whether she had the capacity to consent to sexual activity or not. Interventions included adjusting voice tone; administering medications as ordered; engaging in activities; leaving over the bed light on for reassurance; psychological consult as needed; frequent observation throughout the shift (added 11/03/25); and checking the resident every 15 minutes (added 12/12/25).Review of nursing note dated 07/25/25 at 4:45 P.M. completed by Agency Licensed Practical Nurse (LPN) #615 revealed prior to dinner the aide informed her that she discovered Resident #22 in bed with another resident. The aide had stated she was checking rooms and looking for Resident #22 and upon walking into Former Resident #53's room she had observed Resident #22 laying beneath Former Resident #53 in the bed and both residents' pants were down. The residents were separated. Review of nursing note dated 12/11/25 at 10:30 P.M. completed by LPN #617 revealed he was notified that when the aides were doing rounds they had noticed Resident #22 was not in her room and they immediately looked in other rooms to find her. Resident #22 was found in another resident's bed (Former Resident #54) with Former Resident #54 sitting beside her. The note revealed both residents were naked with their clothing on the floor. Former Resident #54 had several fingers in her vaginal area and Resident #22 had her legs open allowing access. Both residents were separated and Resident #22 was dressed and taken to her room. Both residents were checked, no injuries were noted and both residents were placed on 15-minute checks. Primary Care Physician (PCP) #610 was notified. Review of Kardex (a brief overview/guideline of a resident) for Resident #22 dated 04/23/26 revealed under behaviors staff were to distract from wandering by offering pleasant diversions, structured activities, food conversation, and television. Other interventions included adjusting voice and tone; behavior monitoring (no specifics identified); and reapproaching as needed. There was nothing on the Kardex regarding 15-minute checks as per the care plan and there was nothing on the Kardex about sexual inappropriate behaviors. 2. Review of the closed medical record for Former Resident #53 revealed he was admitted on [DATE] and discharged on 09/26/25. His diagnoses included dementia, viral hepatitis C (a liver disease caused by a virus that spreads when blood from an infected person enters another), antisocial personality disorder, and high risk of heterosexual behavior (sexual practices that significantly increase likelihood of sexually transmitted infections) which was added on 07/29/25. He was assigned by the courts a legal guardian and there was nothing in his medical record regarding if Former Resident #53 was evaluated whether he had the capacity to consent to sexual activity. Review of the care plan dated 11/20/24 revealed Former Resident #53 had impaired cognition related to dementia. Interventions included approaching the resident to maximize involvement daily and communicating with the resident regarding his needs. There was nothing in his care plan regarding whether he had the capacity to consent to sexual activity or not. Review of the Quarterly MDS dated [DATE] revealed Former Resident #53 had cognitive impairment as his BIMS was 11. He was independent and/or only required set-up with his activities of daily living tasks including dressing, transfers and ambulation. Review of nursing note dated 07/25/25 at 4:45 P.M. completed by LPN #615 revealed she was informed by the aide prior to dinner upon checking rooms that Resident #22 was discovered in Former Resident #53's room with him lying on top of her in his bed. The two residents were immediately separated and the Director of Nursing (DON) contacted. Former Resident #53 had stated Resident #22 had come into his room, sat on his bed, he rubbed her leg and the aide came in. 3. Review of the closed medical record for Former Resident #54 revealed an admission date of 11/22/25 and he was discharged home on [DATE]. His diagnoses included brief psychotic disorder, dementia, agitation, and hypertension. There was nothing in his medical record regarding if Former Resident #54 was evaluated whether he had the capacity to consent to sexual activity. Review of the Medicare Five Day MDS dated [DATE] revealed Former Resident #54 had impaired cognition as his BIMS score was three. Review of the nursing note dated with a late entry of 12/12/25 at 9:58 A.M. completed by LPN #617 revealed he was notified that when the aides were doing rounds they had noticed Resident #22 was not in her room and they immediately looked in other rooms to find her. Resident #22 was found in another resident's bed (Former Resident #54) with Former Resident #54 sitting beside her. Both residents were naked with their clothing on the floor. Former Resident #54 had several fingers in her vaginal area and Resident #22 had her legs open allowing access. Both residents were separated and Resident #22 was dressed and taken to her room. Both residents were checked, no injuries were noted and both residents were placed on 15-minute checks. PCP #610 was notified. 4. Review of the state survey agency database for SRI reporting from 07/25/25 to 04/21/26 revealed the facility had not filed an SRI regarding the alleged sexual abuse incident that had occurred on 07/25/26 between Resident #22 and Former Resident #53. Review of witness statement dated 07/25/25 completed by Agency Certified Nursing Assistant (CNA) #614 revealed she came off break at 3:45 P.M., Resident #22 had walked up to her at the nursing station, and she also had seen Former Resident #53. She started her rounds, taking residents into the dining room and then started to look for Resident #22 room to room. She walked into Former Resident #53's room at 4:40 P.M. and Former Resident #53 was on top of Resident #22 on his bed with both their pants down. Agency CNA #614 did not see Resident #53's genitals inside her vagina and she had separated the residents immediately. Review of witness statement dated 07/25/25 completed by Agency CNA #616 revealed she was the second CNA on the floor on 07/25/25 at the time of incident but was on break and did not witness the incident between Residents #22 and Former Resident #53. Review of witness statement dated 07/25/25 completed by Agency LPN #615 revealed the CNA reported to her that upon looking for Resident #22 that she walked past Former Resident #53's room to find Former Resident #53 on top of Resident #22 and both their pants were down. The CNA immediately separated the residents, and she contacted the Former Director of Nursing (DON) #625. Review of witness statement dated 07/25/25 completed by Infection Control/Assistant Director of Nursing (ADON) #609 revealed she completed a full body assessment for Resident #22 and there was no blood in her brief. There was no bruising, abrasion, skin laceration, and when asked if she was having pain and/or if it hurt she only smiled. She completed a vaginal assessment and no penetration was noted. Review of witness statement dated 07/25/25 completed by Former Administrator #626 and MDS/Registered Nurse (RN) #627 revealed they interviewed Former Resident #53, and he had stated he was sitting on his bed when the lady came into his room and sat on his bed. He stated she did not say anything, she was just looking at him, and he was rubbing her leg. He stated she had black pants on, and a top and the aide came in and said, Both y'all get up. He denied kissing her and stated that both of their pants were on. Interview on 04/22/26 at 12:45 P.M. with Regional Director #612, Regional Nurse/Registered Nurse (RN) #600, and Infection Control/ADON #609 verified Former Resident #53 was on top of Resident #22 in Resident #53's bed and both of their pants were down. They verified Former Resident #53 had a diagnosis of Hepatitis C and as precaution PCP #610 had ordered lab testing for Resident #22. They also verified the police were not contacted regarding the incident and that there was no documentation Former Resident #53's guardian was asked regarding police involvement. They verified Resident #22 had a friend listed as her POA of finance, but the friend did not want anything to do with her healthcare. When asked who made Resident #22's decisions since she had severe cognitive impairment they stated that nobody did right now. They verified the incident was not reported to the state agency including making a self-reported incident and they had only completed an internal investigation. Interview on 04/22/26 at 3:47 P.M. with the DON and Infection Control/ADON #609 verified there was not an assessment/evaluation completed prior to the incident on 07/25/25 and/or after it for either Resident #22 or Former Resident #53 whether they had the capacity to consent to sexual activity. They stated they only go by the BIMS score and if the resident scored 12 or above then they would be able to give consent and if they scored below they were not able. They stated they felt both residents, Resident #22 and Former Resident #53 could not give consent for sexual activity based on their BIMS score. Interview on 04/22/26 at 4:21 P.M. with Agency CNA #614 revealed she no longer went to the facility because of the incident on 07/25/25 as she stated it was disturbing it just was not right. She revealed she had walked in and found Former Resident #53 on top of Resident #22 in his bed, and they did not have any clothing on below the waist. She yelled get off of her and he jumped up. She was unsure if sexual activity had occurred as when she yelled he jumped up fast. She assisted Resident #22 off his bed and walked her to the nurse. She stated it was difficult to know if Resident #22 was affected by the incident as she always had a distressed look on her face. 5. Review of SRI #268530 dated 12/11/25 for alleged sexual abuse with another resident revealed on 12/11/25 at 10:30 P.M. an aide observed two residents, Former Resident #54 and Resident #22, engaged in inappropriate touch on the secured dementia unit. The residents were immediately separated, assessed by the nurse and placed on 15-minute checks. No injuries were identified. On 12/13/25, Former Resident #54 was discharged home with his wife. The facility unsubstantiated the SRI for sexual abuse. Review of witness statement dated 12/11/25 completed by LPN #617 revealed during rounds, the aides noticed that Resident #22 was not in her room and found her in Former Resident #54's room. Both residents were naked and their clothing was on the floor. The aide observed Former Resident #54 with his hand in Resident #22's groin region. The aide immediately separated them and called for assistance. Skin checks were completed, 15-minute checks were implemented, and PCP #610 was notified. Review of witness statement dated 12/11/25 completed by CNA #619 revealed on 12/11/25 around 10:30 P.M. they were completing rounds and when checking, Resident #22 was not in her bed. Another aide went into Former Resident #54's room, hollered out for her and saw Resident #22's pants and incontinent pull-up was off and Former Resident #54 naked. Former Resident #54 had stated, she wanted. Both residents were separated and they got the nurse. Review of witness statement dated 12/11/25 and completed by CNA #618 revealed on 12/11/25 at 10:30 P.M. she was doing rounds and could not find Resident #22. She went looking room to room and walked into Former Resident #54's room and he had the curtain pulled. She walked over, pulled the curtain and saw Resident #22 with her pants and incontinent pull-up off and Former Resident #54 naked. Former Resident #54 had his fingers in her vagina and stated she wanted it. She pulled him away and called for help. Interview on 04/23/26 at 7:58 A.M. with CNA #603 revealed she worked on the second floor Monday through Thursday where Resident #22 resided and was not aware of anyone on special checks including 15-minute checks. She checked on each resident every hour including Resident #22. Interview on 04/23/26 at 8:03 A.M. with Agency RN #620 revealed it was his first time at the facility, and he was assigned to the second floor where Resident #22 resided. He was not aware of any residents on the unit that were on special monitoring including 15-minute checks and had not received anything in report. Interview on 04/23/26 at 8:06 A.M. with CNA #605 revealed she worked on the second floor Monday through Thursday, where Resident #22 resided and was not aware of anyone on special checks including 15-minute checks. She routinely checked all residents but there were no formal checks that she was aware of. Interview on 04/23/26 at 9:53 A.M. with PCP #610 revealed she was the PCP for Resident #22 and Former Resident #53. This surveyor read the nursing note dated 07/25/25 regarding the incident to PCP #610 and in response she stated she was not aware of the explicit details of the incident but she was aware of a potential sexual encounter and they were not sure if penetration had occurred which was why she had ordered the Hepatitis C testing for Resident #22 as Former Resident #53 had a diagnosis of Hepatitis C. She stated Resident #22 could not give informed consent as when she attempted to ask Resident #22 any questions, the resident just looked in her eyes with a blank stare and did not communicate. She felt Former Resident #53 was able to give informed consent for sexual activity as he could verbalize that he wanted to have sex and could give consent. PCP #610 was asked what preventative interventions were ordered after the incident on 07/25/25 and she stated there was a facility protocol they followed for a sexually inappropriate incident, but she did not know it off hand and would have to get it from the facility. She was not sure what monitoring standards they had in place. This surveyor read the incident that had occurred on 12/11/25 and PCP #610 stated the incident did not sound familiar and did not feel she was notified. She was not familiar with who Former Resident #54 was and did not feel she ever met him, so she was unable to provide whether he was able to give informed consent for sexual activity. She revealed after both incidents were reviewed what recommendations and/or interventions were needed to ensure safety. She stated if she had known about the second incident, to be honest it was not feasible to keep Resident #22 and other residents safe especially with only having two aides on the second floor. Resident #22 almost needed one-on-one because whenever she was at the facility, Resident #22 ambulated all over, and was fast as she had to chase her around just to get an assessment completed. She stated either one-on-one or a facility with all women as, I do not see how to keep her and others safe otherwise. Interview on 04/23/26 at 10:15 A.M. with Regional Nurse/RN #600, DON and Infection Control/ADON #609 verified they were not aware of a protocol that the facility implemented if an incident of alleged sexual abuse occurred or standard protocols that were to be implemented including specific monitoring. They verified per the care plan Resident #22 was to be on 15-minute checks but on staff interviews staff were not completing it. They revealed they felt it was a documentation error as Resident #22 was to be no longer on 15-minute checks and that was why staff were not doing them. They stated they were unaware PCP #610 was not aware of the incident on 12/11/25 involving Resident #22 and Former Resident #54, and unaware PCP #610 felt the only way to keep Resident #22 safe, as well as others, was with one-on-one or a facility with all women since PCP #610 had not shared that with them. Review of facility policy labeled, Identifying Types of Abuse last revised 2022 revealed sexual abuse was non-consensual sexual conduct of any type with a resident. Sexual abuse incidents included but not limited to unwanted intimate touching of any kind especially breasts and perineal area, and all types of sexual assault or battery. Sexual contact was nonconsensual if the residents appeared to want the contact to occur but lacked the cognitive ability to consent. Residents had the right to engage in consensual activity however anytime there was reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse including evaluating whether the resident had the capacity to consent to sexual activity. Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2025 revealed the purpose of the policy was to ensure residents were free from abuse. Residents had the right to engage in consensual sexual activity; however, anytime the facility had reason to suspect that a resident may not have the capacity to consent to sexual activity the facility would take steps to ensure that the resident was protected from abuse. These steps shall include evaluating whether the resident had capacity to consent to sexual activity. When the facility identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse. The policy revealed the facility would report the alleged violation and investigate within the required timeframes pursuant to Federal and State statutes and regulations. The policy revealed the facility would report the results of all investigation to the Administrator or designee and to other officials including the state survey agency within five working days of the incident.

Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the state survey agency database for SRI reporting, the facility investigation and facility policy, the facility failed to report to the state survey agency and/or local law enforcement an allegation of sexual abuse. This affected two residents (Residents #22 and #53) out of six residents reviewed for abuse. The facility census was 50.Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed Resident #22's Brief Interview for Mental Status (BIMS) was zero indicating severe cognitive impairment. She required partial to moderate staff assistance with dressing. She was independent with transfers and required supervision with ambulation. Review of the care plan dated 06/30/25 revealed Resident #22 had impaired cognition and impaired thought processes related to Alzheimer's disease. Interventions included asking her yes or no questions to determine needs; cue, reorient and supervise as needed; and keeping her routine consistent. Additional review of the care plan dated 06/30/25 revealed Resident #22 had tearful episodes and was crying out. On 07/25/25 Resident #22 was observed in an inappropriate situation with a male resident. There was nothing in her care plan regarding whether she had the capacity to consent to sexual activity or not. Review of nursing note dated 07/25/25 at 4:45 P.M. completed by Agency Licensed Practical Nurse (LPN) #615 revealed prior to dinner the aide informed her that she discovered Resident #22 in bed with another resident. The aide had stated she was checking rooms and looking for Resident #22 and upon walking into Former Resident #53's room she had observed Resident #22 laying beneath Former Resident #53 in the bed and both residents' pants were down. The residents were separated. 2. Review of the closed medical record for Former Resident #53 revealed he was admitted on [DATE] and discharged on 09/26/25. His diagnoses included dementia, viral hepatitis C (a liver disease caused by a virus that spreads when blood from an infected person enters another), antisocial personality disorder, and high risk of heterosexual behavior (sexual practices that significantly increase likelihood of sexually transmitted infections) which was added on 07/29/25. He was assigned by the courts a legal guardian and there was nothing in his medical record regarding if Former Resident #53 was evaluated whether he had the capacity to consent to sexual activity. Review of the care plan dated 11/20/24 revealed Former Resident #53 had impaired cognition related to dementia. Interventions included approaching the resident to maximize involvement daily and communicating with the resident regarding his needs. There was nothing in his care plan regarding whether he had the capacity to consent to sexual activity or not. Review of the Quarterly MDS dated [DATE] revealed Former Resident #53 had cognitive impairment as his BIMS was 11. He was independent and/or only required set-up with his activities of daily living tasks including dressing, transfers and ambulation. Review of nursing note dated 07/25/25 at 4:45 P.M. completed by LPN #615 revealed she was informed by the aide prior to dinner upon checking rooms that Resident #22 was discovered in Former Resident #53's room with him lying on top of her in his bed. The two residents were immediately separated and the Director of Nursing (DON) contacted. Former Resident #53 had stated Resident #22 had come into his room, sat on his bed, he rubbed her leg and the aide came in. 3. Review of the state survey agency database for SRI reporting from 07/25/25 to 04/21/26 revealed the facility had not filed an SRI regarding the alleged sexual abuse incident that had occurred on 07/25/26 between Resident #22 and Former Resident #53. Review of witness statement dated 07/25/25 completed by Agency Certified Nursing Assistant (CNA) #614 revealed she came off break at 3:45 P.M., Resident #22 had walked up to her at the nursing station, and she also had seen Former Resident #53. She started her rounds, taking residents into the dining room and then started to look for Resident #22 room to room. She walked into Former Resident #53's room at 4:40 P.M. and Former Resident #53 was on top of Resident #22 on his bed with both their pants down. Agency CNA #614 did not see Resident #53's genitals inside her vagina and she had separated the residents immediately. Review of witness statement dated 07/25/25 completed by Agency CNA #616 revealed she was the second CNA on the floor on 07/25/25 at the time of incident but was on break and did not witness the incident between Residents #22 and Former Resident #53. Review of witness statement dated 07/25/25 completed by Agency LPN #615 revealed the CNA reported to her that upon looking for Resident #22 that she walked past Former Resident #53's room to find Former Resident #53 on top of Resident #22 and both their pants were down. The CNA immediately separated the residents, and she contacted the Former Director of Nursing (DON) #625. Review of witness statement dated 07/25/25 completed by Infection Control/Assistant Director of Nursing (ADON) #609 revealed she completed a full body assessment for Resident #22 and there was no blood in her brief. There was no bruising, abrasion, skin laceration, and when asked if she was having pain and/or if it hurt she only smiled. She completed a vaginal assessment and no penetration was noted. Review of witness statement dated 07/25/25 completed by Former Administrator #626 and MDS/Registered Nurse (RN) #627 revealed they interviewed Former Resident #53, and he had stated he was sitting on his bed when the lady came into his room and sat on his bed. He stated she did not say anything, she was just looking at him, and he was rubbing her leg. He stated she had black pants on, and a top and the aide came in and said, Both y'all get up. He denied kissing her and stated that both of their pants were on. Interview on 04/22/26 at 12:45 P.M. with Regional Director #612, Regional Nurse/Registered Nurse (RN) #600, and Infection Control/ADON #609 verified Former Resident #53 was on top of Resident #22 in Resident #53's bed and both of their pants were down. They verified Former Resident #53 had a diagnosis of Hepatitis C and as precaution PCP #610 had ordered lab testing for Resident #22. They also verified the police were not contacted regarding the incident and that there was no documentation Former Resident #53's guardian was asked regarding police involvement. They verified Resident #22 had a friend listed as her POA of finance, but the friend did not want anything to do with her healthcare. When asked who made Resident #22's decisions since she had severe cognitive impairment they stated that nobody did right now. They verified the incident was not reported to the state agency including making a self-reported incident and they had only completed an internal investigation. Interview on 04/22/26 at 3:47 P.M. with the DON and Infection Control/ADON #609 verified there was not an assessment/evaluation completed prior to the incident on 07/25/25 and/or after it for either Resident #22 or Former Resident #53 whether they had the capacity to consent to sexual activity. They stated they only go by the BIMS score and if the resident scored 12 or above then they would be able to give consent and if they scored below they were not able. They stated they felt both residents, Resident #22 and Former Resident #53 could not give consent for sexual activity based on their BIMS score. Interview on 04/22/26 at 4:21 P.M. with Agency CNA #614 revealed she no longer went to the facility because of the incident on 07/25/25 as she stated it was disturbing it just was not right. She revealed she had walked in and found Former Resident #53 on top of Resident #22 in his bed, and they did not have any clothing on below the waist. She yelled get off of her and he jumped up. She was unsure if sexual activity had occurred as when she yelled he jumped up fast. She assisted Resident #22 off his bed and walked her to the nurse. She stated it was difficult to know if Resident #22 was affected by the incident as she always had a distressed look on her face. Interview on 04/23/26 at 9:53 A.M. with PCP #610 revealed she was the PCP for Resident #22 and Former Resident #53. This surveyor read the nursing note dated 07/25/25 regarding the incident to PCP #610 and in response she stated she was not aware of the explicit details of the incident but she was aware of a potential sexual encounter and they were not sure if penetration had occurred which was why she had ordered the Hepatitis C testing for Resident #22 as Former Resident #53 had a diagnosis of Hepatitis C. She stated Resident #22 could not give informed consent as when she attempted to ask Resident #22 any questions, the resident just looked in her eyes with a blank stare and did not communicate. She felt Former Resident #53 was able to give informed consent for sexual activity as he could verbalize that he wanted to have sex and could give consent. Review of facility policy labeled, Identifying Types of Abuse last revised 2022 revealed sexual abuse was non-consensual sexual conduct of any type with a resident. Sexual abuse incidents included but not limited to unwanted intimate touching of any kind especially breasts and perineal area, and all types of sexual assault or battery. Sexual contact was nonconsensual if the residents appeared to want the contact to occur but lacked the cognitive ability to consent. Residents had the right to engage in consensual activity however anytime there was reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse including evaluating whether the resident had the capacity to consent to sexual activity. Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2025 revealed the purpose of the policy was to ensure residents were free from abuse. Residents had the right to engage in consensual sexual activity; however, anytime the facility had reason to suspect that a resident may not have the capacity to consent to sexual activity the facility would take steps to ensure that the resident was protected from abuse. These steps shall include evaluating whether the resident had capacity to consent to sexual activity. When the facility identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse. The policy revealed the facility would report the alleged violation and investigate within the required timeframes pursuant to Federal and State statutes and regulations. The policy revealed the facility would report the results of all investigation to the Administrator or designee and to other officials including the state survey agency within five working days of the incident.

Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the facility investigation and facility policy, the facility failed to ensure preventative measures were implemented to prevent sexual abuse. This affected three residents (Residents #22, #53 and #54) out of six residents reviewed for abuse. The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed Resident #22's Brief Interview for Mental Status (BIMS) was zero indicating severe cognitive impairment. She required partial to moderate staff assistance with dressing. She was independent with transfers and required supervision with ambulation. Review of the care plan dated 06/30/25 revealed Resident #22 had impaired cognition and impaired thought processes related to Alzheimer's disease. Interventions included asking her yes or no questions to determine needs; cue, reorient and supervise as needed; and keeping her routine consistent. Additional review of the care plan dated 06/30/25 revealed Resident #22 had tearful episodes and was crying out. On 07/25/25 Resident #22 was observed in an inappropriate situation with a male resident. On 12/12/25 Resident #22 was observed in an inappropriate situation with a male resident. There was nothing in her care plan regarding whether she had the capacity to consent to sexual activity or not. Interventions included adjusting voice tone; administering medications as ordered; engaging in activities; leaving over the bed light on for reassurance; psychological consult as needed; frequent observation throughout the shift (added 11/03/25); and checking the resident every 15 minutes (added 12/12/25).Review of nursing note dated 07/25/25 at 4:45 P.M. completed by Agency Licensed Practical Nurse (LPN) #615 revealed prior to dinner the aide informed her that she discovered Resident #22 in bed with another resident. The aide had stated she was checking rooms and looking for Resident #22 and upon walking into Former Resident #53's room she had observed Resident #22 laying beneath Former Resident #53 in the bed and both residents' pants were down. The residents were separated. Review of nursing note dated 12/11/25 at 10:30 P.M. completed by LPN #617 revealed he was notified that when the aides were doing rounds they had noticed Resident #22 was not in her room and they immediately looked in other rooms to find her. Resident #22 was found in another resident's bed (Former Resident #54) with Former Resident #54 sitting beside her. The note revealed both residents were naked with their clothing on the floor. Former Resident #54 had several fingers in her vaginal area and Resident #22 had her legs open allowing access. Both residents were separated and Resident #22 was dressed and taken to her room. Both residents were checked, no injuries were noted and both residents were placed on 15-minute checks. Primary Care Physician (PCP) #610 was notified. Review of Kardex (a brief overview/guideline of a resident) for Resident #22 dated 04/23/26 revealed under behaviors staff were to distract from wandering by offering pleasant diversions, structured activities, food conversation, and television. Other interventions included adjusting voice and tone; behavior monitoring (no specifics identified); and reapproaching as needed. There was nothing on the Kardex regarding 15-minute checks as per the care plan and there was nothing on the Kardex about sexual inappropriate behaviors. 2. Review of the closed medical record for Former Resident #53 revealed he was admitted on [DATE] and discharged on 09/26/25. His diagnoses included dementia, viral hepatitis C (a liver disease caused by a virus that spreads when blood from an infected person enters another), antisocial personality disorder, and high risk of heterosexual behavior (sexual practices that significantly increase likelihood of sexually transmitted infections) which was added on 07/29/25. He was assigned by the courts a legal guardian and there was nothing in his medical record regarding if Former Resident #53 was evaluated whether he had the capacity to consent to sexual activity. Review of the care plan dated 11/20/24 revealed Former Resident #53 had impaired cognition related to dementia. Interventions included approaching the resident to maximize involvement daily and communicating with the resident regarding his needs. There was nothing in his care plan regarding whether he had the capacity to consent to sexual activity or not. Review of the Quarterly MDS dated [DATE] revealed Former Resident #53 had cognitive impairment as his BIMS was 11. He was independent and/or only required set-up with his activities of daily living tasks including dressing, transfers and ambulation. Review of nursing note dated 07/25/25 at 4:45 P.M. completed by LPN #615 revealed she was informed by the aide prior to dinner upon checking rooms that Resident #22 was discovered in Former Resident #53's room with him lying on top of her in his bed. The two residents were immediately separated and the Director of Nursing (DON) contacted. Former Resident #53 had stated Resident #22 had come into his room, sat on his bed, he rubbed her leg and the aide came in. 3. Review of the closed medical record for Former Resident #54 revealed an admission date of 11/22/25 and he was discharged home on [DATE]. His diagnoses included brief psychotic disorder, dementia, agitation, and hypertension. There was nothing in his medical record regarding if Former Resident #54 was evaluated whether he had the capacity to consent to sexual activity. Review of the Medicare Five Day MDS dated [DATE] revealed Former Resident #54 had impaired cognition as his BIMS score was three. Review of the nursing note dated with a late entry of 12/12/25 at 9:58 A.M. completed by LPN #617 revealed he was notified that when the aides were doing rounds they had noticed Resident #22 was not in her room and they immediately looked in other rooms to find her. Resident #22 was found in another resident's bed (Former Resident #54) with Former Resident #54 sitting beside her. Both residents were naked with their clothing on the floor. Former Resident #54 had several fingers in her vaginal area and Resident #22 had her legs open allowing access. Both residents were separated and Resident #22 was dressed and taken to her room. Both residents were checked, no injuries were noted and both residents were placed on 15-minute checks. PCP #610 was notified. 4. Review of witness statement dated 07/25/25 completed by Agency Certified Nursing Assistant (CNA) #614 revealed she came off break at 3:45 P.M., Resident #22 had walked up to her at the nursing station, and she also had seen Former Resident #53. She started her rounds, taking residents into the dining room and then started to look for Resident #22 room to room. She walked into Former Resident #53's room at 4:40 P.M. and Former Resident #53 was on top of Resident #22 on his bed with both their pants down. Agency CNA #614 did not see Resident #53's genitals inside her vagina and she had separated the residents immediately. Review of witness statement dated 07/25/25 completed by Agency LPN #615 revealed the CNA reported to her that upon looking for Resident #22 that she walked past Former Resident #53's room to find Former Resident #53 on top of Resident #22 and both their pants were down. The CNA immediately separated the residents, and she contacted the Former Director of Nursing (DON) #625. Review of witness statement dated 07/25/25 completed by Former Administrator #626 and MDS/Registered Nurse (RN) #627 revealed they interviewed Former Resident #53, and he had stated he was sitting on his bed when the lady came into his room and sat on his bed. He stated she did not say anything, she was just looking at him, and he was rubbing her leg. He stated she had black pants on, and a top and the aide came in and said, Both y'all get up. He denied kissing her and stated that both of their pants were on. Interview on 04/22/26 at 12:45 P.M. with Regional Director #612, Regional Nurse/Registered Nurse (RN) #600, and Infection Control/ADON #609 verified Former Resident #53 was on top of Resident #22 in Resident #53's bed and both of their pants were down. They verified Former Resident #53 had a diagnosis of Hepatitis C and as precaution PCP #610 had ordered lab testing for Resident #22. They also verified the police were not contacted regarding the incident and that there was no documentation Former Resident #53's guardian was asked regarding police involvement. They verified Resident #22 had a friend listed as her POA of finance, but the friend did not want anything to do with her healthcare. When asked who made Resident #22's decisions since she had severe cognitive impairment they stated that nobody did right now. They verified the incident was not reported to the state agency including making a self-reported incident and they had only completed an internal investigation. Interview on 04/22/26 at 3:47 P.M. with the DON and Infection Control/ADON #609 verified there was not an assessment/evaluation completed prior to the incident on 07/25/25 and/or after it for either Resident #22 or Former Resident #53 whether they had the capacity to consent to sexual activity. They stated they only go by the BIMS score and if the resident scored 12 or above then they would be able to give consent and if they scored below they were not able. They stated they felt both residents, Resident #22 and Former Resident #53 could not give consent for sexual activity based on their BIMS score. Interview on 04/22/26 at 4:21 P.M. with Agency CNA #614 revealed she no longer went to the facility because of the incident on 07/25/25 as she stated it was disturbing it just was not right. She revealed she had walked in and found Former Resident #53 on top of Resident #22 in his bed, and they did not have any clothing on below the waist. She yelled get off of her and he jumped up. She was unsure if sexual activity had occurred as when she yelled he jumped up fast. She assisted Resident #22 off his bed and walked her to the nurse. She stated it was difficult to know if Resident #22 was affected by the incident as she always had a distressed look on her face. 5. Review of SRI #268530 dated 12/11/25 for alleged sexual abuse with another resident revealed on 12/11/25 at 10:30 P.M. an aide observed two residents, Former Resident #54 and Resident #22, engaged in inappropriate touch on the secured dementia unit. The residents were immediately separated, assessed by the nurse and placed on 15-minute checks. No injuries were identified. On 12/13/25, Former Resident #54 was discharged home with his wife. The facility unsubstantiated the SRI for sexual abuse. Review of witness statement dated 12/11/25 completed by LPN #617 revealed during rounds, the aides noticed that Resident #22 was not in her room and found her in Former Resident #54's room. Both residents were naked and their clothing was on the floor. The aide observed Former Resident #54 with his hand in Resident #22's groin region. The aide immediately separated them and called for assistance. Skin checks were completed, 15-minute checks were implemented, and PCP #610 was notified. Review of witness statement dated 12/11/25 completed by CNA #619 revealed on 12/11/25 around 10:30 P.M. they were completing rounds and when checking, Resident #22 was not in her bed. Another aide went into Former Resident #54's room, hollered out for her and saw Resident #22's pants and incontinent pull-up was off and Former Resident #54 naked. Former Resident #54 had stated, she wanted. Both residents were separated and they got the nurse. Review of witness statement dated 12/11/25 and completed by CNA #618 revealed on 12/11/25 at 10:30 P.M. she was doing rounds and could not find Resident #22. She went looking room to room and walked into Former Resident #54's room and he had the curtain pulled. She walked over, pulled the curtain and saw Resident #22 with her pants and incontinent pull-up off and Former Resident #54 naked. Former Resident #54 had his fingers in her vagina and stated she wanted it. She pulled him away and called for help. Interview on 04/23/26 at 7:58 A.M. with CNA #603 revealed she worked on the second floor Monday through Thursday where Resident #22 resided and was not aware of anyone on special checks including 15-minute checks. She checked on each resident every hour including Resident #22. Interview on 04/23/26 at 8:03 A.M. with Agency RN #620 revealed it was his first time at the facility, and he was assigned to the second floor where Resident #22 resided. He was not aware of any residents on the unit that were on special monitoring including 15-minute checks and had not received anything in report. Interview on 04/23/26 at 8:06 A.M. with CNA #605 revealed she worked on the second floor Monday through Thursday, where Resident #22 resided and was not aware of anyone on special checks including 15-minute checks. She routinely checked all residents but there were no formal checks that she was aware of. Interview on 04/23/26 at 9:53 A.M. with PCP #610 revealed she was the PCP for Resident #22 and Former Resident #53. This surveyor read the nursing note dated 07/25/25 regarding the incident to PCP #610 and in response she stated she was not aware of the explicit details of the incident but she was aware of a potential sexual encounter and they were not sure if penetration had occurred which was why she had ordered the Hepatitis C testing for Resident #22 as Former Resident #53 had a diagnosis of Hepatitis C. She stated Resident #22 could not give informed consent as when she attempted to ask Resident #22 any questions, the resident just looked in her eyes with a blank stare and did not communicate. She felt Former Resident #53 was able to give informed consent for sexual activity as he could verbalize that he wanted to have sex and could give consent. PCP #610 was asked what preventative interventions were ordered after the incident on 07/25/25 and she stated there was a facility protocol they followed for a sexually inappropriate incident, but she did not know it off hand and would have to get it from the facility. She was not sure what monitoring standards they had in place. This surveyor read the incident that had occurred on 12/11/25 and PCP #610 stated the incident did not sound familiar and did not feel she was notified. She was not familiar with who Former Resident #54 was and did not feel she ever met him, so she was unable to provide whether he was able to give informed consent for sexual activity. She revealed after both incidents were reviewed what recommendations and/or interventions were needed to ensure safety. She stated if she had known about the second incident, to be honest it was not feasible to keep Resident #22 and other residents safe especially with only having two aides on the second floor. Resident #22 almost needed one-on-one because whenever she was at the facility, Resident #22 ambulated all over, and was fast as she had to chase her around just to get an assessment completed. She stated either one-on-one or a facility with all women as, I do not see how to keep her and others safe otherwise. Interview on 04/23/26 at 10:15 A.M. with Regional Nurse/RN #600, DON and Infection Control/ADON #609 verified they were not aware of a protocol that the facility implemented if an incident of alleged sexual abuse occurred or standard protocols that were to be implemented including specific monitoring. They verified per the care plan Resident #22 was to be on 15-minute checks but on staff interviews staff were not completing it. They revealed they felt it was a documentation error as Resident #22 was to be no longer on 15-minute checks and that was why staff were not doing them. They stated they were unaware PCP #610 was not aware of the incident on 12/11/25 involving Resident #22 and Former Resident #54, and unaware PCP #610 felt the only way to keep Resident #22 safe, as well as others, was with one-on-one or a facility with all women since PCP #610 had not shared that with them. Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2025 revealed the purpose of the policy was to ensure residents were free from abuse. Residents had the right to engage in consensual sexual activity; however, anytime the facility had reason to suspect that a resident may not have the capacity to consent to sexual activity the facility would take steps to ensure that the resident was protected from abuse. These steps included evaluating whether the resident had the capacity to consent to sexual activity. When the facility identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse. The facility would develop written procedures to determine whether the resident was protected, risk factors that contributed to the abuse, whether there is further need for systemic action such as insight on needed revisions to procedures, increased training, measure and verify the implementation of corrective actions, and tracking patterns for similar occurrences.

Based on record review, interview, and review of Self-Reported Incident (SRI) #268530 and the facility investigation, the facility failed to ensure Resident #22 was provided medically related social service to attain the highest practicable wellbeing by seeking guardianship to assist with decision making. This affected one resident (Resident #22) out of six residents reviewed for social service needs. This had the potential to affect four residents (Residents #15, #18, #22 and #37) who were identified by the facility as residents unable to make informed decisions without a guardian and/or responsible party. The facility census was 50. Findings include: Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed Resident #22's Brief Interview for Mental Status (BIMS) was zero indicating severe cognitive impairment. She required partial to moderate staff assistance with dressing. She was independent with transfers and required supervision with ambulation. Review of the care plan dated 06/30/25 revealed Resident #22 had impaired cognition and impaired thought processes related to Alzheimer's disease. Interventions included asking her yes or no questions to determine needs; cue, reorient and supervise as needed; and keeping her routine consistent. Additional review of the care plan dated 06/30/25 revealed Resident #22 had tearful episodes and was crying out. On 07/25/25 Resident #22 was observed in an inappropriate situation with a male resident. On 12/12/25 Resident #22 was observed in an inappropriate situation with a male resident. There was nothing in her care plan regarding whether she had the capacity to consent to sexual activity or not. Interventions included adjusting voice tone; administering medications as ordered; engaging in activities; leaving over the bed light on for reassurance; psychological consult as needed; frequent observation throughout the shift (added 11/03/25); and checking the resident every 15 minutes (added 12/12/25).Review of nursing note dated 07/25/25 at 4:45 P.M. completed by Agency Licensed Practical Nurse (LPN) #615 revealed prior to dinner the aide informed her that she discovered Resident #22 in bed with another resident. The aide had stated she was checking rooms and looking for Resident #22 and upon walking into Former Resident #53's room she had observed Resident #22 laying beneath Former Resident #53 in the bed and both residents' pants were down. The residents were separated. Review of witness statement dated 07/25/25 completed by Agency Certified Nursing Assistant (CNA) #614 revealed she came off break at 3:45 P.M., Resident #22 had walked up to her at the nursing station, and she also had seen Former Resident #53. She started her rounds, taking residents into the dining room and then started to look for Resident #22 room to room. She walked into Former Resident #53's room at 4:40 P.M. and Former Resident #53 was on top of Resident #22 on his bed with both their pants down. Agency CNA #614 did not see Resident #53's genitals inside her vagina and she had separated the residents immediately. Review of nursing note dated 12/11/25 at 10:30 P.M. completed by LPN #617 revealed he was notified that when the aides were doing rounds they had noticed Resident #22 was not in her room and they immediately looked in other rooms to find her. Resident #22 was found in another resident's bed (Former Resident #54) with Former Resident #54 sitting beside her. The note revealed both residents were naked with their clothing on the floor. Former Resident #54 had several fingers in her vaginal area and Resident #22 had her legs open allowing access. Both residents were separated and Resident #22 was dressed and taken to her room. Both residents were checked, no injuries were noted and both residents were placed on 15-minute checks. Primary Care Physician (PCP) #610 was notified. Review of SRI #268530 dated 12/11/25 for alleged sexual abuse with another resident revealed on 12/11/25 at 10:30 P.M. an aide observed two residents, Former Resident #54 and Resident #22, engaged in inappropriate touch on the secured dementia unit. The residents were immediately separated, assessed by the nurse and placed on 15-minute checks. No injuries were identified. On 12/13/25, Former Resident #54 was discharged home with his wife. The facility unsubstantiated the SRI for sexual abuse. Review of witness statement dated 12/11/25 and completed by CNA #618 revealed on 12/11/25 at 10:30 P.M. she was doing rounds and could not find Resident #22. She went looking room to room and walked into Former Resident #54's room and he had the curtain pulled. She walked over, pulled the curtain and saw Resident #22 with her pants and incontinent pull-up off and Former Resident #54 naked. Former Resident #54 had his fingers in her vagina and stated she wanted it. She pulled him away and called for help. Review of Kardex (a brief overview/guideline of a resident) for Resident #22 dated 04/23/26 revealed under behaviors staff were to distract from wandering by offering pleasant diversions, structured activities, food conversation, and television. Other interventions included adjusting voice and tone; behavior monitoring (no specifics identified); and reapproaching as needed. There was nothing on the Kardex regarding 15-minute checks as per the care plan and there was nothing on the Kardex about sexual inappropriate behaviors. Interview on 04/22/26 at 12:45 P.M. with Regional Director #612, Regional Nurse/Registered Nurse (RN) #600, and Infection Control/ADON #609 verified Former Resident #53 was on top of Resident #22 in Resident #53's bed and both of their pants were down. They verified Former Resident #53 had a diagnosis of Hepatitis C and as precaution PCP #610 had ordered lab testing for Resident #22. They also verified the police were not contacted regarding the incident and that there was no documentation Former Resident #53's guardian was asked regarding police involvement. They verified Resident #22 had a friend listed as her POA of finance, but the friend did not want anything to do with her healthcare. When asked who made Resident #22's decisions since she had severe cognitive impairment they stated that nobody did right now. They verified the incident was not reported to the state survey agency including making a self-reported incident and they had only completed an internal investigation. Interview on 04/22/26 at 3:47 P.M. with the DON and Infection Control/ADON #609 verified there was not an assessment/evaluation completed prior to the incident on 07/25/25 and/or after it for either Resident #22 or Former Resident #53 whether they had the capacity to consent to sexual activity. They stated they only go by the BIMS score and if the resident scored 12 or above then they would be able to give consent and if they scored below they were not able. They stated they felt both residents, Resident #22 and Former Resident #53 could not give consent for sexual activity based on their BIMS score. They also verified after the incident on 12/11/25 Resident #22 was not assessed if she was able to consent for sexual activity. They revealed they did not have a policy regarding guardianship or residents with cognitive impairment and making informed decisions. Interview on 04/22/26 at 2:13 P.M. with Social Service Designee (SSD) #616 verified Resident #22 could not make her own decisions due to severe cognitive impairment and that she had scored a zero on her BIMS assessment. She revealed the current POA for finance did not want anything to do with her healthcare decisions and that Resident #22 needed a guardian. There was nothing documented regarding attempts at getting Resident #22 a guardian. She had just started in the position in February 2026 and was trying to figure things out but was not aware of any prior interventions trying to get a guardian for Resident #22. She was asked who then made Resident #22's healthcare decisions and she stated, I guess us, there is nobody else to make her decisions and she cannot make decisions. She stated the facility made her decisions for her. Interview on 04/23/26 at 9:53 A.M. with PCP #610 revealed Resident #22 could not give informed consent as when she attempted to ask Resident #22 any questions, the resident just looked in her eyes with a blank stare and did not communicate. She stated after review of both incidents on 07/25/25 and 12/11/25 and asked what recommendations and/or interventions were needed to ensure safety, to be honest it was not feasible to keep Resident #22 and other residents safe especially with only having two aides on the second floor. Resident #22 almost needed one-on-one because whenever she was at the facility, Resident #22 ambulated all over, and was fast as she had to chase her around just to get an assessment completed. She stated either one-on-one or a facility with all women as, I do not see how to keep her and others safe otherwise.Interview on 04/23/26 at 10:15 A.M. with Regional Nurse/RN #600, DON and Infection Control/ADON #609 revealed they were unaware PCP #610 was not aware of the incident on 12/11/25 involving Resident #22 and Former Resident #54, and unaware PCP #610 felt the only way to keep Resident #22 safe, as well as others, was with one-on-one or a facility with all women since PCP #610 had not shared that with them.

Based on record review, interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors by providing residents with antibiotic (ATB) therapy in a timely manner and in accordance with physician orders. This affected two residents (Residents #39, and #51) out of three residents reviewed for ATB therapy. The facility census was 50.Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 10/16/25 and he was discharged to the hospital on [DATE]. His diagnoses on admission included enterocolitis due to Clostridium Difficile (C-Diff) (a highly contagious bacterium that causes severe diarrhea and inflammation of colon), hypertension, malignant neoplasm of the prostate, and chronic kidney disease.Review of October 2025 physician orders revealed Resident #51 had an order dated 10/16/25 for fidaxomicin (ATB) oral tablet 200 milligram (mg) give one tablet by mouth every morning and at bedtime for five days due to C-Diff. Review of October 2025 Medication Administration Record (MAR) revealed Resident #51 had an order for fidaxomicin oral tablet 200 mg give one tablet by mouth every morning and at bedtime for five days due to C-Diff and the MAR indicated the following doses were not given: the 10/16/25 bedtime dose; the 10/17/25 morning and bedtime dose; and the 10/18/25 morning dose (a total of four doses).Review of Hospital Discharge Medication List for Resident #51 dated 10/16/25 revealed upon discharge from the hospital he had an order for fidaxomicin oral tablet 200 mg give one tablet by mouth every morning and at bedtime for five days due to C-Diff. The last dose he received in the hospital was on 10/16/25 at 7:29 A.M.Review of nursing note dated 10/16/25 at 5:55 P.M. completed by Licensed Practical Nurse (LPN) #617 revealed Resident #51 was admitted to the facility. Review of the Medicare Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment as he was rarely and/or never understood. Review of nursing note dated 10/18/25 at 6:00 P.M. completed by LPN #629 revealed Resident #51's daughter came into the facility on [DATE] at approximately 10:30 A.M. inquiring about his ATB therapy (fidaxomicin) and the nurse informed the daughter that the medication was not in from pharmacy and that she would get more information as to why the medication was not available. The nurse informed the daughter that the facility had received an Expensive Medication Authorization Form, and they were reaching out to Primary Care Physician (PCP) #610 to see what medication she wanted the fidaxomicin changed to. The note then revealed Resident #51's daughter requested Resident #51 be sent to the ER. Review of emergency room (ER) progress note dated 10/18/25 completed by ER Physician #628 revealed Resident #51 was in the ER for medication administration as he had not received his ATB for C-Diff in two days because the nursing home stated it was too expensive to be given. The note revealed Resident #51 had been in the hospital prior from 10/09/25 to 10/16/25 and was diagnosed with C-Diff and ordered fidaxomicin per infectious disease. The ER had administered his fidaxomicin on 10/18/25 at 6:24 P.M. and he was discharged home with family and a prescription for the remaining doses of fidaxomicin. Interview on 04/21/26 at 2:53 P.M. with Infection Control/Assistant Director of Nursing (ADON) #609 revealed she received a call from the facility nurse on 10/18/25 that Resident #51's daughter was upset that he had not started his ATB. She contacted pharmacy and the medication was not covered and would have cost over two thousand dollars for ten tablets. She contacted PCP #610 who was going to look at researching why the medication was ordered from the hospital but before she was able Resident #51's daughter requested he be sent to the hospital because he had not received his ATB since admission [DATE]). Interview on 04/21/26 at 3:05 P.M. with PCP #610 revealed he was ordered fidaxomicin by infectious disease through the hospital for C-Diff. She stated usually any resident ordered this medication needed the medication because they most likely already had trialed a course of a different ATB that was not effective. She felt infectious disease had ordered Resident #51 the medication because they felt he needed it despite how expensive the medication was. She felt where it went wrong was prior to admission the facility needed to review Resident #51's medications and make the decision prior to admission if they were able to accommodate including the cost of his medication or if not then they should not have admitted him. She stated the facility should have been prepared and the medication given in a timely manner after he was admitted . She was not aware he had missed doses until Resident #51's daughter was upset and requested he was sent to the ER.Interview on 04/21/26 at 3:15 A.M. with Regional Nurse/RN #600, Director of Nursing (DON), and Infection Control/ADON #609 revealed the last dose of fidaxomicin Resident #51 had received was on 10/16/25 at 7:29 A.M. in the hospital and verified he was to receive it by mouth every morning and at bedtime for five days due to C-Diff. They verified Resident #51 did not receive the following doses of medication: the 10/16/25 bedtime dose; the 10/17/25 morning and bedtime dose; and the 10/18/25 morning dose. They had no documentation PCP #610 was aware he had missed the doses until Resident #51's daughter requested he was sent to the ER due to the missed doses. 2. Review of the medical record for Resident #39 revealed an admission date of 05/06/24 and her diagnoses included chronic obstructive pulmonary disease with acute exacerbation, schizoaffective disorder, and bipolar disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #39 had intact cognition but had delusions.Review of progress note dated 03/27/26 at 4:28 P.M. completed by Nurse Practitioner (NP) #630 revealed Resident #39 was examined due to sinus symptoms and acute cough. Resident #39 had stated she had sinus pressure, nasal congestion and a nonproductive cough. NP #630 ordered Augmentin (ATB) 500-125 mg by mouth twice a day for seven days. Review of March 2025 Physician Orders revealed Resident #39 had an order dated 03/28/26 for Augmentin 500-125 mg tablet give one tablet by mouth two times a day for seven days for acute frontal sinusitis. Review of March 2025 MAR revealed an order for Augmentin 500-125 mg give one tablet by mouth two times a day for acute frontal sinusitis dated 03/28/26 at 8:00 A.M. The MAR was blank on 03/28/26 at 8:00 A.M. and 4:00 P.M., and 03/29/26 at 8:00 A.M. and 4:00 P.M. which indicated Resident #39 did not receive the medication. The first dose of Augmentin Resident #39 received was on 03/30/26 at 8:00 A.M.Interview on 04/21/26 at 8:38 A.M. with Resident #39 denied any concerns with medication administration. Interview on 04/22/26 at 3:47 P.M. and 4:15 P.M. with DON and Infection Control/ADON #609 verified Resident #39 was ordered Augmentin 500-125 mg by mouth twice a day for seven days per NP #630's progress note dated 03/27/26 and she had not received the first dose until 03/30/26 at 8:00 A.M. They revealed NP #630 had put the order in her progress note on 03/27/26 but the facility was not aware. They verified an order was written on 03/28/26 at 8:00 A.M. for Augmentin but stated most likely because it was the weekend the nurse did not take the initiative to follow through. They revealed most weekends the facility staffs the facility with agency nurses, and they do not have access to the emergency medication box (a box the facility had at the facility of common medication including ATBs) and that was the reason the medication was not pulled from the emergency medication box to start it on time and/or the agency nurse did not contact pharmacy to check on the delivery. They verified the Augmentin was in the emergency medication box. They confirmed all ATBs were to be administered right away unless there was an order from the physician approving the ATB to be given later. Review of facility policy labeled, Administering Medication dated 2001 revealed medications were to be administered in a safe and timely manner as prescribed. Medications were administered in accordance with orders including required time frame including within one hour of prescribed time unless otherwise specified. If the drug was withheld, refused or given at a time other than scheduled time the individual administering the medication would initial and circle the MAR space provided. There was nothing in the policy regarding notifying the physician of withheld doses of medications. This deficiency represents non-compliance investigated under Complaint Number 2655931.

Based on record review, interview, facility self-reported incident (SRI) and investigation review, the facility failed to ensure a SRI was thoroughly investigated related to an allegation of resident-to-resident sexual abuse. This affected two residents (#16 and #49) of five residents reviewed for abuse. The facility census was 47. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 05/06/24. Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease, restlessness and agitation, and anxiety. Review of the care plan dated 05/01/25 revealed Resident #16 wandered up and down hallways and into other resident's rooms. Interventions included engaging the resident in activities, moving him into a less stimulating area and redirecting him as needed. Resident #16 also made sexually inappropriate advances towards staff members and mistook a female resident as his wife, becoming verbally and physically aggressive when redirected. Interventions included analyzing key times, places, circumstances, and triggers and documenting, assessing, and anticipating the residents' needs, administering medication as ordered and psychiatric consultations as needed. Review of the nursing dated 06/21/25 at 6:15 P.M. revealed Resident #16 was noted to be completely naked sitting on the side of his bed. The behavior was identified as new for the resident, and he was placed on 15-minute checks while he was in his room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. He required setup help for eating, oral hygiene, toileting, supervision for showering and substantial or maximum assistance for personal hygiene. He displayed behaviors including but not limited to hitting or scratching himself, pacing, public sexual acts, and disrobing in public. Review of the Psychiatric Nurse Practitioner (NP) #202's note dated 07/02/25 revealed she was asked to see Resident #16 due to an episode of sexually inappropriate behavior. According to facility staff, Resident #16 was found nude and exposed himself to another resident. The Director of Nursing (DON) revealed Resident #16 had been on medication in the past for sexually inappropriate behaviors. She placed Resident #16 on Tagamet for sexually inappropriate behavior. Review of the physicians' orders for August 2025 revealed an order for Tagamet 200 milligrams (mg) at bedtime for unspecified mood disorder. The order began on 07/04/25. 2. Review of the medical record for Resident #49 revealed an admission date of 08/18/21 and a discharge date of 08/18/25. Diagnoses included dementia, anxiety, insomnia, depression and a need for assistance with personal care. Review of the care plan dated 06/10/25 revealed Resident #49 had a communication problem and was able to respond with general, yes or no responses. Interventions included anticipating the resident's needs, encouraging the resident to state her thoughts even if having difficulty, asking yes or no questions, and monitoring for physical or nonverbal indicators of distress. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. She was dependent on staff for all activities of daily living and displayed no behaviors. Review of the nursing note dated 08/13/25 at 9:00 P.M. revealed Resident #16 was observed in Resident #49's room sitting on her bed. Resident #49's incontinence brief was opened and down. Resident #16 was observed rubbing Resident #49's private area inappropriately. Resident #16 was asked to leave the room and placed on one-to-one supervision. Both Resident #16 and Resident #49's physicians and responsible parties were notified. Review of SRI tracking number 264021 dated 08/13/25 revealed on 08/13/25 at approximately 9:00 P.M., Licensed Practical Nurse (LPN) #200 observed Resident #16 in Resident #49's room sitting on her bed. Resident #16 was observed rubbing Resident #49's private area inappropriately. LPN #200 asked Resident #16 to leave the room, and he was placed on one-to-one supervision. The Administrator and DON were notified. LPN #200 and the DON performed a full body assessment on Resident #49, and no injuries were noted. Resident #49's physician was notified, and she was placed on 15-minute checks. Witness statements obtained in the investigation revealed no evidence when Resident #16 was last seen or checked on by staff prior to the incident to determine how long the Resident #16 was in Resident #49's room. Interview on 08/26/25 at 10:14 A.M. with the DON revealed he received a call from LPN #200 on 08/13/25 informing him Resident #16 was sitting on Resident #49's bed. Resident #49 was described as sitting on the edge of her bed with her incontinence brief down. Resident #16 was touching her private area. LPN #200 immediately separated the residents and assessed Resident #49; no negative findings were discovered. Resident #16 was placed on one-to-one supervision, and Resident #49 was placed on 15-minute checks. Both residents' physicians and families were notified. A referral was made to a psychiatric inpatient facility for Resident #16; Resident #16 remained on one-to-one supervision until the transfer to the inpatient psychiatric facility took place. Resident #49 was seen by her psychiatric care team the following day and was assessed with no changes in psychiatric or mental status noted. The DON denied having any knowledge Resident #16 had any history of sexually inappropriate behaviors. Interview on 08/27/25 at 7:25 A.M. with Social Service Designee (SSD) #208 revealed she was aware Resident #16 had a history of wandering but was generally redirectable. She could not verify when the resident had last been checked on prior to the incident and confirmed the resident was not on any type of increased supervision or checks at the time of the incident. She verified the investigation could have been more thorough and included more specific information regarding when Resident #16 had last been seen to determine how long Resident #16 was in Resident #49's room. Interview on 08/28/25 at 3:57 P.M. with LPN #200 revealed she entered Resident #49's room to give her medications and saw Resident #16 sitting on her bed. Resident #49's incontinence brief was open, and his fingers were in her vagina. She could not recall if she asked him what he was doing or what Resident #49's reaction was to the situation. She could not verify what time she had seen either resident prior to the incident. The facility did not have a policy related to investigation of SRI's. This deficiency represents noncompliance investigated under Complaint Number 2959789.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #16, who was cognitively impaired and had a history of wandering and sexually inappropriate behaviors, received appropriate supervision to ensure the safety of Resident #49. This affected two residents (#16 and #49) of five reviewed for abuse and behavior monitoring. The facility census was 47. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 05/06/24. Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease, restlessness and agitation, and anxiety. Review of the care plan dated 05/01/25 revealed Resident #16 wandered up and down hallways and into other resident's rooms. Interventions included engaging the resident in activities, moving him into a less stimulating area and redirecting him as needed. Resident #16 also made sexually inappropriate advances towards staff members and mistook a female resident as his wife, becoming verbally and physically aggressive when redirected. Interventions included analyzing key times, places, circumstances, and triggers and documenting, assessing, and anticipating the residents' needs, administering medication as ordered and psychiatric consultations as needed. Review of the nursing dated 06/21/25 at 6:15 P.M. revealed Resident #16 was noted to be completely naked sitting on the side of his bed. The behavior was identified as new for the resident, and he was placed on 15-minute checks while he was in his room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. He required setup help for eating, oral hygiene, toileting, supervision for showering and substantial or maximum assistance for personal hygiene. He displayed behaviors including but not limited to hitting or scratching himself, pacing, public sexual acts, and disrobing in public. Review of the psychiatric Nurse Practitioner (NP) #202's note dated 07/02/25 revealed she was asked to see Resident #16 due to an episode of sexually inappropriate behavior. According to facility staff, Resident #16 was found nude and exposed himself to another resident. The Director of Nursing (DON) revealed Resident #16 had been on medication in the past for sexually inappropriate behaviors. She placed Resident #16 on Tagamet for sexually inappropriate behavior. Review of the physicians' orders for August 2025 revealed an order for Tagamet 200 milligrams (mg) at bedtime for unspecified mood disorder. The order began on 07/04/25. 2. Review of the medical record for Resident #49 revealed an admission date of 08/18/21 and a discharge date of 08/18/25. Diagnoses included dementia, anxiety, insomnia, depression and a need for assistance with personal care. Review of the care plan dated 06/10/25 revealed Resident #49 had a communication problem and was able to respond with general, yes or no responses. Interventions included anticipating the resident's needs, encouraging the resident to state her thoughts even if having difficulty, asking yes or no questions, and monitoring for physical or nonverbal indicators of distress. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. She was dependent on staff for all activities of daily living and displayed no behaviors. Review of the nursing note dated 08/13/25 at 9:00 P.M. revealed Resident #16 was observed in Resident #49's room sitting on her bed. Resident #49's incontinence brief was opened and down. Resident #16 was observed rubbing Resident #49's private area inappropriately. Resident #16 was asked to leave the room and placed on one-to-one supervision. Both Resident #16 and Resident #49's physicians and responsible parties were notified. Interview on 08/26/25 at 10:14 A.M. with the DON revealed he received a call from Licensed Practical Nurse (LPN) #200 on 08/13/25 informing him Resident #16 was sitting on Resident #49's bed. Resident #49 was described as sitting on the edge of her bed with her incontinence brief down. Resident #16 was touching her private area. LPN #200 immediately separated the residents and assessed Resident #49; no negative findings were discovered. Resident #16 was placed on one-to-one supervision, and Resident #49 was placed on 15-minute checks. Both residents' physicians and families were notified. A referral was made to a psychiatric inpatient facility for Resident #16; Resident #16 remained on one-to-one supervision until the transfer to the inpatient psychiatric facility took place. Resident #49 was seen by her psychiatric care team the following day and was assessed with no changes in psychiatric or mental status noted. The DON denied having any knowledge Resident #16 had any history of sexually inappropriate behaviors. Interview on 08/26/25 at 1:19 P.M. with LPN #203 revealed Resident #16 did have a history of wandering, he typically wandered into other people's bedrooms and bathrooms. She said the facility did the best they could in redirecting and monitoring him, but she had no knowledge of the resident being on any type of increased supervision prior to the incident with Resident #49. Interview on 08/26/25 at 1:25 P.M. with Certified Nurse Aide (CNA) #204 revealed she had no knowledge of Resident #16 ever being sexually inappropriate with any other resident; however, she was aware that he wandered and while it was difficult at times, the facility attempted to redirect him as much as possible. She confirmed there was no increased level of supervision immediately prior to the incident occurring with Resident #49, and no tracking in place to verify when Resident #16 had last been checked on. Interview on 08/26/25 at 2:07 P.M. with Resident #49's sister revealed she was aware Resident #16 had a history of wandering, and during her visits to the facility, she felt he had been wandering more frequently prior to the incident, in and out of people's rooms and sitting on their beds. She visited Resident #49 the morning after the incident was reported to her and revealed Resident #49 gave no indication of the incident the night prior and did not seem in any distress. She spoke with the former Administrator who confirmed Resident #16 was being transferred for psychiatric care but may return to the facility upon discharge. Resident #49's sister spoke with her family and felt it was in Resident #49's best interest to have her moved to a different facility. Interview on 08/27/25 at 7:25 A.M. with Social Service Designee (SSD) #208 revealed she was aware Resident #16 had a history of wandering but was generally redirectable. She could not verify when the resident had last been checked on prior to the incident on 08/13/25, and confirmed there was no discussion of the need for Resident #16 to be on any kind of increased supervision or checks after his visit from psychiatric NP #202 on 07/02/25. Interview on 08/27/25 at 12:48 P.M. with Corporate Risk Manager #207 revealed the psychiatric NP #202 note dated 07/02/25 regarding Resident #16 being sexually inappropriate was in reference to the resident being found sitting naked on his bed on 06/21/25. At that time the facility implemented 15-minute checks while the resident was in his room and discontinued those checks on 07/02/25 when psychiatric NP #202 saw him and started him on medications. Interview on 08/28/25 at 3:57 P.M. with LPN #200 revealed she entered Resident #49's room to give her medications and saw Resident #16 sitting on her bed. Resident #49's incontinence brief was open, and his fingers were in her vagina. She could not recall if she asked him what he was doing or what Resident #49's reaction was to the situation. She could not verify what time she had last seen either resident. She confirmed neither resident was on 15-minute checks, one to one supervision or any other type of additional supervision or monitoring immediately prior to this incident. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated March 2019, revealed The interdisciplinary team (IDT) put evaluate behavioral symptoms to determine the degree of severity, distress and potential safety risk to the resident. Safety strategies would be implemented to protect the resident and others from harm. Interventions would be adjusted based on the impact of the behavior. This deficiency represents noncompliance investigated under Incident Number 2600512 and Complaint Number 2595789.

Based on closed medical record review, review of the facility Resident Transfer and Discharge Policy and interviews, the facility failed to provide a safe discharge to an appropriate location for Resident #49. On 05/20/25 Resident #49 was discharged to a homeless shelter with no referral for follow up care, no access to transportation and no evidence the resident's representative/emergency contact was involved in the discharge planning process or aware of the resident's discharge to the homeless shelter. In addition, there was no evidence Resident #49 was safe to discharge to this location. Upon arrival to the shelter, staff at the shelter identified Resident #49 was not appropriate to remain there and the resident voiced she wanted to return to the facility; however, the facility failed to allow the resident to return. This resulted in Immediate Jeopardy and the potential for actual harm, injury or death beginning on 07/01/25 when Resident #49's, who had diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, depression, anxiety, and cocaine dependence whereabouts could not be determined. This affected one (Resident #49) of three residents reviewed for discharge. The facility census was 47. On 07/02/25 at 4:52 P.M., the Administrator was notified Immediate Jeopardy began on 07/01/25 when the location of Resident #49 could not be determined after the facility discharged the resident (on 05/20/25) to a homeless shelter. Information obtained during the investigation revealed concerns identified by the local ombudsman as well as homeless shelter staff related to the homeless shelter not being an adequate or appropriate and safe discharge location for Resident #49. The Immediately Jeopardy was removed on 07/03/25 when the facility implemented the following corrective actions: • On 07/02/25 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) to discuss an incident report completed by the Administrator and Director of Nursing (DON) regarding the discharge process for Resident #49 who discharged from the facility on 05/20/25. Root cause analysis and preventative measures were discussed. The discharge policy was reviewed, and no changes were made to the policy. Those attending included the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Worker, Minimum Data Set (MDS) nurse, Medical Director, Regional Director of Clinical (RDC), Regional Director of Operations, and Admissions Employee. • On 07/02/25 six of six LPNs, four of four RNs, and one Social Service Designee (SSD)/case manager, admissions director, respiratory therapist received education on safe discharge criteria and federal regulation F627 by the Administrator and/or DON who would validate that the staff read and understood the content by verbal return demonstration. All agency nurses who had worked at the facility from 07/02/25 to 07/08/25 received the education and this would continue for agency nurses for at least two weeks. • On 07/03/25 the Administrator phoned the Youngstown Police Department and contacted the Rescue Mission to see if Resident #49 had been reported as a missing person. The facility plan included if the facility could locate Resident #49 and Resident #49 wanted to return due to being in an unsafe situation, the facility would attempt to get Resident #49 assessed for emergency PAS-RR and level of care as an immediate intervention, including transportation and re-admission if necessary and appropriate. • On 07/03/25 the [NAME] President of Operations expanded staff education related to safe discharge criteria and the regulation at F627 to all staff via the electronic education dissemination and would validate that the staff read and understood the content via return verbal demonstration. • On 07/03/25 the Administrator audited all in-house residents' medical records and care plans for any upcoming plans for discharge, to determine how many residents had plans for discharge and to ensure safe discharge would be completed. The facility identified there were no residents with upcoming discharge, as all current residents were identified as long-term care residents. • On 07/03/25 the Administrator contacted the Ombudsman and Home Choice Program to discuss present and future collaboration regarding discharge planning, in order to prevent reoccurrence. • The facility implemented a plan for the Administrator and/or DON to do monthly audits of 100% of discharges for the next three months prior to discharge to ensure they meet the requirements of F627. • The facility implemented a plan for the Administrator and/or DON to complete an audit on all new admissions to the facility to ensure all new admissions had discharge planning in their care plan per the resident's preference. Audits would be conducted five to seven times a week for four weeks, then as needed, as determined by QAPI meetings. • After three months, the facility would reduce audit frequency as determined by the QAPI committee. Although the Immediate Jeopardy was removed on 07/03/25, the deficiency remains at Severity Level 2 (no actual harm with the 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: Review of the closed medical record for Resident #49 revealed an admission date of 02/21/25 and a discharge date of 05/20/25. Resident #49 had diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, depression, anxiety, and cocaine dependence. Resident #49's sister was listed as her emergency contact. The resident's primary payer type on admission was noted to be Medicaid. Review of Resident #49's referral admission paperwork dated 02/03/25 revealed Resident #49 required assistance for safe medication administration, supervision and direction for activities of daily living (ADL) and medical and mental health management related to diabetes, anxiety, depression and COPD. Record review revealed Resident #49 admitted to the facility from a drug and alcohol rehabilitation center where she had been admitted on [DATE] after a hospitalization for depression. It was noted that the resident had reported being homeless in the Columbus area prior to her hospitalization. The discharge plan from the drug and alcohol rehabilitation center included the resident had come from a drug and alcohol rehab in Cleveland. The resident reported to be homeless in Columbus prior to that stay as well. The discharge plan from the drug rehab including Discharge Planning: Social work to follow patient to establish with primary care provider (PCP). Patient will need to establish with psychiatry for chronic mental health needs. Care team will need to determine the current level of support and recommend a significant comprehensive relapse prevention plan in place at time of discharge. Recommend sober living to provide safe, supportive drug and alcohol-free living environments, to provide peer accountability and support alongside regular drug testing and house meetings and Intensive Outpatient Program (IOP). Sober Living/Medication Assisted Treatment (MAT) provider. Review of the physician's orders for May 2025 revealed the resident had orders for the following medications: Topamax 50 milligrams (mg) every morning and at bedtime for mood disorder, Humalog 100 milliliters (ml) given on a sliding scale before meals and at bedtime for diabetes, Omeprazole 40 mg every morning and at bedtime for indigestion, Quetiapine 25 mg at bedtime for depression, Atorvastatin 40 mg at bedtime for cholesterol, Seroquel 100 mg at bedtime for depression, Amlodipine 10 mg by mouth once per day for hypertension, Duloxetine 60 mg one time per day for depression, Januvia 50 mg one time per day for diabetes, Alogplitin 12.5 mg one time per day for diabetes, Methocarbamol 500 mg three times per day for muscle spasms. In addition, the resident had a physician order for monitoring blood glucose levels every 24 hours for diabetes. Review of the baseline care plan dated 02/21/25 revealed Resident #49's initial discharge plan was to remain in the facility. Review of a facility document titled Care Plan Conference Summary, dated 02/24/25 and authored by Social Service Designee (SSD) #214 revealed Resident #49 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Resident #49's discharge potential was marked homeless. There were no special requests for discharge. Under the summary of discussion section, it was noted D/C (discharge) plan: wants to D/C to Columbus, Ohio, homeless. Sister lives in Columbus, won't let R stay with her. However, no comprehensive care plan was developed or implemented related to the information contained on the care plan conference summary to ensure adequate and proper discharge planning was in place for the resident. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #49 had intact cognition. The assessment included Resident #49 was independent for toileting, required (staff) supervision for dressing and personal hygiene and staff set-up help for eating and oral hygiene. The MDS noted the resident's goal was to discharge to the community. Review of a Case Note Report dated 03/17/25 completed by Long Term Care Consultation (LTCC) Employee #210 revealed an in-person visit was completed at the facility to review generation of participating provider level of care (PAR LOC) with Resident #49 and LTCC Employee #210. The facility social worker was in morning meeting during the LTCC. Documentation on the report revealed Resident #49 appeared alert and oriented to person, place, and time and able to actively participate in the consultation process. Resident #49 reported diabetes, blood clot in lung, mental health diagnosis, and minor weakness. A falls risk tool completed revealed some fall risks were identified at this time, such as weakness, diabetes, and many medications taken. Discussion of in-home services available to reduce fall risks, emergency response system (ERS), as well as encouragement of continued use of durable medical equipment (DME), consultation of physician, and removal of throw rugs and other fall hazards. The assessment revealed Resident #49 required hands-on assistance with instrumental activities of daily living (IADL). (IADL included managing finances, shopping for groceries, preparing meals, housekeeping, transportation, etc.). The documentation included it was not clear if Resident #49 was realistic about all her needs. Resident #49 said she could self-medicate but currently received set-up and prompting. Currently, family and friends could not offer regular support throughout the week. She reported she had a sister in Columbus. No informal support received. She stated she was on a list for apartments from the work of a social worker but does not recall details. All criteria discussed for Medicaid, low-income housing (LIH), home energy assistance program (HEAP), Assisted Living Waiver Program (ALWP), Family Caregiver Support Program (FCSP), and community resources, including Title III and Sr. [NAME]. Information for Veterans Service Commission and services available through Veteran's Affairs (VA) were discussed and offered. Information on community resources was discussed and provided to Resident #49. A Community Service Plan was developed with Resident #49's input for community discharge assistance (Home Choice), Assisted Living (AL) Waiver/PASPORT (Direction Home, and Title III services ([NAME] County). Numbers were provided for utilization. Resident #49 was provided with contact information for all providers mentioned in the Community Plan. Information on the appeal rights process was discussed and how to request a hearing. The note indicated Resident #49 would continue to work with the social worker and call on her own, as requested. Resident #49 was aware she could request another consultation if her needs changed. Contact information, information/pamphlets discussed, and Community Service Plan was completed and provided. Record review revealed no facility comprehensive care plan was developed or implemented related to the information contained on the case note report following the review completed on 03/17/25 to address the resident's discharge planning needs and/or to ensure an adequate and proper discharge planning was in place for the resident Record review revealed a 30-day discharge notice was issued to Resident #49 dated 05/09/25. The document revealed a 30-day discharge notice was issued on this date for non-payment and due to Resident #49 significantly improving enough that she no longer needed services provided by the facility. The proposed discharge location on the 30-day notice was to a homeless shelter- the Rescue Mission of the Mahoning Valley. Review of an Administrator note dated 05/14/25 at 10:57 A.M. revealed Resident #49 received a call from the Ombudsman (#209) concerning the 30-day discharge. The Ombudsman requested the facility assist the resident with an application for Home Choice (the Home Choice program is a Medicaid initiative designed to help adults age [AGE] and over leave long-term institutional settings, like nursing homes, hospitals, or intermediate care facilities, and return to living in their own homes or community-based settings). The note included an application was sent for the Home Choice Program (reference number 202505141C6R). Further review of the medical record revealed no evidence the facility administration had followed up on Resident #49's discharge plan to go to Columbus or to help her apply to Home Choice until the Ombudsman called the facility on 05/14/25. Review of Resident #49's plan of care revealed no care plan was developed related to the resident's desire to discharge to the community or following the referral made to Home Choice. Review of the physician's orders revealed a verbal order dated 05/20/25 from Medical Director #205 to discharge Resident #49. Review of the progress note dated 05/20/25 authored by Admissions #208 revealed Resident #49 was discharged to a local homeless shelter on 05/20/25 via a private vehicle, after Admissions #208 spoke with Director of Women and Families (DWF) #203 (from the homeless shelter) and completed an intake assessment. Resident #49 was discharged with her personal belongings and remaining medications. The note included Resident #49 chose to relocate to the shelter. She did not require home health or medical equipment. Review of the Discharge summary dated [DATE] revealed Resident #49 was discharged to a local homeless shelter with her medications. There was no documented evidence that this information was shared with the Rescue Mission. There were no prescriptions sent, and no follow-up appointments scheduled. Review of the resident's medical record revealed no additional social service notes/discharge planning notes during this time period or after the Care Plan Conference Summary Note (dated 02/24/25). Interview on 07/01/25 at 9:14 AM with Resident #49's sister revealed she was not contacted by the facility to discuss the resident's discharge plan. She stated if they would have asked her if she was able to care for her sister, she would have said no because she did not have room, but they did not contact her. The resident's sister was not able to provide any additional information as to the resident's current location. Interview on 07/01/25 at 9:51 A.M. with the Administrator revealed Resident #49 along with Admissions #208 spoke to the homeless shelter and completed a phone assessment prior to discharge on [DATE]. The Administrator stated Resident #49 was told the homeless shelter could help take care of all her appointments and medications. The resident did not have a debit card and to obtain one, she would need a driver's license, which the Administrator reported the homeless shelter told her they could assist her with. Per the Administrator, at that point, Resident #49 decided she did not want to stay (in the facility) until 06/09/25, which would be 30 days after the discharge notice was issued, and she chose to leave on 5/20/25. The Administrator confirmed the facility did not attempt to place the resident at any other location because the Administrator stated the resident was anxious to leave. The Administrator also indicated Resident #49's family was contacted, and no one would allow the resident to stay with them. However, there was no documentation contained in the resident's medical record to support this. Interview on 07/01/25 at 9:57 A.M. with DWF #203 revealed Resident #49 called into the homeless shelter with a representative from the facility to complete a pre-intake assessment on 05/20/25. However, when she arrived (on 05/20/25), her abilities did not match what she and the representative told them she was able to do. The resident needed to be able to ambulate throughout the building independently as well as climb stairs to sleep in a top [NAME]. DWF #203 said Resident #49 had difficulty walking on the sidewalk on the way toward the building and needed help carrying her belongings. She also could not climb the first step on the ladder to reach the top [NAME]. The homeless shelter determined the resident was not an appropriate fit to stay, and the resident wanted to return to the facility. However, when they contacted the facility, an unidentified person (believed to be a nurse) said they could not take the resident back because they did not accept discharged residents, and Resident #49 was not allowed to return due to lack of payment. The resident was permitted to stay overnight at the shelter but then left the next day. DWF #203 revealed the current location of the resident was unknown. During the interview, DWF #203 also confirmed staff at the shelter did not make appointments for residents, did not have physicians on staff, did not provide any type of transportation and had no social services available. They were a first come, first serve emergency shelter only. Interview on 07/01/25 at 10:12 A.M. with Licensed Practical Nurse (LPN) #204 revealed she was the nurse on duty who discharged Resident #49 on 05/20/25. She said the resident appeared content at the time of discharge and was hoping to eventually get herself back to the Columbus area, where she was originally from. The LPN stated the resident was discharged with approximately two weeks' worth of medications. Interview on 07/01/25 at 11:30 A.M, with Medical Director (MD) #205 revealed she was told by the facility that Resident #49 wanted to discharge to the homeless shelter. While MD #205 stated she felt this was an odd discharge plan because nursing home residents were not typically discharged to a homeless shelter, she did not oppose the resident's plan since the resident was cognitively intact. She denied having any documentation of her knowledge of the discharge or an order to discharge Resident #49. Interview 07/01/25 at 12:58 P.M. with Admissions #208 and the Administrator revealed the homeless shelter did not require any information to be sent to them regarding the resident's care needs. The Administrator revealed she was told the homeless shelter's physician would see Resident #49 and ensure she could continue getting her medications. Interview on 07/01/25 at 3:11 P.M. with Ombudsman #209 revealed she had spoken with Resident #49 along with the Administrator after the facility issued the resident the 30-day discharge notice (exact date not recalled). She stated she had asked Resident #49 what she would like to do, and the resident stated she would like to get her own place. Resident #49 stated she did not want to go to a homeless shelter. She stated the Administrator agreed to apply for the Home Choice program at that point. At the time of the interview, Ombudsman #209 had no information on Resident #49's current whereabouts or status. Interview on 07/02/25 at 8:43 A.M. with the Administrator revealed Admissions #208 contacted homeless shelters in [NAME] County (where Resident #49 previously resided) and was told they could not assist with placement until Resident #49 resided in [NAME] County. The Administrator revealed Resident #49 received a phone call from Ombudsman #209 on 05/14/25 regarding the 30-day notice. Ombudsman #209 requested the facility assist the resident with the Home Choice application, which was completed. The Administrator revealed Resident #49 did not want to reside in [NAME] County and would not have qualified for the Home Choice program because she had no income. (However, Resident #49 has SSI in the amount of $974 per month). At the time of the interview, the Administrator thought Resident #49 was still at the homeless shelter but denied knowledge of the resident's actual whereabouts as of this date. Interview on 07/02/25 at 1:18 P.M. with Ombudsman #209 revealed Resident #49 told her she received SSI in the amount of $974 per month. She also confirmed Resident #49 told her and the Administrator, she did not want to go to a homeless shelter, she wanted a place of her own. Ombudsman #209 stated that she talked to the facility about the Home Choice program first before having to take the case to an appeal. On 07/07/25 at 8:16 A.M. interview with the Administrator revealed she was the person who drove Resident #49 to the Rescue Mission on 05/20/25. The Administrator revealed the resident was taken in a personal vehicle to the shelter. Interview on 07/07/25 at 9:23 AM with Assistant Director of Ombudsman #211 revealed the Administrator called on 07/06/26 and asked very general questions related to what was expected when they discharged a resident. The Administrator did not discuss or ask anything specific about Resident #49. Review of the email communication dated 07/08/25 of the case notes from Transition Coordinator (TC) #215 revealed the Home Choice assessment review took place 06/02/25. The assessment included Resident #49 needed some physical assistance with dressing and bathing such as set up and cues. The resident required total assistance with set up and reminders for Humalog injections. A call was made on 06/03/25 by TC #215 to the facility since the resident did not have a telephone. TC #215 was told by the facility Resident #49 was no longer at the facility and was sent to the Rescue Mission of the Mahoning Valley on 05/20/25. The case was closed on 06/04/25 due to the resident being discharged after the assessment without home choice assistance. Interview on 07/08/25 at 1:51 PM with Assistant Director of Ombudsman #211 revealed she believed Resident #49 was assessed for the Home Choice program on 05/19/25 and approved the same date. Review of facility undated policy titled Resident Transfer and Discharge Policy and Procedure revealed the facility would discharge residents in a safe manner to include the specific services the receiving facility would provide to meet the needs of the resident, documentation of the discharge by the physician, contact information for the practitioner responsible for providing care for the resident, resident representative information including contact information and all necessary information relevant to the residence discharge to ensure continuity of care. This deficiency represents noncompliance investigated under Complaint Number OH00167024.

Based on observation, staff interview, record review, and review of facility policy, the facility failed to ensure call lights were within reach of Resident #3, #27, #34 and #43. This affected four residents of 19 residents reviewed for accommodation of need. The facility census was 47. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 11/07/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), hemiplegia affecting right dominant side, major depressive disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/25, revealed Resident #3 was moderately impaired cognitively, had upper and lower extremity impairment on one side, was dependent on staff for all activities of daily living except required substantial/maximum assistance from staff for eating, required substantial/maximum assistance to roll left and right, was independent for maneuvering his motorized wheelchair, was always incontinent of bowel and bladder and had two or more falls without major injury since the previous assessment. Review of the care plan, date initiated 11/07/24, revealed Resident #3 was at risk for falls. Interventions included to ensure call light was available to resident. An observation on 05/27/25 at 9:37 A.M. revealed Resident #3 was awake and lying in his bed with the call light out of his reach. The call button was clipped half way down the privacy curtain located to the right of the resident and out of arms reach from the bed. An observation was conducted on 05/27/25 at 9:46 A.M. of Resident #3 in his room with Certified Nursing Assistant (CNA) #214 present during the observation. The call light remained out of reach and an interview with CNA #214 at the time of the observation verified Resident #3 was not able to reach the call light because it was clipped to the privacy curtain. 2. Review of the medical record for Resident #27 revealed an admission date of 11/27/20 with diagnoses including senile degeneration of brain, vascular dementia, anxiety disorder, delirium due to known physiological condition, major depressive disorder, and insomnia. Review of the quarterly MDS 3.0 assessment, dated 05/08/25, revealed Resident #27 was severely impaired cognitively, was independent for mobility except required supervision or touch assistance from staff for tub/shower transfer, had an indwelling catheter, was always incontinent of bowel, and had one fall since prior assessment. Review of the care plan for Resident #27, date initiated 12/10/20, revealed Resident #27 was at risk for falls due to altered mental status, cognition, and psychotropic medication use. Interventions included to be sure call light was within reach and encourage him to use it for assistance as needed. An observation on 05/27/25 at 9:32 A.M. revealed Resident #27 was awake and was lying on his bed. Resident #27's call light was clipped to the call light cord coming out of the wall and not within reach of Resident #27. An interview on 05/27/25 at 9:32 A.M. with Housekeeping Supervisor (HS) #225 at the time of the observation revealed HS #225 verified Resident #27 could not reach his call light to call for help if he needed it. 3. Review of the medical record for Resident #43 revealed an admission date of 11/06/24 with diagnoses including dementia, gastro-esophageal reflux disease (GERD), and liver disease. Review of the quarterly MDS 3.0 assessment, dated 04/15/25, revealed Resident #43 was moderately impaired cognitively and was independent for all activities of daily living except required setup or cleanup assistance from staff for shower/bathe self and personal hygiene. The resident was independent for mobility which included walking independently up to 150 feet. Review of the care plan, date initiated 11/12/24, revealed Resident #43 was at risk for falls due to a dementia diagnosis. Interventions included be sure call light was within reach and encourage him to use it for assistance as needed. An observation on 05/27/25 at 9:29 A.M. revealed Resident #43 was awake and was lying on his bed. The call light button was clipped to the call light cord coming out of the wall behind the headboard of Resident #43's bed where it could not be reached by the resident. An observation on 05/27/25 at 9:46 A.M. with HS #225 present in Resident #43's room revealed the call light remained out of reach. An interview with HS #225 at the time of the observation verified Resident #43 was not able to reach his call light. 4. Review of the medical record for Resident #34 revealed an admission date of 05/06/24 with diagnoses including metabolic encephalopathy (brain dysfunction), lack of coordination, cognitive communication deficit, reduced mobility, dementia, need for assistance with personal care, insomnia, and anxiety disorder. Review of the MDS 3.0 assessment, dated 05/01/25, revealed Resident #34 was severely impaired cognitively, was independent for mobility except required supervision or touch assistance for tub/shower transfer and was continent of bowel and bladder. Review of the care plan, date initiated 05/14/24, revealed Resident #34 was at risk for falls. Interventions included to be sure call light was within reach and encourage him to use it for assistance as needed. An observation on 05/27/25 at 9:35 A.M. revealed Resident #34 was sleeping in his bed. The call light button was clipped to the cord coming out of the wall and was not within reach of Resident #34. An observation on 05/27/25 at 9:47 A.M. with HS #225 present in Resident #34's room revealed the call light remained out of reach. An interview with HS #225 at the time of the observation verified Resident #34 was not able to reach his call light. Review of the facility policy titled Call System, Residents, undated, revealed each resident would be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on record review, interviews and observation, the facility did not ensure Resident #1, Resident #20 and Resident #37 were explicitly informed of their right to not sign a binding arbitration agreement and were given the option to not sign the binding arbitration agreement. This affected three residents (#1, #20 and #37) out of five residents reviewed for arbitration agreements. The facility identified 35 residents (#1, #2, #3, #5, #6, #8, #10, #11, #13, #17, #18, #19, #20, #21, #22, #23, #25, #27, #30, #32, #33, #34, #37, #38, #39, #41, #42, #43, #45, #46, #47, #49, #50, #103, and #104) with a binding arbitration agreement. The facility census was 47. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 01/02/25. Diagnoses included transverse myelitis in demyelinating disease of the central nervous system, type two diabetes, functional quadriplegia, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, anxiety disorder, and persistent mood disorders. Review of Resident #37's Minimum Data Set (MDS) 3.0 assessment, dated 04/05/25, revealed the resident was cognitively intact. Review of Resident #37 admission paperwork revealed on page 30 of the admission packet was a document titled Optional Arbitration Agreement which indicated the facility and Resident #37 agreed that any and all disputes of any kind between the resident and family would be submitted to binding arbitration and by signing the arbitration agreement the resident and the facility were waiving the right to a jury trial for any dispute disagreement, controversy, demand, or claim and agree that the arbitrator's decision would bind both parties and was final. The resident or representative could rescind the agreement within 30 days from the date of when the agreement was signed. After 30 days, the agreement would remain in effect for all care and services at the facility. On page 32 of the admission packet, Resident #37 electronically signed his name on 01/06/25 indicating he had accepted the arbitration agreement. There was no area on the agreement that gave an option to decline it. Interview on 05/28/25 at 3:52 P.M. with Resident #37 revealed he knew what an arbitration agreement was, and the resident hadn't recalled signing an arbitration agreement. He stated he was told nothing about an arbitration agreement and went on to state he would have liked to have known he was signing an arbitration agreement because he wouldn't have signed it. 2. Review of the medical record for Resident #20 revealed an admission date of 01/28/25. Pertinent diagnoses included dementia, injury of head, major depressive disorder, major depressive disorder, and repeated falls. Review of quarterly MDS 3.0 assessment, dated 05/07/25, revealed Resident #20 was severely impaired cognitively. The resident's son was listed as the responsible party. Review of Resident #20's admission paperwork revealed on page 30 of the admission packet was a document titled Optional Arbitration Agreement which indicated the facility and Resident #20 agreed that any and all disputes of any kind between the resident and family would be submitted to binding arbitration and by signing the arbitration agreement the resident and the facility were waiving the right to a jury trial for any dispute disagreement, controversy, demand, or claim and agree that the arbitrator's decision would bind both parties and was final. The resident or representative could rescind the agreement within 30 days from the date of when the agreement was signed. After 30 days, the agreement would remain in effect for all care and services at the facility. On page 32 of the admission packet Resident #20's responsible party electronically signed his name on 02/04/25 indicating he had accepted the arbitration agreement. There was no area on the agreement that gave an option to decline it. 3. Review of the medical record for Resident #1 revealed an admission date of 04/04/25. Pertinent diagnoses included cerebral infarction (stroke), schizophrenia, and attention and concentration deficit. Review of admission MDS 3.0 assessment, dated 04/11/25, revealed the resident was cognitively intact and exhibited behavioral symptoms not directed toward others four to six days and rejected care one to three days during the assessment reference period. Further review of the medical record revealed a guardian had been appointed for Resident #1. Review of Resident #1's admission paperwork revealed on page 30 of the admission packet was a document titled Optional Arbitration Agreement which indicated the facility and Resident #1 agreed that any and all disputes of any kind between the resident and family would be submitted to binding arbitration and by signing the arbitration agreement the resident and the facility were waiving the right to a jury trial for any dispute disagreement, controversy, demand, or claim and agree that the arbitrator's decision would bind both parties and was final. The resident or representative could rescind the agreement within 30 days from the date of when the agreement was signed. After 30 days, the agreement would remain in effect for all care and services at the facility. On page 32 of the admission packet Resident #1's guardian had electronically signed her name on 04/25/25 indicating she had accepted the arbitration agreement. There was no area on the agreement that gave an option to decline it. Interview and observation of the facility electronic admission packet with admission Director (AD) #205 revealed the program being used for the electronic admission packet would have the resident/resident representative adopt an electronic signature in the beginning and the program would then prompt the resident/ resident representative where to sign throughout the admission paperwork. She stated the optional arbitration agreement was included in the admission packet. When reviewing an example of an electronic admission packet on the admission Director's computer, when it came to the arbitration agreement, the program prompted the resident/resident representative to sign the arbitration agreement. There was no option to decline the agreement. AD #205 confirmed there was no option to decline the arbitration agreement and stated it had been that way since she started in August 2024. She stated in order for the admission paperwork to be completed, the resident/resident representative would have to sign to agree to an arbitration agreement. She confirmed Resident #1, Resident #20 and Resident #37 or their responsible party would have had to sign the arbitration agreement in order for the admission paperwork to be completed therefore they had no choice but to agree to it. Interview on 05/29/25 at 10:41 A.M. with the Administrator revealed she had been made aware that there was no option to decline the arbitration agreement when it was signed electronically and in order for the admission paperwork to be completed the person had to sign to agree to the arbitration agreement.

Based on record review, interview and policy review, the facility failed to refund resident funds within 30 days of discharge. This affected two residents (#253 and #254) of six residents (#2, #5, #15, #24, #253 and #254) reviewed for resident funds. The facility census was 47. Findings include: 1. Review of resident records for Resident #253 revealed an initial admission date of 09/12/14 and a discharge date of 11/15/24. Diagnosis included schizoaffective disorder bipolar type. A review of the face sheet for Resident #253 revealed they had a court appointed guardian. Review of the discharge Minimum Data Set (MDS) assessment revealed Resident #253 had severe cognitive impairment. Review of the facility document titled Resident Fund Authorization revealed resident #253 authorized the facility to hold, safeguard and account for personal funds. The document was signed by Resident #253 on 09/08/15. On 05/28/25 at 11:00 A.M. a review of the resident fund account for Resident #253 revealed on 01/07/25 the facility distributed check #1901 in the amount of $5,588.60 to the guardian of Resident #253 to close the resident fund account. However, deposits and withdrawls from the account continued as followed: • 02/03/25 a deposit from Social Security (SS) in the amount of $917.30. • 02/28/25 an interest deposit of $1.69. • 03/03/25 a SS deposit of $917.30 • 03/12/25 check #1917 in the amount of $1836.29 was issued to the guardian of Resident #253. • 04/01/25 a deposit labeled pension in the amount of $917.30. • 04/03/25 a SS deposit in the amount of $2556.00. • 04/30/25 an interest deposit of $5.17. • 05/01/25 a deposit labeled pension in the amount of $917.30. • 05/02/25 check #1925 in the amount of $2561.17 was issued as a return to SS and check #1924 for $1834.60 issued as a return to Railroad Retirement Fund. • 05/15/25 check #1927 for $852.00 issued to SS and SS was notified in writing that Resident #253 was discharged from the facility on 11/15/24. On 05/28/25 at 12:30 P.M. an interview with the Administrator verified the aforementioned accounting for Resident #253, and stated Social Security kept making deposits. The Administrator also verified the notification to Social Security regarding the discharge of Resident #253 did not occur until 05/15/25. The Administrator also verified the closure of the resident fund account occurred past 30 days post discharge for Resident #253. 2. Review of resident records for Resident #254 revealed an admission date of 11/07/24 and a discharge date of 11/09/24. Significant diagnoses included schizoaffective disorder, bipolar type, anxiety, and major depression. A review of the face sheet for Resident #254 revealed they were their own responsible party. The face sheet also listed a daughter as power of attorney for financial matters. A clinical admission note dated 11/07/24 revealed Resident #254 to be alert and oriented to person, place and time. A review of the facility document titled Resident Fund Authorization revealed resident #254 authorized the facility to hold, safeguard and account for personal funds. The document was signed by Resident #254 on 09/30/20. On 05/28/25 at 11:15 A.M. a review of resident fund accounts revealed on 01/03/25 the facility issued check #1898 in the amount of $1975.07 to the nursing facility where Resident #254 transferred to on 11/09/24. On 05/28/25 at 12:30 P.M. an interview with the Administrator revealed the date of 09/30/20 on the fund authorization for Resident #254 was correct as Resident #254 had transferred from a sister facility that closed. The Administrator verified the closure of the account for Resident #254 occurred 01/03/25 and past 30 days post discharge. A review of the document titled Resident admission Agreement revealed on page 20 funds to be disbursed within 30 days of discharge or death. A review of the document titled Resident Fund Authorization revealed upon discharge account will be closed and funds returned.

Based on observation, record review, interview and policy review the facility failed to ensure a bed alarm assessment was completed prior to implementing a bed alarm for Resident #46. This affected one resident (Resident #46) of two residents reviewed for bed alarms. The facility identified two residents (#46 and #33) ordered bed alarms. The facility census was 47. Findings include: A review of medical records for Resident #46 revealed an admission date of 02/20/25 with pertinent diagnoses including Alzheimer's disease, major depressive disorder, repeated falls, vascular dementia and anxiety. Significant Review of physician orders included Buckeye Hospice admission dated 05/27/25 and bed alarm to remind resident not to get up unassisted dated 05/23/25. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had severe cognitive impairment. The MDS also revealed a history of falls in the last month prior to admission. There was no alarm usage noted within the MDS. Review of the care plan dated 05/30/25 revealed Resident #46 had actual falls. Interventions included perimeter defined mattress dated 05/18/25 and bed alarm to remind resident not to get up unassisted dated 05/23/25. Review of a device decision assessment dated [DATE] for Resident #46 revealed no bed alarm in use and no need for further restraint assessment. Further review of the medical record for Resident #46 revealed a device decision assessment had not been completed for the bed alarm intervention dated 05/23/25. On 05/28/25 at 2:15 P.M. an observation of Resident #46 revealed them in bed with the bed alarm in use. On 05/29/25 at 8:15 A.M. an observation of Resident #46 revealed them in bed with the bed alarm in use. An interview conducted on 05/29/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #227 verified Resident #46 was in bed with a bed alarm in use at the time of the observation. On 05/29/25 at 12:30 P.M. an interview with the Administrator verified the lack of an assessment for bed alarm use for Resident #46. The Administrator stated it was missed. A review of the policy titled Physical Restraint Application dated 10/2010 revealed the purpose of the procedure was to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints. The policy also revealed physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. The definition of restraints was based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.

Based on record review and interview the facility did not ensure a complete summary of discharge was provided to Resident #27 for continuation of necessary care and services at home. This effected one resident (Resident #27) of three residents reviewed for discharge. The facility census was 26. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and discharged home on 08/28/24. Medical diagnoses included pressure induced deep tissue damage of the back, buttocks and hip, paraplegia, immobile, bacteremia, pressure ulcer right heel stage four, chronic pain, neuromuscular dysfunction of bladder, anemia, sacral ulcer stage four, hip dislocation, anxiety, protein calorie malnutrition, sepsis, colostomy, and need for assistance for personal care. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #27 entered the facility on 07/19/24 from a hospital. Resident #27 had good cognition. Lower extremity range of motion was impaired on both sides and the resident required set up assistance for eating, moderate assistance for oral hygiene and toilet hygiene, dependent for bathing, moderate assistance for upper body dressing and maximal assistance for lower body dressing, moderate assistance to roll left and right in bed, sit on the side of bed and lie back in bed. Resident #27 did not sit to stand, was dependent to transfer to chair and toilet transfer. Resident #27 did not walk ten feet. Resident participated in goal setting. There was no legal guardian or representative. Overall goal was discharge to the community. Review of the care plan dated 08/01/24 revealed Resident #27 intended to return home after completing skilled stay. Interventions included make arrangements with required community resources to support independence post discharge such as home care, physical therapy, occupational therapy, doctors, wound nurse and to make necessary referrals as needed. Review of the physician treatment order dated 08/14/24 revealed Resident #27 was ordered barrier cream to the sacrum and scrotum every shift and as needed. Review of the Physical Therapy Discharge Summary dated 08/15/24 written by Physical Therapist (PT) #337 revealed discharge recommendations included a home exercise program, in-home aid twenty-four care and an air mattress. Review of the physician treatment order dated 08/22/24 revealed Resident #27 had orders to cleanse coccyx with Vashe, pat dry, apply small amount of zinc to peri wound. Pack wound bed with collagen and silver and calcium alginate and cover with dry dressing. Review of the physician treatment orders dated 08/28/24 revealed Resident #27 had an order to cleanse right hip with twenty-five percent Dakins, apply skin preparation to outer edges of wound. Pack with silver alginate and cover with dry dressing. Review of the progress note dated 08/28/24 revealed the resident was sent home via personal vehicle with a seven day supply of medication and palliative care. Review of physician orders dated 08/29/24 revealed an order for Resident #27 to be discharged home. Review of the facility document titled IDT Discharge Summary V-2 dated 08/27/24 and provided by the Administrator revealed under section B1 Treatments it was indicated the resident had a pressure ulcer to his sacrum and for a right hip wound the type was listed as other. There were no measurements listed and treatments said to see orders. Under section C Appointments there were no names, phone numbers or date/time of follow up appointments listed for continuation of care after discharge. Under the Physical Therapy section it was indicated N/A for physical therapy and stated resident has specialty equipment at home, but no specific equipment was listed such as the air mattress that was recommended in the Physical Therapy Discharge Summary. At the bottom of the last page (page eight) was written 08/12 met with resident concerning discharge. Resident did not want any services. Stated I already have help in place. This was signed by the Administrator. There was no signature from the resident on this document, and this document was in the electronic medical record. Review of a second facility document provided to the surveyor and titled IDT-Discharge Summary V-2 dated 08/27/24 (this was provided after the first IDT Discharge Summary V-2 from the electronic medical record) and revealed under section B1 Treatments it was indicated the resident had a pressure ulcer to his sacrum and the right hip area wound type listed as other. There were no measurements listed and treatments said to see orders. Under section C Appointments there were no names, phone numbers or date/time of follow up appointments listed for continuation of care after discharge. Under the Physical Therapy section it was indicated N/A for physical therapy and stated resident has specialty equipment at home, but no specific equipment was listed such as the air mattress that was recommended in the Physical Therapy Discharge Summary. On the last page (page eight) there was a signature from the resident dated 08/28/24 instead of the written statement from the Administrator as noted prior. This discharge summary was located from the paper hard chart and did not have an attached list of treatment orders for his wound care. Interview on 10/08/24 at 2:30 P.M. with the Director of Nursing (DON) revealed the facility was to verify if the resident was safe for discharge. Resident #27 threatened to leave against medical advice so the facility had to provide a quick discharge. Interview on 10/08/24 at 3:31 P.M. with Social Service Designee (SSD) #309 revealed no referrals were made by the facility for wound care or other home-based services on the Discharge Summary because Resident #27 left before discharge plans were put in place. SSD #309 stated the Administrator was the interim social worker before SSD #309 started at the facility two months ago. SSD #309 said the Administrator met with Resident #27 on 08/12/24 to discuss discharge but did not document in the progress notes. SSD #309 stated Resident #27 had stated to the facility he had planned for wound care and nurse assistance at home so the facility did not follow up with wound care needs and nurse care needs for discharge home. Interview on 10/08/24 at 3:36 P.M. with the DON revealed Resident #27 did not give the name of his preferred wound care provider or nurse provider, therefore the facility did not follow up or make arrangements for wound care needs at discharge. Interview on 10/09/24 at 8:23 A.M. with Resident #27's mother, who was his primary contact, revealed Resident #27 did not have wound care or nurse care set up at home after discharge so he was going to have to do his own wound care. Interview on 10/09/24 at 11:00 A.M. with Occupational Therapist #338, who worked with Resident #27, revealed Resident #27 wound not be able to care for his wounds on his own at home. Interview on 10/09/24 at 11:34 A.M. revealed the Administrator verified she did not document discharge planning in the electronic medical record progress notes while acting as the interim social service designee but did document in her personal notebook which was not part of the legal medical record. The Administrator also verified the paper copy of the Discharge Summary document with the resident's signature did not have physician treatment orders attached to it, and verified the electronic copy of the Discharge Summary did not have the resident's signature on it. Interview on 10/09/24 at 12:09 P.M. with PT #337, who worked with Resident #27, revealed Resident #27 would need a home health care agency nurse for wound care to ensure the correct procedure was done. This deficiency represents non-compliance investigated under Complaint Number OH00158232.

Based on observation, staff interview and document review, the facility failed to maintain a sanitary environment. This had the potential to effect all 26 residents residing in the facility. Findings include: Review of the document titled State of Ohio Food Inspection Report, dated 09/20/24, revealed there was several spots on the wall in the back storage room, near the mop closet and near the stairway that had dark colored growth on the walls. It was noted the inspector was concerned the water that leaked from the ceiling or walls caused the dark colored growth in the kitchen area. An observation on 10/08/24 at 11:24 A.M. with the Maintenance Director (MD) #330 revealed a black-like substance resembling mold growth on the lower northwest wall leading into the kitchen. Additionally, the facility stored resident service wear on plastic shelves and a freezer was positioned in front of this wall. An Interview conducted on 10/08/24 at 11:26 A.M. with MD #330 confirmed the presence of a black-like substance on the wall leading to the kitchen, as well as behind the plastic shelving and a freezer. An interview with the Director of Nursing and the Administrator on 10/08/24 revealed they were aware of the results of the local county health inspection since 09/20/24 regarding the dark colored growth on the wall leading into the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00158268.

Based on meal schedule review, menu review, staff interview, and observation, the facility failed to provide a substantial evening snack when greater than 14 hours elapsed between the evening meal and breakfast. This had the potential to affect 33 out of 33 residents that received meals from the kitchen. The facility census was 33. Findings include: Review of scheduled mealtimes revealed dinner was at 4:45 P.M. for the second floor and at 5:05 P.M. for the first floor, and breakfast was at 7:30 A.M. for the second floor and 7:50 A.M. for the first floor. Review of the 11/20/22 to 11/26/22 facility menus revealed evening snacks were not listed on the menu. Interview on 11/22/22 at 9:00 A.M. with Dietary Supervisor #407 revealed the facility filled two rectangular plastic containers with lids with peanut crackers, cheese curls, short bread cookies, and occasional left-over muffins. The plastic containers were placed behind the nurse's stations on each of the two floors of the facility. A dietary employee checked the containers at 10:00 A.M. and 3:00 P.M. to see if they needed replenished and would refill both of the containers for the evening. Other snacks were available upon resident request. Dietary Supervisor #407 confirmed there was greater than a 14-hour difference between the evening meal and breakfast, and the facility was not offering substantial snacks to all residents. Observation on 11/22/22 between 9:07 A.M. and 9:15 A.M. with Dietary Supervisor #407 revealed there were plastic containers with lids with crackers, cheese crackers, and short bread cookies containers behind each of the two nurse's stations. Interview with Registered Nurse #411 on 11/22/22 at 11:37 A.M. confirmed there was a container of snacks in the nurse's station, and snacks were often incorporated into an activity but usually offered upon request. Interview on 11/22/22 at 1:14 P.M. with Dietitian #434 confirmed mealtimes between the evening meal and breakfast was longer than 14 hours, and a substantial snack was not offered to everyone.

Based on record review, interview and observation the facility failed to ensure Resident #20's wheelchair was maintained in safe condition. This affected one of 28 residents observed for environment. The facility census was 28. Findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care with an initial date of 08/08/19 revealed he was at risk for skin breakdown due to his [MEDICAL CONDITION] and diabetes mellitus type two. The Minimum Data Set assessment ((MDS) dated [DATE] revealed he had cognitive impairment, needed limited assistance of one person for bed mobility and transfers and extensive assistance of one person for toileting, dressing and hygiene. He was able to move on an off the unit using his wheelchair. Observation was conducted on 12/30/19 at 9:26 [NAME]M. of Resident #20 sitting in the hallway. The right arm of his wheelchair was missing the padded covering exposing the bare metal. There were two metal pins approximately 1/3 inch in diameter and half an inch long protruding out of the arm rest and leaving multiple indents in the skin of his right arm. Activity Director (AD) #900 was passing by at 9:46 [NAME]M. and verified the right arm rest was missing the padding. AD #900 said she was unaware it was broken. Resident #20 interjected it had been like that for one month. Observation and interview was conducted on 12/31/19 at 8:57 [NAME]M. to 9:10 [NAME]M. with Resident #20. The right arm rest padding was still missing. The metal pins were digging into his arm leaving multiple circular indents in the shape of the pin head. This was verified with the Administrator at 8:58 [NAME]M. The Administrator added Resident #20 was supposed to be getting a new chair from Hospice due to his tendency to slide forward in his current chair. At 9:10 [NAME]M. the Administrator found a replacement handle from a spare wheelchair in storage at the facility and fixed the wheelchair arm rest for the resident.

Based on record review, interview and review of facility policy and procedure the facility failed to notify the physician when Resident #19's blood sugar was above 350 per physician order. This affected one resident (Resident #19) out of two residents reviewed for unnecessary medication that received glucometer checks. This had the potential to affect seven residents (Resident #10, #19, #20, #21, #27, #131, and #181) that received blood sugar checks per glucometer. The facility census was 28. Findings include: Review of the medical record for Resident #19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the care plan dated 09/03/19 revealed Resident #19 had diabetes. Interventions included diabetes medications as ordered by the physician, monitor, document, and report to the physician as needed signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (low/high blood sugar). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #19 had impaired cognition and required supervision with bed mobility and limited assistance of one person with transfers. She was unable to ambulate. Review of physician orders [REDACTED].#19 had an order for [REDACTED]. was to notify her physician. Review of the Medication Administration Record [REDACTED].M. was 385, and on 12/26/19 her accu-chek at 9:00 P.M. was 386. She received two units of Humalog solution subcutaneously. Review of nursing notes for Resident #19 from 12/01/19 through 12/31/19 revealed on 12/09/19 and on 12/26/19 there was no documentation the physician was contacted regarding Resident #19's accu-chek above 350 per her physician order. Interview with the Director of Nursing (DON) on 01/02/19 at 2:05 P.M. verified Resident #19 had an order to contact the physician if her blood sugar was above 350. She verified on 12/09/19 her accu- chek was 385 and on 12/26/19 her accu-chek was 386. She verified in the nursing notes there was no evidence of any documentation the physician was notified per the physician's orders [REDACTED]. Review of facility policy titled, Change in a Resident's Condition or Status dated (MONTH) (YEAR) revealed the facility would promptly notify the physician of changes in the resident's medical condition. The nurse was to notify the resident's attending physician when there was a specific instruction to notify the physician.

Based on record review, interview, and review of policy the facility failed to develop a baseline care plan with the minimum necessary mental health information for Resident #181. This affected one (Resident #181) of one resident reviewed for baseline care plan. Findings include: Resident #181 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of the Ohio Department of Mental Health Pre-Admission Screen and Resident Review (PASRR) Determination for Resident #181 revealed a list of information important for the facility to know about the resident's needs which included [DIAGNOSES REDACTED]. Listed information of services the facility would need to provide for Resident #181 included occupational therapy evaluation, physical therapy evaluation, education regarding medication compliance and/or side effects, mental health counseling, and an ongoing evaluation of the effectiveness of current [MEDICAL CONDITION] medications and target symptoms. Review of the baseline care plan dated 12/19/19 revealed Resident #181 was to remain in the facility, had normal vision with glasses, was a diabetic, received insulin with blood sugars, ate in the dining room, was independent with bed mobility, transfers, walking, toileting, locomotion, eating, grooming, hygiene and bathing, and was continent of bowel and bladder. There was no information found in the baseline care plan related to Resident #181's mental illness or PASRR Determination. Interview on 01/02/20 at 12:59 P.M. with Licensed Practical Nurse (LPN) #361 indicated pertinent diagnoses, doctors orders, and PASRR information should be included in baseline care plans, and verified Resident #181's baseline care plan did not include information related to his mental illness or the results of his PASRR Determination. Interview on 01/02/20 at 4:14 P.M. with Social Worker #360 revealed Resident #181 was scheduled to begin mental health counseling services on 01/03/20. Social Worker #360 verified mental health information and PASRR Determination information was not included in Resident #181's baseline care plan. Review of facility policy entitled, Care Plans - Baseline, revised (MONTH) (YEAR), revealed the Interdisciplinary Team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission order; physician orders; dietary orders; therapy services; social services; and PASARR recommendation, if applicable.

Based on interview, and record review the facility failed to ensure they monitored frequency of bowel movements, and developed and implemented a bowel management protocol to prevent constipation for Resident #21. This affected one (Resident #21) of one resident reviewed for constipation and had the potential to affect all 29 residents currently residing in the facility. Findings include: Review of medical record for Resident #21 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of an admission five-day minimum data set ((MDS) dated [DATE] revealed Resident #21 had intact cognition. She was totally dependent on one person for bed mobility and transfers occurred only once or twice with two person assist. She was unable to ambulate. She was totally dependent on two persons with toileting and was always continent of the bowel. Review of care plan dated 10/31/19 revealed Resident #21 had the potential for constipation related to decreased mobility, and medication side effects. Interventions included to follow the bowel protocol for bowel management, monitor, document, and report signs and symptoms related to constipation to the physician, and record bowel movement pattern each day describing the amount, and consistency. Review of a nursing note dated 11/19/19 at 5:52 P.M. revealed Resident #21 stated she had not had a bowel movement in a few days. Her abdomen was mildly distended and bowel sounds were present. She denied pain. She received [MEDICATION NAME] one 100 milligram (mg) capsule per an as needed order. The physician was contacted and ordered a [MEDICATION NAME] suppository (rectal) 10 mg every 24 hours as needed for constipation. Review of current physician orders [REDACTED].#21 had an order for [REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) 2019 revealed bowel movement monitoring for Resident #21 as follows: On 12/13/19 she had two bowel movements and no size was recorded, on 12/19/19 she had one small bowel movement, and on 12/27/19 she had a large and a medium bowel movement. There was no evidence of documentation per the MAR from 12/14/19 to 12/18/19 (four days) and none from 12/20/19 to 12/26/19 (six days) that indicated Resident #21 had a bowel movement. Review of the MAR for (MONTH) 2019 revealed Resident #21 did not receive any [MEDICATION NAME] sodium 100 mg capsules every 12 hours as needed for a stool softener or any [MEDICATION NAME] suppository 10 mg every 24 hours as needed for constipation for the month of (MONTH) 2019. Interview on 12/31/19 at 10:41 [NAME]M. with the Director of Nursing (DON) revealed the nurses were expected to document Resident #21's bowel movements in the MAR. She verified per documentation Resident #21 did not have a bowel movement from 12/14/19 to 12/18/19 (four days) and from 12/20/19 to 12/26/19 (six days). She verified Resident #21 was not administered any as needed medications to prevent constipation for the month of (MONTH) 2019. She revealed the facility did not have a specific bowel protocol or policy in place instead it was up to each nurse to check the bowel patterns per the MAR and administer as needed medication as ordered. She verified the nurses should have assessed and provided interventions to prevent constipation from 12/14/19 to 12/18/19 and from 12/20/19 to 12/26/19. Interview on 12/31/19 at 10:47 [NAME]M. with Resident #21 revealed she had issues with constipation as it was hard to have a bowel movement at times and she went several days without having a bowel movement which caused discomfort.

Based on observation, record review, interview and the reasonable person concept, the facility failed to prevent sexual abuse for Resident #22. Harm occurred when Resident #22 was unable to physically or verbally consent to, or refuse, witnessing the sexual aggressive behavior of Resident #38. This affected one three residents reviewed for abuse. Findings include: On 08/01/16, review of a facility self-reported incident (SRI) dated 07/24/16 indicated an allegation of sexual abuse by Resident #38 against Resident #22. The report indicated Resident #38 was observed in the room of Resident #22 masturbating near the face of Resident #22. The facility investigation determined that sexual abuse did not occur because there was no resident to resident contact and Resident #22 did not seem aware of the incident. Review of the closed medical record for Resident #38 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was alert and oriented and exhibited signs of depression. review of a care plan dated 06/13/16 indicated Resident #38 had the potential to demonstrate verbally abusive behaviors related to mental and emotional illness and had poor impulse control. He also had a history of [REDACTED]. Interventions included to identify triggers, assess coping skills, allow the resident to express himself, correct inappropriate behavior, provide choices for care and activities, give positive feedback for good behavior, emphasize positive aspects of compliance, a psychiatric consult as indicated, remind him that sexual comments were not appropriate, and intervene before agitation escalated. He was seen by the psychiatrist on 07/15/16 and his antipsychotic medication was increased. Review of the record for Resident #22 revealed she was admitted [DATE] and had [DIAGNOSES REDACTED]. The MDS 3.0 dated 07/03/16 indicated the resident had severe cognitive impairment. She had a care plan dated 04/18/12 that indicated she had impaired cognitive function, impaired thought processes, had expressive and receptive [MEDICAL CONDITION] and was totally dependent on staff for activities of daily living. On 08/01/16 at 8:15 A.M., a tour of the facility was conducted. Resident #22 was observed in her room in a recliner chair with her legs elevated. State tested Nurse Aide (STNA) #13 was washing the resident's hands and placing rolls into both hands. Resident #22 responded to touch with facial expressions, but did not respond to speech or verbalize. STNA #13 said Resident #22 was non-verbal and did not seem to comprehend her surroundings. On 08/01/16 at 10:10 A.M., interview with STNA #13 revealed on 07/24/16 Resident #38 was in the shower at about 8:50 A.M. STNA #13 was assisting a resident who was being discharged home. She said it was time to check on Resident #38, who was on every 15 minute checks. A few minutes after 9:00 A.M., STNA #13 said she looked in the shower and Resident #38 was not there. STNA #13 went room to room until she reached the room of Resident #22. The room door was half closed. She went in and Resident #38 was kneeling on the edge of Resident #22's bed, with both feet off the floor and his knees near the resident's face. He was leaning forward and his left hand was against the wall on the opposite side of the bed. He had the front of his shorts pulled down and his penis was exposed. He was stroking his penis with his right hand. His penis was close to the mouth of Resident #22, but not touching it. He did not appear to have ejaculated. He was not touching any other part of the resident's body. Resident #22's eyes were open, but STNA #13 said Resident #22 did not appear to notice Resident #38. STNA #13 said she asked Resident #38 what he was doing and told him to leave the room. He said he was looking for his phone and asked STNA #13 to look for it. Resident #38 left the room and STNA #13 followed him to his room. STNA #13 immediately reported the observation to LPN #11. She said Resident #22 had been up and dressed for breakfast previously and was assisted to lay down after breakfast. Resident #22 was in bed, covered, had on a shirt and a disposable brief. Her shirt was on properly and her brief was on, with the closure tabs in place and no tears noted. There were no bodily fluids noted on or around the resident. Interview with LPN #11 on 08/01/16 at 12:10 P.M. revealed Resident #38 was on 15 minute checks for a week or so prior to the incident with Resident #22, due to going in and out of other resident's rooms. She said on 07/24/16, she worked the first shift. She said Resident #38 asked to take a shower. She asked STNA #13 and STNA #17 to get him set up for his shower. LPN #13 then went outside for a break. She said within five minutes, STNA #13 came running out and said she needed her right away. STNA #13 told LPN #11 that she found Resident #38 on Resident #22's bed, masturbating. LPN #11 and STNA #17 went down the hallway and observed Resident #38 in his room. He had his head down. LPN #11 asked him if he was in another resident's room and what he was doing. He said he was looking for his phone. LPN #11 told STNA #17 to be 1:1 with Resident #38 from that moment on. LPN #11 went to Resident #22's room to examine her and look for any obvious signs of injury. LPN #11 did not see any signs of injury on Resident #22 and then called the DON for further instructions. The DON instructed LPN #11 to keep Resident #38 on 1:1 supervision and separated from other residents. She was to call the police department and make a report and notify the physicians of both residents. She was to do body assessments of all cognitively impaired female residents on the first floor, and interview all alert and oriented female residents on the first floor. She obtained witness statements form all staff on duty at the time of the incident. The DON said she would contact the guardian of Resident #22. She said LPN #17, the nurse from upstairs, did a full assessment of Resident #22 and did not find any injuries or signs of abuse. LPN #11 notified the the local police department who took the names, birth dates and room numbers of both residents and said a detective would follow-up. She notified the attending physicians, the medical director and the family of Resident #38 of the incident . There were no new orders from the physicians. Resident #38 was discharged to the hospital on [DATE] at 5:05 P.M. Review of the SRI investigation dated 07/24/16 revealed the facility did not substantiate abuse due to no contact made between the two residents could be verified, that Resident #22 had no recognition of what occurred, and there was no evidence of emotional negative outcome from witnessing the act. During interview with the DON on 08/01/16 at 3:10 P.M. it was verified the sexual conduct of Resident #38 in the presence of Resident #22 occurred on 07/24/16 without the consent of the resident. Based on the concept of a reasonable person, Resident #22 experienced sexual abuse when she was unable to physically or verbally consent to, or refuse, the witnessing of the sexual aggressive behavior of Resident #38. This deficiency substantiates Self-Reported Incident Control Number OH 847.

Based on medical record review, observation, staff and resident interview, review of witness statements, review of incident reports and review of the facility ' s Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property policy and procedure, the facility failed to protect residents from sexual abuse. Actual harm occurred when Resident #14 and Resident #2 were sexually abused by Resident #6. This resulted in Immediate Jeopardy for two (Resident #14 and Resident #2) of four residents reviewed for abuse and had the potential to affect all 46 residents residing in the facility. On 03/30/16 at 11:55 A.M. the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #12 were notified that Immediate Jeopardy began on 03/20/15 at 4:00 A.M. when state tested nursing assistant (STNA) #10 reported to Licensed Practical Nurse (LPN) #15 that Resident #14, who had dementia and was totally dependent on two persons for assistance with bed mobility, dressing, and personal hygiene, was found clutching the collar of his shirt and appeared irritated. Resident #14 ' s blankets were removed from his bed and were found on a chair in the room. Resident #14 ' s brief was open, his penis was exposed and flipped up toward his abdomen. STNA #10 reported Resident #14 ' s brief was ripped open and not just unfastened. STNA #10 also indicated the roommate, Resident #6 (diagnosed with [REDACTED]. The facility failed to complete an investigation related to this incident and protect residents from Resident #6. The Immediate Jeopardy continued on 03/28/16 at 2:40 A.M. when Resident #2 (diagnosed with [REDACTED].#16 with his brief open and the blankets on the floor at the foot of his bed. Resident #2 ' s penis and scrotum were flipped up toward his abdomen. Resident #2 ' s scrotum and penis were red and swollen. His new roommate, Resident #6, was observed in the room, on the opposite side of the privacy curtain, awake and sitting in bed. The Immediate Jeopardy was removed on 04/01/16 when the facility implemented the following corrective actions: · On 03/28/16 (time not recorded) the DON in-serviced nine STNA ' s (STNA #11, STNA #34, STNA#10, STNA #37, STNA #38, STNA #14, STNA #39, STNA #41, STNA #44), six LPN ' s (LPN #20, LPN #35, LPN #17, LPN #43, LPN #42 and LPN #24) , the Business Office Manager #30, two activities staff (Activities #26 and Activities #31), three dietary staff (Dietary #46, Dietary#32, Dietary #33) and Dietary Supervisor #47, two housekeeping staff (Housekeeping #36, Laundry aide #45), Dietitian #48 and Maintenance #40 staff on abuse, mistreatment, neglect, injuries of unknown source and misappropriation of resident property. · On 03/28/16 at 2:45 A.M. Resident #6 was placed in a private room. · On 03/28/16 at 5:00 P.M. a motion sensor was placed on Resident #6 ' s bed to ensure Resident #6 was not exiting his private room. The facility did not implement a system to monitor resident #6 when he was out of bed. · On 03/28/16 (no time) Resident #6 ' s plan of care was updated to reflect possible sexual behaviors toward another resident. The care card indicated to remind Resident #6 of boundaries as needed and if any incident of inappropriate behavior was noted, to place Resident #6 on one to ones. · On 03/30/16 at 10:10 P.M. four RN ' s( RN #58, RN #59, RN #22, RN #25), eight LPN ' s (LPN #57, LPN #24, LPN #15, LPN #29, LPN #35, LPN #20, LPN #49, LPN #43) , 16 STNA ' s (STNA #39, STNA #11, STNA #41, STNA #56, STNA #14, STNA #51, STNA #38, STNA #50, STNA #33, STNA #52, STNA #34, STNA #18, STNA #65, STNA #66, STNA #67, STNA #28), six dietary staff (Dietary Supervisor #47, Dietary #32, Dietary #46, Dietary #62, Dietary #60, Dietary #33), five housekeeping and laundry staff (Housekeeping #63, Housekeeping #64, Laundry #45, Housekeeping #54, Housekeeping #68), two activities staff (Activities #31, Activities Director #26), Business Office Manager #30, Licensed Social Worker #61, two maintenance staff (Maintenance #53, and Maintenance #40) and Billing staff #55 were in-serviced by the Administrator and DON on identifying possible situations that would require investigation as related to possible abuse or neglect. · On 03/30/16 at 11:59 A.M. a new template noted as investigation and incident follow-up guidelines was provided by the DON for both units of the facility for staff reference. The templates were observed hanging at the nurse ' s station on both units. · On 03/30/16 at 11:59 A.M. Regional Director of Nursing Services #12 provided education to the Administrator and the Director of Nursing on completing investigations. · On 03/30/16 (between approximately 4:00 P.M. and 5:00 P.M.) RN #25 interviewed Resident #14 for additional information. · Observation on 03/29/16 at 8:44 A.M. revealed Resident #6 ambulating independently throughout the hallway. Resident #6 greeted the surveyor with a handshake and attempted to hug the surveyor. The administrator was present during this observation. Observation on 03/29/16 at 10:51 A.M. revealed Resident #6 in the dining room with staff present. Resident #6 was seated in a chair and was waving and blowing kisses at the surveyor. Observation on 03/29/16 at 2:12 P.M. revealed Resident #6 involved in activities in the second floor dining room with additional residents and staff present. Observation on 03/30/16 at 5:37 A.M. revealed Resident #6 in room in bed with covers on and a motion sensor to the bed; no roommate. Observation on 03/31/16 at 8:00 A.M. Resident #6 was observed in the dining area on the second floor with staff present. Observation on 04/01/16 at 8:42 A.M. revealed Resident #6 ambulating independently in the hallway on the unit and staff were present in the hallway during this observation. · On 04/01/16 at 12:00 P.M. Resident #6 was discharged to another long term care facility. · Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. · Interview on 04/04/16 at 8:55 A.M with the DON revealed evidence of knowledge of investigating suspected abuse, and reporting and completing the investigation. · Interview on 04/04/16 at 8:53 A.M. with the Administrator revealed evidence of knowledge of investigating suspected abuse and reporting and completing the investigation Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility has not implemented any auditing procedures. The facility also has not implemented procedures to inform agency staff of the facility ' s policies and procedures. Findings Include: 1. Review of Resident #14 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14 ' s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident could not complete the brief interview of mental status section. The staff assessment indicated Resident #14 was severely impaired for cognitive skills in daily decision making. Resident #14 ' s functional assessment revealed the resident required total dependence of two person physical assistance for transfers and bed mobility. The assessment indicated Resident #14 required total dependence of one person physical assist for dressing. Review of Resident #6 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6 ' s MDS assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was independent for bed mobility, transfer and walking in room. Review of the current plan of care initiated on 09/29/14 revealed Resident #6 had a behavior problem related to wandering in others ' rooms and looking in their belongings. Resident #6 was very intrusive in nature and invades others personal space during conversation. Resident #6 makes threats towards staff when he gets anxious/upset and resident frequently masturbates in his room. Review of Resident #6 ' s physician progress notes [REDACTED].#6 approached the physician to shake hands and tried to hug. The note indicated Resident #6 was intrusive, impulsive, and had poor boundaries. The note indicated Resident #6 ' s antipsychotic medication was increased during this visit. Review of Resident #6 ' s nurse ' s note dated 03/12/16 at 9:00 A.M. revealed Resident #6 keeps following another unidentified resident around being loud and mean. The nurse did not recall which resident this was. One to one given without effectiveness and as needed medications were given. A nurse ' s note dated 03/18/16 at 4:00 AM. revealed Resident #6 was up most of the night. The note stated Resident #6 was in his room and popping up and down hallway occasionally. The nurse ' s note dated 03/21/16 at 5:30 P.M. revealed Resident #6 was transferred to another room. Review of a witness statement dated 3/28/16 and written by STNA #10 indicated last weekend (03/19/16 into 03/20/16) while working midnight shift, STNA #10 came across Resident #14 ' s blankets and foot braces that were placed in the wheelchair across the room from Resident #14 ' s bed. The statement indicated the blankets and foot braces were not placed in the wheelchair by staff. The statement indicated upon further observation this resident ' s privates were exposed. Observation on 03/29/16 at 9:16 A.M. revealed Resident #14 in bed with his arms crossed and eyes open. Resident #14 would not respond to the surveyor when interview attempted. On 03/29/16 at 2:50 P.M. Resident #14 was attempted to be interviewed and again did not respond to any questions. Interview on 03/29/16 at 3:39 P.M. with STNA #10 revealed she and STNA #21 were working on 03/20/16 in the early morning on the first floor of the facility. STNA #10 stated she was walking in the hallway and observed Resident #14 with his blankets and his heel boots on the wheelchair in his room. Resident #14 was clutching the collar of his shirt and was irritated . Resident #14 ' s brief was torn and his penis was exposed and flipped up on his abdomen. STNA #10 stated Resident #14 ' s roommate ' s (Resident #6) curtain was pulled and STNA #10 stated she informed LPN #15 of this finding. STNA #10 stated LPN #15 entered Resident #14 and Resident #6 ' s room and asked Resident #6 if he touched Resident #14. STNA #10 stated Resident #6 responded no and stated he had a nightmare. STNA #10 stated Resident #6 was up and ambulating in the room when the observation was made. STNA #10 stated the nurse left the room without assessing Resident #14. STNA #10 stated she was unaware of any further interventions or investigation related to the cause of Resident #14 ' s appearance. STNA #10 stated she also reported the incident to the day shift STNA (STNA #14). STNA #10 indicated the observation was suspicious because Resident #14 was not physically capable of moving his blankets to the chair and his penis is normally tucked down to prevent urination out of the brief. STNA #10 indicated Resident #14 was not physically capable of opening the brief. STNA #10 stated Resident #14 ' s testicles were also repositioned up. STNA #10 stated Resident #6 was moved to a different room a couple of days after this incident. STNA #10 stated Resident #6 was placed in another room with a roommate who was not mentally capable of speaking for himself (Resident #2). Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed on 03/20/16, she and STNA #14 arrived for the day shift when STNA #10 reported to STNA #14 that during the night she went down to check on Resident #14 because he was yelling out. STNA #10 told STNA #14 that Resident #6 was standing over Resident #14 and Resident #14 had an erection. STNA #23 stated STNA #14 reported that she told the midnight nurse. STNA #23 stated LPN #24 was heard talking to the DON related to the above concern and the DON stated we can ' t open that can of worms because we didn ' t see him (referring to Resident #6). STNA #23 stated Resident #14 was bedridden and could not move his covers off and place them across the room where they were found by STNA #10. Interview on 03/30/16 at 6:05 A.M. with STNA #14 revealed on 03/20/16 STNA #10 told her in report that Resident #6 was found standing over Resident #14 and Resident #14 ' s blankets were off of him and found on a wheelchair. STNA #14 stated she did not say anything because that was something that should be reported by the person who observed it. Interview on 03/30/16 at 6:07 A.M. with STNA #10 revealed on 03/20/16 at 4:00 A.M. she found Resident #14 with his blankets off, his brief open and his genitals exposed. STNA #10 stated Resident #6 was observed walking on his side of the room at this time. STNA #10 stated the nurse (LPN #15) asked Resident #6 if he was touching Resident #14 and Resident #6 replied he had a nightmare. Interview on 03/30/16 at 6:29 A.M. with LPN #24 revealed she was never told in report on 03/20/16 about Resident #14 being found exposed. LPN #24 stated later on in the day, someone (unidentified) told her Resident #6 was standing by Resident #14 ' s bed. LPN #24 stated she asked Resident #6 about it and he said he had a bad dream. LPN #24 stated she was aware Resident #6 had bad dreams and would become anxious and unaware of what was going on. LPN #24 stated she specifically asked Resident #6 what he was doing when he was standing over Resident #14 ' s bed and he stated he didn ' t know where he was. LPN #24 stated she informed the DON as an FYI kind of thing . LPN #24 stated she was not concerned about the incident. LPN #24 stated Resident #14 does knock his blankets off sometimes, however she did not recall if the blankets were found off during this incident. LPN #24 indicated no statements were obtained at that time. Interview on 03/30/16 at 12:05 P.M. with the DON verified she was notified by an unidentified staff member that Resident #14 ' s bed sheets were moved to a different place. The DON stated the staff member started her conversation with rumor is and then the DON stopped the staff member and stated we don ' t adhere to rumors. 2. Review of Resident #2 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s MDS assessment dated [DATE] revealed Resident #2 was unable to conduct the interview and the staff assessment revealed cognitive skills for daily decision making were severely impaired. Review of Resident #2 ' s functional assessment revealed Resident #2 required limited assistance of one person for bed mobility and transfer. The assessment revealed Resident #2 required extensive assistance of one person physical assistance for dressing and personal hygiene. Review of the incident report dated 03/28/16 revealed at 2:40 A.M. Resident #2 was found with his penis a bit swollen and red at the head of the penis. Review of Resident #2 ' s body audit dated 03/28/16 (no time) revealed Resident #2 ' s male privates were swollen and the genital area was circled on the audit. Review of the nurse ' s note dated 03/28/16 at 6:00 P.M. revealed the tip of Resident #2 ' s uncircumcised penis was red and swollen with no drainage noted. The resident had no signs or symptoms of discomfort. The area was cleansed and Resident #2 ' s physician was made aware. Review of the nurse ' s notes dated 03/28/16 at 9:05 P.M. revealed Resident #2 ' s room was changed this shift (time of room change not documented). Interview on 03/29/16 at 11:05 A.M. with STNA #16 revealed she normally works night shift. STNA #16 indicated due to suspicions that were reported to her related another resident (unidentified) being found in the room with Resident #6 with his penis exposed, she was trying to ensure Resident #2 and Resident #6 ' s door was left open. STNA #16 stated they were roommates on 03/28/16 at the time of the incident. STNA #16 stated around 1:00 A.M. on 03/28/16 she noticed the residents ' door shut. STNA #16 stated she opened the door, both residents were in the room and everything was normal. STNA #16 stated on 03/28/16 at approximately 2:45 A.M. Resident #2 ' s door was closed again. STNA #16 opened the door and found Resident #2 with his sheets and blankets on the floor at the foot of his bed. STNA #16 stated Resident #2 was found with his brief torn open and his penis pulled upward. STNA #16 stated Resident #2 ' s penis was red and swollen. STNA #16 stated Resident #6 was in the room with the privacy curtain closed. STNA #16 stated it was obvious to her something happened. STNA #16 stated Resident #2 cannot speak for himself and normally sleeps with his arms contracted over him. STNA #16 stated Resident #2 does not move much on the bed and has never moved his sheets throughout the night that she was aware of. STNA #16 stated she notified LPN #17 who came in and assessed the resident. STNA #16 stated LPN #17 did try to call the DON to report the incident but was unable to reach her. STNA #16 stated Resident #6 was removed from the room and every fifteen minute checks were completed by STNA #18. Interview on 03/29/16 at 11:57 A.M. with STNA #18 revealed Resident #2 was a creature of habit. STNA #18 stated Resident #2 always keeps his blankets up to his neck because he likes to rub the covers between his thumbs while he sleeps. STNA #18 stated she cares for Resident #2 four nights a week and has never observed him remove his covers or his brief during the night. STNA #18 stated STNA #16 went down to check on Resident #2 between 2:30 A.M. and 3:00 A.M. on 03/28/16. STNA #16 called for STNA #18 after checking on Resident #2 due to the condition Resident #2 was found in. STNA #16 stated when she walked in, STNA #16 had placed a blanket over Resident #2 because it was cold. STNA #16 stated Resident #2 was wet which was odd because he wears a brief. STNA #16 stated Resident #2 ' s brief was torn in the front which was also weird . STNA #16 stated Resident #2 sleeps with his legs crossed and does not roll or move much in bed and it was odd that Resident #2 ' s sheets were on the floor at the foot of the bed. Resident #2 ' s penis was found out of the brief. STNA #16 stated Resident #2 ' s penis and testicles are normally tucked down under him and they were both placed up and out of the torn brief. STNA #16 stated they were also concerned because his penis looked irritated. STNA #16 stated she notified LPN #17 of the circumstances she found Resident #2 in. STNA #16 stated LPN #17 peeked around the privacy curtain, saw Resident #6 and stated he was awake. STNA #16 stated Resident #6 was moved to an empty room immediately following this incident and placed on fifteen minute checks. STNA #16 indicated Resident #6 was jittery, appeared nervous and required redirection. After redirection into another room, Resident #6 remained in the private room he was provided for the night. STNA #16 stated on the following night (03/29/16) Resident #6 was in a private room and a motion sensor alarm was placed on the bed to alert staff if Resident #6 exited the room. Interview with the DON on 03/29/16 at 1:27 P.M. revealed she was unaware of any further abuse allegations related to Resident #6 and any other residents. Observation on 03/29/16 at 2:30 P.M. revealed a motion sensor observed on the floor under the bed near the door of Resident #6 ' s room. Resident #6 remained in a private room. Interview on 03/29/16 at 2:32 P.M. with Resident #6 revealed he loved both of his roommates. Resident #6 revealed he has bad dreams and the nurse (unidentified) was mad at him and said not to touch his roommate anymore. Resident #6 stated he did not touch his roommate. Interview on 03/29/16 at 4:22 P.M. with the DON verified LPN #17 attempted to call her on 03/28/16 about finding Resident #2 with covers on the floor, brief ripped open and his genitals swollen at the tip. The DON indicated they did not get a hold of her due to her phone not working. The DON stated when she was talking to LPN #17 on the morning of 03/28/16 the nurse reported the incident. The DON stated I asked what was being reported. The DON stated these things happen people take briefs off . The DON stated the staff were wondering if Resident #6 had done anything. The DON stated she told LPN #17 before we even go there, did you see anything or did anyone else? The DON stated LPN #17 said the staff just observed the condition Resident #2 was found in. The DON stated she told LPN #17 we can ' t assume, we have to go on what we know before you make accusations. The DON verified LPN #17 told her Resident #2 does not move. The DON stated she told LPN #17 so what you are telling me is his blankets are on the floor and his brief is open . The DON stated because of the rumors she did have an investigation started regarding the incident at on 03/28/16 at 6:00 A.M. The DON revealed the ombudsman came to the facility on [DATE] after 3:00 P.M. and wanted to know where the investigation was for the incident regarding Resident #2. The DON stated she told him that she had a statement of something odd but no staff witnessed anything. Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed she cared for Resident #2 multiple times. STNA #23 stated Resident #2 has never unfastened his brief or taken his blankets off during the night. Interview on 03/30/16 at 10:37 A.M. with LPN #17 revealed STNA #18 and STNA #16 reported Resident #2 ' s blanket was on the floor and Resident #2 ' s brief was undone. LPN #17 stated she never observed Resident #2 move at night or do anything with his sheets. LPN #17 stated Resident #2 sleeps exactly the same way every night on his back. LPN #17 stated STNA #18 and STNA #16 changed Resident #2 prior to entering the room so she did not witness the way the resident was first observed by the STNA ' s. LPN #17 stated she did assess Resident #2 ' s genital area and found the tip of his penis slightly swollen. LPN #17 stated it is abnormal for Resident #2 to be awake at night. LPN #17 stated she did not document anything because she herself did not see anything. LPN #17 stated she did attempt to call the DON, however did not actually talk to the DON until she came in for the day around 6:00 A.M. LPN #17 stated Resident #6 was moved to another room and kept away from Resident #2 for the remainder of the night. LPN #17 stated STNA #16 and STNA #18 were suspicious of how they found Resident #2 because Resident #2 never moved at night. LPN #17 stated Resident #6 can be intrusive at times but was unaware of any further behaviors. LPN #17 stated she did not think to have STNA #16 or STNA #18 write statements of what they witnessed at that time. Interview on 03/31/16 at 8:40 A.M. with RN #25 revealed she was present on 03/28/16 at 2:45 A.M. RN #25 stated LPN #17 came to the office and wanted to talk to her. RN #25 verified LPN #17 informed RN #25 that Resident #2 ' s covers were off and the top of his brief was messed with . RN #25 stated according to the staff it was not normal for the covers to not be on Resident #2. RN #25 stated she asked LPN #17 if anyone saw or heard anything. RN #25 stated LPN #17 said they did not see anything but his brief was messed with. LPN #17 insinuated Resident #6 messed with his roommate. RN #25 stated LPN #17 asked her why Resident #6 was moved upstairs and did Resident #6 do something wrong downstairs? RN #25 informed LPN #17 that Resident #6 did not do anything wrong downstairs (his previous room). RN #25 stated LPN #17 wanted to separate Resident #6 and Resident #2. RN #25 stated Resident #6 was very intrusive and gets very close to you. RN #25 stated she told LPN #17 you cannot document something you did not witness. Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. Review of the (undated) abuse policy revealed procedures for prevention included assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: residents who have behaviors such as entering other residents rooms, residents with a history of aggressive behaviors, the identification of events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation. The response portion of the policy revealed to protect the resident. This included the staff should report all incidents immediately to their direct supervisors, staff should not leave a resident unattended unless it is necessary to summon assistance. Staff should not move the resident until he/she has been assessed by a nurse supervisor for possible injuries. A nurse should perform an initial assessment of the resident. Documentation in the nurse ' s notes should include the results of the resident ' s range of motion, body assessment, vital signs, the notification of the physician and the responsible party, and treatment provided. Appropriate quality assurance documentation should be completed as well. All allegations of abuse and neglect, injuries of unknown source and misappropriation of resident property must be reported immediately to both the Administrator and to the Ohio Department of Health. The policy indicated if a suspected crime has been committed it will report that suspicion in accordance with its crime reporting policies. Once the Administrator and the Ohio Department of Health are notified an investigation of the allegation or suspicion will be conducted. Interview the resident accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, including other residents, family members and employees who worked closely with the alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. Obtain written statements from the resident, if possible, the accused and each witness. After completion of the investigation, all of the evidence should be analyzed and the administrator will make a determination regarding whether the allegation or suspicion is substantiated and for injuries of unknown source a determination regarding the probable source of the injury.

Based on medical record review, observation, staff and resident interview, review of witness statements, review of incident reports and review of the facility ' s Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property policy and procedure, the facility failed to thoroughly investigate and immediately report allegations of sexual abuse. Actual harm occurred when two residents (Resident #14 and Resident #2) were sexually abused by Resident #6 and the facility failed to report and/or investigate the abuse. This resulted in Immediate Jeopardy for two (Resident #14 and Resident #2) of four residents reviewed for abuse and had the potential to affect all 46 residents residing in the facility. On 03/30/16 at 11:55 A.M. the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #12 were notified that Immediate Jeopardy began on 03/20/15 at 4:00 A.M. when state tested nursing assistant (STNA) #10 reported to Licensed Practical Nurse (LPN) #15 that Resident #14, who had dementia and was totally dependent on two persons for assistance with bed mobility, dressing, and personal hygiene, was found clutching the collar of his shirt and appeared irritated. Resident #14 ' s blankets were removed from his bed and were found on a chair in the room. Resident #14 ' s brief was open, his penis was exposed and flipped up toward his abdomen. STNA #10 reported Resident #14 ' s brief was ripped open and not just unfastened. STNA #10 also indicated the roommate, Resident #6 (diagnosed with [REDACTED]. The facility failed to complete an investigation related to this incident and protect residents from Resident #6. The Immediate Jeopardy continued on 03/28/16 at 2:40 A.M. when Resident #2 (diagnosed with [REDACTED].#16 with his brief open and the blankets on the floor at the foot of his bed. Resident #2 ' s penis and scrotum were flipped up toward his abdomen. Resident #2 ' s scrotum and penis were red and swollen. His new roommate, Resident #6, was observed in the room, on the opposite side of the privacy curtain, awake and sitting in bed. The Immediate Jeopardy was removed on 04/01/16 when the facility implemented the following corrective actions: · On 03/28/16 (time not recorded) the DON in-serviced nine STNA ' s (STNA #11, STNA #34, STNA#10, STNA #37, STNA #38, STNA #14, STNA #39, STNA #41, STNA #44), six LPN ' s (LPN #20, LPN #35, LPN #17, LPN #43, LPN #42 and LPN #24) , the Business Office Manager #30, two activities staff (Activities #26 and Activities #31), three dietary staff (Dietary #46, Dietary#32, Dietary #33) and Dietary Supervisor #47, two housekeeping staff (Housekeeping #36, Laundry aide #45), Dietitian #48 and Maintenance #40 staff on abuse, mistreatment, neglect, injuries of unknown source and misappropriation of resident property. · On 03/28/16 at 2:45 A.M. Resident #6 was placed in a private room. · On 03/28/16 at 5:00 P.M. a motion sensor was placed on Resident #6 ' s bed to ensure Resident #6 was not exiting his private room. The facility did not implement a system to monitor resident #6 when he was out of bed. · On 03/28/16 (no time) Resident #6 ' s plan of care was updated to reflect possible sexual behaviors toward another resident. The care card indicated to remind Resident #6 of boundaries as needed and if any incident of inappropriate behavior was noted, to place Resident #6 on one to ones. · On 03/30/16 at 10:10 P.M. four RN ' s( RN #58, RN #59, RN #22, RN #25), eight LPN ' s (LPN #57, LPN #24, LPN #15, LPN #29, LPN #35, LPN #20, LPN #49, LPN #43) , 16 STNA ' s (STNA #39, STNA #11, STNA #41, STNA #56, STNA #14, STNA #51, STNA #38, STNA #50, STNA #33, STNA #52, STNA #34, STNA #18, STNA #65, STNA #66, STNA #67, STNA #28), six dietary staff (Dietary Supervisor #47, Dietary #32, Dietary #46, Dietary #62, Dietary #60, Dietary #33), five housekeeping and laundry staff (Housekeeping #63, Housekeeping #64, Laundry #45, Housekeeping #54, Housekeeping #68), two activities staff (Activities #31, Activities Director #26), Business Office Manager #30, Licensed Social Worker #61, two maintenance staff (Maintenance #53, and Maintenance #40) and Billing staff #55 were in-serviced by the Administrator and DON on identifying possible situations that would require investigation as related to possible abuse or neglect. · On 03/30/16 at 11:59 A.M. a new template noted as investigation and incident follow-up guidelines was provided by the DON for both units of the facility for staff reference. The templates were observed hanging at the nurse ' s station on both units. · On 03/30/16 at 11:59 A.M. Regional Director of Nursing Services #12 provided education to the Administrator and the Director of Nursing on completing investigations. · On 03/30/16 (between approximately 4:00 P.M. and 5:00 P.M.) RN #25 interviewed Resident #14 for additional information. · Observation on 03/29/16 at 8:44 A.M. revealed Resident #6 ambulating independently throughout the hallway. Resident #6 greeted the surveyor with a handshake and attempted to hug the surveyor. The administrator was present during this observation. Observation on 03/29/16 at 10:51 A.M. revealed Resident #6 in the dining room with staff present. Resident #6 was seated in a chair and was waving and blowing kisses at the surveyor. Observation on 03/29/16 at 2:12 P.M. revealed Resident #6 involved in activities in the second floor dining room with additional residents and staff present. Observation on 03/30/16 at 5:37 A.M. revealed Resident #6 in room in bed with covers on and a motion sensor to the bed; no roommate. Observation on 03/31/16 at 8:00 A.M. Resident #6 was observed in the dining area on the second floor with staff present. Observation on 04/01/16 at 8:42 A.M. revealed Resident #6 ambulating independently in the hallway on the unit and staff were present in the hallway during this observation. · On 04/01/16 at 12:00 P.M. Resident #6 was discharged to another long term care facility. · Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. · Interview on 04/04/16 at 8:55 A.M with the DON revealed evidence of knowledge of investigating suspected abuse, and reporting and completing the investigation. · Interview on 04/04/16 at 8:53 A.M. with the Administrator revealed evidence of knowledge of investigating suspected abuse and reporting and completing the investigation Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility has not implemented any auditing procedures. The facility also has not implemented procedures to inform agency staff of the facility ' s policies and procedures. Findings Include: 1. Review of Resident #14 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14 ' s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident could not complete the brief interview of mental status section. The staff assessment indicated Resident #14 was severely impaired for cognitive skills in daily decision making. Resident #14 ' s functional assessment revealed the resident required total dependence of two person physical assistance for transfers and bed mobility. The assessment indicated Resident #14 required total dependence of one person physical assist for dressing. Review of Resident #6 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6 ' s MDS assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was independent for bed mobility, transfer and walking in room. Review of the current plan of care initiated on 09/29/14 revealed Resident #6 had a behavior problem related to wandering in others ' rooms and looking in their belongings. Resident #6 was very intrusive in nature and invades others personal space during conversation. Resident #6 makes threats towards staff when he gets anxious/upset and resident frequently masturbates in his room. Review of Resident #6 ' s physician progress notes [REDACTED].#6 approached the physician to shake hands and tried to hug. The note indicated Resident #6 was intrusive, impulsive, and had poor boundaries. The note indicated Resident #6 ' s antipsychotic medication was increased during this visit. Review of Resident #6 ' s nurse ' s note dated 03/12/16 at 9:00 A.M. revealed Resident #6 keeps following another unidentified resident around being loud and mean. The nurse did not recall which resident this was. One to one given without effectiveness and as needed medications were given. A nurse ' s note dated 03/18/16 at 4:00 AM. revealed Resident #6 was up most of the night. The note stated Resident #6 was in his room and popping up and down hallway occasionally. The nurse ' s note dated 03/21/16 at 5:30 P.M. revealed Resident #6 was transferred to another room. Review of a witness statement dated 3/28/16 and written by STNA #10 indicated last weekend (03/19/16 into 03/20/16) while working midnight shift, STNA #10 came across Resident #14 ' s blankets and foot braces that were placed in the wheelchair across the room from Resident #14 ' s bed. The statement indicated the blankets and foot braces were not placed in the wheelchair by staff. The statement indicated upon further observation this resident ' s privates were exposed. Observation on 03/29/16 at 9:16 A.M. revealed Resident #14 in bed with his arms crossed and eyes open. Resident #14 would not respond to the surveyor when interview attempted. On 03/29/16 at 2:50 P.M. Resident #14 was attempted to be interviewed and again did not respond to any questions. Interview on 03/29/16 at 3:39 P.M. with STNA #10 revealed she and STNA #21 were working on 03/20/16 in the early morning on the first floor of the facility. STNA #10 stated she was walking in the hallway and observed Resident #14 with his blankets and his heel boots on the wheelchair in his room. Resident #14 was clutching the collar of his shirt and was irritated . Resident #14 ' s brief was torn and his penis was exposed and flipped up on his abdomen. STNA #10 stated Resident #14 ' s roommate ' s (Resident #6) curtain was pulled and STNA #10 stated she informed LPN #15 of this finding. STNA #10 stated LPN #15 entered Resident #14 and Resident #6 ' s room and asked Resident #6 if he touched Resident #14. STNA #10 stated Resident #6 responded no and stated he had a nightmare. STNA #10 stated Resident #6 was up and ambulating in the room when the observation was made. STNA #10 stated the nurse left the room without assessing Resident #14. STNA #10 stated she was unaware of any further interventions or investigation related to the cause of Resident #14 ' s appearance. STNA #10 stated she also reported the incident to the day shift STNA (STNA #14). STNA #10 indicated the observation was suspicious because Resident #14 was not physically capable of moving his blankets to the chair and his penis is normally tucked down to prevent urination out of the brief. STNA #10 indicated Resident #14 was not physically capable of opening the brief. STNA #10 stated Resident #14 ' s testicles were also repositioned up. STNA #10 stated Resident #6 was moved to a different room a couple of days after this incident. STNA #10 stated Resident #6 was placed in another room with a roommate who was not mentally capable of speaking for himself (Resident #2). Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed on 03/20/16, she and STNA #14 arrived for the day shift when STNA #10 reported to STNA #14 that during the night she went down to check on Resident #14 because he was yelling out. STNA #10 told STNA #14 that Resident #6 was standing over Resident #14 and Resident #14 had an erection. STNA #23 stated STNA #14 reported that she told the midnight nurse. STNA #23 stated LPN #24 was heard talking to the DON related to the above concern and the DON stated we can ' t open that can of worms because we didn ' t see him (referring to Resident #6). STNA #23 stated Resident #14 was bedridden and could not move his covers off and place them across the room where they were found by STNA #10. Interview on 03/30/16 at 6:05 A.M. with STNA #14 revealed on 03/20/16 STNA #10 told her in report that Resident #6 was found standing over Resident #14 and Resident #14 ' s blankets were off of him and found on a wheelchair. STNA #14 stated she did not say anything because that was something that should be reported by the person who observed it. Interview on 03/30/16 at 6:07 A.M. with STNA #10 revealed on 03/20/16 at 4:00 A.M. she found Resident #14 with his blankets off, his brief open and his genitals exposed. STNA #10 stated Resident #6 was observed walking on his side of the room at this time. STNA #10 stated the nurse (LPN #15) asked Resident #6 if he was touching Resident #14 and Resident #6 replied he had a nightmare. Interview on 03/30/16 at 6:29 A.M. with LPN #24 revealed she was never told in report on 03/20/16 about Resident #14 being found exposed. LPN #24 stated later on in the day, someone (unidentified) told her Resident #6 was standing by Resident #14 ' s bed. LPN #24 stated she asked Resident #6 about it and he said he had a bad dream. LPN #24 stated she was aware Resident #6 had bad dreams and would become anxious and unaware of what was going on. LPN #24 stated she specifically asked Resident #6 what he was doing when he was standing over Resident #14 ' s bed and he stated he didn ' t know where he was. LPN #24 stated she informed the DON as an FYI kind of thing . LPN #24 stated she was not concerned about the incident. LPN #24 stated Resident #14 does knock his blankets off sometimes, however she did not recall if the blankets were found off during this incident. LPN #24 indicated no statements were obtained at that time. Interview on 03/30/16 at 12:05 P.M. with the DON verified she was notified by an unidentified staff member that Resident #14 ' s bed sheets were moved to a different place. The DON stated the staff member started her conversation with rumor is and then the DON stopped the staff member and stated we don ' t adhere to rumors. 2. Review of Resident #2 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s MDS assessment dated [DATE] revealed Resident #2 was unable to conduct the interview and the staff assessment revealed cognitive skills for daily decision making were severely impaired. Review of Resident #2 ' s functional assessment revealed Resident #2 required limited assistance of one person for bed mobility and transfer. The assessment revealed Resident #2 required extensive assistance of one person physical assistance for dressing and personal hygiene. Review of the incident report dated 03/28/16 revealed at 2:40 A.M. Resident #2 was found with his penis a bit swollen and red at the head of the penis. Review of Resident #2 ' s body audit dated 03/28/16 (no time) revealed Resident #2 ' s male privates were swollen and the genital area was circled on the audit. Review of the nurse ' s note dated 03/28/16 at 6:00 P.M. revealed the tip of Resident #2 ' s uncircumcised penis was red and swollen with no drainage noted. The resident had no signs or symptoms of discomfort. The area was cleansed and Resident #2 ' s physician was made aware. Review of the nurse ' s notes dated 03/28/16 at 9:05 P.M. revealed Resident #2 ' s room was changed this shift (time of room change not documented). Interview on 03/29/16 at 11:05 A.M. with STNA #16 revealed she normally works night shift. STNA #16 indicated due to suspicions that were reported to her related another resident (unidentified) being found in the room with Resident #6 with his penis exposed, she was trying to ensure Resident #2 and Resident #6 ' s door was left open. STNA #16 stated they were roommates on 03/28/16 at the time of the incident. STNA #16 stated around 1:00 A.M. on 03/28/16 she noticed the residents ' door shut. STNA #16 stated she opened the door, both residents were in the room and everything was normal. STNA #16 stated on 03/28/16 at approximately 2:45 A.M. Resident #2 ' s door was closed again. STNA #16 opened the door and found Resident #2 with his sheets and blankets on the floor at the foot of his bed. STNA #16 stated Resident #2 was found with his brief torn open and his penis pulled upward. STNA #16 stated Resident #2 ' s penis was red and swollen. STNA #16 stated Resident #6 was in the room with the privacy curtain closed. STNA #16 stated it was obvious to her something happened. STNA #16 stated Resident #2 cannot speak for himself and normally sleeps with his arms contracted over him. STNA #16 stated Resident #2 does not move much on the bed and has never moved his sheets throughout the night that she was aware of. STNA #16 stated she notified LPN #17 who came in and assessed the resident. STNA #16 stated LPN #17 did try to call the DON to report the incident but was unable to reach her. STNA #16 stated Resident #6 was removed from the room and every fifteen minute checks were completed by STNA #18. Interview on 03/29/16 at 11:57 A.M. with STNA #18 revealed Resident #2 was a creature of habit. STNA #18 stated Resident #2 always keeps his blankets up to his neck because he likes to rub the covers between his thumbs while he sleeps. STNA #18 stated she cares for Resident #2 four nights a week and has never observed him remove his covers or his brief during the night. STNA #18 stated STNA #16 went down to check on Resident #2 between 2:30 A.M. and 3:00 A.M. on 03/28/16. STNA #16 called for STNA #18 after checking on Resident #2 due to the condition Resident #2 was found in. STNA #16 stated when she walked in, STNA #16 had placed a blanket over Resident #2 because it was cold. STNA #16 stated Resident #2 was wet which was odd because he wears a brief. STNA #16 stated Resident #2 ' s brief was torn in the front which was also weird . STNA #16 stated Resident #2 sleeps with his legs crossed and does not roll or move much in bed and it was odd that Resident #2 ' s sheets were on the floor at the foot of the bed. Resident #2 ' s penis was found out of the brief. STNA #16 stated Resident #2 ' s penis and testicles are normally tucked down under him and they were both placed up and out of the torn brief. STNA #16 stated they were also concerned because his penis looked irritated. STNA #16 stated she notified LPN #17 of the circumstances she found Resident #2 in. STNA #16 stated LPN #17 peeked around the privacy curtain, saw Resident #6 and stated he was awake. STNA #16 stated Resident #6 was moved to an empty room immediately following this incident and placed on fifteen minute checks. STNA #16 indicated Resident #6 was jittery, appeared nervous and required redirection. After redirection into another room, Resident #6 remained in the private room he was provided for the night. STNA #16 stated on the following night (03/29/16) Resident #6 was in a private room and a motion sensor alarm was placed on the bed to alert staff if Resident #6 exited the room. Interview with the DON on 03/29/16 at 1:27 P.M. revealed she was unaware of any further abuse allegations related to Resident #6 and any other residents. Observation on 03/29/16 at 2:30 P.M. revealed a motion sensor observed on the floor under the bed near the door of Resident #6 ' s room. Resident #6 remained in a private room. Interview on 03/29/16 at 2:32 P.M. with Resident #6 revealed he loved both of his roommates. Resident #6 revealed he has bad dreams and the nurse (unidentified) was mad at him and said not to touch his roommate anymore. Resident #6 stated he did not touch his roommate. Interview on 03/29/16 at 4:22 P.M. with the DON verified LPN #17 attempted to call her on 03/28/16 about finding Resident #2 with covers on the floor, brief ripped open and his genitals swollen at the tip. The DON indicated they did not get a hold of her due to her phone not working. The DON stated when she was talking to LPN #17 on the morning of 03/28/16 the nurse reported the incident. The DON stated I asked what was being reported. The DON stated these things happen people take briefs off . The DON stated the staff were wondering if Resident #6 had done anything. The DON stated she told LPN #17 before we even go there, did you see anything or did anyone else? The DON stated LPN #17 said the staff just observed the condition Resident #2 was found in. The DON stated she told LPN #17 we can ' t assume, we have to go on what we know before you make accusations. The DON verified LPN #17 told her Resident #2 does not move. The DON stated she told LPN #17 so what you are telling me is his blankets are on the floor and his brief is open . The DON stated because of the rumors she did have an investigation started regarding the incident at on 03/28/16 at 6:00 A.M. The DON revealed the ombudsman came to the facility on [DATE] after 3:00 P.M. and wanted to know where the investigation was for the incident regarding Resident #2. The DON stated she told him that she had a statement of something odd but no staff witnessed anything. Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed she cared for Resident #2 multiple times. STNA #23 stated Resident #2 has never unfastened his brief or taken his blankets off during the night. Interview on 03/30/16 at 10:37 A.M. with LPN #17 revealed STNA #18 and STNA #16 reported Resident #2 ' s blanket was on the floor and Resident #2 ' s brief was undone. LPN #17 stated she never observed Resident #2 move at night or do anything with his sheets. LPN #17 stated Resident #2 sleeps exactly the same way every night on his back. LPN #17 stated STNA #18 and STNA #16 changed Resident #2 prior to entering the room so she did not witness the way the resident was first observed by the STNA ' s. LPN #17 stated she did assess Resident #2 ' s genital area and found the tip of his penis slightly swollen. LPN #17 stated it is abnormal for Resident #2 to be awake at night. LPN #17 stated she did not document anything because she herself did not see anything. LPN #17 stated she did attempt to call the DON, however did not actually talk to the DON until she came in for the day around 6:00 A.M. LPN #17 stated Resident #6 was moved to another room and kept away from Resident #2 for the remainder of the night. LPN #17 stated STNA #16 and STNA #18 were suspicious of how they found Resident #2 because Resident #2 never moved at night. LPN #17 stated Resident #6 can be intrusive at times but was unaware of any further behaviors. LPN #17 stated she did not think to have STNA #16 or STNA #18 write statements of what they witnessed at that time. Interview on 03/31/16 at 8:40 A.M. with RN #25 revealed she was present on 03/28/16 at 2:45 A.M. RN #25 stated LPN #17 came to the office and wanted to talk to her. RN #25 verified LPN #17 informed RN #25 that Resident #2 ' s covers were off and the top of his brief was messed with . RN #25 stated according to the staff it was not normal for the covers to not be on Resident #2. RN #25 stated she asked LPN #17 if anyone saw or heard anything. RN #25 stated LPN #17 said they did not see anything but his brief was messed with. LPN #17 insinuated Resident #6 messed with his roommate. RN #25 stated LPN #17 asked her why Resident #6 was moved upstairs and did Resident #6 do something wrong downstairs? RN #25 informed LPN #17 that Resident #6 did not do anything wrong downstairs (his previous room). RN #25 stated LPN #17 wanted to separate Resident #6 and Resident #2. RN #25 stated Resident #6 was very intrusive and gets very close to you. RN #25 stated she told LPN #17 you cannot document something you did not witness. Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. Review of the (undated) abuse policy revealed procedures for prevention included assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: residents who have behaviors such as entering other residents rooms, residents with a history of aggressive behaviors, the identification of events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation. The response portion of the policy revealed to protect the resident. This included the staff should report all incidents immediately to their direct supervisors, staff should not leave a resident unattended unless it is necessary to summon assistance. Staff should not move the resident until he/she has been assessed by a nurse supervisor for possible injuries. A nurse should perform an initial assessment of the resident. Documentation in the nurse ' s notes should include the results of the resident ' s range of motion, body assessment, vital signs, the notification of the physician and the responsible party, and treatment provided. Appropriate quality assurance documentation should be completed as well. All allegations of abuse and neglect, injuries of unknown source and misappropriation of resident property must be reported immediately to both the Administrator and to the Ohio Department of Health. The policy indicated if a suspected crime has been committed it will report that suspicion in accordance with its crime reporting policies. Once the Administrator and the Ohio Department of Health are notified an investigation of the allegation or suspicion will be conducted. Interview the resident accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, including other residents, family members and employees who worked closely with the alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. Obtain written statements from the resident, if possible, the accused and each witness. After completion of the investigation, all of the evidence should be analyzed and the administrator will make a determination regarding whether the allegation or suspicion is substantiated and for injuries of unknown source a determination regarding the probable source of the injury.

Based on medical record review, observation, staff and resident interview, review of witness statements, review of incident reports and review of the facility ' s Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property policy and procedure, the facility failed to follow the abuse policy and procedure related to allegations of sexual abuse. Actual harm occurred when two residents (Resident #14 and Resident #2) were sexually abused by Resident #6 and the facility failed to report and/or investigate the abuse. This resulted in Immediate Jeopardy for two (Resident #14 and Resident #2) of four residents reviewed for abuse and had the potential to affect all 46 residents residing in the facility. On 03/30/16 at 11:55 A.M. the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #12 were notified that Immediate Jeopardy began on 03/20/15 at 4:00 A.M. when state tested nursing assistant (STNA) #10 reported to Licensed Practical Nurse (LPN) #15 that Resident #14, who had dementia and was totally dependent on two persons for assistance with bed mobility, dressing, and personal hygiene, was found clutching the collar of his shirt and appeared irritated. Resident #14 ' s blankets were removed from his bed and were found on a chair in the room. Resident #14 ' s brief was open, his penis was exposed and flipped up toward his abdomen. STNA #10 reported Resident #14 ' s brief was ripped open and not just unfastened. STNA #10 also indicated the roommate, Resident #6 (diagnosed with [REDACTED]. The facility failed to complete an investigation related to this incident and protect residents from Resident #6. The Immediate Jeopardy continued on 03/28/16 at 2:40 A.M. when Resident #2 (diagnosed with [REDACTED].#16 with his brief open and the blankets on the floor at the foot of his bed. Resident #2 ' s penis and scrotum were flipped up toward his abdomen. Resident #2 ' s scrotum and penis were red and swollen. His new roommate, Resident #6, was observed in the room, on the opposite side of the privacy curtain, awake and sitting in bed. The Immediate Jeopardy was removed on 04/01/16 when the facility implemented the following corrective actions: · On 03/28/16 (time not recorded) the DON in-serviced nine STNA ' s (STNA #11, STNA #34, STNA#10, STNA #37, STNA #38, STNA #14, STNA #39, STNA #41, STNA #44), six LPN ' s (LPN #20, LPN #35, LPN #17, LPN #43, LPN #42 and LPN #24) , the Business Office Manager #30, two activities staff (Activities #26 and Activities #31), three dietary staff (Dietary #46, Dietary#32, Dietary #33) and Dietary Supervisor #47, two housekeeping staff (Housekeeping #36, Laundry aide #45), Dietitian #48 and Maintenance #40 staff on abuse, mistreatment, neglect, injuries of unknown source and misappropriation of resident property. · On 03/28/16 at 2:45 A.M. Resident #6 was placed in a private room. · On 03/28/16 at 5:00 P.M. a motion sensor was placed on Resident #6 ' s bed to ensure Resident #6 was not exiting his private room. The facility did not implement a system to monitor resident #6 when he was out of bed. · On 03/28/16 (no time) Resident #6 ' s plan of care was updated to reflect possible sexual behaviors toward another resident. The care card indicated to remind Resident #6 of boundaries as needed and if any incident of inappropriate behavior was noted, to place Resident #6 on one to ones. · On 03/30/16 at 10:10 P.M. four RN ' s( RN #58, RN #59, RN #22, RN #25), eight LPN ' s (LPN #57, LPN #24, LPN #15, LPN #29, LPN #35, LPN #20, LPN #49, LPN #43) , 16 STNA ' s (STNA #39, STNA #11, STNA #41, STNA #56, STNA #14, STNA #51, STNA #38, STNA #50, STNA #33, STNA #52, STNA #34, STNA #18, STNA #65, STNA #66, STNA #67, STNA #28), six dietary staff (Dietary Supervisor #47, Dietary #32, Dietary #46, Dietary #62, Dietary #60, Dietary #33), five housekeeping and laundry staff (Housekeeping #63, Housekeeping #64, Laundry #45, Housekeeping #54, Housekeeping #68), two activities staff (Activities #31, Activities Director #26), Business Office Manager #30, Licensed Social Worker #61, two maintenance staff (Maintenance #53, and Maintenance #40) and Billing staff #55 were in-serviced by the Administrator and DON on identifying possible situations that would require investigation as related to possible abuse or neglect. · On 03/30/16 at 11:59 A.M. a new template noted as investigation and incident follow-up guidelines was provided by the DON for both units of the facility for staff reference. The templates were observed hanging at the nurse ' s station on both units. · On 03/30/16 at 11:59 A.M. Regional Director of Nursing Services #12 provided education to the Administrator and the Director of Nursing on completing investigations. · On 03/30/16 (between approximately 4:00 P.M. and 5:00 P.M.) RN #25 interviewed Resident #14 for additional information. · Observation on 03/29/16 at 8:44 A.M. revealed Resident #6 ambulating independently throughout the hallway. Resident #6 greeted the surveyor with a handshake and attempted to hug the surveyor. The administrator was present during this observation. Observation on 03/29/16 at 10:51 A.M. revealed Resident #6 in the dining room with staff present. Resident #6 was seated in a chair and was waving and blowing kisses at the surveyor. Observation on 03/29/16 at 2:12 P.M. revealed Resident #6 involved in activities in the second floor dining room with additional residents and staff present. Observation on 03/30/16 at 5:37 A.M. revealed Resident #6 in room in bed with covers on and a motion sensor to the bed; no roommate. Observation on 03/31/16 at 8:00 A.M. Resident #6 was observed in the dining area on the second floor with staff present. Observation on 04/01/16 at 8:42 A.M. revealed Resident #6 ambulating independently in the hallway on the unit and staff were present in the hallway during this observation. · On 04/01/16 at 12:00 P.M. Resident #6 was discharged to another long term care facility. · Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. · Interview on 04/04/16 at 8:55 A.M with the DON revealed evidence of knowledge of investigating suspected abuse, and reporting and completing the investigation. · Interview on 04/04/16 at 8:53 A.M. with the Administrator revealed evidence of knowledge of investigating suspected abuse and reporting and completing the investigation Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility has not implemented any auditing procedures. The facility also has not implemented procedures to inform agency staff of the facility ' s policies and procedures. Findings Include: 1. Review of Resident #14 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14 ' s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident could not complete the brief interview of mental status section. The staff assessment indicated Resident #14 was severely impaired for cognitive skills in daily decision making. Resident #14 ' s functional assessment revealed the resident required total dependence of two person physical assistance for transfers and bed mobility. The assessment indicated Resident #14 required total dependence of one person physical assist for dressing. Review of Resident #6 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6 ' s MDS assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was independent for bed mobility, transfer and walking in room. Review of the current plan of care initiated on 09/29/14 revealed Resident #6 had a behavior problem related to wandering in others ' rooms and looking in their belongings. Resident #6 was very intrusive in nature and invades others personal space during conversation. Resident #6 makes threats towards staff when he gets anxious/upset and resident frequently masturbates in his room. Review of Resident #6 ' s physician progress notes [REDACTED].#6 approached the physician to shake hands and tried to hug. The note indicated Resident #6 was intrusive, impulsive, and had poor boundaries. The note indicated Resident #6 ' s antipsychotic medication was increased during this visit. Review of Resident #6 ' s nurse ' s note dated 03/12/16 at 9:00 A.M. revealed Resident #6 keeps following another unidentified resident around being loud and mean. The nurse did not recall which resident this was. One to one given without effectiveness and as needed medications were given. A nurse ' s note dated 03/18/16 at 4:00 AM. revealed Resident #6 was up most of the night. The note stated Resident #6 was in his room and popping up and down hallway occasionally. The nurse ' s note dated 03/21/16 at 5:30 P.M. revealed Resident #6 was transferred to another room. Review of a witness statement dated 3/28/16 and written by STNA #10 indicated last weekend (03/19/16 into 03/20/16) while working midnight shift, STNA #10 came across Resident #14 ' s blankets and foot braces that were placed in the wheelchair across the room from Resident #14 ' s bed. The statement indicated the blankets and foot braces were not placed in the wheelchair by staff. The statement indicated upon further observation this resident ' s privates were exposed. Observation on 03/29/16 at 9:16 A.M. revealed Resident #14 in bed with his arms crossed and eyes open. Resident #14 would not respond to the surveyor when interview attempted. On 03/29/16 at 2:50 P.M. Resident #14 was attempted to be interviewed and again did not respond to any questions. Interview on 03/29/16 at 3:39 P.M. with STNA #10 revealed she and STNA #21 were working on 03/20/16 in the early morning on the first floor of the facility. STNA #10 stated she was walking in the hallway and observed Resident #14 with his blankets and his heel boots on the wheelchair in his room. Resident #14 was clutching the collar of his shirt and was irritated . Resident #14 ' s brief was torn and his penis was exposed and flipped up on his abdomen. STNA #10 stated Resident #14 ' s roommate ' s (Resident #6) curtain was pulled and STNA #10 stated she informed LPN #15 of this finding. STNA #10 stated LPN #15 entered Resident #14 and Resident #6 ' s room and asked Resident #6 if he touched Resident #14. STNA #10 stated Resident #6 responded no and stated he had a nightmare. STNA #10 stated Resident #6 was up and ambulating in the room when the observation was made. STNA #10 stated the nurse left the room without assessing Resident #14. STNA #10 stated she was unaware of any further interventions or investigation related to the cause of Resident #14 ' s appearance. STNA #10 stated she also reported the incident to the day shift STNA (STNA #14). STNA #10 indicated the observation was suspicious because Resident #14 was not physically capable of moving his blankets to the chair and his penis is normally tucked down to prevent urination out of the brief. STNA #10 indicated Resident #14 was not physically capable of opening the brief. STNA #10 stated Resident #14 ' s testicles were also repositioned up. STNA #10 stated Resident #6 was moved to a different room a couple of days after this incident. STNA #10 stated Resident #6 was placed in another room with a roommate who was not mentally capable of speaking for himself (Resident #2). Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed on 03/20/16, she and STNA #14 arrived for the day shift when STNA #10 reported to STNA #14 that during the night she went down to check on Resident #14 because he was yelling out. STNA #10 told STNA #14 that Resident #6 was standing over Resident #14 and Resident #14 had an erection. STNA #23 stated STNA #14 reported that she told the midnight nurse. STNA #23 stated LPN #24 was heard talking to the DON related to the above concern and the DON stated we can ' t open that can of worms because we didn ' t see him (referring to Resident #6). STNA #23 stated Resident #14 was bedridden and could not move his covers off and place them across the room where they were found by STNA #10. Interview on 03/30/16 at 6:05 A.M. with STNA #14 revealed on 03/20/16 STNA #10 told her in report that Resident #6 was found standing over Resident #14 and Resident #14 ' s blankets were off of him and found on a wheelchair. STNA #14 stated she did not say anything because that was something that should be reported by the person who observed it. Interview on 03/30/16 at 6:07 A.M. with STNA #10 revealed on 03/20/16 at 4:00 A.M. she found Resident #14 with his blankets off, his brief open and his genitals exposed. STNA #10 stated Resident #6 was observed walking on his side of the room at this time. STNA #10 stated the nurse (LPN #15) asked Resident #6 if he was touching Resident #14 and Resident #6 replied he had a nightmare. Interview on 03/30/16 at 6:29 A.M. with LPN #24 revealed she was never told in report on 03/20/16 about Resident #14 being found exposed. LPN #24 stated later on in the day, someone (unidentified) told her Resident #6 was standing by Resident #14 ' s bed. LPN #24 stated she asked Resident #6 about it and he said he had a bad dream. LPN #24 stated she was aware Resident #6 had bad dreams and would become anxious and unaware of what was going on. LPN #24 stated she specifically asked Resident #6 what he was doing when he was standing over Resident #14 ' s bed and he stated he didn ' t know where he was. LPN #24 stated she informed the DON as an FYI kind of thing . LPN #24 stated she was not concerned about the incident. LPN #24 stated Resident #14 does knock his blankets off sometimes, however she did not recall if the blankets were found off during this incident. LPN #24 indicated no statements were obtained at that time. Interview on 03/30/16 at 12:05 P.M. with the DON verified she was notified by an unidentified staff member that Resident #14 ' s bed sheets were moved to a different place. The DON stated the staff member started her conversation with rumor is and then the DON stopped the staff member and stated we don ' t adhere to rumors. 2. Review of Resident #2 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s MDS assessment dated [DATE] revealed Resident #2 was unable to conduct the interview and the staff assessment revealed cognitive skills for daily decision making were severely impaired. Review of Resident #2 ' s functional assessment revealed Resident #2 required limited assistance of one person for bed mobility and transfer. The assessment revealed Resident #2 required extensive assistance of one person physical assistance for dressing and personal hygiene. Review of the incident report dated 03/28/16 revealed at 2:40 A.M. Resident #2 was found with his penis a bit swollen and red at the head of the penis. Review of Resident #2 ' s body audit dated 03/28/16 (no time) revealed Resident #2 ' s male privates were swollen and the genital area was circled on the audit. Review of the nurse ' s note dated 03/28/16 at 6:00 P.M. revealed the tip of Resident #2 ' s uncircumcised penis was red and swollen with no drainage noted. The resident had no signs or symptoms of discomfort. The area was cleansed and Resident #2 ' s physician was made aware. Review of the nurse ' s notes dated 03/28/16 at 9:05 P.M. revealed Resident #2 ' s room was changed this shift (time of room change not documented). Interview on 03/29/16 at 11:05 A.M. with STNA #16 revealed she normally works night shift. STNA #16 indicated due to suspicions that were reported to her related another resident (unidentified) being found in the room with Resident #6 with his penis exposed, she was trying to ensure Resident #2 and Resident #6 ' s door was left open. STNA #16 stated they were roommates on 03/28/16 at the time of the incident. STNA #16 stated around 1:00 A.M. on 03/28/16 she noticed the residents ' door shut. STNA #16 stated she opened the door, both residents were in the room and everything was normal. STNA #16 stated on 03/28/16 at approximately 2:45 A.M. Resident #2 ' s door was closed again. STNA #16 opened the door and found Resident #2 with his sheets and blankets on the floor at the foot of his bed. STNA #16 stated Resident #2 was found with his brief torn open and his penis pulled upward. STNA #16 stated Resident #2 ' s penis was red and swollen. STNA #16 stated Resident #6 was in the room with the privacy curtain closed. STNA #16 stated it was obvious to her something happened. STNA #16 stated Resident #2 cannot speak for himself and normally sleeps with his arms contracted over him. STNA #16 stated Resident #2 does not move much on the bed and has never moved his sheets throughout the night that she was aware of. STNA #16 stated she notified LPN #17 who came in and assessed the resident. STNA #16 stated LPN #17 did try to call the DON to report the incident but was unable to reach her. STNA #16 stated Resident #6 was removed from the room and every fifteen minute checks were completed by STNA #18. Interview on 03/29/16 at 11:57 A.M. with STNA #18 revealed Resident #2 was a creature of habit. STNA #18 stated Resident #2 always keeps his blankets up to his neck because he likes to rub the covers between his thumbs while he sleeps. STNA #18 stated she cares for Resident #2 four nights a week and has never observed him remove his covers or his brief during the night. STNA #18 stated STNA #16 went down to check on Resident #2 between 2:30 A.M. and 3:00 A.M. on 03/28/16. STNA #16 called for STNA #18 after checking on Resident #2 due to the condition Resident #2 was found in. STNA #16 stated when she walked in, STNA #16 had placed a blanket over Resident #2 because it was cold. STNA #16 stated Resident #2 was wet which was odd because he wears a brief. STNA #16 stated Resident #2 ' s brief was torn in the front which was also weird . STNA #16 stated Resident #2 sleeps with his legs crossed and does not roll or move much in bed and it was odd that Resident #2 ' s sheets were on the floor at the foot of the bed. Resident #2 ' s penis was found out of the brief. STNA #16 stated Resident #2 ' s penis and testicles are normally tucked down under him and they were both placed up and out of the torn brief. STNA #16 stated they were also concerned because his penis looked irritated. STNA #16 stated she notified LPN #17 of the circumstances she found Resident #2 in. STNA #16 stated LPN #17 peeked around the privacy curtain, saw Resident #6 and stated he was awake. STNA #16 stated Resident #6 was moved to an empty room immediately following this incident and placed on fifteen minute checks. STNA #16 indicated Resident #6 was jittery, appeared nervous and required redirection. After redirection into another room, Resident #6 remained in the private room he was provided for the night. STNA #16 stated on the following night (03/29/16) Resident #6 was in a private room and a motion sensor alarm was placed on the bed to alert staff if Resident #6 exited the room. Interview with the DON on 03/29/16 at 1:27 P.M. revealed she was unaware of any further abuse allegations related to Resident #6 and any other residents. Observation on 03/29/16 at 2:30 P.M. revealed a motion sensor observed on the floor under the bed near the door of Resident #6 ' s room. Resident #6 remained in a private room. Interview on 03/29/16 at 2:32 P.M. with Resident #6 revealed he loved both of his roommates. Resident #6 revealed he has bad dreams and the nurse (unidentified) was mad at him and said not to touch his roommate anymore. Resident #6 stated he did not touch his roommate. Interview on 03/29/16 at 4:22 P.M. with the DON verified LPN #17 attempted to call her on 03/28/16 about finding Resident #2 with covers on the floor, brief ripped open and his genitals swollen at the tip. The DON indicated they did not get a hold of her due to her phone not working. The DON stated when she was talking to LPN #17 on the morning of 03/28/16 the nurse reported the incident. The DON stated I asked what was being reported. The DON stated these things happen people take briefs off . The DON stated the staff were wondering if Resident #6 had done anything. The DON stated she told LPN #17 before we even go there, did you see anything or did anyone else? The DON stated LPN #17 said the staff just observed the condition Resident #2 was found in. The DON stated she told LPN #17 we can ' t assume, we have to go on what we know before you make accusations. The DON verified LPN #17 told her Resident #2 does not move. The DON stated she told LPN #17 so what you are telling me is his blankets are on the floor and his brief is open . The DON stated because of the rumors she did have an investigation started regarding the incident at on 03/28/16 at 6:00 A.M. The DON revealed the ombudsman came to the facility on [DATE] after 3:00 P.M. and wanted to know where the investigation was for the incident regarding Resident #2. The DON stated she told him that she had a statement of something odd but no staff witnessed anything. Interview on 03/30/16 at 5:58 A.M. with STNA #23 revealed she cared for Resident #2 multiple times. STNA #23 stated Resident #2 has never unfastened his brief or taken his blankets off during the night. Interview on 03/30/16 at 10:37 A.M. with LPN #17 revealed STNA #18 and STNA #16 reported Resident #2 ' s blanket was on the floor and Resident #2 ' s brief was undone. LPN #17 stated she never observed Resident #2 move at night or do anything with his sheets. LPN #17 stated Resident #2 sleeps exactly the same way every night on his back. LPN #17 stated STNA #18 and STNA #16 changed Resident #2 prior to entering the room so she did not witness the way the resident was first observed by the STNA ' s. LPN #17 stated she did assess Resident #2 ' s genital area and found the tip of his penis slightly swollen. LPN #17 stated it is abnormal for Resident #2 to be awake at night. LPN #17 stated she did not document anything because she herself did not see anything. LPN #17 stated she did attempt to call the DON, however did not actually talk to the DON until she came in for the day around 6:00 A.M. LPN #17 stated Resident #6 was moved to another room and kept away from Resident #2 for the remainder of the night. LPN #17 stated STNA #16 and STNA #18 were suspicious of how they found Resident #2 because Resident #2 never moved at night. LPN #17 stated Resident #6 can be intrusive at times but was unaware of any further behaviors. LPN #17 stated she did not think to have STNA #16 or STNA #18 write statements of what they witnessed at that time. Interview on 03/31/16 at 8:40 A.M. with RN #25 revealed she was present on 03/28/16 at 2:45 A.M. RN #25 stated LPN #17 came to the office and wanted to talk to her. RN #25 verified LPN #17 informed RN #25 that Resident #2 ' s covers were off and the top of his brief was messed with . RN #25 stated according to the staff it was not normal for the covers to not be on Resident #2. RN #25 stated she asked LPN #17 if anyone saw or heard anything. RN #25 stated LPN #17 said they did not see anything but his brief was messed with. LPN #17 insinuated Resident #6 messed with his roommate. RN #25 stated LPN #17 asked her why Resident #6 was moved upstairs and did Resident #6 do something wrong downstairs? RN #25 informed LPN #17 that Resident #6 did not do anything wrong downstairs (his previous room). RN #25 stated LPN #17 wanted to separate Resident #6 and Resident #2. RN #25 stated Resident #6 was very intrusive and gets very close to you. RN #25 stated she told LPN #17 you cannot document something you did not witness. Interviews on 04/01/16 at 8:48 A.M. with Activities Staff #26, at 8:50 A.M. with STNA #27, at 8:53 A.M. with LPN #29, at 8:57 A.M. with STNA #28 and at 9:01 A.M. with LPN #24 revealed all interviewed staff had proper knowledge of signs and symptoms of abuse. The staff were knowledgeable related to the proper reporting and investigating procedures. Review of the (undated) abuse policy revealed procedures for prevention included assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: residents who have behaviors such as entering other residents rooms, residents with a history of aggressive behaviors, the identification of events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation. The response portion of the policy revealed to protect the resident. This included the staff should report all incidents immediately to their direct supervisors, staff should not leave a resident unattended unless it is necessary to summon assistance. Staff should not move the resident until he/she has been assessed by a nurse supervisor for possible injuries. A nurse should perform an initial assessment of the resident. Documentation in the nurse ' s notes should include the results of the resident ' s range of motion, body assessment, vital signs, the notification of the physician and the responsible party, and treatment provided. Appropriate quality assurance documentation should be completed as well. All allegations of abuse and neglect, injuries of unknown source and misappropriation of resident property must be reported immediately to both the Administrator and to the Ohio Department of Health. The policy indicated if a suspected crime has been committed it will report that suspicion in accordance with its crime reporting policies. Once the Administrator and the Ohio Department of Health are notified an investigation of the allegation or suspicion will be conducted. Interview the resident accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, including other residents, family members and employees who worked closely with the alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. Obtain written statements from the resident, if possible, the accused and each witness. After completion of the investigation, all of the evidence should be analyzed and the administrator will make a determination regarding whether the allegation or suspicion is substantiated and for injuries of unknown source a determination regarding the probable source of the injury.

Based on record review, observation, staff interview, review of the facility self-reported incident, review of staff inservices for elopement, review of the facility's Smoking Policy and procedure (dated 08/24/05), review of the Elopement Alarm Response policy and procedure (dated 08/24/05), review of the Missing Resident policy and procedure (dated 08/24/15), review of the Elopement Risk Resident (Exit Seeking Resident) policy and procedure (dated 08/24/05), and review of the Post Elopement policy and procedure (dated 08/24/05), the facility failed to provide adequate supervision for Resident #21 who successfully eloped on 11/14/15. Resident #21 was found by local fireman at 1:08 A.M. in the dense rural wooded area behind the facility, which was three hours after he was last seen by staff at 10:00 P.M. in the facility. According to the archived temperature records from the nearby Youngstown-Warren Airport, the air temperature on 11/15/15 at 1:00 A.M. was 37.9 degrees Fahrenheit (F). Resident #21 was found wearing a black jacket, sweatshirt, jeans, and shoes without socks. There were no visible injuries documented when he was found. Resident #21 had previously eloped from the facility on 07/11/15. This resulted in Immediate Jeopardy for one of 10 residents, Resident #21, identified at risk for elopement of 47 facility residents. On 11/23/15 at 3:45 P.M. the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 11/14/15 at 10:00 P.M. when Resident #21 was last seen in facility and then left unsupervised and without staff knowledge of his location. Registered Nurse (RN) #55 reporting giving the resident his medication at 8:30 P.M. STNA #78 reported seeing him in the foyer at 9:00 P.M. During the 10:00 P.M. smoke break on 11/14/15, two residents (Residents #29 and #46) saw him at the smoke break. However, State tested Nurse Aide (STNA) #77 who was assigned to supervise the smoke break, denied the resident was present. RN #54 reported observing Resident #21 was not in his room at 10:40 P.M. and began a search. RN #54 notified the administrator, DON and 911 by 10:53 P.M. On 11/15/15 at 1:08 A.M. RN #54 overheard on the fireman's radio that Resident #21 was located in the wooded area behind the facility. On 11/15/15 at 1:30 A.M. Resident #21 was transported to the hospital and was admitted for evaluation. The hospital report indicated Resident #21 had a urinary tract infection and there were no injuries documented from this incident. The Immediate Jeopardy was removed on 11/24/15 at 10:30 A.M. when the facility implemented the following actions: · On 11/14/15 at 11:45 P.M., inservices conducted by the DON and corporate nurse began for all staff which reviewed the following facility policies: Elopement Risk Assessment (Exit Seeking Residents), Missing Resident, Elopement Alarm Response and Post Elopement. These inservices were attended on 11/14/15 by three RN's, four Licensed Practical Nurses (LPN's), 10 STNA's, two housekeepers, one maintenance staff, one laundry staff, one activity staff and four dietary staff. On 11/15/15 between 1:57 P.M. and 2:08 P.M. inservices continued and were attended by two RN's, four LPN's, nine STNA's, three dietary staff, two laundry staff, one housekeeper, one transport aide, one activity staff, one business office manager, and one maintenance staff. · On 11/15/15, 15 minute checks and/or 30 minute checks were completed by the nurses for six residents on the first floor as planned for their behaviors, which were not related to elopement. · On 11/15/15 between 1:00 A.M. and 2:00 A.M. hourly checks began for all facility residents which was completed by the STNA's. · On 11/15/15 beginning at 1:45 A.M. all doors were secured and alarms checked by the maintenance man during the day shift and unit nurses when maintenance was not onsite, on an hourly basis, which is continuing. · On 11/15/15, STNA #85 received a written warning because Resident #21 was unaccounted for between 9:10 P.M. and 10:00 P.M. · On 11/16/15 the smoking policy was updated with the smoking time changed from 10:00 P.M. to 9:00 P.M. because this elopement was thought to have occurred at the shift change (2:00 P.M.-10:30 P.M.). · On 11/16/15 the DON posted a large note at both nurses stations indicating the foyer door must be closed at all times, and to double check the patio door frequently to make sure it is secured. · On 11/16/15 and 11/19/15 the facility maintenance man conducted elopement drills with all facility staff. · On 11/16/15, RN #55 was terminated because Resident #21 was able to leave the building without her knowledge and she did not hold the STNA's accountable for completing last rounds. · On 11/16/15 all residents who lived on the first floor were reassessed for elopement risk. No residents living on the first floor were identified as being at risk for elopement. Nine residents (Residents #2, #3, #17, #18 #28, #32, #39, #44 and #47) who lived on the second floor, which is a secured unit, were identified as being at risk for elopement/wandering. The STNAs were conducting hourly monitoring of all residents living on the first and second floors and was observed being carried out by the staff during the complaint investigation. · On 11/19/15 STNA #78 received a written warning for failing to ensure Resident #21's whereabouts. · On 11/24/15 at 10:00 A.M. the facility initiated a smoking tracker form to document residents who were out of the building for a smoke break and when they returned. · On 11/24/15 at 10:30 A.M. the facility initiated a staff person to sit by the front entrance door to monitor who enters and exits, which was observed during all days of the complaint survey. Although the Immediate Jeopardy was removed, 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 installing a wanderguard system which was ordered on [DATE]. On 11/24/15 the facility initiated monitoring the exit door on all shifts. On 11/24/15 the STNAs began documenting head counts of those residents present during smoking breaks. The facility was in the process of developing an updated plan of care for the supervision of Resident #21 to address his second successful elopement as he remains in the hospital at this time. Findings include: Review of the clinical record revealed Resident #21 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #21 has an attorney as his legal guardian. Review of a facility Self-Reported Incident dated 11/14/15 at 10:30 P.M., indicated the nurse was making rounds at 10:30 P.M. RN #54 entered Resident #21's room and found he was not in his bed. The facility was searched. A head count was completed and all other residents were accounted for. The outside perimeter of the building was searched. RN #54 notified the DON at 10:44 P.M. and then called 911. Safety services arrived and took over the search for Resident #21. Statements collected from staff noted he was seen at 8:30 P.M. by RN #55 who gave him medications, a STNA #78 saw him at 9:00 P.M. walking down the hall to the foyer; at 10:00 P.M. two residents (Residents #29 and #46) saw him waiting in the foyer for the smoke break. The residents reported Resident #21 assisted a female resident in her wheelchair out the door to the patio for a smoke break. Resident #29 reported Resident #21 said I got Mavericks in reference to the type of cigarettes he smokes. Resident #21 was located on 11/15/15 at approximately 1:10 A.M. in a densely wooded area behind the facility. The resident was awake and alert. He was wearing a black coat, black sweatshirt, jeans, tennis shoes and one glove. Resident #21 stated he was going to Toledo to get help to (expletive). Resident #21 was assessed by emergency medical services and transported to the hospital. Review of hospital physician consultation report dated 11/19/15 at 7:53 A.M. revealed Resident #21 was admitted with [DIAGNOSES REDACTED]. It was noted he had psychosis and paranoid schizophrenia with possible schizo-affective disorder. He was sent to the geri-psych unit when medically stable. The emergency room physician indicated a recent reduction in Zyprexa (an anti-psychotic medication) and Klonopin (an anti-anxiety medication) and notated that could have been the reason for his exacerbation. Review of the archived temperatures at the Youngstown-Warren Airport revealed on 11/14/15 at 10:00 P.M. the air temperature was 37.4 degrees Fahrenheit, and on 11/15/15 at 1:00 A.M. the air temperature was 37.9 degrees Fahrenheit. Review of the elopement risk assessment dated [DATE] indicated Resident #21 was not at risk for elopement/wandering at that time. The elopement risk re-assessment dated [DATE] identified him at risk for elopement/wandering due to his unauthorized leave of absence from the facility and was recently heard talking about getting out of this place. The facility indicated frequent monitoring was initiated and that staff were aware of his wandering risk. However, there was no further description of frequent monitoring and no documented evidence of the frequent monitoring. The 10/05/15 elopement risk re-assessment indicated he was not at risk for elopement/wandering because he made no recent attempts to elope. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 was severely cognitively impaired, displayed delusions, and had verbal behavioral symptoms directed toward others, but did not display wandering symptoms. Resident #21 required supervision and set up only for locomotion on and off the unit. He was not steady but able to stabilize without staff assistance. The quarterly MDS 3.0 dated 10/10/15 indicated he remained severely cognitively impaired, no behavioral symptoms were displayed and required supervision and set up for locomotion on and off the unit. Review of the Certified Nurse Practitioner note dated 07/21/15 revealed Resident #21 was often irritable, angry, and wanted to leave, and he eloped the previous week looking for a store. The Certified Nurse Practitioner added an anti-depressant medication. Review of the plan of care written by RN #56 related to exit seeking behaviors, initiated on 07/11/15, indicated the intervention was to provide activities of interest following meals so he was not bored. Review of the activity documentation revealed July and August 2015 after meal activities were provided. There was no activity documentation for September 2015, three entries for October 2015, and none for November 2015. Review of the activity progress note dated 08/04/15 revealed one to one visits were discontinued due to increased activity participation, but indicated he would receive one to one visits only immediately following dinner. Review of the smoking assessment dated [DATE] indicated Resident #21 must be supervised at all times while smoking. Interview with LPN #66 on 11/23/15 at 10:07 A.M. revealed Resident #21 spent most of his time listening to music, eating meals in the dining room and going out for smoke breaks. LPN #66 was not on duty at the time of his elopement and was surprised this occurred. LPN #66 reported yes and no for Resident #21 as an elopement risk. She stated once or twice he got mad and state he was leaving but went to his room. Observation of Resident #21's room on 11/23/15 at 10:15 A.M. with LPN #66 revealed little personal effects. Resident #21 had a radio/CD player and CD's as well as a television. Smoking times were posted on his wall. Interview with the DON on 11/23/15 at 11:00 A.M. revealed Resident #21 had been very ill and was initially wheelchair dependent. The DON reported he improved and desired to smoke again but the guardian did not want him to start smoking. The DON stated on 07/11/15 the resident decided he was going to leave to get smokes and a pop. He was found on the adjacent property's lawn by the neighbor who called the facility and the police. He was evaluated at the hospital and returned to the facility. He was placed on the second floor secured unit for 24 hours for observation and then returned to his room on the first floor. The DON stated he was reassessed as an elopement risk at that time and that evening activities were initiated to keep him busy. The facility spoke with the guardian who agreed to let him smoke. That appeased the resident and he never mentioned another word about leaving. He had been fine. His smoking was supervised. Then he was re-assessed on 10/05/15 to not be at risk for elopement or wandering because of no recent attempts to elope had been made. Resident #21 continued to reside on the first floor without a wanderguard. She reported all of the doors alarm. The DON said the guardian wanted him in the least restricted area. On 11/14/15 at 10:45 P.M. she was notified he was not found in the facility and once found he was hospitalized for [REDACTED]. Then because of the behaviors he was displaying at the hospital they admitted him to their geriatric psychiatric unit where he remained. The DON initiated the change in the last smoke tine from 10:00 P.M. to 9:00 P.M. indicating it was because it was close to the change of shift at 10:30 P.M. The DON said Resident #21 was not provided a wanderguard. The DON said RN #55 was definitely culpable because she did not do her end of shift check and was terminated because of not checking on the resident. She indicated STNA #77 was assigned the 10:00 P.M. smoke break on 11/14/15 and stated she did not see him during the smoke break. Her written statement indicated upon doing their 10:30 P.M. rounds the nurse notified the STNA's that Resident #21 was missing. STNA #77 assisted in the search. STNA #77 did not mention anything in her statement about the smoke break. The DON verified two alert and oriented residents (#29 and #46) saw Resident #21 at the smoke break. On 11/24/15 at 8:00 A.M. the DON reported she contacted members of the night shift staff who worked on 11/14/15 for further information and provided the statements as follows: STNA #78 added that she was busy taking laundry to the basement and did not recall if Resident #21 did or did not go out to smoke break. STNA #79 added that Resident #21 did not go outside for the 10:00 P.M. smoke break, however, she did not indicate where the resident was at that time. STNA #82 added she did not see Resident #21 at the 10:00 P.M. smoke break. She also did not indicate where he was at that time. STNA #76 added she did not see or hear Resident #21 in the foyer. She did not see him go out to the 10:00 P.M. smoke break. Interview with STNA #81 on 11/23/15 at 3:30 P.M. indicated she had to get his cigarettes prior to getting Resident #21. She stated she did not routinely supervise the smokers, as her co-worker STNA #69 usually had that task. She reported she would do a head count before and after. She verified there was no documented evidence of the head counts. She stated she considered all residents at risk for elopement. She stated she does hourly checks to make sure their needs were met. Interview with STNA #69 on 11/23/15 at 3:35 P.M. verified she assisted with the smoke breaks on the second shift. She stated she did a head count before and after. She verified there was no documented evidence of the head counts. She reported she was not on duty when Resident #21 eloped from the facility. Interview with STNA #82 on 11/24/15 at 8:30 A.M. revealed she was working the first and third shift on 11/14/15. She reported it was a typical day, with nothing emergent or escalating for the residents. She stated Resident #21 displayed his typical behaviors of wanting his cigarettes and there was nothing out of the ordinary. She stated she came on duty 11/14/15 at 10:00 P.M. and did not see Resident #21 in the foyer as per his usual. She did not know where he was. Interview with the activity director on 11/24/15 at 8:50 A.M. revealed she had been employed at the facility for only a month. She stated Resident #21 loved BINGO and would attend all four games per week. She reported the previous activity director discontinued the one to one activities but was unsure why. She stated she asked the activity staff and they reported they were told to stop providing Resident #21 one to one activities because he was becoming more involved in the group activities. Interview with the DON on 11/24/15 at 8:55 A.M. verified staff were not responding to the door alarm between the foyer and the administrative part of the facility. She reported they had increased the volume of the alarm at the nurse's station. As the DON opened the door, the alarm sounded and staff ignored the alarm. She verified the alarm went off constantly throughout the day and staff were supposed to monitor it. At that time someone entered the front entrance door and an alarm sounded. No staff responded. Observation of the front entrance door revealed it to be unlocked with only an alarm to notify staff of entrance or exit. This door is down a corridor in the administrative part of the facility. No one was monitoring this door for the last two days. The DON said no resident was restricted from coming into that part of the facility because that was where the activity room, therapy room, and snack machines were located. According to interview with the administrator on 11/24/15 at 9:30 A.M. monitoring of this exit door began on 11/24/15 at 10:00 A.M. and will on all shifts until the wanderguard system is installed. Interview with Maintenance Director #87 on 11/24/15 at 9:00 A.M. revealed each door alarm was functioning and he had been monitoring them. He took the surveyor to each door and demonstrated that the exit door alarms were functioning. Interview with STNA #77 on 11/24/15 at 9:10 A.M. via telephone revealed on 11/14/15 she came on duty at 10:00 P.M. Her shift was 10:00 P.M. until 6:30 A.M. She stated there was nothing unusual happening at that time. She was assigned to work her regular assignment on the first floor. She stated when she walked in they (the smokers) were out there in the foyer hooting and hollering to go outside to smoke. She stated she went upstairs to the second floor where their smokers were waiting. She stated they were usually lined up to smoke. Then she escorted them from the second floor to the first floor with their STNA's aware. The first floor nurse got the cigarettes and lighters. She reported the 10:00 P.M. smoke break always included the same four smokers (Residents #17, #18, #29 and #41) at a minimum. They never missed a smoke break but Resident #21 did not attend every smoke break. It was not unusual for him to miss a break. She admitted she was alone with residents on a smoke break and did not document a head count before and after the smoke break. She was sure Resident #21 was not out at the smoke break on 11/14/15 at 10:00 P.M. She reported that she even said no Resident #21 tonight? She claimed Resident #29 told her he was in bed. She discounted Resident #29 ' s story and indicated he did not even know the day of the week half of the time. STNA #77 stated Resident #21 was impatient and probably did not want to wait for the smoke break. She claimed he never voiced that he was going to leave. Interview with Resident #29 on 11/24/15 at 9:20 A.M. was consistent with his witness statement. Resident #29 stated he saw Resident #21 push Resident #46 in her wheelchair from the foyer to the back porch to smoke then never saw him again. He denied telling STNA #77 that he was in bed. Interview with Resident #46 on 11/24/15 at 9:25 A.M. revealed she was insistent that Resident #21 pushed her in the wheelchair out for the 10:00 P.M. smoke break. She stated she was certain it was the 10:00 P.M. smoke break because he never did anything nice and was surprised he helped her. Interview with RN #56, on 11/25/15 at 2:00 P.M. who was the assessment nurse, revealed there were no current residents residing on the first floor and outside of the secured unit who were at risk for elopement. Review of the smoking policy dated 11/16/15 indicated all smoking materials would be stored in a designated locked area supervised by the nursing staff. No resident could have smoking materials in their room or on their person. The residents will have a smoking schedule posted in their room and at the nurse ' s station. The outside patio would be the designated smoking area. Smokers would be supervised at all times by facility staff. An accurate head count would be taken prior to going out to smoke and when coming back into the building. Review of the Missing Resident policy and procedure dated 08/24/05 indicated the charge nurse was to be notified immediately. If the resident was not located within 15-30 minutes then to contact the administrator, director of nursing, physician and family. The whole facility would be searched and a head count of residents conducted. If the resident was not located, contact the police department. Review of the Post Elopement policy and procedure dated 08/24/05 indicated any resident who has eloped, and has been brought back safely into the facility would be thoroughly assessed for injuries by the charge nurse. The nurse will also document attire of the resident, the weather condition and temperature outside. In the event that the resident did not have a wanderguard bracelet on, one would be issued at that time. Thirty minute checks would continue for 24 hours or until discontinued by the DON. The interdisciplinary team would review the plan of care quarterly and determine if the resident continued to be at risk for elopement. Review of the Elopement Risk Resident (Exit Seeking Resident) policy dated 08/24/05 revealed all residents would be assessed for possible elopement from the facility. If appropriate, a wanderguard would be placed on the resident. The resident would have a wanderguard applied per the physician's orders [REDACTED].>This deficiency substantiates Self Reported Incident Number OH 604.

Based on medical record review, observation, staff interview, interview with local fire department staff, review of an incident report read by the facility staff, review of the facility in-service for smoke breaks, and review of the Smoking and Missing Person policies, the facility failed to provide adequate supervision to Resident #41, who was identified at risk for elopement, when the resident eloped and was located six miles away from the facility. This resulted in Immediate Jeopardy for one resident (Resident #41) of 8 sampled residents identified by the facility to be at risk for elopement. The resident census was 49. On 06/16/14 at 2:22 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 01/14/14 at 10:00 A.M. when Resident #41 left the facility unsupervised. During the 10:00 A.M. smoke break on 01/14/14, Resident #41 finished his cigarette and then went into the foyer of the facility unaccompanied by staff. Resident #41 then exited the building without staff knowledge and was not noted missing until 12:35 P.M. that day. At 12:35 P.M., a search of the building and grounds surrounding the building was conducted by staff. Resident #41 was located by Maintenance #14 at a diner approximately six miles from the facility at 2:06 P.M. Resident #41 walked to the diner which was located on a highly traveled state highway. Resident #41 was returned to the facility at 2:10 P.M. The Immediate Jeopardy was removed on 01/16/14 when the facility implemented the following actions: *On 01/14/14 at 2:30 P.M. the nursing staff implemented every fifteen minute safety checks for Resident #41. *On 01/14/14 at 6:10 P.M. an in-service was completed by the Director of Nursing (DON) with seven Registered Nurses (RN), seven Licensed Practical Nurses (LPN), 21 State-tested Nurse Aides (STNA), one licensed social worker, one business office manager, one registered dietician, two dietary staff, one activities director, one maintenance staff, and one housekeeping staff member. The training included requiring two staff members for supervision of smoke breaks and counting residents during smoke breaks. *Review of the employee files for LPN #10 and STNA #11 dated 01/14/14 revealed both staff members were given a written warning related failing to ensure all of the residents were accounted for when bringing the residents back inside the facility following a smoke break. *On 01/16/14 review of the Morning Meeting Notes for the facility revealed the facility was implementing a new policy requiring two staff members to supervise all smoke breaks. Although the Immediate Jeopardy was removed, 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) because the facility did not update Resident #41's plan of care with any new interventions to prevent further elopements and the facility did not provide evidence to indicate the smoking policy was updated to reflect the implementation of two staff members to supervise smoke breaks, as written in the 01/16/14 Morning Meeting Notes. Findings include: Review of the medical record for Resident #41 reflected a history and physical dated 07/16/13 when Resident #41 was admitted in the psychiatric unit of a local hospital involuntarily with worsening of depression and psychotic symptoms. Resident #41 was found wandering in the street and he was hearing voices telling him to cross the street. Review of Resident #41's history and physical revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set assessment ((MDS) dated [DATE] revealed Resident #41 required supervision for locomotion on and off the unit. Review of Resident #41's admission elopement assessment dated [DATE] revealed Resident #41 was found wandering in the street and had a history of [REDACTED]. Resident #41 was ambulatory and resided on the second floor (a secured unit). Resident #41's elopement assessment dated [DATE] revealed Resident #41 continued to reside on the second floor (a secured unit) and was ambulatory. Resident #41's plan of care implemented on 07/24/13, and reviewed on 11/05/13, revealed the resident resided on the secure unit and was an elopement risk with [DIAGNOSES REDACTED].#41 included the resident was to be monitored every one hour as needed to assure resident's safety and the environment was to be kept free of possible hazards. There was no evidence in the medical record to indicate the facility routinely monitored Resident #41 every one hour to ensure the residents safety. There was no documentation in Resident #41's medical record related to an elopement on 01/14/14. Interview with STNA #12 on 06/16/14 at 12:10 P.M. revealed Resident #41 eloped from the facility a few months ago but could not remember the date. STNA #12 indicated Resident #41 was gone for about two hours before the staff realized he was missing. STNA #12 indicated Resident #41 stated he walked right past the DON when it happened and it happened on the day shift. STNA #12 indicated Resident #41's mother called the facility and notified the facility that Resident #41 was not in the facility but was seen walking down the road. STNA #12 indicated STNA #13 may know more of the information since STNA #12 was not working during the time of the incident. Interview with STNA #13 on 06/16/14 at 12:20 P.M. revealed Resident #41 did elope from the facility and the STNA #13 was working when the incident occurred (could not recall exact date). STNA #13 indicated she and STNA #11 (who is no longer employed at the facility) were the STNAs for the secured unit where Resident #41 resided. STNA #11 indicated LPN #10 was the nurse on the secured unit when the incident occurred. STNA #11 indicated they were passing lunch trays, went to get Resident #41 and he wasn't there. STNA #11 indicated they did a room search on that unit when Resident#41 was noted to be missing. They did not find Resident #41 during the room search and she returned to passing trays. STNA #13 could not remember any further details about the incident. Interview with the DON on 06/16/14 at 12:41 P.M. revealed on 01/14/14 at 12:35 P.M., LPN #10 notified her that they couldn't find Resident #41 on the unit. LPN #10 called to see if he was on the first floor. At that time, all of the department heads looked in the rooms on the first and second floors and then searched the rest of the building and the grounds to see if Resident #41 was in-house first. Once it was determined that he was not in the facility or on the grounds, the business office manager (BOM) #22 notified the Administrator. The DON indicated the Trumbull County Sheriff's office was called and they sent a deputy to the facility. When the deputy arrived at the facility, a photograph of Resident #41 and a description of what he was wearing were given to the officer. The DON indicated the facility sent out the department heads in vehicles to start looking around the area for Resident #41. The staff at the facility conducted another facility search and grounds search. The DON indicated the resident's mother called the facility and notified the facility someone saw the resident in an adjacent town (could not recall the exact time on 01/14/14). The DON indicated she then called the fire department, gave them the description of Resident #41 and they sent the squad out. The DON indicated at that time she called the department heads that were driving around and sent them to the adjacent town to look for him. One of the department heads found him at a diner at 2:06 P.M. on 01/14/14. The Maintenance #14 brought Resident #41 back to the facility in the facility van arriving at the facility at 2:10 P.M. on 01/14/14. When Resident #41 was returned to the facility, an assessment was completed and no injuries were found. The DON revealed Resident #41 identified that when he was outside a male voice told him to go outside and take a walk. Resident #41 stated it was a warm day he was dressed appropriately and he decided he was leaving. The DON indicated that through their investigation of the incident, it was determined that Resident #41 left the building during the 10:00 A.M. smoke break on 01/14/14. The DON indicated an incident report was completed, the two employees who were responsible for supervising the smoke break were disciplined and all staff was inserviced on ensuring all residents were accounted for prior and after the smoke break. The DON was unable to explain why there was no documentation in Resident #41's medical record related to the elopement. Interview with LPN #10 on 06/16/14 at 1:21 P.M., revealed she worked on the day Resident #41 eloped from the facility. LPN #10 could not remember the exact date of the incident. LPN #10 indicated she and the residents who smoked went out for the smoke break on the back patio. After smoking, some of the residents would come in the foyer and sit down. LPN #10 indicated after the smoke break, she thought she took everyone back upstairs, but it was a chaotic day and she did not complete a head count to make sure all residents were present after the cigarette break. LPN #10 indicated that about an hour or so later, she went to give Resident #41 his medications and discovered he was not in his room so she searched all the rooms on the secured unit. LPN #10 indicated she did a head count of the residents in the secured unit and notified the DON that Resident #41 was not on the secured unit. LPN #10 revealed the DON indicated they would look on the first floor and outside. LPN #10 indicated she remained on the secured unit at the time of the search. Resident #41's mother called in and said someone saw the resident at the diner but she was unsure who saw him. A former employee, Maintenance #26, went and picked up Resident #41 at the diner. LPN #10 indicated the Maintenance #26, who was driving the van, was no longer employed at the facility. When Resident #41 arrived back at the facility, LPN #10 did a full "head to toe assessment" and skin assessment on the resident, the resident was cooperative and there were no concerns found. LPN #10 indicated she did not call the mother when Resident #41 was noted to be missing because the mother called in to the facility. After the resident returned, Resident #41's mother was notified. LPN #10 indicated she was the only staff member with the residents on 01/14/14 when they were smoking and now the residents are not permitted to come into the facility and sit in the foyer after finishing their cigarettes. LPN #10 indicated two staff now monitored the cigarette breaks. LPN #10 indicated the smoke break is usually taken and finished between 10:00 A.M. to 10:30 A.M. When asked if Resident #41 was an elopement risk prior to the resident eloping, LPN #10 indicated that he did reside on the secured unit but to her knowledge had never tried to get out, therefore was not an elopement risk. LPN #10 did not think the facility had one hour checks and if there were, there was no documentation. LPN #10 indicated the DON told her not to document anything about Resident #41 eloping from the facility therefore she did not document the incident or any assessments related to the incident. LPN #10 indicated an incident report was completed. Interview on 06/16/14 at 1:46 P.M. with Maintenance Staff #14 revealed he was present when Resident #41 eloped from the facility. He could not remember how he was notified the resident eloped. Maintenance Staff #14 indicated the other maintenance man (Maintenance #26) from the sister facility showed up with the van and the Maintenance #26 and Maintenance #14 drove around looking for him. Maintenance Staff #14 indicated they did not have any idea where to look for Resident #41, however on a 'hunch', they went into the adjacent town and stopped at the diner. Maintenance Staff #14 indicated Resident #41 was preparing to exit the diner when he walked in. Maintenance Staff #14 could not remember what time it was, or the date, other than it was his second day of work at the facility. Maintenance Staff #14 indicated he was not aware of any communication with anyone from the facility during the search. Maintenance Staff #14 indicated the areas checked were all in the direction of the adjacent town. Others involved in the search via van/bus were Dietician #15 and STNA #16. Maintenance Staff #14 indicated he could not remember any further details regarding the situation. On 01/16/14 at 2:33 P.M., the police and the fire department dispatcher (Dispatcher #1) were called. Dispatcher #1 verified the elopement was reported to 911 on 01/14/14. Dispatcher #1 revealed no reports were made by the departments because the facility found Resident #41 and returned him to the facility. Dispatcher #1 revealed the 911 sheet read: "Resident missing, [AGE] year old male. Spotted in (named the adjacent town). Found by maintenance staff. Returned to facility." Dispatcher #1 did not have a time for the incident. The incident report was read to the surveyor on 06/16/14 at 2:55 P.M. by the Administrator, RNs #17 and #18. The Administrator revealed the incident report was dated 01/14/14 at 12:37 P.M. RN #17 indicated the incident report could not be given to the surveyor due to the corporate policy. The Administrator read the report and the investigation. The incident report indicated Resident #41 had [DIAGNOSES REDACTED]. Resident #41 was an adult resident. The Administrator revealed Resident #41 was not found on the grounds or around the facility. The report revealed the facility did an assessment. Resident #41 was found to be alert and oriented with no injury noted. Resident #41's vital signs were within normal limits. The physician was notified at 12:40 P.M. and Resident #41's mother was notified at 12:55 P.M. The Administrator revealed that was the extent of the information located on the incident report form. The Administrator read the following witness statements to the surveyor: *Witness statement from the DON dated 01/14/14 12:35 P.M. revealed the DON was having lunch in the activity room when STNA #11 came in and asked if she saw Resident #41 at all. The DON said no and LPN #10 called on the intercom and said that she looked for Resident #41 to give him his noon medications and STNA #11 could not find him. The DON assisted with searching for him on the unit and in the basement, the first floor, and outside. The last time the DON saw Resident #41 was at 9:30 A.M. on the floor when the DON was doing rounds. *Witness statement from LPN #10 dated 01/14/14 at 12:35 P.M. revealed Resident #41 was outside on smoke break with this nurse. LPN #10 indicated Resident #41 went into the foyer and LPN #10 remained outside while another resident finished his cigarette. Another employee had most of the residents from the foyer on the elevator. LPN #10 locked the door to the smoking area then got on the elevator. The other residents and staff person waited for LPN #10 and they exited on the second floor. *Witness statement from STNA #13 dated 01/14/14 at 12:35 P.M. revealed the last time STNA #13 saw Resident #41, he was running up the hall for the smoke break and the nurse told him to slow down. STNA #13 saw some of the residents come back from smoke break. *Witness statement from STNA #11 dated 01/14/14 at 12:35 P.M. revealed STNA #11 took Resident #41 down for smoke break at 10:00 A.M. for LPN #10. When LPN #10 came down, STNA #11 went back upstairs and that was the last time STNA #11 saw Resident #41. *Witness Statement from RN #19 dated 01/14/14 at 12:35 P.M. revealed RN #19 was having lunch in the activity room when STNA #11 came in and asked if she saw Resident #41. Several seconds later, LPN #10 called on the intercom that she had searched the hall from room to room and could not find Resident #41. RN #19 indicated she did not see Resident #41 at all that day. RN #19 indicated she was working the first floor and did not here any door alarms sound. *Witness statement from STNA #20 dated 01/14/14 at 12:35 P.M. revealed she was sitting in the dining room waiting for the lunch trays to come up from the kitchen, when an aide from the second floor came in the dining room and asked if they saw Resident #41. STNA #20 indicated she did not know Resident #41 was missing. Upon learning the resident was missing, STNA #20 searched every room on the first floor. *Witness statement from STNA #21 dated 01/14/14 at 12:35 P.M. revealed STNA #21 was at the snack machine at about 10:30 A.M. when she saw a guy walking up the road. STNA #21 revealed "he looked like he was one of our guys." *An Interview with Resident #41 was conducted by the DON dated 01/14/14 at 2:25 P.M. The first question to Resident #41 was "can you show me what door you walked out of?" Resident #41's response was "yes" and the resident walked the DON over to the visitor entrance door. The second question was "When did you leave to go on a walk?" Resident #41's response was "after I smoked." The third question was "Did you go upstairs first after the smoke break?" Resident #41's responded "no." The resident revealed after he smoked he walked out the door and went on a walk. *Also included in the dictated investigation was a print out of Accuweather for 01/14/14 indicating the temperature for 01/14/14 was 46 degrees Fahrenheit. Interview with RN #17 on 06/16/14 at 3:30 P.M. revealed the facility does not have a policy specific for residents at risk for elopement, but did have the missing person policy. RN #17 confirmed the Smoking policy had not been revised to reflect the head count of the residents to be performed prior to and after the smoking break or the implementation of the two staff member supervised smoke breaks. Interview with BOM #22 on 06/16/14 at 4:03 P.M., revealed she was at the facility on the date Resident #41 eloped. BOM #22 indicated she was in her office and someone called and said he eloped. BOM #22 could not remember who called. BOM #22 indicated she pulled out the missing person policy to make sure it was followed and she was not involved in any other aspect of the search. BOM #22 indicated Dietician #15, STNA #16, and Maintenance #14 were looking for Resident #41 in vehicles and the DON was also involved in the search at the facility. BOM #22 indicated she thought it was between 12:00 P.M. and 2:00 P.M. that the facility noted Resident #41 was missing. She did not remember what time they found Resident #41. Interview Dietician #15 on 06/16/14 at 4:14 P.M. revealed she was working the day Resident #41 eloped. Dietician #15 could not remember what month or day the elopement happened. Dietician #15 indicated she usually worked in the activities room and she was in that room when someone said Resident #41 was not in the facility. Dietician #15 indicated they checked the building. Dietician #15 indicated she and STNA #16 went out in the facility's bus and drove around looking for Resident #41. Dietician #15 indicated they went to the adjacent town and told the town's fire department about who they were looking for. At that time, the DON was on the phone with them telling them who they were looking for. They also stopped at convenience store and left the phone number for the facility if anyone saw the resident. Dietician #15 indicated she was not very familiar with the area but she knew they were also searching by the local lake area. Dietician #15 indicated STNA #16 had a cell phone she was using to communicate to the facility. They did not find Resident #41 and could not remember the time that Resident #41 was found. She indicated he was found before she left work, which was between 4:00 P.M. and 4:30 P.M. She was unaware of any other elopements from the facility. Interview with STNA #16 on 06/16/14 at 4:21 P.M. revealed she was working the day Resident #41 eloped from the facility. STNA #16 indicated she was out on an appointment with a resident from the sister facility. STNA #16 indicated as she pulled in the parking lot, everyone was outside. One of the staff came up to the vehicle and said she had to go look for Resident #41. Dietician #15 rode with STNA #16. STNA #16 indicated the Maintenance #14 and Maintenance #26 stopped at the diner. STNA #16 stated she believed the mother called the facility and said someone who knew Resident #41 thought they saw him walking up the road in the area of the adjacent town's cemetery and the town's center and that is how they localized the search area. STNA #16 indicated they were in contact with Maintenance #14 and Maintenance #26 and were driving for approximately thirty minutes before Resident #41 was found. STNA #16 indicated they started to look for the resident prior to Resident #41's mother calling. STNA #16 indicated she was unsure of the exact time of the search, but knew it was around lunch time. Interview with Resident #41 was attempted at 8:38 A.M., on 06/17/14. Resident #41 was unable to complete the interview and was easily distracted and stood up and walked around multiple times during the attempt at an interview. Resident #41 was mumbling during these episodes and was not able to be understood. Interview with the DON on 06/17/14 at 8:50 A.M. revealed she monitored the smoke breaks when she was here and checked to see if the residents needed more cigarettes. However, she indicated there was no written evidence related to the actual monitoring of the two person smoke breaks and the head counts prior to and after the smoke breaks. Interview with STNA #20 on 06/17/14 at 8:55 A.M. revealed she was working the day Resident #41 eloped from the facility. STNA #20 indicated she was working on the first floor and was not involved in the search for Resident #41. STNA #20 indicated "they finally realized he was missing at about 25 minutes till one." STNA #20 indicated the last time Resident #41 was observed was at 10:00 A.M. STNA #20 indicated sometimes Resident #41 made sense and sometimes he did not and he mumbled. At 11:20 A.M. on 06/17/14, the DON provided documentation of every one hour checks for Resident #41 dated 01/07/14 through 01/14/14. This documentation was completed every hour and in the same hand writing. The DON also provided a weekly audit tool of monitoring of two person smoke breaks initialed as done by the DON beginning the date of 01/16/14. The DON indicated that she created the documentation of the audit tools on 06/17/14 for the survey team. Interview with RN #17 on 06/17/14 at 11:25 A.M. confirmed the documentation provided at 11:20 A.M. related to Resident #41's every one hour checks was not completed by the nurses during the shifts they were assigned to monitor the resident. RN #17 verified the documentation was created 06/17/14. Interview with STNA #21 on 06/17/14 at 11:47 A.M. revealed she was working the day Resident #41 eloped but could not remember what day it was or what time. STNA #21 indicated she was at the snack machine when she and another female were discussing the type of chips she purchased from the snack machine. STNA #21 stated she could not remember who the other female was with her, or if she was staff, a resident or a family member. STNA #21 indicated the female stated she saw a man walking up the street and was not sure if he was a resident that lived at the facility or not. STNA #21 was unable to give any further details regarding the incident. Review of the facility's undated Missing Resident Policy revealed it was the policy of the facility that when a resident was determined as missing, an immediate search for the resident is initiated and the charge nurse should be notified immediately. Review of the facility's smoking policy updated August 2013 revealed no evidence the policy was updated to include the head count of the residents prior to and after smoke breaks or the revision to require two staff persons to supervise the residents while smoking. Review of the facility's incident log for January 2014 revealed no evidence of Resident #41's elopement. This deficiency substantiates Complaint Number OH 110.