Every finding on record at Mother Angeline Mccrory Manor

Based on review of medical records, observation, interview, policy review and review of provided videos and pictures, the facility failed to ensure residents with trauma received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This affected one resident (#55) out of three residents reviewed for abuse.Findings Include:Review of Resident #55's medical Record revealed an admission date of 06/05/25 and medical diagnosis of covid-19, weakness, need for personal assistance with care, pain due to trauma, cerebral vascular accident, abnormal gait and mobility, dysphagia, traumatic subarachnoid hemorrhage without loss of consciousness, wedge compression fracture of fifth lumbar vertebra, hyperlipidemia, cervical disc degeneration, depression, anxiety, dementia mild with mood disturbance, muscle wasting and atrophy. Review of the undated document titled Care for [Resident #55] revealed the residents family brought up some care related concerns and that the resident preferred not to have male care givers. Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 06 revealing severe cognitive impairment and the need for personal assistance requiring one to two staff members for activities of daily living and incontinence care. Review of Resident #55's care plan dated 06/07/25, revealed the resident was resistive to care with interventions to reassure the resident, leave and return 5 to 10 minutes later and try again. Further review of the care plan, last updated 11/17/25, revealed the resident had a self-care performance deficit related to dementia and preferred female caregivers only related to showers and checks/changes due to a past assault when she was in the community. Interventions included one to two staff assistance with showering/bathing, bed mobility, dressing, eating, personal hygiene/oral care, toilet use, and transfers. Review of Resident #55's psychiatric note dated 09/15/25 revealed per the residents family she had history of trauma growing up as well as when a man entered her home when she was a new mother, and she encountered a stranger in her staircase in her home. Review of Resident #55's lab draw dated 10/24/25 revealed the resident had a lab draw to the back of the left hand. Review of Resident #55's November and December 2025 physician orders revealed an order dated 10/11/25 for Aspirin 81 milligrams (mg) oral tablet with instructions to give one table in the morning as an antiplatelet. Review of Resident #55's Medication Administration Record (MAR) for November 2025 revealed the resident received Aspirin 81 mg's daily. Review of Resident #55's lab draw dated 11/07/25 revealed the resident had a lab draw to the back of the right hand.Review of Resident #55's fall report dated 11/15/25 revealed the resident had an unwitnessed fall and sustained no injuries. Review of Resident #55's skin assessment dated [DATE] revealed no documented skin issues, including no documented bruising. Review of the facility Self-Reported Incident (SRI) dated 11/17/25 revealed on 11/17/25 the facility was contacted by Resident #55's Power of Attorney (POA) with concerns of abuse provided by two male caregivers (Certified Nursing Assistant (CNA) #4 and Agency Nurse #687) during incontinence care on 11/17/25 at approximately 5:45 A.M. The facility placed both caregivers on administrative leave pending the investigation. A skin assessment was performed on 11/17/25 by Unit Manager #141 and Assistant Director of Nursing (ADON) #71 and revealed unmeasured black round marks on the back of Resident #55's bilateral hands and no fresh, bright red or maroon bruising were noted to the bilateral hands arms, or wrist. Additional assessments revealed Resident #55 denied pain or discomfort, nor did she express non-verbal pain indicators. The facility also contacted the local Police Department and filed a police report. Review of the preliminary police report #250847274, dated 11/17/25 revealed the residents responsible party noticed two male employees, and RN and an aide, at the residential home were her mother resided, changed her clothing and generally tended to her. It noted Resident #55 had a past trauma event involving males in general and also had dementia. Resident #55 was advising the two males to stop what they were doing and stated that they were hurting her. The resident's family believed this was assault and had the video saved from the incident. Review of Resident #55's video footage dated 11/17/25 at approximately 6:00 A.M. revealed two male caregivers (CNA #4 and Agency Nurse #687) providing incontinence care for Resident #55. Resident #55's bed was against the wall and the two male caregivers backs were facing the camera. The resident was addressed by name, was told by staff to hold their hand while they performed incontinence care. Resident #55 objected to incontinence care and yelled no multiple times. The two caregivers proceeded with incontinence care and the resident then yelled, you are breaking my hand. The video then showed a night gown was removed from the resident and placed on the top of the bed, then shortly after, a female staff (RN #95) arrived and she provided the remaining care to the resident while the two male caregivers left the room.Review of photos provided anonymously dated 11/18/25 revealed Resident #55 had black bruises to the back of the bilateral hands, bruises the front and back of the right wrist, a bruise to the right wrist, and a bruise to the right forearm. Resident #55's face was in the photos showing the back of the bilateral hands and arms. Review of Resident #55's skin assessment dated [DATE] revealed a skin tear to the right lower leg (from a previous unrelated injury) and no documentation of bruising to the resident's hands and arms. Review of the unsigned and undated witness statement filled out for CNA #4 by Assistant Director of Nursing (ADON) #71 revealed during evening report on 11/16/25, CNA #4 introduced himself to Resident #55's family and was handed clothes and told to change the resident. The resident did not object to being changed and allowed CNA #4 to provide incontinence care at midnight and 3:00 A.M. without issue. On the last round the resident said no and held a blanket to herself. CNA #4 contacted the supervisor, RN #95 and were told the supervisor would be down. RN #687 assisted the CNA with incontinence care by holding the resident's hands and RN #95 changed the residents shirt. Review of Agency Nurse #687's witness statement revealed the nurse observed CNA #4 provide incontinence care throughout the evening [indicating from 11/16/25 into 11/17/25] to Resident #55 without issue. At approximately 4:00 A.M. [on 11/17/25] the resident was noted to be soiled and had soaked through her depends and onto her nightgown. Resident #55 allowed CNA #4 to provide incontinence care but refused to allow her night gown to be changed. Further review revealed the nurse did not feel comfortable leaving the resident in soiled clothes due to the behavior the daughter exhibited the night before during shift change. While providing care to the resident, the resident refused care and a short break in care was performed to call the night shift supervisor. Afterwards the residents soiled night gown was removed from the resident and the night shift supervisor arrived and finished changing the resident. The witness statement did not specify the behavior that the residents daughter exhibited the night before. Interview on 12/03/25 at 10:51 A.M. with Unit Manager #141 confirmed when Resident #55 was admitted the family requested no male caregivers. The request was accommodated until the resident was moved from the fourth floor to the second floor and then the resident had a male caregiver again. The family was aware and didn't express concerns at that time. The resident was later moved to the third floor and continued receiving assistance from male caregivers without incident until 11/17/25. Observation on 12/03/25 at 12:23 P.M. of Resident #55 revealed a small red area with dark edges to the right forearm and slight discoloration to the back of the left hand but no bruising or dark marks to the back of the bilateral hands or wrist. Resident #55 was unable to provide any information regarding the 11/17/25 incident. During an interview on 12/04/25 at 9:35 A.M. with CNA #4 revealed they had no recollection of the 11/17/25 event with Resident #55 and could not recall giving a witness statement of the event. Interview on 12/04/25 at 11:09 A.M. with the Director of Nursing (DON) and review of the video from 11/17/25 at approximately 6:00 A.M. of Resident #55 receiving incontinence care, confirmed the presence of two male caregivers (CNA #4 and Agency RN #687), the resident refusing care and the care givers continuing to provide incontinence care by lifting a gown over the residents head, and the resident and yelling you are breaking my hand. The DON confirmed that resident care plans are to be followed and when Resident #55 told the caregivers no, they should have stopped and came back shortly after to continue providing care. Interview on 12/04/25 at 3:49 P.M. with the DON and review of Resident #55's photos provided confirmed they were dated 11/18/25 and confirmed the presence of dark areas on the back of the right hand, the back of the left hand, the right thumb, and the right forearm and confirmed the facility did not have supportive documentation showing the bruises were present during the 11/15/25 or 11/19/25 skin assessment. The facility suspected the dark area on the back of the right hand was from a lab draw performed on 11/07/25. The facility suspected the dark area on the back of the left hand was from a lab draw performed on 10/24/25. The facility suspected the dark area on the right thumb and the dark area to the right forearm were from a fall on 11/15/25. Review of facility policy, Dementia Care implemented 01/11/25 revealed care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity autonomy, privacy, socialization, independence, choice, and safety.This deficiency represents non-compliance investigated under Complaint Number 2676381.

Based on review of resident medical record, observations, staff interview, CDC website review, and review of facility policies, the facility failed to serve food in a safe and sanitary manner. This had the potential to affect 116 out of 117 residents who ate food from the kitchen. The facility identified one resident (Resident #72) as not eating food from the kitchen. The facility also failed to thoroughly perform legionella surveillance. This had the potential to affect all 117 residents residing in the facility. The facility also failed to provide designated disposal bins for used personal protective equipment in a resident's room when the resident was under contact precautions. This affected one resident (#125) out of three residents (#48, #72 and #125) reviewed for transmission-based precautions. The facility census was 117.Findings include:1. Observation of food lunch service on 07/23/25 from 11:55 A.M. to 12:40 P.M. revealed that while recording temperatures of the food in the steam wells, Dietary Aide # 382 was observed sticking the thermometer into the mashed potatoes and also into the chicken. The plastic body of the digital thermometer (beyond the metal probe) was plastic and was observed to be resting on and in the food products that were being temped. The plastic body of the digital thermometer was not sanitized between food items.Interview with Dietary Director #340 on 07/23/25 at 12:49 P.M. confirmed that the body of the digital thermometer had been observed resting on and in the chicken and mashed potatoes and had not been sanitized between taking the temperature of the two food items. 2. Review of the Legionella infection control surveillance revealed that the facility could not produce evidence of regular flushing of pipes for the rooms in the facility, nor could they produce evidence of cleaning shower heads and faucets.Interview with the Administrator on 07/28/25 at 2:58 P.M. revealed that the facility does not keep flush logs to show ongoing prevention of Legionella.Review of the facility's Legionella water management program revealed that the control measures that the facility will take include to flush the pipes of the low use areas, and to disinfect the shower heads. Review of the procedure titled Visual inspection of the water system revealed that the shower heads will be checked for leaks and corrosion on a monthly basis. Review of the procedure titled Flushing of low use piping in the Legionella Control plan revealed that the facility will flush cold and hot water piping for a minimum of five minutes if the room has a less that fourteen day vacancy period and that if a room is vacated for over fourteen days, the aerators, hoses, shower heads and sprayers will be removed and disinfected. The cold and hot water piping and outlets will be flushed for a minimum of ten minutes. All flushing shall be completed with the same day, preferably a four hour period if possible.3. Review of the medical record for Resident #125 revealed that he was admitted on [DATE] with diagnoses that included chronic kidney disease stage 4, adult failure to thrive and enterocolitis.Review of Resident #125's treatment administration record for July 2025 revealed that he had enhanced barrier precautions in place, which included wearing a glove and gown with dressing, bathing, transferring, changing lines, toileting and ostomy care.Review of Resident #125's physician orders dated 07/17/25 revealed that he was on contact precautions for possible clostridium difficile, an infectious bacteria that can cause diarrhea and damage to the colon.Observation of Resident #125's door on 07/23/25 at 8:44 A.M. revealed that he had a contact precautions sign on his door and personal protective equipment (PPE) outside of his door. Observation of Resident #125's ostomy care on 07/23/25 from 8:44 A.M. to 8:50 A.M. revealed that Registered Nurse (RN) #386 donned PPE appropriately per protocol. At the end of the ostomy care, there was not a designated bin for RN #386 to dispose of her contaminated PPE in.Interview with RN #386 on 07/23/25 at 8:51 A.M. confirmed that there was not a designated bin to dispose of contaminated PPE in within Resident #125's room.Review of the facility policy titled Infection Prevention and Control Program dated 06/11/25 revealed that a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.Review of a document on the CDC website titled Donning and Doffing PPE: Proper Wearing, Removal, and Disposal recommends disposing of all PPE in appropriate waste containers.1. 2.

Based on medical record review, interviews and facility policy review, the facility failed to ensure an appropriate diagnosis for the use of antipsychotic medications and to identify target behaviors and monitor the target behaviors for the use of antipsychotic medications. This affected five residents (#12, #45, #71, #93 and #106) of five residents reviewed for unnecessary medications. The facility census was 117.Findings Include: 1. Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/24/25 revealed the resident used an psychotropic medication (Trazadone) related to depression. Interventions included administer medications as ordered by physician, monitor for side effects, discuss with physician, family regarding ongoing need for use of medication review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, evaluate for psychotropic related risks every shift and as needed, provide non-pharmacological interventions and report any changes in condition to primary care provider. Further review of the plan of care revealed no identified target behaviors to monitor for the use of the medication Trazadone. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. Review of the resident's monthly physician orders for July 2025 identified orders dated 02/23/25 monitor for Depression, for signs & symptoms of feeling of hopelessness, loss of interest in socializing or hobbies, new onset neglecting person care, skipping meals, new onset slowed movement, loss of self-worth, sadness, insomnia, negative statements, tearfulness, feeling despair, unexplained or aggravated aches and pains, target behaviors of: (fill in). If present document and notify Nursing Supervisor every shift and 02/24/25 Trazadone 150 milligrams (mg) by mouth daily at bedtime for depression. Review of the medical record revealed no documented evidence the facility identified targeted behaviors or monitored the resident for behaviors for the use of the antipsychotropic medication Trazadone. On 07/28/2025 at 10:28 A.M., an interview with the Director of Nursing (DON) verified the resident had no identified targeted behaviors or monitoring for the use of the antipsychotropic medication Trazadone. 2. Review of the medical record for Resident #93 revealed an initial admission date of 03/28/25 with the diagnoses including but not limited to cerebrovascular disease, myelodysplastic syndrome, dementia with psychotic disturbance, congestive heart failure, chronic kidney failure, diabetes mellitus, anemia, emphysema, peripheral venous insufficiency, major depressive disorder, secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes, hypothyroidism, hyperlipidemia, calculus of gallbladder, macular degeneration and hypertension. Review of the plan of care dated 05/01/25 revealed the resident was at risk for behaviors associated with cognitive decline, takes clean clothes out of drawer and mixes them up with dirty clothes, makes it look as though there are more dirty clothes than it actually is, she packs up items in her room, attempts to leave, exit seeking at times. Interventions included evaluate for medication side effects, give medication as ordered, monitor/document behavior every shift and as needed, provide non-pharmacological interventions, report change in condition to primary care provider and staff to observe when the resident is pulling clean clothes out of drawer and redirect when applicable. Review of the plan of care dated 06/18/25 revealed the resident utilizes psychotropic medications Seroquel due to dementia with psychotic features and depression. Interventions included administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift, discuss with physician, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, document evaluation any signs/symptoms identified, evaluate for psychotropic related risks every shift and as needed, monitor/document/report as any adverse reactions of psychotropic medications and monitor/record occurrence of for target behavior symptoms and document per facility protocol. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident had indicators of depression and displayed no behaviors. The assessment indicated non-Alzheimer's dementia and depression was a current diagnosis. The MDS indicated psychotic disorder was not a diagnosis. Review of the resident's April 2025 MAR revealed the resident was receiving Seroquel 50 mg by mouth twice daily for behaviors. The order was discontinued on 04/24/25 and written as Seroquel 50 mg by mouth twice daily related to unspecified dementia with psychotic disturbance. Review of the pharmacy recommendation dated 04/16/25 revealed the pharmacist recommended an acceptable diagnosis for the antipsychotic medication Seroquel 50 mg by mouth twice daily. The physician addressed on 04/22/25 and added the diagnoses dementia with psychotic behavior. Review of the resident's physician orders for July 2025 identified orders dated 06/24/25 monitor for antipsychotic medication potential side effects, 04/24/25 Seroquel 50 milligrams (mg) by mouth twice daily for unspecified dementia with psychotic disturbance. Review of the medical record revealed the no identified target behaviors, behavior monitoring or diagnosis to support the use of the antipsychotic medication Seroquel. On 07/28/2025 at 10:28 A.M., an interview with the Director of Nursing (DON) verified the resident had no identified targeted behaviors, behavior monitoring or diagnosis to support the use of the medication Seroquel. 3. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 04/29/25 revealed on that date, prior to his hospitalization, Resident #12 had primary diagnosis of Spinal Stenosis. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Review of the hospital after visit summary from Resident #12's hospital stay from 04/30/25-05/07/25 revealed a new prescription of Olanzapine (an anti-psychotic). Review of pharmacy review note to attending provider for Resident #12 dated 05/20/25 revealed the resident received Olanzapine 2.5 mg BID (twice daily) for anxiety. The pharmacist asked if the antipsychotic order could be updated to an accepted diagnosis for use. The pharmacist also suggested if the resident did not require Olanzapine, could an attempt to discontinue it be made. On the document, the provider noted they would update to dementia with behaviors. Interview on 07/29/25 at 8:53 A.M. with Consulting Pharmacist #555 confirmed that he looks at the facility list of diagnoses and the physician notes when he is making recommendations regarding an anti-psychotic medication. Consulting pharmacist #555 said he would recommend a different frequency for gradual dose reduction (GDR) for residents who had dementia in addition a diagnosis of Schizophrenia or Bipolar disorder due to the increased risks. He confirmed that Olanzapine was off label (not approved by the Food and Drug Administration) for a resident who had dementia without a co-occurring diagnosis of Schizophrenia or Bipolar Diagnosis. Interview on 07/28/25 at 09:40 A.M. with Certified Nurse Practitioner (CNP) #412 confirmed she understood there was a black box warning regarding the medication for residents with dementia, however, she felt he had a better quality of life. She said if they stopped the medicine, she thought he would be manic again. Interview on 07/28/25 at 2:54 P.M. with facility medical director confirmed that Resident #12 did not have a psychotic disorder as was noted in the medical record when Resident #12 returned from hospital. She noted the Olanzapine was for his behaviors. Interview on 07/23/25 at 10:55 A.M. with Resident #12 in his room who said he felt no one visited him and he felt ignored. Interview on 07/23/25 at 12:26 P.M. with Activity Director #259 who said the resident has little to no involvement in activities aside from attending Mass. She said she did remember when he came to an activity to dance but doesn't do that anymore and attributed it to him being a fall risk. Interview on 07/23/25 at 3:12 P.M. with Licensed Practical Nurse (LPN) #385 who stated resident had not had any behaviors or acting out in about three months. Interview on 07/23/25 at 5:26 P.M. with the CEO who is also a Sister. She said that Resident #12 comes to Mass every day. She said he had behavioral issues with anger outbursts almost daily or weekly but they hadn't happened in three months. She did say he hasn't struck out at other residents in probably six months. She said people visits the resident but he forgets. She agreed that he seemed very sad although did not attribute this to his medication. Interview on 07/24/25 at 09:55 A.M. with the Administrator who said resident had not had behaviors since he had returned from hospitalization in early May. Review of Olanzapine label dated 03/2025 revealed a warning that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Olanzapine is not approved for the treatment of patients with dementia-related psychosis. 4. Review of the medical record for Resident #71 revealed an admission date of 02/17/23 with diagnoses including severe dementia with behavioral disturbance, Alzheimer's disease, anxiety and major depressive disorder. Review of care plan dated 06/22/25 for Resident #71 documented use of psychotropic medications. Interventions included administering medications as ordered, evaluating behavioral responses, discussing continued need with the physician and family, offering non-pharmacological interventions and reporting changes in condition. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/26/25 for Resident #71 showed the resident had severe cognitive impairment, with symptoms of inattention, disorganized thinking and physical/verbal behaviors toward others. Active psychiatric conditions included anxiety and depression. Review of an updated care plan dated 07/01/25 for Resident #71 identified aggressive behaviors such as throwing objects and inappropriate language. Interventions included medication administration, monitoring for side effects and effectiveness, anticipating needs, and documenting behavior patterns and possible triggers. Review of physician orders dated 06/30/25 for Resident #71 revealed olanzapine 5 milligrams (mg) at bedtime for behaviors. Review of behavior monitoring documentation from 07/12/25 to 07/28/25 for Resident #71 revealed one behavioral incident on 07/18/25 involving grabbing and disruptive sounds. No other behavioral concerns were noted during this period. Review of additional orders dated 07/16/25 for Resident #71 showed Depakote 250 mg delayed-release tablets was initiated at bedtime for dementia with agitation. Review of a psychiatric progress note dated 07/21/25 stated Resident #71 was increasingly confused and agitated, with episodes of falling to the floor and combativeness. The psychiatrist recommended continuing the current medication regimen and increasing social support engagement. Interview on 07/28/25 at 2:57 P.M. with the Director of Nursing confirmed Depakote and Zyprexa were not being used in accordance with their approved indications and were being used off-label. Review of Depakote (anticonvulsant) FDA labeling dated 01/2025 showed approved uses for treatment of bipolar disorder (mania), seizure therapy, and migraine prophylaxis. Review of Zyprexa (atypical antipsychotic) FDA labeling dated 01/2025 showed approved uses for treatment of schizophrenia, bipolar disorder, and treatment-resistant depression in adults. 5. Resident #126 was admitted on [DATE] with diagnoses that included Alzheimer's disease. Her diagnoses were silent for bipolar disease or schizophrenia. Review of Resident #126's physician orders revealed that she was to have Quetiapine Fumarate, an atypical antipsychotic medication, oral tablet 25 milligrams (mg) one tablet daily. Review of Resident #126's Medication Administration Record (MAR) for July 2025 revealed that she was receiving Quetiapine Fumarate as ordered. Review of Resident #126's care plan dated 07/16/25 revealed that she had impaired cognitive function related to dementia. Interventions included administering medications as ordered. Review of Resident #126's care plan dated 07/16/25 revealed that she had a mood problem related to dementia. A goal was to have an improved mood state through the review date. Interventions included administering medications as ordered. Interview with the Director of Nursing on 07/24/25 at 9:40 A.M. confirmed that Resident #126 did not have the appropriate diagnosis to justify the use of Quetiapine Fumarate. Review of a facility policy titled, Use of Psychotropic Medication, dated 02/05/25 revealed that psychotropic medications should only be received by residents when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms. For psychotropic medications, without explanation as to why the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for its use is inadequate. Adequate indication means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. Review of the Centers for Medicare and Medicaid Atypical Antipsychotics Approved Indications and Dosages for Use in Adults indicates that olanzapine is indicated in schizophrenia, quatiapine is indicated for bipolar I disorder, bipolar mania, bipolar depressive episodes, and schizophrenia.

Based on staff interview, record review and facility policy review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for PASARR. The facility census was 117. Findings include:1. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/13/25 for Resident #9 completed by facility staff noted no mental health diagnoses. Review of the medical record for Resident #9 revealed an admission date of 05/17/25 with diagnoses including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. Review of the care plan dated 05/19/25 revealed Resident #9 had a mood problem related to diagnoses of insomnia, dementia, and depression. Interventions included administering medications as ordered, monitoring and documenting for side effects, and monitoring mood to determine needs. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact, exhibited no mood or behavior problems, and had active psychiatric/mood diagnoses of anxiety, depression, psychotic disorder, and schizophrenia. Review of a PASRR identification screen dated 07/23/25 completed by Social Services Director (SSD) #255 revealed mental health diagnoses of schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, insomnia, and depression. Interview on 07/24/25 at 11:50 A.M. with Social Services Director (SSD) #255 stated that the PASRR completed on 05/13/25 did not reflect several mental health diagnoses that were documented at the time of admission on [DATE]. These diagnoses included schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. SSD #255 confirmed these diagnoses should have been submitted promptly to the Department of Aging through an updated PASRR in accordance with facility policy. SSD acknowledged that the PASRR was not updated until 07/23/25, following a request from the surveyor. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of depression (08/03/23) and major depressive disorder (11/04/24). Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 11/01/24 revealed no documented mental health diagnoses. Review of the care plan dated 11/05/24 revealed Resident #79 had a diagnosis of depression. Interventions included administering medications, discussing any concerns with the resident, and monitoring for additional signs and symptoms of depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #79 was moderately cognitively impaired and had an active psychiatric/mood diagnosis of depression. Review of a PASRR identification screen dated 02/04/25 completed by Social services Director (SSD) #255 listed a diagnosis of mood disorder. Interview on 07/24/25 at 11:50 A.M. with SSD #255 stated that Resident #79 was diagnosed with major depressive disorder on 11/04/24. SSD confirmed that this diagnosis was not reflected in the PASRR completed on 11/01/24 and acknowledged that, per facility policy, an updated PASRR should have been submitted to the Department of Aging to reflect this change. SSD confirmed that the PASRR was not revised until 02/04/25 to reflect the updated diagnosis. 3. Review of the medical record for Resident #6 revealed an admission date of 05/05/23 with diagnoses dated 05/05/23 of bipolar disorder, anxiety and insomnia, and schizoaffective disorder – bipolar type dated 09/12/23 and unspecified mood (affective) disorder dated 07/26/24. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/25/23 listed mental health diagnoses of panic or other severe anxiety disorder and personality disorder. Review of the care plan dated 10/07/23 revealed Resident #6 had a potential for mood problems related to bipolar disorder, mood disorder, anxiety, depression, insomnia, hallucinations, and schizoaffective disorder. Interventions included administering medications as ordered, initiating referrals as needed, consulting behavioral health services as necessary, and monitoring for issues related to the resident's diagnoses. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired and had active psychiatric/mood diagnoses of anxiety and bipolar disorder. Review of a PASRR identification screen dated 07/23/25 completed by SSD #255 listed diagnoses including mood disorder, other psychotic disorder, insomnia, depression, anxiety, bipolar disorder, schizoaffective disorder, hallucinations, and mood affective disorder. Interview on 07/24/25 at 11:50 A.M. with SSD #255 acknowledged that the PASRR completed on 05/25/23 for Resident #6 did not reflect multiple mental health diagnoses that were added after that date. These included schizoaffective disorder, bipolar type (added 09/12/23); unspecified mood (affective) disorder (added 07/26/24); as well as bipolar disorder, anxiety, and insomnia (all added on 05/05/23). SSD #255 confirmed that an updated PASRR including these diagnoses was not submitted to the Department of Aging until 07/23/25, after it was requested by the surveyor. Review of Resident assessment- coordination with PASARR program dated 09/18/24 revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program to ensure individuals with a mental disorder, intellectual disability or related condition receives care and services, a resident who experiences a significant change in status will be referred promptly to the state mental health board for resident review, those changes include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder. 4. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Review of psychiatric note dated 05/12/25 for Resident #12 indicated while the resident was hospitalized , he was brought to the ED (emergency department) for combativeness and enroute received ketamine 150 IM (intramuscular) and at the ED he was kept on a wrist restraint and received 10 milligrams (mg) Geodon (antipsychotic). Review of facility medical record documentation for Resident #12 revealed the most recent PASRR (Preadmission Screening and Resident Review) on file was one that had been completed 09/09/20. The document listed that resident #12 had a mood disorder and no other mental health diagnoses. Interview on 07/24/25 at 09:02 A.M. with SSD #255 confirmed she had not completed an updated PASRR to include his documented diagnosis of psychotic disorder, his hospitalization for psychosis or his ongoing psychiatric case management. She confirmed she also did not notify the Department of Aging of the additional indications of serious mental illness. Review of facility policy titled, Resident Assessment-Coordination with PASARR Program dated 09/18/24 revealed that residents should receive a PASRR level I screening prior to admission. If the resident has a negative Level I screen, admission may processed unless a possible serious mental disorder or intellectual disability arises later. If there is a positive Level I screen, this necessitates a comprehensive evaluation by the appropriate state-designated authority and this screening cannot be completed by the facility. If a resident was not screened prior to admission due to an exception (readmitted from a hospital) and remains in facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a serious mental disorder to the appropriate state-designated authority for Level II PASARR evaluation and determination. This screening should be completed within 40 calendar days of admission.

Based on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for Pre-admission Screening and Resident Review (PASRR). The facility census was 117. Findings include: 1.Review of the medical record for Resident #9 revealed an admission date of 05/17/25 with diagnoses including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/13/25 for Resident #9 completed by facility staff noted no mental health diagnoses. Review of the care plan dated 05/19/25 documented Resident #9 had a mood problem related to diagnoses of insomnia, dementia, and depression. Interventions included administering medications as ordered, monitoring and documenting for side effects, and recording mood to determine needs. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #9 was cognitively intact and had active psychiatric/mood diagnoses of anxiety, depression, psychotic disorder, and schizophrenia. Review of the Pre-admission Screening and Resident Review (PASRR) dated 05/13/25, completed prior to admission, showed no identified mental health diagnoses. A subsequent PASRR dated 07/23/25 completed by Social Services Director (SSD) #255 included the resident's mental health diagnoses: schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, insomnia, and depression. Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the diagnoses documented on 05/17/25—including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder—were not reflected in the PASRR completed prior to admission. SSD stated the PASRR should have been updated and submitted to the Department of Aging promptly, and acknowledged this was not done until 07/23/25, after the surveyor requested the most recent PASRR record. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of depression (08/03/23) and major depressive disorder (11/04/24). Review of the care plan dated 11/05/24 documented Resident #79 had a diagnosis of depression. Interventions included administering medications, discussing any concerns with the resident, and monitoring for signs and symptoms of depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #79 was moderately cognitively impaired and had an active psychiatric/mood diagnosis of depression. Review of the Pre-admission Screening and Resident Review (PASRR) dated 11/01/24 showed no documented mental health diagnoses. A subsequent PASRR dated 02/04/25 completed by SSD #255 reflected a diagnosis of mood disorder. Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the resident's diagnosis of major depressive disorder was added on 11/04/24 and should have been included in a revised PASRR. SSD acknowledged that an updated PASRR was not submitted to the Department of Aging until 07/23/25, after it was requested by the surveyor. 3. Review of the medical record for Resident #6 revealed an admission date of 05/05/23 with diagnoses dated 05/05/23 of bipolar disorder, anxiety and insomnia, and schizoaffective disorder – bipolar type dated 09/12/23 and unspecified mood (affective) disorder dated 07/26/24. Review of the care plan dated 10/07/23 documented Resident #6 had the potential for mood problems related to bipolar disorder, mood disorder, anxiety, depression, insomnia, hallucinations, and schizoaffective disorder. Interventions included administering medications as ordered, initiating referrals and behavioral health consults as needed, and monitoring for changes related to these diagnoses. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] showed Resident #6 was moderately cognitively impaired and had active psychiatric/mood diagnoses of anxiety and bipolar disorder. Review of the Pre-admission Screening and Resident Review (PASRR) dated 05/25/23 identified mental health diagnoses of panic or other severe anxiety disorder and personality disorder. A revised PASRR dated 07/23/25 completed by SSD #255 reflected updated mental health diagnoses of mood disorder, other psychotic disorder, insomnia, depression, anxiety, bipolar disorder, schizoaffective disorder, hallucinations, and mood affective disorder. Review of Quarterly Minimum Data Set (3.0) completed 06/05/25 revealed Resident #6 is cognitively intact and has active psychiatric/mood disorders of anxiety, bipolar and schizophrenia. Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the PASRR completed on 05/25/23 did not reflect multiple mental health diagnoses that had been added to the resident's record after that date, including schizoaffective disorder, bipolar type (09/12/23), unspecified mood (affective) disorder (07/26/24), bipolar disorder, anxiety, and insomnia (all 05/05/23). SSD stated that a revised PASRR should have been submitted to the Department of Aging and acknowledged it was not done until 07/23/25, after the surveyor requested the most recent PASRR record. 4. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Review of psychiatric note dated 05/12/25 for Resident #12 indicated while the resident was hospitalized , he was brought to the ED (emergency department) for combativeness and enroute received ketamine 150 IM (intramuscular) and at the ED he was kept on a wrist restraint and received 10 milligrams (mg) Geodon (antipsychotic). Review of facility medical record documentation for Resident #12 revealed the most recent PASARR (Preadmission screening and resident review) on file was one that had been completed 09/09/20. The document listed that resident #12 had a mood disorder and no other mental health diagnoses. Review of facility Minimum Data Set (MDS) documentation dated 06/04/25 revealed Resident #12 was discharged from skilled services on this date. Interview on 07/24/25 at 09:02 A.M. with SSD #255 confirmed she had not completed an updated PASRR to include his documented diagnosis of psychotic disorder, his hospitalization for psychosis or his ongoing psychiatric case management. She confirmed she also did not notify the Department of Aging of the additional indications of serious mental illness. SSD #255 indicated she thought she had more time to file a PASRR after a change of condition. Review of facility policy titled, Resident Assessment-Coordination with PASARR Program dated 09/18/24 revealed that any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper skin monitoring for Residents #79, #95, and #58; failed to remove medication patches as ordered for Resident #50; failed to ensure Geri sleeves and related care plans were implemented for Resident #58; and failed to monitor and implement dental care recommendations following the extraction of seven teeth for Resident #49. These failures affected five (Residents #79, #95, #58, #50, and #49) out of 26 residents reviewed for quality of care. The facility census was 117.Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 02/28/25 with diagnoses of morbid obesity, type two diabetes mellitus, mixed hyperlipidemia, shortness of breath and hypertension. Review of physician order dated 03/01/25 revealed clonidine transdermal patch weekly 0.3 milligrams per 24 hours. Apply one patch every seven days for hypertension and remove prior to application of new patch. Review of medication administration record revealed on 07/12/25 clonidine patch was removed and placed, and on 07/19/25 clonidine patch was removed and placed. Review of physician order dated 07/12/25 revealed lidocaine external patch 5 percent to be applied to back topically one time a day for back pain for seven days and removed every 12 hours. Review of medication administration record revealed on 07/19/25 lidocaine external patch 5 percent was documented as removed at 8:59 A.M. Observation of Resident #50 on 07/24/25 at 1:50 P.M. during interview with family revealed a round patch located on the resident's left upper chest. Family noted they were unsure what the patch was for. The patch was dated 07/12/25. Observation of Resident #50 on 07/24/25 at 1:55 P.M. with Licensed Practical Nurse (LPN) #279 confirmed presence of a round patch on the resident's left upper chest, dated 07/12/25. Review of medication administration record revealed on 07/24/25 a new order was received to remove clonidine patch and apply a new one for seven days. Interview on 07/24/25 at 2:10 P.M. with LPN #279 and Nurse Manager #266 confirmed the patch on Resident #50's chest was a clonidine transdermal patch, ordered to be removed weekly. Observation of Resident #50 on 07/24/25 at 2:44 P.M. with LPN #279 confirmed no additional clonidine patches were located on the resident's chest, upper extremities, shoulders, or back as documented on the medication administration record as given on 07/19/25. However, a lidocaine patch dated 07/19/25 was found on the resident's right lower backside. LPN #279 confirmed the patch should have been removed per physician order on 07/19/25. Additionally, the patch should have been identified and removed during routine care before observation on 07/24/25. Review of federal drug administration drug labeling dated 02/02/23 revealed Catapres TTS (clonidine transdermal system) provides continuous systemic delivery of clonidine for seven days at an approximately constant rate. Application of a new system to a fresh skin site at weekly intervals maintains therapeutic plasma concentration of clonidine. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of metabolic encephalopathy, type two diabetes mellitus, obesity, hemiplegia and hemiparesis, chronic kidney disease stage four, atherosclerotic heart disease, peripheral vascular disease and tachycardia. Review of physician orders dated 11/05/24 revealed ace wraps to bilateral lower extremities on in the morning and off at night time. This treatment is scheduled to be completed at 8:00 A.M. daily. Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed 05/13/25 revealed Resident #79 requires partial or moderate assistance with lower body dressing and has active diagnoses of coronary artery disease, heart failure, hypertension and peripheral vascular disease. Review of care plan dated 05/20/25 revealed Resident #79 has congestive heart failure (CHF) with interventions to monitor lungs, give cardiac medications as ordered, and monitor for signs and symptoms of CHF including edema, shortness of breath, distended neck veins, weight gain and abnormal vital signs. Observation on 07/23/25 at 8:49 A.M., 10:20 A.M., and 11:27 A.M. of Resident #79 revealed ace wraps to bilateral lower extremities were not in place. Resident #79 voiced agreement to placement of the wraps during all observations. Interview on 07/23/25 at 10:23 A.M. with LPN #235 confirmed the ace wraps were not yet in place and they would be applied as soon as possible. Review of treatment administration record dated 07/23/25 at 12:04 P.M. revealed application of ace wraps to bilateral extremities had not occurred for the day. 3. Review of the medical record for Resident #58, revealed an admission date of 09/12/23. Diagnoses included but were not limited to chronic pain, Alzheimer's disease, and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, mobility and transfers. Review of the active care plan for Resident #58 revealed to have a potential/actual impairment to skin integrity with an intervention including but not limited to weekly treatment documentation to include measurement of each area of the skins breakdown's width, length, depth and type of tissue and exudate and any other notable changes or observations. Review of the progress note dated 07/09/25 at 5:45 A.M. for Resident #58 revealed a new skin issue measuring 0.1 centimeters (cm) by 0.2 cm located on the sacrum. Further review of the progress note dated 07/09/25 at 1:00 P.M. for this resident revealed the Interdisciplinary team discussed the area and noted it to be an abscess. Review of the weekly skin check dated 07/16/25 for Resident #58 revealed no assessment of the abscess of the sacrum. Review of the weekly skin check dated 07/23/25 for Resident #58 revealed no assessment of the abscess of the sacrum. Interview on 07/28/25 at 12:40 P.M. with the Director of Nursing verified Resident #58's abscess to the sacrum obtained on 07/09/25 did not have weekly documentation assessments and should have to monitor it. 4. Review of the medical record for Resident #95, revealed an admission date of 8/9/24. Diagnoses included but were not limited to cerebral infarction, cognitive communication deficit, other abnormalities of gait and mobility, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. The resident was assessed to require total dependence with toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the active plan of care for Resident #95 revealed none for the prevention/treatment of potential skin integrity issues. Review of the active physician order dated 01/22/25 for Resident #95 revealed apply Geri sleeves to legs in the AM and remove in the PM as tolerated. Review of the medical record for Resident #95 for 01/22/25 through 07/28/25 revealed no refusals to wear the Geri sleeves to the bilateral legs. Review of the weekly skin assessment dated [DATE] for Resident #95 revealed a right later lower leg skin tear that measured 0.5 cm X 0.6cm. Review of the weekly skin assessments dated 07/11/25, 07/18/25 and 07/25/25 for Resident #95 revealed no assessment to monitor the left lower leg skin tear. Observation on 07/21/25 at 10:05 A.M. of Resident #95 revealed no Geri sleeves to bilateral legs. Observation on 07/28/25 at 11:34 A.M. of Resident #95 revealed no Geri sleeves to bilateral legs. Interview on 07/28/25 at 11:34 A.M. with LPN #279 verified Resident #95 did not have Geri sleeves to bilateral legs. Interview on 07/28/25 at 12:03 P.M. with the DON verified Resident #95 did not have weekly documentations for the right lower leg skin tear acquired on 07/04/25 and did not have a plan of care for the prevention/treatment of potential skin issues. Review of the facility policy titled Skin Integrity-Skin Tears no date revealed for monitoring, the Registered Nurses and Licensed Practical Nurses will participate in the management of skin tears and medical conditions by following physician orders, assessment of the residents, and reporting changes in condition to the residents physicians. 5. Review of the closed medical record for Resident #49 revealed an initial admission date of 01/02/25 with the diagnoses including but not limited to dementia with psychotic disturbances, dysphagia, cerebrovascular accident with left sided hemiplegia, gastro-esophageal reflux disease, hypertension, congestive heart failure, insomnia, major depressive disorder, presence of cardiac pacemaker, hyperlipidemia, anemia, constipation, chronic pain, atrial fibrillation and hypothyroidism. The resident expired on 07/08/25 at the facility. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the dental progress note dated 05/07/25 revealed the dentist recommended the resident to have seven teeth extracted (#21 through #27). The resident's tongue, mucosa, lips and gums were within normal limits. Review of the progress note dated 06/10/25 at 12:26 P.M. revealed the resident returned from having a tooth extraction procedure. The resident was not to use straws and have soft foods and liquids. A new order was received for Tylenol 500 milligrams (mg) and Ibuprofen 800 mg by mouth three times a day for even days. The resident was to keep the head of her bed elevated. Review of the resident's dental extraction instructions dated 06/10/25 revealed the following recommendations, apply an ice bag to the area of swelling for 30 minutes and remove for 20 minutes, continue this cycle until swelling subsides. After 24 hours is tis okay to gently rinse mouth with a warm saltwater solution after meals. Review of the progress note dated 06/16/25 at 6:23 P.M. revealed the resident was observed having bruises to her chin post tooth extraction. Review of the medical record revealed no documented evidence the resident's seven tooth extraction cites were monitored for complications or signs/symptoms of infection. On 07/22/2025 at 2:12 P.M., an interview with the Director of Nursing (DON) verified there was no documented evidence the resident was monitored for complications or signs/symptoms of infection. This deficiency represents non-compliance investigated under Complaint Number OH001386198.

Based on interview, observation, and record reviews, the facility failed to ensure air mattress bed settings were appropriate and ordered for four (Residents #2, #8, #53 and #70) of four residents who were at risk for developing pressure ulcers. The facility census was 117.Findings include:1. Review of the medical record for Resident #2, revealed an admission date of 11/1/22 . Diagnoses included but were not limited to dementia, weakness, need for assistance for personal care, and lack of coordination. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of not assessed with memory problem with short term and long term memory. The resident was assessed to require total dependence with toilet hygiene, shower/bathe self, bed mobility, and transfers. this resident was also assessed to be at risk for pressure ulcers.Review of the active care pian for Resident #2 revealed her to have a potential for developing pressure injuries due related to weakness, incontinence, risk for malnutrition and dementia with an intervention not including a low air loss mattress.Review of the active physician order dated 04/09/25 for Resident #2 revealed a low air loss mattress; check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/12/25 for Resident #2 revealed a score of 13.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #2 to be at moderate risk for skin breakdown.Review of the medical record for Resident #2 revealed a date of 07/06/25 with a weight of 103.4 pounds. Observation on 07/21/25 at 2:14 P.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to firm (over 250 pounds). Observation on 07/28/25 at 10:11 A.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to firm (over 250 pounds). Interview on 07/28/25 at 10:12 A.M. with Licensed Practical Nurse (LPN) #279 verified Resident #2's low air loss mattress was set to firm (over 250 pounds) and the resident was to only weigh 103.4 pounds. Also verified she is not sure how to adjust/set the low air loss mattress when it gets turned off and does not know where to find the appropriate settings. Interview on 07/28/25 at 10:27 A.M. with the Director of Nursing verified Resident #2's low air loss mattress order did not contain appropriate settings for the floor nurses to follow and that type of bed should be set to their weight unless other indicated by the physician in the order.2. Review of the medical record for Resident #8, revealed an admission date of 08/05/23. Diagnoses included but were not limited to depression, weakness, generalized anxiety disorder, with a new diagnosis of contracture to the right elbow on 6/20/24. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 08 out of 15 suggested severe cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to be at risk for developing pressure ulcers.Review of the active care plan for Resident #8 revealed her to have a protentional for developing pressure injuries related to weakness, lack of coordination, general bedbound status and history of pressure injury to the coccyx with an intervention not including a low air loss mattress. Review of the active physician order dated 04/29/25 for Resident #8 revealed a low air loss mattress to bed; check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/22/25 for Resident #8 revealed a score of 10.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #8 to be at high risk for skin breakdown.Review of the medical record for Resident #8 revealed a date of 7/20/25 weight of 116.2 pounds. Observation on 07/21/25 at 10:42 A.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to 60 pounds. Observation on 07/28/25 at 9:34 A.M. of Resident #2 revealed her to bed in bed with her low air loss mattress set to 60 pounds. Interview on 07/28/25 at 10:04 A.M. with LPN #233 verified Resident #8's low air loss mattress was set to 60 pounds, and the resident was recently weighed at 116.2 pounds. Also verified the company sets up the settings and does not know where to find appropriate settings from the physician. 3. Review of the medical record for Resident #53, revealed an admission date of 10/01/24. Diagnoses included but were not limited to hypertensive heart disease without heart failure, muscle weakness, dementia, bipolar disorder, and dyspnea. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 01 out of 15 suggested severe cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility, and transfers. This resident was also assessed to be at risk for pressure ulcers. Review of the active care plan for Resident #53 revealed her have no care plan for the potential of the development of pressure injuries. Review of the active physician order dated 04/29/25 for Resident #53 revealed a low air loss mattress to bed' check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/28/25 for Resident #53 revealed a score of 10.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #53 to be at moderate risk for skin breakdown.Review of the medical record for Resident #53 revealed a date of 07/07/25 with a weight of 139.6 pounds. Observation on 07/21/25 at 2:05 P.M. of Resident #53 revealed her to be in bed with the low air loss mattress set to 240 pounds.Observation on 07/28/25 at 9:31 A.M. revealed Resident #53 to her to bed in bed with the low air loss mattress set to 240 pounds.Interview on 07/28/25 at 9:59 A.M. with LPN #233 verified Resident #53's low air loss mattress was set to 240 pounds with the resident currently weighing at 139.6 pounds. 4. Review of the medical record for Resident #70, revealed an admission date of 03/09/23. Diagnoses included but were not limited to adult failure to thrive, anxiety disorder, need for assistance with personal care, muscle weakness and muscle wasting and atrophy. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 suggested severe cognitive impairment. The resident was assessed to require toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to be at risk for pressure ulcers.Review of the active care plan for Resident #70 revealed to have the protentional for developing pressure injuries related to weakness, chronic debility, cognitive impairment and incontinence with an intervention including but not limited to a low air loss mattress. Review of the active physician order dated 02/14/25 for Resident #70 revealed an air mattress to bed' check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 04/28/25 for Resident #8 revealed a score of 14.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #8 to be at moderate risk for skin breakdown.Review of the medical record for Resident #70 revealed a date of 07/18/25 with a weight of 113 pounds. Observation on 07/21/25 at 10:34 A.M. of Resident #70 revealed the resident to be in bed with the low air loss mattress set between 250-280 pounds. Observation on 07/28/25 at 9:33 A.M. of Resident #70 revealed the resident to be in bed and with the low air loss mattress set to 250 pounds. Interview on 07/28/25 at 10:01 A.M. with LPN #233 verified Resident #70s low air loss mattress was set to 250 pounds, with the residents current weight being 113 pounds.

Based on review of resident medical records, observations, staff interviews and review of company policies, the facility failed to provide supervision with dining for residents that were identified as choking risks. This affected two residents (Resident #4 and 18) out of thirty three residents that the facility identified as at risk for choking. The facility also failed to ensure that transfers were completed as required for Resident #116 and that the call light cord wiring was not exposed for Resident #79. These affected two residents (Resident #79 and #116) out of six residents that were reviewed for accidents. The facility census was 117 residents.Findings include:1. Review of Resident #18's medical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, multiple sclerosis and postural kyphosis. Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he was cognitively intact. Review of dietary progress note on 07/09/25 revealed that Resident #18 had mild to moderate oral phase dysphagia and suspected moderate to severe pharyngeal dysphagia. Review of Resident #18's dysphagia care plan dated 01/06/21 and revised on 11/14/24 revealed that Resident #18 had dysphagia. Some interventions included instructing and reminding Resident #18 to eat in an upright position, to eat slowly and to chew each bite thoroughly, and to monitor for signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth and appearing concerns during meals. Review of Resident #18's activities of daily (ADL) living care plan dated 09/19/24 and revised on 07/14/25 revealed that Resident #18 was at risk for a decline in his ADL status due to weakness. An intervention for eating included that he was at continued risk for aspiration and therefore will need to be supervised during meals. Review of Resident #18's speech therapy evaluation and plan of treatment for dysphagia dated 07/09/25 revealed that he had a history of dysphagia with multiple courses of speech therapy including modified barium swallow studies with the identification of aspiration. He was permitted to have a pureed diet texture with nectar thickened liquids for quality of life in lieu of having a modified barium swallow study or pursuing an alternative means of nutrition support. Observation of the fourth-floor dining room on 07/21/25 from 5:40 P.M. to 5:46 P.M. revealed that no licensed nursing staff was present in the dining room. Observation revealed that there were seven residents that were unattended in the dining room, including Resident #18, who was observed to be drooling and coughing after he ate food. Interview with Certified Nursing Aide (CNA) #253 on 07/21/25 at 5:46 P.M. confirmed that the residents had been left unattended in the dining room and that the residents needed to be supervised while dining in the dining room. 2. Review of Resident #4's medical record revealed that he was admitted to the facility on [DATE] and that his diagnoses included dementia and dysphagia. Review of Resident #4's physician orders revealed that he was to have a pureed diet with this liquids via straw and that regular bananas were permitted. His physician orders revealed that he was on aspiration precautions. Observation of the second floor dining room on 07/22/25 from 5:15 P.M. to 5:16 P.M. revealed that three residents were feeding themselves in the dining room without a licensed nursing staff member in the dining room. The residents included Resident #4, #29, and #66. Interview with CNA # 241 on 07/22/25 at 5:16 P.M. confirmed that there had been no licensed nursing staff in the dining room for a period of time and that some of the residents in the dining room needed supervision while eating. 3. Review of the medical record for Resident #116 revealed an initial admission date of 06/01/21 with the diagnoses including but not limited to polyosteoarthritis, zoster, atrial fibrillation, chronic kidney disease, anemia, congestive heart failure, asthma, dry eye syndrome, myopia, presbyopia, constipation, abdominal aortic aneurysm, seasonal allergic allergies, hyperlipidemia, aortic valve stenosis, overactive bladder, insomnia, presence of cardiac pacemaker, peripheral vascular disease, hypertension and obstructive sleep apnea. Review of the plan of care dated 06/01/21 revealed the resident was at risk for falls related to weakness, difficulty walking, history of falling and incontinence. Interventions included anticipate and meet needs, be sure call light is within reach and encourage resident to use it for assistance as needed, ensure resident is wearing appropriate nonskid footwear when ambulating or mobilizing in wheelchair, Offer frequent assistance with toileting/incontinence care, sign posted in bathroom to remind resident to lock wheelchair breaks before transferring, staff education for most recent fall and therapy to evaluate for appropriate use of sit to stand and therapy recommends use of Hoyer lift at time of evaluation. Review of the plan of care dated 08/04/21 and last revised on 03/10/25 revealed the resident had impaired self-transfer related to weakness. Interventions included make sure resident wears non-skid footwear when up, praise for efforts and success, provide verbal cues and physical assistance as needed, reassess quarterly and as needed, restorative transfer program from wheelchair to toilet and back with assist of one staff, for at least 15 minutes, six to seven days a week. Review of the resident's fall risk assessment dated [DATE] revealed a score of 16 indicated the resident was at increased risk for falls. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was dependent on staff for transfers. The assessment indicated the resident had not had any falls since prior assessment. Review of the medical record revealed no documented evidence the facility's therapy department evaluated the resident for the use of the sit to stand lift to ensure the resident's safety. Review of the progress note dated 04/15/25 at 11:46 P.M. revealed an aide reported to the nurse the resident slid off the sit to stand lift to the floor when being transferred to bed. The resident reported a 5/10 pain level, with zero being no pain and 10 being the worst pain possible to her left shoulder. The resident was administered as needed Tylenol. The resident's range of motion (ROM) was within normal limits for all extremities. The resident sustained a scratch to her right arm measuring 0.5 centimeters (cm). The wound was cleansed and covered with a Band-Aid. The resident's physician and power of attorney (POA) was notified of the incident. Review of the incident/accident interview form dated 04/15/25 at 9:55 P.M. revealed while the Certified Nursing Assistant (CNA) as transferring the resident from a shower chair to her bed with the sit to stand lift, the resident let go of the handles and her knees buckled causing her to slide to the floor. The CNA went and retrieved assistance to lift the resident into bed. On 07/24/2025 at 12:27 P.M., interview with the Director of Nursing (DON) verified the CNA was utilizing the sit to stand lift with only one assist and all mechanical lifts should be used with two assists. Review of the facility policy titled, Safe Resident Handling/Transfers, dated 12/17/24 revealed it was the facility's policy to ensure the residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking in account other factors as well. Two staff members must be utilized when transferring residents with a mechanical lift. 4. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of need for assistance with personal care, cognitive communication deficit, metabolic encephalopathy, and transient cerebral ischemic attack. Review of care plan dated 01/13/25 revealed Resident #79 has impaired cognitive and thought process related to dementia, resulting in difficulty making decisions, long term memory loss, short term memory loss, and cognitive communication deficit. Interventions include asking yes or no questions to determine the resident's needs. Review of Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 has a memory problem and requires modified independence for daily decision making, has no impairment of upper or lower extremities, and requires partial or moderate assistance with bed mobility. Observation on 07/21/25 at 10:03 A.M. revealed Resident #79 was lying in bed with exposed call light wiring approximately two inches outside the wall. The cord was found behind the headboard, wrapped around the bed railing. Observation on 07/21/25 at 1:29 P.M. revealed the call light cord wiring remained exposed. Observation on 07/22/25 at 7:42 A.M. revealed the call light cord wiring remained exposed. Observation on 07/22/25 at 7:46 A.M. with Registered Nurse (RN) #345 revealed he believed the cord had been pulled out earlier in the morning. He entered the room and reconnected the cord, stating it was an easy fix staff had not identified. Review of call light policy dated 10/21/24 revealed staff will report problems with the call light or call system immediately to the supervisor or maintenance director and provide immediate or alternative solutions until the problem can be remedied.

Based on observation, record review, interview and facility policy review, the facility failed to ensure pain management monitoring, evaluations and indication for usage for residents. This affected four (Resident #58, #9, #50 and #13) out of five residents reviewed for pain. The facility also failed to ensure Dexcom (continuous glucose monitoring system) was not expired, this affected one (Resident #114) out of one reviewed for insulin usage. The facility census was 117. Findings include:1.Review of the medical record for Resident #9 revealed an admission date of [DATE] with diagnoses including fracture of the left patella, weakness, age-related osteoporosis, and pain in the left leg. Review of care plan dated [DATE] identified Resident #9 is at risk for alteration in comfort related to arthritis and left patella fracture. Interventions include completing a comprehensive pain evaluation, administering pain medications as ordered, monitoring and documenting the effectiveness of pain interventions, providing appropriate non-pharmacological measures and reporting unrelieved pain or changes in condition to the physician. Review of the admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #9 is cognitively intact. Review of physician's order dated [DATE] revealed an order for tramadol 50 milligrams (mg) oral tablet, one tablet by mouth every six hours for pain. Review of pain assessment tool dated [DATE] showed Resident #9's pain management regimen includes medication with a goal to remain pain-free. Review of the Medication Administration Record (MAR) for Resident #9 from [DATE] through [DATE] showed tramadol 50 mg was administered a total of 64 times with resident's documented pain level at 0 out of 10 at the time of administration. Specifically, tramadol was administered on: [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 12:00 P.M. [DATE] at 12:00 A.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] and [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] and [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 6:00 P.M. [DATE] at 6:00 P.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] at 12:00 A.M. [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 12:00 P.M. [DATE] at 12:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M. [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.; and [DATE] at 12:00 A.M. 2. Review of the medical record for Resident #13 revealed an admission date of [DATE] with diagnoses of Alzheimer's disease, dementia, displaced fracture of the second cervical vertebra, constipation, and malignant neoplasm of the breast. Review of care plan dated [DATE] revealed Resident #13 has the potential for alteration in comfort related to a history of breast cancer, generalized pain, headache, cervicalgia, and skin impairment. Interventions included administering pain medication as ordered, nursing staff to perform pain evaluations, providing appropriate non-pharmacological measures, and reporting unrelieved pain or changes in condition to the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 is moderately cognitively impaired and receives a high-risk medication (opioid). Review of pain interview dated [DATE] revealed Resident #13 reported occasional pain. The resident stated the pain rarely interfered with sleep and day-to-day activities. Review of physician's order dated [DATE] prescribed hydrocodone-acetaminophen 10-325 mg, one tablet by mouth twice daily for neck pain. Review of the Medication Administration Record (MAR) from [DATE] through [DATE] revealed hydrocodone-acetaminophen 10-325 mg was administered a total of 22 times, despite the resident's documented pain level being 0 out of 10 at the time of administration. Specifically, the medication was administered on: [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. Interview conducted on [DATE] at 2:44 P.M. with the Director of Nursing confirmed administration of narcotic medication at a pain level of 0 out of 10 is not acceptable according to nursing standards of practice, confirmed the presence on Resident #13 medical record in the month of July. In addition, nursing staff should be consistently evaluating and documenting the resident's pain level prior to administration and reassessing after medication administration to determine effectiveness. 3. Review of the medical record for Resident #58, revealed an admission date of [DATE]. Diagnoses included but were not limited to chronic pain, Alzheimer's disease, and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, mobility and transfers. Review of the active plan of care revised [DATE] for Resident #58 revealed her to be at risk for alteration in comfort related to chronic pain with interventions including but not limited to give pain medications as ordered. Review of the physician order dated [DATE] for Resident #58 revealed a pain medication for Acetaminophen tablet 325milligrams (mg) give two tablets by mouth every four hours as needed for pain. Further review of the physician orders for this resident revealed a pain medication dated [DATE] for Hydrocodone-Acetaminophen oral tablet 5mg /325mg, give one tablet by mouth every 12 hours as needed for pain. Interview on [DATE] at 12:40 P.M. with the Director of Nursing verified Resident #58 had two pain medications ordered for as needed, both not containing pain parameters with a pain scale for appropriate administration. Review of facility Pain Management Policy dated [DATE] revealed the facility must ensure that pain management is provided to resident who require such services, consistent with professional standards of practice, comprehensive person-centered care plan, and the residents goals and preferences. Additionally staff should reassess and adjust the medication dose to optimize the residents pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Pharmacological interventions will follow a systemic approach for selecting medications and doses to treat pain. Use lower doses of medication initially and titrate slowly upward until comfort is achieved. 4. Review of the medical record for Resident #114 revealed an initial admission date of [DATE] with the diagnoses including but not limited to diabetes mellitus, dementia, hypertension, hyperlipidemia, anxiety disorder, glaucoma and long-term use of insulin. Review of the plan of care dated [DATE] revealed the resident had diabetes mellitus with other complications. Interventions included check all of body for breaks in skin and treat promptly as ordered by doctor, diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, dietary consult for nutritional regimen and ongoing monitoring, encourage resident to practice good general health practices. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received daily insulin injections and received hypoglycemic medications. Review of the resident's monthly physician orders for [DATE] identified orders dated [DATE] Dexcom 7 sensor apply to upper arm topically every day shift every 14 days. Review of the resident's [DATE] Medication Administration Record (MAR) revealed the resident's Dexcome7 sensor was in place for 14 instead of the 10 days as designed. Review of the Decom7 instruction booklet located in the medication administration cart indicated the sensor was good for only 10 days with a 12-hour grace period. On [DATE] at 11:22 A.M., an interview with Registered Nurse (RN) #216 verified the Decom7 sensor was good for only 10 days with a 12-hour grace period and the facility was using the sensor for 14 days.

Based on observations, staff interview and review of facility policy, the facility failed to store food in a safe and sanitary method. This had the potential to affect 116 residents who ate food from the kitchen. The facility identified one resident (Resident #72) who did not eat food from the kitchen. The facility census was 117 residents.Findings include: Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the dry storage area, there was an opened undated box of elbow macaroni, an opened undated package of spaghetti, and an opened one-gallon container of soy sauce that was undated. Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the freezer there was an opened unlabeled and undated container of french fries. Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the walk in refrigerator, there was an uncovered bun rack that contained three uncovered sheet pans full of diced potatoes and two sheets of uncovered raw burger patties. Observation of the fans in the walk-in refrigerator revealed that the fans were covered in a brown fuzzy substance resembling dust, and the fans were blowing in the direction of the uncovered bun rack containing the potatoes and burger patties. Interview with [NAME] #360 on 07/21/25 at 8:29 A.M. confirmed that the box of elbow macaroni, the package of spaghetti and the container of soy sauce were open and undated, that the freezer contained an unlabeled and undated opened bag of french fries, and that the walk-in refrigerator had an uncovered bun rack containing two sheets of raw burger patties and three sheets of diced potatoes. [NAME] #360 also confirmed that the fan appeared to be dusty and blowing onto the uncovered food items. Review of the facility policy titled, Food and Supply Storage: Labeling and Dating, dated 02/11/25 revealed that all food used in food preparation shall be stored in such a manner to prevent contamination and maintain the safety and wholesomeness of the food. All foods in the walk-in refrigerator, freezer and pantry should be properly labeled and include a produced on or opened date. All foods are to be securely covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment in multiple resident areas. This affected one (Resident #50) out of six residents reviewed for environmental concerns. Additionally the facility failed to maintain the cleanliness of common areas this had the potential to affect 40 residents (#40, #14, #58, #2, #41, #93, #85, #24, #95, #13, #75, #114, #115, #99, #30, #80, #97, #10, #89, #49, #131, #6, #73, #69, #104, #86, #1, #51, #76, #71, #26, #9, #62, #34, #21, #60, #79, #50, #64, and #74) identified using the affected areas. The facility census was 117. Findings include:1. Review of the medical record for Resident #50 revealed an admission date of 02/28/25 with diagnoses of type two diabetes mellitus, severe protein-calorie malnutrition, morbid obesity, gastro-esophageal reflux disease and gastrostomy status. Review of care plan dated 03/03/25 revealed Resident #50 has potential nutritional problem related to need to mechanically altered diet, need for tube feed due to inadequate oral intake and need for appetite stimulant. Interventions include monitor speech therapy recommendations, monitor weight and labs as ordered, provide supplement and diet as ordered and registered dietician to evaluate and make changes as needed.Review of physician orders dated 05/16/25 revealed enteral feed order for feeding Osmolite 1.2 at 50 milliliters per hour to start at 6:00 P.M. and end at 6:00 A.M.Review of quarterly minimum data set (MDS) 3.0 assessment completed 06/06/25 revealed Resident #50 is cognitively intact, is dependent on staff for all activities of daily living and receives tube feeding and mechanically altered diet. On 07/23/25 at 11:20 A.M., six dried brown spots resembling splattered tube feeding formula were observed on the legs of the tube feeding pole.Observation on 07/24/25 at 8:42 A.M., and 1:55 P.M. revealed the dried brown residue remained. Observation on 07/28/25 at 10:20 A.M., of Resident #50's room with Licensed Practical Nurse (LPN) #370 confirmed the dried brown residue was present on the pole legs, along with a large puddle of dried formula on the floor beneath the pole stated she had not previously noticed the spill or buildup on the pole and left to notify housekeeping. LPN #370 confirmed spills should be cleaned up immediately or as soon as it is identified by staff. 2. Observation on 07/21/25 at 10:22 A.M. of the hallway near Resident #79's room revealed splatter marks on two walls. The first wall, directly outside the resident's room, had mixed brown and orange splatters with visible water staining around the droplets. The second wall, located perpendicular to the room on the left, had brown drip marks running down the wall.Observation on 07/22/25 at 2:28 P.M. with Nurse Manager #266 and Registered Nurse #210 confirmed the presence of carpet staining and wall splatter in the hallway.3. Observation on 07/22/25 at 7:48 A.M. of the wall directly across from the memory care nurses' station, near the walkway to the bathroom and laundry room, revealed various splattered colors and drips along the wall surface.Observation on 07/22/25 at 2:36 P.M. with Certified Nursing Assistant (CNA) #312 confirmed the presence of splatter marks behind the medication cart, stating she had not noticed them prior but would notify housekeeping.Interview on 07/22/25 at 2:42 P.M. with Environmental Services Director #321 revealed he was unaware of any cleanliness issues in the building. He acknowledged that nursing staff can clean minor spills or housekeeping concerns as needed, and he also stated he was unaware the hallway carpets required cleaning outside of Resident #79's room and walls requiring cleaning on the floor.Review of safe and homelike environment policy dated 07/22/25 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the call light was in reach for Resident #03. This affected one resident (#03) of four residents reviewed for call light accessibility. The facility census was 117.Findings included:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 dated 04/25/25 for Resident #03 revealed she was dependent on staff for toileting, rolling left to right, sit to lying and lying to sitting on side of bed.Review of care plan focus for Resident #03 dated 04/10/25 revealed Resident #03 was at increased risk for falls and intervention suggested was for staff to be sure resident's call light was within reach.Observation and interview on 07/22/25 at 2:22 P.M. of Resident #03 in bed with call light behind the resident, out of sight and out of reach. Resident #03 confirmed she was unable to see or reach the call light.Observation and interview on 07/22/25 at 2:44 P.M. the call light continued to be out of reach for Resident #03. Certified Nursing Assistant (CNA) #226 said the call light should be clipped nearby the resident so that she could reach it. She confirmed it was not within reach of the resident and moved it in place.Observation and interview on 07/23/2025 at 8:28 AM. Resident #03 sitting up in bed eating breakfast. Call light was not within her reach. A family friend was assisting resident. The friend confirmed call light was not in reach and moved it where resident could reach. Review of facility policy titled, Call Lights: Accessibility and Timely Response dated 10/21/24 revealed staff will ensure the call light is within reach of resident and secured, as needed.This deficiency represents non compliance investigated under Complaint Number OH001386198.

Based on observation, interview, record review and facility policy review, the facility failed to ensure private medical record information for Resident #03 was not visible to facility visitors. This affected one resident (#03) of four residents reviewed for privacy concerns. The facility census was 117.Findings include:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder, hyperthyroidism and ileostomy status.Observation on 07/21/25 at 9:35 A.M. on the outside door to room of Resident #03 a sign which said, Synthroid - take whole- no crushing it - 4 hours before breakfast. Place bottom of ostomy bag towards right wall, not over crotch.Observation and interview on 07/22/2025 at 2:45 P.M. the sign remained on outside of door of Resident #03. Certified Nursing Assistant (CNA) #226 confirmed the sign was on the door, confirmed she knew it was HIPAA violation and said the sign had been there since she started in February. CNA #226 said she did not want to be the one who removed it.Interview on 07/22/2025 at 2:50 P.M. with Licensed Practical Nurse (LPN) #385 confirmed the sign on door was a privacy violation. He said the sister had put it up and that he thought a physician had even expressed concern to the sister regarding the sign. He said he didn't know if he had personally ever said anything to the sister but was hopeful that it would be removed now that it was noticed by a surveyor.Observation and interview on 07/23/25 at 8:00 A.M. with LPN #385 who confirmed the sign was no longer on the outside of the door. He said he brought up the privacy concern to the sister of Resident #03 and she had moved the sign to the inside of the resident's room. The sign was on the hand-sanitizing dispenser inside the resident's room.Review of the facility policy titled, Confidentiality of Personal and Medical Records, dated 05/12/25 revealed paper notes or reminders with resident's personal or medical information shall not be unattended or viewable by unauthorized persons.

Based on review of resident medical record, family interview, staff interviews, dentist interview, review of facility self-reported incident investigation, review of hospital notes, and review of facility policies, the facility failed to complete a thorough investigation of an injury of unknown origin. This affected one resident (Resident #48) that was reviewed for abuse. The facility census was 117 residents. Findings include: Review of Resident #48's medical record revealed that Resident #48 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, anxiety disorder and unspecified dementia with mood disturbance. Review of Resident #48's comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had modified independence for daily decision making. She was assessed as needing touch assistance for transfers and touch assist for rolling from lying on her back to left and right side. Review of Resident #48's activities of daily living (ADL) care plan dated 06/06/25 revealed that she had a self-care performance deficit. An intervention listed was that for bed mobility, she required substantial and dependent assistance from one to two staff members. She also required substantial to dependent assistance for transfers. Review of Resident #48's fall care plan dated 06/06/25 and revised on 07/04/25 revealed that Resident #48 was at an increased risk for falls related to a history of falls and a diagnosis of arthritis with unsteady gait. An intervention added on 07/16/25 included to have the bed in the lowest position while resident was in bed. Review of a progress note authored by Nurse Practitioner #410 on 06/30/25 indicated that her skin was warm and dry. The progress note indicated that Resident #48 was being treated for a urinary tract infection. Review of a progress note authored by Nurse Practitioner #410 on 07/01/25 revealed that she was asked to assess Resident #48 after a recent injury and questionable fall. Resident #48 was assessed as having a traumatic injury which was unclear due to Resident #48 being a poor historian and it was unwitnessed. A hip and rib X-ray was ordered. The plan included to decrease the dosage of Zoloft due to recent falls. Resident #48's skin was noted to have a bruise to her right temporal. Review of nursing progress note dated 07/01/25 revealed that Resident #48 was having complaints of pain to her right rib area. Review of nursing notes on 07/01/25 revealed that social services was notified of family request for dental service due to missing teeth. Review of progress note authored by Physician #408 on 07/02/25 revealed that Resident #48 was being seen due to an unwitnessed fall. The physician note addressed rib pain and that the X-rays were negative for any fractures. There was an injury of Resident #48's head, which was unwitnessed, but noted to be likely due to a fall. Physician #408 noted bruising to her temple as well as two cracked/ missing teeth and bruising to her right lower ribs. The physician notes noted a fall and stated, unwitnessed fall with likely head strike, given right temple bruise and dental injuries noted above. Continue fall precautions and safety measures. Broken teeth not found. Her skin was noted to be warm, dry, and a visible quarter sized bruise to her right temple, mildly tender. Review of nursing progress notes dated 07/02/25 indicated that the Nurse Practitioner #410 has ordered for Resident #48 to be sent to the hospital for a CT scan. Review of the hospital notes for Resident #48 on 07/03/25 revealed that on the morning of 07/01/25, Resident #48's daughter visited the facility where Resident #48 resides and noticed that Resident #48 had several teeth missing, bruising to the right side of her face, and right sided rib pain. The facility denies knowledge of her falling. ST imaging showed a traumatic right subarachnoid hemorrhage. Her physical exam on 07/03/25 showed right forehead bruising and tenderness to right chest wall. The injury assessment concluded that Resident #48 had acute traumatic pain and acute traumatic right temporal subarachnoid hemorrhage. An interview with the Resident Representative and Power of Attorney for Resident #48 on 07/21/25 at 9:58 A.M. revealed that on 07/01/25, family had found Resident #48 to be missing three teeth, a bruise on her face, and complaining of rib pain. The interview revealed that family had been with Resident #48 on the evening of 06/30/25 and Resident #48 did not have those signs and symptoms at that time and date. Review of self-reported incident (SRI) #262287 revealed that Resident #48 was found with a bruise on her temple, rib pain and two teeth missing. There was no conclusion marked on the self-reported incident. The investigation by the facility revealed that Resident #48 was not found on the floor and that the daughter thinks that she fell and broke a tooth. The Director of Nursing noted in her investigation that she felt that the bruising on the right side of her forehead was due to a previous fall that was investigated on 06/22/25. The oral examination was assessed as having a broken tooth in the front and broken teeth to the side that appeared to look as if the tooth had crumbled. Further review of SRI #262287 revealed that the nursing staff that had been working on the evening of 06/30/25 and morning of 07/01/25 were all interviewed, staff was educated on abuse. An interview with the Director of Nursing (DON) on 07/23/25 at 3:37 P.M. revealed that she came to the conclusion that Resident #48 did not fall because there was no swelling or bruising, no bleeding and that no teeth were found. The DON stated that they did not come to a conclusion on how Resident #48 possibly sustained her injuries, but the DON stated that there was no evidence that she fell. The DON also stated that no fall intervention or fall prevention education was given to staff members during the course of the SRI investigation process. Review of Resident #48's medical record on 07/23/25 revealed that she had seen the dentist for an oral examination. Interview with Dentist #414, who examined Resident #48 on 07/23/25, including dental X-rays, on 07/23/25 at 10:45 A.M. revealed that the injury to Resident #48's front teeth was likely caused by acute blunt force trauma, such as which would happen in the course of a fall. Dentist #414 indicated that the bone underneath in Resident #48's jaw was intact and showed no signs of deterioration. Review of the undated facility policy titled Fall Prevention Program revealed that when any resident experiences a fall, the facility will document all assessments and actions. Review of the facility policy titled, Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident effective 02/28/23 revealed that the facility will take all necessary corrective actions depending on the results of the investigation. The facility will analyze the injury of unknown source occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The Administrator will review that the investigation is complete. The investigatory results will be delegated to the DON, Director of Social Work or the Director of Human Resources so that he/she can inform the Resident, if appropriate, the Legal Representative, and the staff member involved. The investigation results will be given to the QAA committee to conduct root cause analysis to see what changes, if any, are needed to policies and procedures to prevent further occurrences or to determine corrective actions and follow up.

Based on medical record review, staff interview and review of facility policy, the facility failed to perform oral assessments on a resident. This affected one resident out (Resident #58) out of twenty nine residents reviewed. The facility census was 117 residents. Findings include: Review of the medical record for Resident # 58 revealed that Resident #58 was admitted to the facility on [DATE] with diagnoses that include chronic pain, Alzheimer's disease and chronic kidney disease stage 3. Review of Resident #58's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15, which suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with oral hygiene and personal hygiene, bed mobility and transfers. She was assessed as having no dental concerns. Review of Resident #58's nursing quarterly assessments on 03/01/25 and 05/02/25 revealed that the nurse did not assess her oral and dental status. Interview with Resident #58's daughter on 07/21/25 at 2:13 P.M. revealed that she had informed the facility about her mother's dentures fitting improperly and rubbing against her gums. Interview with MDS Licensed Practical Nurse #307 on 07/28/25 at 11:03 A.M. confirmed that the facility had not assessed Resident #58's oral status since at least 03/01/25. Review of the facility policy titled, Dental Services, dated 03/04/25 revealed that the dental needs of each resident are identified through physical assessment. The oral and dental status shall be documented according to physical and MDS assessment findings.

Based on interview and record review the facility failed to ensure documented diagnoses were accurate for Resident #12. This affected one resident (#12) out of five residents reviewed. Facility census was 117.Findings include:Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder.Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired) out of 15. Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Further review of the 05/14/25 MDS section I revealed the ICD coded primary diagnosis was F28 which corresponded to the primary diagnosis listed in the Point Click Care (PCC) charting system: Other psychotic disorder not due to a substance or known physiological condition. Additionally, I5950 was checked, indicating Resident #12 had a Psychotic Disorder (other than schizophrenia). Section I8000 listed F28 with Other psych disorder not due to a sub or known physical condition written in.Interview on 07/24/25 from 11:47 A.M. to 12:11 P.M. with MDS Registered Nurse (RN) #358 confirmed she was the one who entered new diagnoses into electronic medical record when Resident #12 returned from hospitalization. She also confirmed she completed the MDS documentation. She said she obtained the diagnoses from the hospital documentation. She was unable to find the source within the hospital documentation of the F28 Other psychotic disorder diagnosis at that time and the interview was ended for her to have time to find the documentation.Interviews on 07/24/25 between 4:00 P.M. and 5:00 P.M. with facility Administrator, who provided a single page printout from Resident #12's hospitalization with the phrase Other psychiatric disorder highlighted. He said that this is where the primary diagnosis came from. When surveyor pointed out that other psychiatric disorder was not identical to other psychotic disorder he agreed they were not the same. He left and returned and relayed that he had confirmed with the MDS nurse that she had entered in both the start date and the diagnosis incorrectly.Record review on 07/24/25 at 5:14 P.M. of diagnoses listing in Point Click Care (PCC) for Resident #12 revealed a primary diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. The diagnosis of Other Psychotic Disorder was struck out and noted to be incorrect documentation.Record review of psychotropic consent form dated 05/08/25 and 06/19/25 revealed that F28 was written in with Psychotic Disorder as one of the diagnoses to justify the resident's anti-psychotic disorder. It was noted on the form that verbal consent was obtained from the emergency contact for Resident #12.Interview on 07/28/25 at 11:36 A.M. with the Director of Nursing (DON) confirmed that the F28 other psychotic disorder had been entered into PCC and MDS incorrectly and that an MDS correction had been filed. She confirmed that the nurse who initially completed the psychotropic consent document signed on 05/08/25 and 06/19/25 document no longer working at the facility, however, they would normally speak to the diagnoses, so it is likely that this erroneous diagnosis was shared with Resident #12's emergency contact on those prior dates. The DON said they recently had obtained another consent for changes in medications, and she noted F28 was no longer listed on the consent form but she could not say whether the emergency contact had been notified that F28 was a false diagnosis. She said she would make sure he was informed.

Based on interview and record review, the facility failed to ensure accurate Preadmission screening and resident review (PASRR) Level I screenings for residents with qualifying mental health diagnoses. This affected one (Resident #90) out of five residents reviewed for PASRR screenings accuracy. The facility census was 117. Findings include:Review of Preadmission screening and resident review (PASRR) identification screen dated 05/12/25 for Resident #90 revealed diagnosis of dementia however no active mental health disorders listed. Review of the medical record for Resident #90 revealed an admission date of 05/14/25 with diagnoses of dementia, bipolar disorder, and history of mental and behavioral disorders. Review of care plan dated 05/16/25 revealed Resident #90 has a mood problem interventions include administer medications as ordered, educate family and resident of treatment and monitor/record mood concerns or changes. Review of admission Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #90 has active psychiatric/mood disorder of bipolar. Interview on 07/24/25 at 11:50 A.M. with Social Services Director #255 confirmed that the PASRR completed at admission on [DATE] did not accurately reflect Resident #90's active mental health diagnoses. The diagnoses of bipolar disorder and a history of mental and behavioral disorders were omitted. SSD #255 stated that an updated PASRR was completed on 07/23/25 to include the correct diagnoses.Review of resident assessment - coordination with PASARR program policy dated 09/18/24 revealed all residents will be screened for serious mental disorders or intellectual disabilities and related conditions and an initial pre-screening is completed prior to admission.

Based on interview, record review and policy review, the facility failed to ensure care plans reflected resident care needs. This affected three residents (#12, #45, and #114) out of four reviewed for care plans. The facility census was 117.1.Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 04/29/25 revealed on that date, prior to his hospitalization, Resident #12 had primary diagnosis of Spinal Stenosis. Review of the diagnosis list on 07/28/25 revealed Resident #12 had primary diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the progress note on 04/25/25 at 3:12 A.M. revealed Resident #12 walked out of his room towards the elevator. Per note, resident was agitated and refused to listen and exited the building. The staff member had to call supervisor and security for assistance to retrieve resident. Review of the progress note dated 04/27/25 at 01:21 A.M. revealed Resident #12 went outside followed by a nurse. The note entails that Resident #12 proceeded to run outside stating he would not fall. Review of the Elopement Assessment for Resident #12 dated 04/27/25 revealed Resident #12 was at high risk for elopement and/or wandering. Review of the Care Plan for Resident #12 on 07/12/25 revealed no focus on ensuring Resident #12 does not wander or elope. Review of psychiatric note dated 05/12/25 revealed Resident #12 has been using his walker but still struggles with agitation, following directions and being safe. Interview on 7/28/25 at 9:40 A.M. with Certified Nurse Practitioner (CNP) #412 who stated that if Resident 12's medication recently changed and she noted that Resident #12 was skipping and happy again and she worried he might be found in the road again. She confirmed he goes to Mass on his own. Interview on 07/28/25 at 9:37 A.M. with Licensed Practical Nurse (LPN) #385 confirmed Resident #12 goes to Mass on his own without being accompanied. He said Resident #12 goes downstairs to work on jigsaw puzzle and confirmed that if Resident #12 left the building after that, he would not know. Interview with Director of Nursing (DON) on 07/28/25 at 11:36 A.M. confirmed the 04/27/25 wandering assessment was the most recent assessment for the resident. She said the resident never tried to elope. She confirmed the care plan did not have plan for elopement. She noted due to Resident #12 being a fall risk, he should be accompanied by staff when he left the floor. She said that he should tell someone if he wants to go downstairs. She admitted that may not be the most practical intervention for a resident with primary diagnosis of dementia. Review of facility policy titled, Elopement and Wandering Residents revealed The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. 2. Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/24/25 revealed the resident uses psychotropic medications (Trazadone) related to depression. Interventions included administer medications as ordered by physician, monitor for side effects, discuss with physician, family regarding ongoing need for use of medication review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, elevate for psychotropic related risks every shift and as needed, provide non-pharmacological interventions and report any changes in condition to primary care provider. Further review of the plan of care revealed no targeted behaviors to be monitored. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. The assessment indicated depression was a current diagnosis. Review of the resident's monthly physician orders for July 2025 identified orders dated 02/24/25 Trazadone 150 milligrams (mg) by mouth daily at bedtime for depression. On 07/23/25 at 3:00 P.M., an interview with MDS Coordinator #307 verified the resident's plan of care had no identified targeted behaviors. 3. Review of the medical record for Resident #114 revealed an initial admission date of 10/18/24 with the diagnoses including but not limited to diabetes mellitus, dementia, hypertension, hyperlipidemia, anxiety disorder, glaucoma and long term use of insulin. Review of the resident's admission assessment dated [DATE] revealed the resident was continent of both bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the resident's bowel and bladder incontinence. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was frequently incontinent of both bowel and bladder. On 07/23/25 at 3:00 P.M., an interview with MDS Coordinator #307 verified the resident has no plan of care addressing the resident's bowel and bladder incontinence.

Based on interviews, observations, record review and facility policy review, the facility failed to ensure shaving needs were completed for two residents (#79 and #120) who required assistance with needs for personal care. Four residents were reviewed for activities of daily living. The facility census was 117.Findings include: 1.Review of the medical record for Resident #120, revealed an admission date of 05/18/18. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, weakness and need for assistance personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of rarely/never understood. The resident was assessed to require partial/moderate assistance with bed mobility and transfers with substantial/maximal assistance with shower/bathe self and toilet hygiene. Review of the active plan of care revealed Resident #120 had no interventions for shaving her facial hair as well as no refusals of care for receiving assistance with activities of daily living. Further review of the medical record for Resident #120 from 06/25/25 through 07/22/25 revealed only two refusals for assistance with activities of daily living including shaving her facial hair on shower days dated 07/02/25 and 07/16/25. No other refusals were noted. Observation on 07/21/25 at 2:01 P.M. of Resident #120 revealed her in a wheelchair at the nurse's station with facial hair noted. Observation on 07/22/25 at 8:39 A.M. of Resident #120 revealed her in the wheelchair at the nurse's station with facial hair noted. Concurrent interview with Certified Nurse Aide #250 verified Resident #120 had facial hair and stated, usually on shower days we shave the resident's facial hair if needed. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of metabolic encephalopathy, hemiplegia and hemiparesis, cognitive communication deficit, need for assistance with personal care, weakness, depression and osteoarthritis. Review of care plan dated 11/05/24 revealed Resident #79 has an activities of daily living self care performance deficit with interventions to provide partial assistance with bathing and personal hygiene. Review of quarterly Minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 has a memory problem, requires modified independence with daily decision making, exhibits no behavior of refusal of care and requires partial/moderate assistance with personal hygiene (including shaving). Review of shaving task from 06/30/25 through 07/28/25 revealed shaving services were received on 06/30/25, 07/10/25 and 07/21/25. Additionally documentation of refusal of this task was noted on 07/14/25. Observation on 07/21/2025 at 10:03 A.M. revealed Resident #79 was laying in bed facial hair was present on both lower chin and upper lip approximately .5 inch in length. Observation on 07/21/2025 at 1:29 P.M. revealed facial hair remained. Observation on 07/22/2025 at 7:42 A.M. revealed facial hair remained. Observation on 07/23/25 at 10:20 A.M. revealed facial hair remained. Interview on 07/24/25 at 10:20 A.M. with State Tested Nursing Assistant #313 (STNA) confirmed presence of long facial hair which should be removed as resident requested, STNA confirmed the assigned nursing assistant would be notified of the residents request. STNA #313 confirmed shaving needs should be offered with bathing services as well as if additional need arise. Interview on 07/24/25 at 4:25 P.M. with the administrator confirmed facial hair should be removed upon resident request. Review of the facility titled Activities of Daily Living (ADLs) no date revealed care and services will be provided for the following activities of daily living including but not limited to bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on medical record review, interview and facility policy review, the facility failed to develop an individualized activity program to meet one resident (#45) needs. This affected one (Resident #45) of two residents reviewed for activities. The facility census was 117.Findings Include:Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/25/25 revealed the resident was a new long term care resident who pursues independent leisure activities, may benefit from groups for social and recreational needs, assimilation to new surroundings, glasses worn for reading and may require wheelchair assistance when attending group activities. Interventions included encourage active participation. Involve in daily facility routine to assimilate to new surroundings, encourage and promote family and friends support via social visits, provide and review activity calendar, provide leisure supplies as needed to facilitate interests; books, current events, cd player and cd's and spiritual material and provide wheelchair when attending group activities. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated it was very important to the resident to be able to do her favorite activities and for her family and friends to be involved in decisions. On 07/21/2025 at 11:22 A.M., an interview with the resident revealed her only concern with the facility was not being able to visit with her husband who resides in the assisted living (AL) across campus. The resident revealed the only time she was able to visit with her husband was when her family brought him to the facility. The resident expressed she had asked the facility to assist with visits with her husband with no arrangements being made. On 07/24/2025 at 8:50 A.M., interview with Activity Director (AD) #259 revealed the AD stated the facility did not have the staff to do individual resident activities and the resident's husband lives at the AL facility across the campus. She said it would be hard to coordinate getting the resident there because they only have the AD and two activity assistants for the entire building and transport staff are out doing transports. On 07/24/2025 at 4:26 P.M., an interview with the Administrator revealed the AD did not give the right answer and if the resident would like to visit her husband, then the arrangements should have been made when requested. Review of the facility policy titled, Activities, dated 02/04/25 revealed it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Activities will encourage both independence and interaction within the community.

Based on clinical record review, hospital record review, interviews with staff and the Ombudsman, and policy review, the facility failed to provide timely care and treatment for a change in Resident #2's condition. Actual Harm occurred when the facility failed to provide timely treatment for the significant injuries including a shoulder injury and a subdural hematoma requiring hospitalization in the Neurological Intensive Care Unit. This affected one resident (#2) of three residents reviewed for accidents. The facility census was 112. Findings include: Clinical record review revealed Resident #2 was admitted on [DATE] with diagnoses including end stage renal disease with hemodialysis, a left knee fracture prior to admission, and heart disease. Resident #2 received Aspirin at 81 milligrams once daily. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required the extensive assistance of one staff for transfers and ambulation, and the limited assistance of one staff for toilet use. The most recent cognitive test dated 03/24/23 revealed the resident had moderately impaired cognition. Review of the most recent fall risk assessment dated [DATE] revealed Resident #2 scored 13, indicating he was a high fall risk. Review of Resident #2's fall prevention care plan developed on 01/13/23 with a target date of 07/18/23 revealed interventions included educating the resident to use the call light, keeping the call light within reach, wearing nonskid shoes, and providing a reacher for the resident. Review of the fall investigations revealed Resident #2 had an unwitnessed fall on 02/22/23 when he lost his balance looking for clothing in his closet and landed on his buttocks. He did not use his call light and had a skin tear on his left arm. Notifications and neurological checks were appropriate, and the new intervention was to educate the resident to use a walker to ambulate. The resident's next fall was unwitnessed on Saturday 04/08/23 at 11:15 A.M. where he was found on the floor in his bathroom when he did not call for assistance. The resident stated he was bending over to pick something up. Review of the change in condition note completed by Licensed Practical Nurse (LPN) #20 revealed there was no change in the resident's skin and no pain reported. There was evidence of notification to the resident's son and Certified Nurse Practitioner (CNP) #39 who was on call for the weekend. The resident's neurological assessments were completed for 24 hours following the fall and revealed the vital signs were normal with no evidence of pain. Review of the progress notes dated 04/08/23 revealed Resident #2 fell and had a skin tear on his left elbow and bump on the left side of his head. LPN #20 gave him ice to place on the head. The progress note completed 04/09/23 at 8:00 A.M. completed by night shift agency LPN #30 revealed the resident reported his head was hurting with no pain level noted and two as needed Acetaminophen 325 milligrams (analgesic) were administered. There was no evidence the CNP #39 was notified of the head pain. On 04/11/23 a nursing note revealed Resident #2 was alert and oriented with normal vital signs and denied any pain or discomfort. On the morning of 04/12/23 Resident #2 had a change in condition, physician and family notified and he was sent out with emergency services after reporting he did not feel well with increased confusion and weakness. There was no evidence in the notes after 04/08/23 of bruising or swelling to the resident's head or any mention of shoulder pain or bruising. Review of the hospital continuity notes dated 04/12/23 revealed Resident #2 reported he felt progressively worse with shoulder pain, headache, and fever since he fell on [DATE]. The physical exam revealed bruising on the left side of the head. Blood work and a brain scan revealed a right frontal subdural hematoma with intraventricular hemorrhage. X-rays of the shoulder and cervical spine revealed no evidence of acute fractures. The resident was started on intravenous fluids plus an antibiotic and transferred to the neurological intensive care unit. Interview with the Director of Nursing (DON) on 04/21/23 at 9:20 A.M. verified Resident #2 had not returned from the hospital. The DON stated a few days after the fall she spoke to Resident #2 who had a bruise on his head and was alert and oriented. The DON verified there was no note in the resident's record in the days following the fall on 04/08/23 regarding a bruise on the resident's head, shoulder pain, or notification to the physician. Interview with Unit Manager LPN #10 on 04/21/23 at 9:45 A.M. revealed she spoke to Resident #2 a few days after the fall who showed no change in his cognition, but he had a bruise on his forehead. LPN #10 verified she did not document the bruise on the resident's forehead or notify the physician in the days following the fall on 04/08/23. A phone interview with LPN #20 on 04/21/23 at 10:00 A.M. revealed she was the nurse who cared for Resident #2 after his fall on 04/08/23 when he was found on the bathroom floor and hit his head. LPN #20 reported she called the resident's son and CNP #39 who told her to put ice on the head bump, monitor and report any change in condition. A phone interview with CNP #35 on 04/21/23 at 12:15 P.M. revealed she was always contacted during the week for any resident concern and was not called regarding Resident #2's bruise on his head. CNP #35 stated nursing should have notified the on call CNP when Resident #2 reported a headache the morning of 04/09/23 within 24 hours of hitting his head on the floor so he could be sent to the hospital. CNP #35 stated this was especially important because Resident #2 took a daily Aspirin which could cause bleeding. A phone interview with agency LPN #30 on 04/21/23 at 12:45 P.M. revealed the morning of 04/09/23 at 7:30 A.M. at shift change she administered two Acetaminophen to Resident #2 after a state tested nurse aide (STNA) reported Resident #2 had a headache. LPN #30 verified she did not report the headache to the physician. Interview with Registered Nurse (RN) #11 on 04/21/23 at 2:30 P.M. revealed she did not notice or document a hematoma or bruising on Resident #2's head when she sent him out with emergency services on 04/12/23 after the resident reported he did not feel right. Phone interview with the Ombudsman on 04/21/23 at 3:15 P.M. revealed they recently received information from the hospital social worker that Resident #2 arrived at the hospital on 04/12/23 four days after a fall at the facility with significant injuries including swelling to his left lateral head that was baseball size, an abrasion on the left side of his face, and shoulder bruising. Review of the policy titled Neurological Assessment, dated 01/01/23, revealed Neurological Assessment Flow Sheet was initiated by a nurse following an unwitnessed fall or fall with a head injury every 15 minutes for four times, every 30 minutes for four times, and every one hour twice. The nurse should document any abnormal findings in the record and notify the physician for orders with each assessment. Review of the policy titled Nursing Services: Notification of Changes, dated 03/01/23, revealed the nurse immediately notified the resident, resident representative and physician of a significant change in the resident's physical, mental or psychosocial status which may require medical physician intervention or change in treatment including a decision to transfer the resident to the hospital. This deficiency represents non-compliance investigated under Complaint Number OH00142055.

Based on observation, medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of an Abuse Investigation Report Form, review of a facility Abuse and Neglect Checklist, review of the facility Abuse policy and procedure and resident and staff interviews, the facility failed to effectively and immediately implement their Abuse policy and procedure following an allegation of staff to resident abuse to ensure the allegation was immediately reported and investigated and to ensure the resident was protected from the staff member involved in the incident. This resulted in Immediate Jeopardy on 01/27/21 at approximately 8:00 P.M. when Resident #15 alleged, to State tested Nursing Assistant (STNA) #143 that she had been physically abused (hit in the head) by Licensed Practical Nurse (LPN) #257 during care. STNA #143 failed to report the allegation until 01/27/21 at 11:10 P.M. resulting in LPN #257 continuing to work providing care for residents including Resident #15 until the end of his shift (on 01/27/21) at 11:54 P.M. On 01/27/21 at 11:10 P.M. the nursing supervisor, Registered Nurse (RN) #240 was notified of the incident but failed to initiate an investigation or report the allegation to administrative staff. This affected one resident (#15) and had the potential to affect all 93 residents residing in the facility who were at risk for potential harm or injury related to incidents of staff to resident abuse. On 01/29/21 at 1:35 P.M. the Administrator, Director of Nursing (DON) and Chief Executive Officer (CEO) #141 were notified Immediate Jeopardy began on 01/27/21 at approximately 8:00 P.M. when Resident #15 reported she was physically abused by LPN #257 to STNA #143 and the STNA failed to immediately report the allegation to the nursing supervisor or administrative staff. The allegation was not reported to RN #240 until 01/27/21 at 11:10 P.M. and the DON was not notified of the allegation until 01/28/21 at 4:13 A.M. which resulted in the lack of timely reporting, an immediate investigation and allowed LPN #257 to continue to work following the allegation made against him. The Immediate Jeopardy was removed on 01/30/21 when the facility implemented the following corrective action: · On 01/28/21 at 5:31 P.M. the DON initiated a Self-Reported Incident, Tracking Number 6 and reported to the State Agency the allegation of physical abuse lodged by Resident #15. The Medical Director was notified of the abuse allegation on 01/28/21 at 6:15 P.M. · On 01/28/21 LPN #257 was suspended pending the outcome of the facility investigation. · On 01/29/21 beginning at 1:00 P.M. education was provided to employees by the administrative team: Business Office Manager (BOM) #117, Maintenance Director #112, RN #145, Nursing Scheduler #158, Missions Director #175, Director of Information Technology #196, Admissions Director #208, Medical Records #121, Food Services Director #249, LPN #338, RN #240, Human resources Director #301, Director of Clinical Nutrition #236, Assistant DON (ADON) #165, Activities Director #116, RN #274, Director of Housekeeping #308, and the DON on the abuse policy to include immediate reporting of allegations of abuse to the nursing supervisor. The education included the accused staff member would be immediately removed from the unit and escorted out of the building by the nursing supervisor, and the DON would be notified immediately. This education was completed for all current staff on 01/29/21 at 11:00 P.M. · On 01/29/21 from 3:30 P.M. through 01/30/21 6:01 P.M. 47 current residents who were cognitively intact were interviewed asking if they felt staff were nice, if any staff had been mean or rude to them or if they had observed any staff being mean/rude to any residents. The interviews were completed by Director of Housekeeping #308, Physical Therapy Department Head #281, the DON, Director of Clinical Nutrition #236, Admissions Director #208, CEO #141, RN #145, and Admissions Assistant #148. No concerns were identified upon the interviews. · On 01/29/21 from 3:30 P.M. through 01/30/21 at 8:00 P.M. skin checks were completed by LPN #338, ADON #165, RN #274, RN #199, LPN #300, LPN #262, LPN #263, LPN #269, and RN #233 on all residents. No unexplained bruises or injuries that could be due to abuse were identified. · On 02/01/21, STNA #143 received a final written warning from the DON, describing non-satisfactory work/conduct detailing that she did not report an allegation of resident abuse to the nursing supervisor. STNA #143 signed the document. · On 01/29/21 at 6:15 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held to address the abuse policy, reporting abuse allegations and immediate removal of staff from the facility. · Beginning on 01/29/21, a plan for 10 percent (%) of all residents to be selected weekly for skin assessments, completed by the unit nursing staff initially and double checked with RN #274, weekly for four weeks and then monthly for three months to monitor for signs of physical abuse was implemented. · Beginning on 01/29/21, a plan for QAPI team members to complete interviews on 10% of interviewable residents weekly for four weeks, and monthly for three months, asking if they felt staff were nice, if any staff had been mean or rude to them, if they had observed any staff being mean/rude to any residents, and if they felt mistreated. · Beginning on 01/29/21 a plan for QAPI team members to complete random interviews of 20% of staff on each shift, weekly four weeks and then monthly for three months, on the abuse policy to include immediate reporting of any allegations of abuse and the removal of staff involved in the allegation from the facility. · Beginning on 01/29/21, the DON will review all abuse investigations to check that timely reporting occurred weekly for four weeks and then monthly for three months. · All audits will be reviewed and analyzed by the DON and the Administrator and reviewed in Quality Assurance Performance Improvement (QAPI) meetings weekly until the facility attains substantial compliance. · On 02/02/21 at 2:05 P.M. staff interviews were conducted to verify receipt and understanding of education including the abuse protocol and reporting with STNA #109, Housekeeper #130, STNA #228, Dietary Aide #243, STNA #244, Housekeeper #246, STNA #264, LPN #306, and LPN #338. All staff confirmed they received the education and were knowledgeable of the abuse protocol. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #15's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s current care plans revealed a plan, initiated 10/14/20 reflecting Resident #15 had the potential for psychosocial well being problems related to anxiety, depression, dementia, and history of paranoid thoughts that belongings were stolen, then later found. Interventions included to cue, reorient, and supervise as needed, encourage participation from the resident who depends on others to make her decisions, and allow her time to answer questions and verbalize feelings, perceptions and fears during care and as needed. Review of a plan of care, initiated 10/14/20 revealed Resident #15 had the potential for mood state problems related to anxiety and depression with interventions to administer medications as ordered, behavioral health consults as needed, and monitor for signs and symptoms of anxiety and depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/02/21 revealed Resident #15 had a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive impairment with no behaviors identified on the assessment. The MDS 3.0 assessment revealed the resident required extensive assistance from one staff for personal hygiene, toileting, dressing, bed mobility and transfers. Review of a nursing note, dated 01/27/21 at 10:15 P.M. and authored by LPN #257, revealed Resident #15 threatened to break his neck and threatened to get him fired. The note also documented the resident accused him of physically harming her. Resident #15 used abusive language and attempted to attack him in the presence of STNA #143. Review of a witness statement, completed by STNA #143 and dated 01/27/21(no time noted) revealed she watched Resident #15 attempt to attack and falsely accuse the nurse (LPN #257) of abuse. At the beginning (no time noted), the resident ' s call light was on and LPN #257 assisted Resident #15 to the toilet while she (STNA #143) assisted another resident. When STNA #143 was done, the nurse approached her and told her about Resident #15's threats and accusations. STNA #143's statement revealed she went to talk to the resident, the resident's bathroom door was closed, and she was crying in the bathroom. The statement revealed LPN #257 followed her into the bathroom. Resident #15 began screaming, cursing and hitting the wall. When asked what was wrong, the resident kept yelling for the nurse to leave the room with curse words and accused him of hitting her. The nurse said, How did I hit you?, the resident didn ' t reply but stated, Get out of my room! and began attempting to kick the nurse. STNA #143 asked LPN #257 to leave the bathroom so she could calm the resident down. Resident #15 explained to the STNA the nurse stood right in front of her and hit her on the forehead and tried to break her glasses. STNA #143 calmed the resident down and assisted her to bed. The statement revealed STNA #143 told LPN #257 to report the incident and he then explained his side of the story to her. LPN #257 explained he bent down to help the resident put her pad on and she began pushing and yelling at him. LPN #257 stated he put his hand up and she started yelling he had hit her. She then told him to get out and close the door so that's what he did. Review of a written witness statement for LPN #257, dated 01/27/21 (no time noted) revealed himself and STNA #143 were the only two staff on the floor. STNA #143 was assisting another resident so LPN #257 answered Resident #15's call light. She asked him to close the blinds and take her to the bathroom. The resident had no pajamas in her drawer, so she asked him to go get them from laundry. He explained that she could have a night gown, but that her pajamas were in laundry and he couldn't find them. Resident #15 began cursing and yelling and told him to go get STNA #143. He explained she was busy with another resident and the resident continued to yell at him to go get STNA #143. Resident #15 stated, Go get the aide. She knows where my pajama is. If she can find my pajama, I will break your neck. The resident was sitting on the toilet when all of this happened, he (LPN #257) left the bathroom and the resident began kicking the wall and yelling. LPN# 257 went to get STNA #143 and both went back to Resident #15's bathroom. Resident #15 kept cursing, trying to kick LPN #257, and threatening to get him fired. In the presence of STNA #143, he stated to the resident that she was not supposed to say that. He then left the room and left Resident #15 with STNA #143. Review of an Abuse and Neglect Checklist for Resident #15, dated 01/28/21 documented RN #240 was notified on 01/28/21 at 3:59 A.M. (approximately eight hours after the incident occurred) of the above incident with Resident #15. A head to toe assessment of Resident #15 was completed on 01/28/21 at 4:05 A.M., the DON was notified at 4:13 A.M., the resident's responsible party was notified at 4:33 A.M., and the physician was notified at 4:40 A.M. This checklist included an incident report and staff witness statements. Review of a facility Detailed Abuse Investigation Report Form, dated 01/28/21 revealed RN #240 completed the form for Resident #15 because the resident made an allegation of abuse/neglect. The form documented Resident #15 complained LPN #257 hit her on her head and left her in the bathroom with the door locked against her will. She complained of pain (rated a four out of ten) and was given an as needed narcotic [MEDICATION NAME] 5-325 mg at 3:54 A.M. Review of the investigative documentation revealed a facility incident report, dated 01/28/21 and timed as A.M. revealed Resident #15 reported that at 3:50 A.M. during the previous shift, LPN #257 hit her head and left her in the bathroom against her will. The report included an assessment of her vital signs and pain assessment. The resident rated her pain a four on a scale of zero to 10 (zero being none and 10 being worse). The resident complained of pain to the left side of her head. No redness, swelling or injuries were observed to the area. Review of a witness statement, dated 01/28/21 (no time noted) from RN #240, revealed (on 01/28/21) at about 3:59 A.M., RN #206 reported to her that Resident #15 complained of pain to the left side of her head, stating it was a result of a staff member hitting her on the head during the previous shift. She immediately went to see Resident #15 and asked her what happened. The resident stated, the nurse from the previous shift; we don't get along well ever since he came to this floor. Last night he hit me on my head and left me in the bathroom with the door closed against my will. She asked her why she didn't report it to the supervisor immediately and she stated she didn't know she had to report it. A head to toe assessment was completed, no redness or swelling noted, her vital signs were within normal limits, her pain to the left side of her head was rated at a four out of ten, and as needed [MEDICATION NAME] was administered. The DON was notified at 4:13 A.M. and the resident's representative was notified at 4:23 A.M., her voice mail box was full, so a text message was sent. The resident's emergency contact was notified at 4:33 A.M. and was informed of the incident. The physician was notified at 4:40 A.M. The resident remained calm and rested in bed. Additional review of the statement revealed a note at the bottom that documented, on 01/27/21 during shift change at about 11:15 P.M. the outgoing nurse and aide, LPN #257 and STNA #143, reported to her Resident #15 had been abusive towards LPN #257, cursing and even raising her hand to hit him. LPN #257 stated he assisted the resident to the restroom and due to some misunderstanding, Resident #15 got angry and asked him to leave her room. He retrieved STNA #143 who continued to assist Resident #15. Both staff were asked to write statements and the resident was asleep at that time. Review of a witness statement/interview with Resident #15, dated 01/28/21 at 11:00 A.M. revealed the resident had put her call light on, and the nurse (LPN #257) came in, she told him she needed to use the bathroom. He assisted her to the commode. She asked him to get her pajamas in the drawer and he stated she didn't have any and offered her a new gown. She instructed him to go to the laundry and he said the resident didn ' t have any pajamas in her drawer. Resident #15 instructed him to retrieve STNA #143 because she would know where they were, and he said she was busy with another resident, she repeated to go get STNA #143. He then put (and she demonstrated) four flat fingers on her forehead. She stated he did it three or four times. She yelled again to go get STNA #143 because she would know where the pajamas were, and she further told him she was going to break his neck. As he was leaving, she said, don't shut the door and he shut the door. STNA #143 came in and put her to bed. In addition, the facility investigation included a second typed interview was obtained from LPN #257 on 01/28/21 at 12:30 P.M. During this interview, LPN #257 reported that following the incident he didn ' t go back into Resident #15 ' s room and STNA #143 assisted the resident to bed. On 01/28/21 at 3:31 P.M. observation of Resident #15 revealed no redness or bruising to her head or face and the resident's eyes showed no signs of injury. An interview with the resident at the time of observation revealed on 01/27/21 at around 8:00 P.M., LPN #257 told her it was time to go to bed and she told him she had to use the bathroom first. He assisted her onto the commode, and she told him, You're so bossy, I'd like to break your neck. The resident revealed the LPN reached over and hit her three to four times across the forehead, one finger hit her left eye, and it was a force enough that she felt it. The resident stated she was on the commode and LPN #257 left her in there and shut the door. She revealed she was crying and yelling and couldn ' t breathe because it was so hot in there and she has asthma. The resident revealed STNA #143 found her after approximately 10 minutes. STNA #143 asked her if she was okay and the resident explained the incident to her. She revealed STNA #143 asked her not to tell anyone, but she stated she didn't want LPN #257 to hurt anyone else. Resident #15 stated she would never try to hit or hurt anyone. On 01/28/21 at 4:17 P.M. interview with STNA #143 revealed on 01/27/21 (shortly before 8:00 P.M.) two call lights were going off at the same time, and LPN #257 said he would take Resident #15's call light. About 10 minutes later (at approximately 8:00 P.M.), LPN #257 told her Resident #15 was acting out, threatening to fire him, and threatening to break his neck. The resident's bathroom door was closed and when she walked in, the resident was crying saying that LPN #257 had hit her. LPN #257 had followed her into the bathroom, and he stated, (Resident #15) did I hit you? she replied, You did hit me! LPN #257 didn't reply, and Resident #15 grabbed her toilet seat and then tried to attack the nurse, but she couldn't reach him, so she began kicking and screaming. STNA #143 asked LPN #257 to leave and Resident #15 began hyperventilating. The resident again stated LPN #257 had hit her forehead. There were no red marks or bruising. STNA #143 revealed she calmed the resident down and assisted her to bed. STNA #143 stated after she left the resident's room she instructed LPN #257 to report the incident to the supervisor and he began explaining to her that he was bent down helping Resident #15 put her Depend on and she began lunging at him. He stated he just put his hands on her shoulders so she wouldn't fall forward, and he had to put his hand up to block her from hitting him. LPN #257 said the resident was saying she was going to get him fired and to go retrieve STNA #143. STNA #143 stated she told LPN #257 to report the incident multiple times. STNA #143 revealed she knew to tell the nurse about incidents but stated LPN #257 was the nurse involved. She stated something told her to tell RN #240 about the incident when RN #240 came onto the unit around 11:00 P.M. She stated at that time she informed RN #240 what had happened, including the allegation of abuse and RN #240 had her and LPN #257 write witness statements. During a follow up interview with STNA #143 on 01/29/21 at 10:11 A.M., the STNA revealed LPN #257 had gone back into Resident #15's room after the incident to administer medications and that she had accompanied the LPN. She stated LPN #257 and Resident #15 didn't speak and STNA #143 was present for the interaction and acted as the mediator. STNA #143 revealed in her opinion Resident #15 would remember some things but would mix up some details and some information might be different from one day to the next. On 01/28/21 at 2:50 P.M. interview with the DON revealed she was not notified of the physical abuse allegation until this morning (01/28/21) and at that time was knowledgeable Resident #15 had verbalized LPN #257 had taken four fingers and pushed on her head four times and then closed her in the bathroom. The DON revealed an investigation into the incident began on 01/28/21 around 4:00 A.M. (which was approximately eight hours after the incident occurred) and verified as of this time she had still not yet filed an SRI with the State Agency because she thought she had 24 hours to notify and start her investigation. Review of the reporting regulatory requirements with the DON verified all abuse allegations must be initially reported within two hours. On 01/28/21 at 4:45 P.M. interview with the DON revealed LPN #257 had been suspended pending the investigation but confirmed he continued to work on 01/27/21 after the allegation of physical abuse was made at approximately 8:00 P.M. until the end of his shift which was unacceptable, as he should have been removed from the floor immediately. Review of the punch detail for LPN #257 revealed he worked on 01/27/21 from 3:05 P.M. until 11:54 P.M. Review of Resident #15's Medication Administration Record [REDACTED].M., which were documented as being administered by LPN #257: [MEDICATION NAME] 10 milligrams (mg) due at 9:00 P.M. for dementia, [MEDICATION NAME] 600 mg due at 9:00 P.M. for pain, Lac-Hydrin Five Lotion 5% apply topically to affected areas every evening shift for dry skin, [MEDICATION NAME] 3 mg due at 9:00 P.M. for [MEDICAL CONDITION], [MEDICATION NAME] Acetate one drop in the left eye due at 9:00 P.M. for corneal transplant status, [MEDICATION NAME] 20 mg due at 9:00 P.M. for [MEDICAL CONDITION], and [MEDICATION NAME] 5-325 mg due at 9:00 P.M. for pain. Review of the nurse's notes from 01/27/21 revealed at 10:29 P.M. LPN #257 documented he applied Lac-Hydrin Five Lotion 5% to the resident ' s affected areas for dry skin. On 01/28/21 at 5:31 P.M. the facility created and submitted an initial self-reported incident (SRI), tracking number 6 to the State Agency related to this incident. The SRI included an allegation of staff to resident physical abuse involving Resident #15. A brief description of the allegation/suspicion revealed resident demonstrated- nurse purring four flat fingers on her forehead that moved her head slightly and said he toileted her and shut the bathroom door. The resident identified LPN #257 as the alleged perpetrator. On 01/29/21 at 8:15 A.M. interview with RN #240 revealed she was the night supervisor on 01/27/21. She stated she had gone to Resident #15's unit later in the shift and LPN #257 and STNA #143 told her Resident #15 was being rude to the nurse, she asked the nurse leave her room and get STNA #143 for assistance. She stated the circumstances for why the resident was rude to the nurse were that Resident #15 asked LPN #257 to get her pajamas and he couldn't find her night gowns, so he needed to retrieve STNA #143. She stated she asked both staff to write statements and when she went to interview Resident #15, the resident was asleep in bed. RN #240 revealed she never read the witness statements, she put them in the DON's mailbox. During the interview, RN #240 denied either STNA #143 or LPN #257 voicing an allegation of physical abuse. RN #240 revealed on 01/28/21 at about 4:00 A.M., RN #206 and STNA #174 informed her Resident #15 was complaining of pain because LPN #257 had hit her on the head. On 01/29/21 at 8:44 A.M. interview with LPN #257 revealed he was the nurse on the floor on 01/27/21 working the 200 halls east and west. He stated Resident #15 had her call light on and he answered it, she asked him to close the blinds around 8:00 P.M. and then asked to go to the bathroom and get ready for bed. He took her to the bathroom, and she asked for a clean pull up so he gave her a clean one. She was wearing her own gown, but she didn ' t have any clean pajamas in her drawer. He explained they must be in the dirty laundry and that she could use a facility gown for the night. She became unhappy with that response and asked him to retrieve STNA #143 because she knows where the gowns are. He explained STNA #143 was busy and she continued to not listen and repeat to go get STNA #143. She began yelling, You don ' t do your job! and as he was talking to her he was assisting with putting on a clean pull up and was kneeling in front of her. The resident then tried to kick and yell and kick the bathroom wall. He backed up and she started stretching to reach him and he was worried she was going to fall off the toilet so he placed his hands on her shoulders and pushed her backwards so she wouldn ' t fall. She asked him to leave, said she would break his neck, report him, and get him fired. At that point he stated he knew her intentions. LPN #257 stated the resident told him to close the door and retrieve STNA #143 so that ' s what he did. He stated he returned with STNA #143 and Resident #15 was crying. STNA #143 tried to calm her down but she kept yelling to get him out. He stated he tried to explain he was there to help her; they didn't want her to be this way and that they didn't deserve this. The resident continued to curse and yell that she would get him fired so he left the room. He stated STNA #143 assisted the resident to bed and spent some time with her. STNA #143 notified him the resident was alleging he had hit her. He further revealed he had never asked the resident if he had hit her (per STNA #143's interview) and stated STNA #143 notifying him of the allegation was the first he had heard of it. LPN #257 further revealed he had not gone back into the resident's room that night. LPN #257 revealed sometime after 9:00 P.M., himself and STNA #143 were instructed by RN #240 to write a report about the incident and he stated at that time he had already written a behavior note. He revealed at that time, they verbalized to RN #240 the resident had made the allegations. He stated STNA #143 told RN #240 what had happened. LPN #257 stated he didn't specifically notify anyone of the allegation because he wasn't leaving the resident in the bathroom as a form of punishment, he was just doing what she had asked. A care plan, dated 02/01/21 (which was initiated on 03/28/17, resolved on 06/20/19 and reinitiated on 02/01/21) revealed the resident had a history of [REDACTED]. Interventions included to anticipate and meet the resident's needs, monitor behavior episodes, medications as ordered and redirect if she was trying to care for others. On 02/02/21 at 12:30 P.M. an additional interview with the DON revealed she again verified she was not notified of the allegation of physical abuse involving Resident #15 until 01/28/21 at approximately 4:00 A.M. She immediately came into the facility to investigate at that time. She stated she asked RN #240 if she knew Resident #15 alleged physical abuse (earlier in her shift) and RN #240 stated she just took verbal statements, collected written witness statements, and put them in the (DON ' s) mailbox. She stated RN #240 told her on 01/27/21 around 11:15 P.M., STNA #143 and LPN #257 reported to her Resident #15 was abusive toward the nurse and not that the nurse was abusive toward the resident. Review of the facility policy and procedure titled, Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property, dated 06/30/17 revealed physical abuse included, but was not limited to, hitting, slapping, pinching, and kicking and it included controlling behavior through corporal punishment. It further revealed all nursing home staff must immediately report to his/her supervisor any suspected abuse, neglect, or exploitation of a resident. The procedure further detailed if reporting was required, the DON or designee would submit the incident report electronically via use of Incident Reporting Form in accordance with applicable state requirements, and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but no later than two hours after the allegation was made if the events that cause the allegations involve abuse or result in serious bodily injury. The policy also stated if the suspected abuse implicates a staff member, the supervisor shall immediately assess and protect the resident and suspend the staff member until the investigation is complete. This deficiency substantiates Complaint Number OH 616.

Based on observation, medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of an Abuse Investigation Report Form, review of a facility Abuse and Neglect Checklist, review of the facility Abuse policy and procedure and resident and staff interviews the facility failed to ensure an allegation of physical abuse was reported immediately, but no later than two hours after the allegation was made to the Administrator and State agency as required. This resulted in Immediate Jeopardy on 01/27/21 at approximately 8:00 P.M. when Resident #15 alleged, to State tested Nursing Assistant (STNA) #143 that she had been physically abused (hit in the head) by Licensed Practical Nurse (LPN) #257 during care. STNA #143 failed to report the allegation until 01/27/21 at 11:10 P.M. On 01/27/21 at 11:10 P.M. the nursing supervisor, Registered Nurse (RN) #240 was notified of the incident, however, RN #240 also failed to immediately report the allegation to administrative staff. This affected one resident (#15) and had the potential to affect all 93 residents residing in the facility who were at risk for potential harm or injury related to incidents of staff to resident abuse. On 01/29/21 at 1:35 P.M. the Administrator, Director of Nursing (DON) and Chief Executive Officer (CEO) #141 were notified Immediate Jeopardy began on 01/27/21 at approximately 8:00 P.M. when Resident #15 reported she was physically abused by LPN #257 to STNA #143 and the STNA failed to immediately report the allegation to the nursing supervisor or administrative staff. The allegation was not reported to RN #240 until 01/27/21 at 11:10 P.M. and the DON was not notified of the allegation until 01/28/21 at 4:13 A.M. which resulted in the lack of timely reporting of the allegation/incident. The Immediate Jeopardy was removed on 01/30/21 when the facility implemented the following corrective action: · On 01/28/21 at 5:31 P.M. the DON initiated a Self-Reported Incident, Tracking Number 6 and reported to the State Agency the allegation of physical abuse lodged by Resident #15. The Medical Director was notified of the abuse allegation on 01/28/21 at 6:15 P.M. · On 01/28/21 LPN #257 was suspended pending the outcome of the facility investigation. · On 01/29/21 beginning at 1:00 P.M. education was provided to employees by the administrative team: Business Office Manager (BOM) #117, Maintenance Director #112, RN #145, Nursing Scheduler #158, Missions Director #175, Director of Information Technology #196, Admissions Director #208, Medical Records #121, Food Services Director #249, LPN #338, RN #240, Human resources Director #301, Director of Clinical Nutrition #236, Assistant DON (ADON) #165, Activities Director #116, RN #274, Director of Housekeeping #308, and the DON on the abuse policy to include immediate reporting of allegations of abuse to the nursing supervisor. The education included the accused staff member would be immediately removed from the unit and escorted out of the building by the nursing supervisor, and the DON would be notified immediately. This education was completed for all current staff on 01/29/21 at 11:00 P.M. · On 01/29/21 from 3:30 P.M. through 01/30/21 6:01 P.M. 47 current residents who were cognitively intact were interviewed asking if they felt staff were nice, if any staff had been mean or rude to them or if they had observed any staff being mean/rude to any residents. The interviews were completed by Director of Housekeeping #308, Physical Therapy Department Head #281, the DON, Director of Clinical Nutrition #236, Admissions Director #208, CEO #141, RN #145, and Admissions Assistant #148. No concerns were identified upon the interviews. · On 01/29/21 from 3:30 P.M. through 01/30/21 at 8:00 P.M. skin checks were completed by LPN #338, ADON #165, RN #274, RN #199, LPN #300, LPN #262, LPN #263, LPN #269, and RN #233 on all residents. No unexplained bruises or injuries that could be due to abuse were identified. · On 02/01/21, STNA #143 received a final written warning from the DON, describing non-satisfactory work/conduct detailing that she did not report an allegation of resident abuse to the nursing supervisor. STNA #143 signed the document. · On 01/29/21 at 6:15 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held to address the abuse policy, reporting abuse allegations and immediate removal of staff from the facility. · Beginning on 01/29/21, a plan for 10 percent (%) of all residents to be selected weekly for skin assessments, completed by the unit nursing staff initially and double checked with RN #274, weekly for four weeks and then monthly for three months to monitor for signs of physical abuse was implemented. · Beginning on 01/29/21, a plan for QAPI team members to complete interviews on 10% of interviewable residents weekly for four weeks, and monthly for three months, asking if they felt staff were nice, if any staff had been mean or rude to them, if they had observed any staff being mean/rude to any residents, and if they felt mistreated. · Beginning on 01/29/21 a plan for QAPI team members to complete random interviews of 20% of staff on each shift, weekly four weeks and then monthly for three months, on the abuse policy to include immediate reporting of any allegations of abuse and the removal of staff involved in the allegation from the facility. · Beginning on 01/29/21, the DON will review all abuse investigations to check that timely reporting occurred weekly for four weeks and then monthly for three months. · All audits will be reviewed and analyzed by the DON and the Administrator and reviewed in Quality Assurance Performance Improvement (QAPI) meetings weekly until the facility attains substantial compliance. · On 02/02/21 at 2:05 P.M. staff interviews were conducted to verify receipt and understanding of education including the abuse protocol and reporting with STNA #109, Housekeeper #130, STNA #228, Dietary Aide #243, STNA #244, Housekeeper #246, STNA #264, LPN #306, and LPN #338. All staff confirmed they received the education and were knowledgeable of the abuse protocol. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #15's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's current care plans revealed a plan, initiated 10/14/20 reflecting Resident #15 had the potential for psychosocial well being problems related to anxiety, depression, dementia, and history of paranoid thoughts that belongings were stolen, then later found. Interventions included to cue, reorient, and supervise as needed, encourage participation from the resident who depends on others to make her decisions, and allow her time to answer questions and verbalize feelings, perceptions and fears during care and as needed. Review of a plan of care, initiated 10/14/20 revealed Resident #15 had the potential for mood state problems related to anxiety and depression with interventions to administer medications as ordered, behavioral health consults as needed, and monitor for signs and symptoms of anxiety and depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/02/21 revealed Resident #15 had a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive impairment with no behaviors identified on the assessment. The MDS 3.0 assessment revealed the resident required extensive assistance from one staff for personal hygiene, toileting, dressing, bed mobility and transfers. Review of a nursing note, dated 01/27/21 at 10:15 P.M. and authored by LPN #257, revealed Resident #15 threatened to break his neck and threatened to get him fired. The note also documented the resident accused him of physically harming her. Resident #15 used abusive language and attempted to attack him in the presence of STNA #143. Review of a witness statement, completed by STNA #143 and dated 01/27/21(no time noted) revealed she watched Resident #15 attempt to attack and falsely accuse the nurse (LPN #257) of abuse. At the beginning (no time noted), the resident's call light was on and LPN #257 assisted Resident #15 to the toilet while she (STNA #143) assisted another resident. When STNA #143 was done, the nurse approached her and told her about Resident #15's threats and accusations. STNA #143's statement revealed she went to talk to the resident, the resident's bathroom door was closed, and she was crying in the bathroom. The statement revealed LPN #257 followed her into the bathroom. Resident #15 began screaming, cursing and hitting the wall. When asked what was wrong, the resident kept yelling for the nurse to leave the room with curse words and accused him of hitting her. The nurse said, How did I hit you?, the resident didn't reply but stated, Get out of my room! and began attempting to kick the nurse. STNA #143 asked LPN #257 to leave the bathroom so she could calm the resident down. Resident #15 explained to the STNA the nurse stood right in front of her and hit her on the forehead and tried to break her glasses. STNA #143 calmed the resident down and assisted her to bed. The statement revealed STNA #143 told LPN #257 to report the incident and he then explained his side of the story to her. LPN #257 explained he bent down to help the resident put her pad on and she began pushing and yelling at him. LPN #257 stated he put his hand up and she started yelling he had hit her. She then told him to get out and close the door so that's what he did. Review of a written witness statement for LPN #257, dated 01/27/21 (no time noted) revealed himself and STNA #143 were the only two staff on the floor. STNA #143 was assisting another resident so LPN #257 answered Resident #15's call light. She asked him to close the blinds and take her to the bathroom. The resident had no pajamas in her drawer, so she asked him to go get them from laundry. He explained that she could have a night gown, but that her pajamas were in laundry and he couldn't find them. Resident #15 began cursing and yelling and told him to go get STNA #143. He explained she was busy with another resident and the resident continued to yell at him to go get STNA #143. Resident #15 stated, Go get the aide. She knows where my pajama is. If she can find my pajama, I will break your neck. The resident was sitting on the toilet when all of this happened, he (LPN #257) left the bathroom and the resident began kicking the wall and yelling. LPN# 257 went to get STNA #143 and both went back to Resident #15's bathroom. Resident #15 kept cursing, trying to kick LPN #257, and threatening to get him fired. In the presence of STNA #143, he stated to the resident that she was not supposed to say that. He then left the room and left Resident #15 with STNA #143. Review of an Abuse and Neglect Checklist for Resident #15, dated 01/28/21 documented RN #240 was notified on 01/28/21 at 3:59 A.M. (approximately eight hours after the incident occurred) of the above incident with Resident #15. A head to toe assessment of Resident #15 was completed on 01/28/21 at 4:05 A.M., the DON was notified at 4:13 A.M., the resident's responsible party was notified at 4:33 A.M., and the physician was notified at 4:40 A.M. This checklist included an incident report and staff witness statements. Review of a facility Detailed Abuse Investigation Report Form, dated 01/28/21 revealed RN #240 completed the form for Resident #15 because the resident made an allegation of abuse/neglect. The form documented Resident #15 complained LPN #257 hit her on her head and left her in the bathroom with the door locked against her will. She complained of pain (rated a four out of ten) and was given an as needed narcotic [MEDICATION NAME] 5-325 mg at 3:54 A.M. Review of the investigative documentation revealed a facility incident report, dated 01/28/21 and timed as A.M. revealed Resident #15 reported that at 3:50 A.M. during the previous shift, LPN #257 hit her head and left her in the bathroom against her will. The report included an assessment of her vital signs and pain assessment. The resident rated her pain a four on a scale of zero to 10 (zero being none and 10 being worse). The resident complained of pain to the left side of her head. No redness, swelling or injuries were observed to the area. Review of a witness statement, dated 01/28/21 (no time noted) from RN #240, revealed (on 01/28/21) at about 3:59 A.M., RN #206 reported to her that Resident #15 complained of pain to the left side of her head, stating it was a result of a staff member hitting her on the head during the previous shift. She immediately went to see Resident #15 and asked her what happened. The resident stated, the nurse from the previous shift; we don't get along well ever since he came to this floor. Last night he hit me on my head and left me in the bathroom with the door closed against my will. She asked her why she didn't report it to the supervisor immediately and she stated she didn't know she had to report it. A head to toe assessment was completed, no redness or swelling noted, her vital signs were within normal limits, her pain to the left side of her head was rated at a four out of ten, and as needed [MEDICATION NAME] was administered. The DON was notified at 4:13 A.M. and the resident's representative was notified at 4:23 A.M., her voice mail box was full, so a text message was sent. The resident's emergency contact was notified at 4:33 A.M. and was informed of the incident. The physician was notified at 4:40 A.M. The resident remained calm and rested in bed. Additional review of the statement revealed a note at the bottom that documented, on 01/27/21 during shift change at about 11:15 P.M. the outgoing nurse and aide, LPN #257 and STNA #143, reported to her Resident #15 had been abusive towards LPN #257, cursing and even raising her hand to hit him. LPN #257 stated he assisted the resident to the restroom and due to some misunderstanding, Resident #15 got angry and asked him to leave her room. He retrieved STNA #143 who continued to assist Resident #15. Both staff were asked to write statements and the resident was asleep at that time. Review of a witness statement/interview with Resident #15, dated 01/28/21 at 11:00 A.M. revealed the resident had put her call light on, and the nurse (LPN #257) came in, she told him she needed to use the bathroom. He assisted her to the commode. She asked him to get her pajamas in the drawer and he stated she didn't have any and offered her a new gown. She instructed him to go to the laundry and he said the resident didn't have any pajamas in her drawer. Resident #15 instructed him to retrieve STNA #143 because she would know where they were, and he said she was busy with another resident, she repeated to go get STNA #143. He then put (and she demonstrated) four flat fingers on her forehead. She stated he did it three or four times. She yelled again to go get STNA #143 because she would know where the pajamas were, and she further told him she was going to break his neck. As he was leaving, she said, don't shut the door and he shut the door. STNA #143 came in and put her to bed. On 01/28/21 at 3:31 P.M. observation of Resident #15 revealed no redness or bruising to her head or face and the resident's eyes showed no signs of injury. An interview with the resident at the time of observation revealed on 01/27/21 at around 8:00 P.M., LPN #257 told her it was time to go to bed and she told him she had to use the bathroom first. He assisted her onto the commode, and she told him, You're so bossy, I'd like to break your neck. The resident revealed the LPN reached over and hit her three to four times across the forehead, one finger hit her left eye, and it was a force enough that she felt it. The resident stated she was on the commode and LPN #257 left her in there and shut the door. She revealed she was crying and yelling and couldn't breathe because it was so hot in there and she has asthma. The resident revealed STNA #143 found her after approximately 10 minutes. STNA #143 asked her if she was okay and the resident explained the incident to her. She revealed STNA #143 asked her not to tell anyone, but she stated she didn't want LPN #257 to hurt anyone else. Resident #15 stated she would never try to hit or hurt anyone. On 01/28/21 at 4:17 P.M. interview with STNA #143 revealed on 01/27/21 (shortly before 8:00 P.M.) two call lights were going off at the same time, and LPN #257 said he would take Resident #15's call light. About 10 minutes later (at approximately 8:00 P.M.), LPN #257 told her Resident #15 was acting out, threatening to fire him, and threatening to break his neck. The resident's bathroom door was closed and when she walked in, the resident was crying saying that LPN #257 had hit her. LPN #257 had followed her into the bathroom, and he stated, (Resident #15) did I hit you? she replied, You did hit me! LPN #257 didn't reply, and Resident #15 grabbed her toilet seat and then tried to attack the nurse, but she couldn't reach him, so she began kicking and screaming. STNA #143 asked LPN #257 to leave and Resident #15 began hyperventilating. The resident again stated LPN #257 had hit her forehead. There were no red marks or bruising. STNA #143 revealed she calmed the resident down and assisted her to bed. STNA #143 stated after she left the resident's room she instructed LPN #257 to report the incident to the supervisor and he began explaining to her that he was bent down helping Resident #15 put her Depend on and she began lunging at him. He stated he just put his hands on her shoulders so she wouldn't fall forward, and he had to put his hand up to block her from hitting him. LPN #257 said the resident was saying she was going to get him fired and to go retrieve STNA #143. STNA #143 stated she told LPN #257 to report the incident multiple times. STNA #143 revealed she knew to tell the nurse about incidents but stated LPN #257 was the nurse involved. She stated something told her to tell RN #240 about the incident when RN #240 came onto the unit around 11:00 P.M. She stated at that time she informed RN #240 what had happened, including the allegation of abuse and RN #240 had her and LPN #257 write witness statements. During a follow up interview with STNA #143 on 01/29/21 at 10:11 A.M., the STNA revealed LPN #257 had gone back into Resident #15's room after the incident to administer medications and that she had accompanied the LPN. She stated LPN #257 and Resident #15 didn't speak and STNA #143 was present for the interaction and acted as the mediator. STNA #143 revealed in her opinion Resident #15 would remember some things but would mix up some details and some information might be different from one day to the next. On 01/28/21 at 2:50 P.M. interview with the DON revealed she was not notified of the physical abuse allegation until this morning (01/28/21) and at that time was knowledgeable Resident #15 had verbalized LPN #257 had taken four fingers and pushed on her head four times and then closed her in the bathroom. The DON revealed an investigation into the incident began on 01/28/21 around 4:00 A.M. (which was approximately eight hours after the incident occurred) and verified as of this time she had still not yet filed an SRI with the State Agency because she thought she had 24 hours to notify and start her investigation. Review of the reporting regulatory requirements with the DON verified all abuse allegations must be initially reported within two hours. On 01/28/21 at 5:31 P.M. (over 21 hours after the incident occurred) the facility created and submitted an initial self-reported incident (SRI), tracking number 6 to the State Agency related to this incident. The SRI included an allegation of staff to resident physical abuse involving Resident #15. A brief description of the allegation/suspicion revealed resident demonstrated- nurse purring four flat fingers on her forehead that moved her head slightly and said he toileted her and shut the bathroom door. The resident identified LPN #257 as the alleged perpetrator. On 01/29/21 at 8:15 A.M. interview with RN #240 revealed she was the night supervisor on 01/27/21. She stated she had gone to Resident #15's unit later in the shift and LPN #257 and STNA #143 told her Resident #15 was being rude to the nurse, she asked the nurse leave her room and get STNA #143 for assistance. She stated the circumstances for why the resident was rude to the nurse were that Resident #15 asked LPN #257 to get her pajamas and he couldn't find her night gowns, so he needed to retrieve STNA #143. She stated she asked both staff to write statements and when she went to interview Resident #15, the resident was asleep in bed. RN #240 revealed she never read the witness statements, she put them in the DON's mailbox. During the interview, RN #240 denied either STNA #143 or LPN #257 voicing an allegation of physical abuse. RN #240 revealed on 01/28/21 at about 4:00 A.M., RN #206 and STNA #174 informed her Resident #15 was complaining of pain because LPN #257 had hit her on the head. On 01/29/21 at 8:44 A.M. interview with LPN #257 revealed he was the nurse on the floor on 01/27/21 working the 200 halls east and west. He stated Resident #15 had her call light on and he answered it, she asked him to close the blinds around 8:00 P.M. and then asked to go to the bathroom and get ready for bed. He took her to the bathroom, and she asked for a clean pull up so he gave her a clean one. She was wearing her own gown, but she didn't have any clean pajamas in her drawer. He explained they must be in the dirty laundry and that she could use a facility gown for the night. She became unhappy with that response and asked him to retrieve STNA #143 because she knows where the gowns are. He explained STNA #143 was busy and she continued to not listen and repeat to go get STNA #143. She began yelling, You don't do your job! and as he was talking to her he was assisting with putting on a clean pull up and was kneeling in front of her. The resident then tried to kick and yell and kick the bathroom wall. He backed up and she started stretching to reach him and he was worried she was going to fall off the toilet so he placed his hands on her shoulders and pushed her backwards so she wouldn't fall. She asked him to leave, said she would break his neck, report him, and get him fired. At that point he stated he knew her intentions. LPN #257 stated the resident told him to close the door and retrieve STNA #143 so that's what he did. He stated he returned with STNA #143 and Resident #15 was crying. STNA #143 tried to calm her down but she kept yelling to get him out. He stated he tried to explain he was there to help her; they didn't want her to be this way and that they didn't deserve this. The resident continued to curse and yell that she would get him fired so he left the room. He stated STNA #143 assisted the resident to bed and spent some time with her. STNA #143 notified him the resident was alleging he had hit her. He further revealed he had never asked the resident if he had hit her (per STNA #143's interview) and stated STNA #143 notifying him of the allegation was the first he had heard of it. LPN #257 further revealed he had not gone back into the resident's room that night. LPN #257 revealed sometime after 9:00 P.M., himself and STNA #143 were instructed by RN #240 to write a report about the incident and he stated at that time he had already written a behavior note. He revealed at that time, they verbalized to RN #240 the resident had made the allegations. He stated STNA #143 told RN #240 what had happened. LPN #257 stated he didn't specifically notify anyone of the allegation because he wasn't leaving the resident in the bathroom as a form of punishment, he was just doing what she had asked. On 02/02/21 at 12:30 P.M. an additional interview with the DON revealed she again verified she was not notified of the allegation of physical abuse involving Resident #15 until 01/28/21 at approximately 4:00 A.M. She immediately came into the facility to investigate at that time. She stated she asked RN #240 if she knew Resident #15 alleged physical abuse (earlier in her shift) and RN #240 stated she just took verbal statements, collected written witness statements, and put them in the (DON's) mailbox. She stated RN #240 told her on 01/27/21 around 11:15 P.M., STNA #143 and LPN #257 reported to her Resident #15 was abusive toward the nurse and not that the nurse was abusive toward the resident. Review of the facility policy and procedure titled, Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property, dated 06/30/17 revealed physical abuse included, but was not limited to, hitting, slapping, pinching, and kicking and it included controlling behavior through corporal punishment. It further revealed all nursing home staff must immediately report to his/her supervisor any suspected abuse, neglect, or exploitation of a resident. The procedure further detailed if reporting was required, the DON or designee would submit the incident report electronically via use of Incident Reporting Form in accordance with applicable state requirements, and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but no later than two hours after the allegation was made if the events that cause the allegations involve abuse or result in serious bodily injury. The policy also stated if the suspected abuse implicates a staff member, the supervisor shall immediately assess and protect the resident and suspend the staff member until the investigation is complete. This deficiency substantiates Complaint Number OH 616.