Every finding on record at Ohio Valley Manor Care Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dented cans were discarded, food items were dated and labeled, and kitchen staff washed their hands utilizing proper technique. These failures had the potential to affect all residents who received meals from the dietary department. Findings included:A facility policy titled, Food Storage, revised 11/2024, indicated, Policy Statement- Food shall be received and stored in a manner that complies with safe food handling practices. The section titled, Policy Interpretation and Implementation revealed, 5. Dry foods will be labeled and dated. Such foods will be rotated using first in - first out system. 6. All foods stored in the refrigerator and freezer will be covered, labeled and dated. a. Refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or date by which the food shall be consumed or discarded when held at 41 degrees F [Fahrenheit] for a maximum of 7 days. The date of preparation counted as day 1. b. Refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held over 24 hours, to indicate the date or date by which the food shall be consumed or discarded when held at 41 degrees F for a maximum of 7 days. The date of preparation shall be counted as day one and date marked may not exceed a manufacturer's use by date if the manufacture determined the use by date based on food safety. A facility policy titled, Handwashing/Hand Hygiene Policy Interpretation and Implementation, reviewed 04/28/2025, indicated, Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use a towel to turn off the faucet. A concurrent observation and interview on 08/18/2025 at 9:25 AM, revealed the Dietary Supervisor washed her hands for about eight seconds prior to entering the dry pantry. The Dietary Supervisor stated she did not know why she washed her hands in haste, she was just in a hurry, and she knew better. The Dietary Supervisor stated the expectation was to wash hands for at least 15 seconds. The Dietary Supervisor stated the risk to residents was foodborne illness. A concurrent observation and interview on 08/18/2025 at 9:27 AM revealed two 50-ounce tomato soup cans in the dry pantry area. One 50-ounce tomato soup can was dented and the other was dented and breached. The Dietary Supervisor stated the spillage from the breached can looked like mold. A concurrent observation and interview on 08/18/2025 at 9:33 AM revealed six meat patties stored in an unlabeled foam container in a refrigerator. The Dietary Supervisor stated the meat patties may have been leftovers from a meal served, the facility held leftovers for seven days, and the expectation was to count the day of opening as day one. The observation also revealed a clear plastic bag with white onion slices and a use by date of 08/20/2025, but no preparation date. A concurrent observation and interview on 08/18/2025 at 9:38 AM revealed an opened, unsealed box of frozen pizza slices; an unsealed clear plastic bag containing five pounds of garlic bread sticks that were not labeled and not dated; and egg patties that were not dated or labeled. The Dietary Supervisor stated the expectation was that all food items be sealed with open and use-by dates. A concurrent observation and interview on 08/20/2025 at 9:26 AM revealed [NAME] #17 did not wash with soap for at least 15 seconds. [NAME] #17 stated she got nervous, and she was supposed to turn on the water, use soap, scrub for 20 seconds, rinse thoroughly, grab a paper towel, dry her hands, and use the paper towel to shut off the water. [NAME] #17 stated not washing hands properly could make residents sick. A concurrent observation and interview on 08/20/2025 at 9:28 AM revealed Dietary Aide #16 washed her hands, shut off the water with her hands, and grabbed a paper towel to dry her hands. Dietary Aide #16 stated she was supposed to leave the water running and use a paper towel to shut off the water after drying her hands. Dietary Aide #16 stated she did not know why she did not use paper towels to shut off the water. She further stated not washing hands properly could make residents sick. During an interview on 08/20/2025 at 2:10 PM, the Administrator stated the expectation for food labeling and storage for the kitchen staff was that they followed regulations and that all food was stored and labeled according to regulations and guidelines. The Administrator stated all kitchen staff were responsible for the proper labeling and storage of food items. The Administrator stated it was important to label and store food items properly to ensure palatability and food safety, and, if food was not labeled and stored properly, there may be potential for foodborne illness. The Administrator stated the expectation for kitchen staff when washing hands was that they should turn the water on, use hot water, use soap, scrub for 20 seconds, rinse thoroughly, dry hands with a clean paper towel, and use a clean dry paper towel to turn off faucets. The Administrator stated she did not know why kitchen staff did not properly wash their hands during the survey, and it was important for staff to wash hands properly to avoid illness. The Administrator stated she expected dented cans to be properly disposed. The Administrator further stated that dented cans were kept in the manager's office until the damaged items could be returned to their vendor.

Based on observation, interview, record review, and facility policy review, the facility failed to follow physician's orders for supplemental oxygen administration for 1 (Resident #41) of 5 residents reviewed for oxygen use. Findings included:A facility policy titled, Policy and Procedure for the Administration of Oxygen Therapy, reviewed 11/2024, revealed, Procedure 1. Oxygen will be administered in accordance with physician's order. 2. Nurse should verify order prior to administering oxygen. An admission Record revealed the facility admitted Resident #41 on 03/27/2019. According to the admission Record, the resident had a medical history that included diagnoses of heart disease, mild intermittent asthma, and personal history of COVID-19. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2025, revealed Resident #41 had a short- and long-term memory problem and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). The MDS revealed Resident #41 received supplemental oxygen therapy while a resident of the facility. Resident #41's Care Plan Report included a problem statement, initiated 05/10/2023, that indicated the resident had a potential for altered respiratory status related to allergic rhinitis and asthma. An intervention initiated on 05/10/2023 directed staff to administer supplemental oxygen per medical doctor (MD) orders. Resident #41's Medication Review Report, dated 08/21/2025, included an order started on 06/03/2024 to administer supplemental oxygen at two liters per minute (LPM) per nasal canula (flexible tubing fitted in the nostrils), routinely every day and night shift for cough and congestion. An observation on 08/18/2025 at 12:33 PM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. An observation on 08/19/2025 at 11:13 AM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. An observation on 08/20/2025 at 8:00 AM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. During an interview on 08/18/2025 at 12:33 PM, Registered Nurse (RN) #13 reviewed Resident #41's electronic medical record (EMR) and stated the resident should be on continuous supplemental oxygen at a rate of 2 LPM. During a concurrent observation and interview on 08/20/2025 at 8:06 AM, State Tested Nurse Aide (STNA) #15 looked at Resident #41's oxygen concentrator and stated, Right now it [the oxygen concentrator] is on at 1.5 LPM. The observation revealed STNA #15 exited the resident's room and did not tell the nurse about Resident #41's oxygen flow rate. During a concurrent observation and interview on 08/20/2025 at 8:59 AM, Licensed Practical Nurse (LPN) #14 checked Resident #41's oxygen concentrator and stated the setting was below 2 LPM but above 1.5 LPM. During an interview on 08/21/2025 at 4:01 PM, the Administrator stated she expected staff to follow orders for oxygen administration.

Based on interview and record review, the facility failed to immediately notify hospice services of a significant change in a resident's physical, mental, social, or emotional status for 1 (Resident #129) of 1 resident reviewed for hospice services. Specifically, Resident #129 fell due to a seizure on 07/27/2025, and the facility did not notify hospice until 07/28/2025. Findings included: An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2025, revealed Resident #129 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. The MDS indicated the resident had a medical history that included diagnoses of non-traumatic brain dysfunction and diabetes mellitus. Resident #129 had a short- and long-term memory problem and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #129 received hospice services while a resident of the facility. Resident #129's Order Summary Report, listing active orders as of 08/21/2025, revealed an order dated 09/03/2024 to admit the resident to hospice services.Resident #129's Care Plan Report included a focus area, initiated 09/27/2024, that indicated the resident had potential for or a decline in condition and the resident received hospice services. An intervention initiated 09/27/2024 directed staff to keep family and hospice informed.During an interview on 08/21/2025 at 2:14 PM, the Hospice Case Manager stated Resident #129 was admitted to hospice services on 09/03/2024. The Hospice Case Manager stated an incident occurred on Sunday, 07/27/2025, that resulted in a shoulder injury to the resident. The Hospice Case Manager stated the facility did not notify hospice about the incident until the next day on Monday, 07/28/2025. The Hospice Case Manager stated hospice had a 24-hour phone contact, and the expectation was that the facility would have reported the incident immediately. The Hospice Case Manager stated that following this incident, she reminded Licensed Practical Nurse (LPN) #2 that hospice had a 24-hour contact number. During an interview on 08/21/2025 at 10:40 PM, LPN #19 stated Resident #129 experienced a seizure on 07/27/2025 and fell on their right shoulder, causing a shoulder injury. LPN #19 stated she was performing a medication pass, and when she noticed Resident #129 was having a seizure, she dropped what she was doing to assist the resident. LPN #19 stated she notified the physician, family, and the unit manager, but did not notify the hospice provider, because she was not aware at the time that the resident received hospice services. LPN #19 stated her main concern at that moment was to provide care to Resident #129 to stabilize the resident. LPN #19 stated she knew the hospice provider should have been notified, and she believed the unit manager notified the hospice provider the next morning.During an interview on 08/22/2025 at 10:33 AM, the Director of Nursing (DON) stated she did not think the attending nurse, LPN #19, was aware Resident #129 was admitted to hospice. The DON stated the electronic medical record (EMR) was unavailable at the time due to a change in the facility's ownership, and nursing staff were working from the resident's paper charts, which had limited documentation. The DON stated the expectation would have been to notify the hospice provider immediately after the resident was stable. The DON stated the unit manager brought it to her attention that hospice was not notified until the following day.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure hand hygiene occurred between glove changes for 1 (Resident #32) of 1 residents observed during wound care and the facility failed to store oxygen equipment appropriately when not in use for 1 (Resident #61) of 5 residents reviewed for respiratory services. Findings included: A facility policy titled, Handwashing/Hand Hygiene Policy Interpretation and Implementation, dated 04/28/2025, did not address hand hygiene between glove changes. An admission Record indicated the facility admitted Resident #32 on 05/13/2025. According to the admission Record, the resident had a medical history that included diagnoses of obesity and chronic pain syndrome. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #32 had one stage 2 pressure ulcer that was present upon admission. Resident #32's Care Plan Report included a focus area, revised 05/20/2025, that indicated the resident had impaired skin integrity. Interventions directed staff to use enhanced barrier precautions related to wounds and to monitor for signs and symptoms of infection. On 08/19/2025 at 2:26 PM, observations of wound care for Resident #32 revealed that Licensed Practical Nurse (LPN) #2 entered the resident's room with gloves on then put another pair of gloves over top of the first pair. The observation revealed LPN #2 cleansed Resident #32's wound with normal saline, patted the wound dry, and applied a skin-protectant and packing material to the wound. The observation revealed that when LPN #2 removed her gloves both pairs of gloves came off. The observation revealed LPN #2 got another pair of gloves and put them on without doing hand hygiene. The observation revealed after applying a dressing to the wound, LPN #2 removed her gloves again and put on new gloves without doing hand hygiene. The observation revealed LPN #2 removed all the supplies, threw the supplies away with her gloves on, and then washed her hands. During an interview on 08/19/2025 at 2:40 PM, LPN #2 stated she used hand sanitizer before she entered the room, and she put on two pairs of gloves. LPN #2 stated when both pairs of gloves came off, she did not do hand hygiene prior to putting on more gloves, but she should have. LPN #2 stated she should have done hand hygiene between each glove change. During an interview on 08/22/2025 at 10:34 AM, the Director of Nursing (DON) stated hand hygiene should occur after staff touched a dirty area, and staff should take off their gloves, perform hand hygiene, and then put on new gloves. The DON stated gloves should be changed anytime they were soiled and hand hygiene should occur in between all glove changes. During an interview on 08/22/2025 at 11:12 AM, the Administrator stated hand hygiene should be done in between glove changes for infection control reasons

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #150) of three reviewed for medication errors. The facility census was 130 residents. Findings include Review of the medical record for Resident #150 revealed an admission date of 04/09/25 with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks. Review of the care plan for Resident #150 initiated on 04/09/25 revealed the resident had a potential for cardiac complications related to atrial fibrillation with interventions including to administer medications per orders. Review of the Minimum Data Set (MDS) assessment for Resident #50 dated 04/15/25 revealed the resident had minimal cognitive impairment and required supervision and assistance from staff with activities of daily living (ADLs) Review of the physician's orders for Resident #150 revealed as order dated 04/24/25 per the resident's primary care provider for Diltiazem 180 milligrams (mg) one tablet by mouth every day. Review of physician's orders for Resident #150 transcribed by facility staff on 04/24/25 revealed an order for Dilantin 180 mg one tablet by mouth every day. Review of the Medication Administration Record (MAR) for Resident #150 dated 04/25/25 revealed the resident received Dilantin 180 mg one tablet by mouth on 04/25/25 Review of the Medication Error Form for Resident #150 revealed the resident received Dilantin instead of Diltiazem due to an error in transcription by the facility staff. Interview on 06/13/25 at 1:00 P.M. with the Director of Nursing (DON) confirmed there was a medication error involving Resident #150 which occurred on 04/25/25. Resident #150 was supposed to received Diltiazem 180 mg but instead got Dilantin 180 mg due to a transcription error. The facility provided education to Licensed Practical Nurse (LPN) #840, the nurse involved with the error for Resident #150, regarding the importance of properly transcribing medications following any changes by the physician. Review of the facility policy titled Administering Medications Policy revised 2022 revealed medications were to be administered in a safe and timely manner and as prescribed. This deficiency represents noncompliance investigated under Complaint Number OH00165207.

Based on record reviews, interviews, review of facility Self Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure a SRI was filed with the State Agency following an allegation of sexual abuse. This affected one resident (#83) out of the three residents reviewed for abuse. The facility census was 136. Findings include: Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included bipolar disorder, anxiety disorder, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/29/15, revealed the resident was assessed by staff to have a long term memory problem. Review of the physicians order, dated 12/30/24, revealed the resident was to be referred to a gynecologist related to vaginal bleeding. Review of the gynecologist visit note, dated 01/28/25, revealed resident in with acute bleeding for one month duration status post complete hysterectomy and Computed Tomography (CT) scan showed no uterus. emergency room (ER) reported on 01/16/25 speculum was full of blood and cleaned once, filled up with blood again. Patient has dementia and reported being sexually active with husband and bleeding started after sex. Physical exam revealed no blood in vagina, intact cuff, urethral meatus normal, external genitalia normal. Assessment/plan- no active vaginal bleeding, concern for prior vaginal laceration based on ER report from 01/16/25. Laceration likely has healed, vaginal cuff intact. The potential of an acute vaginal laceration raises concern for potential sexual assault. Unable to fully assess patient due to mobility issues. Visualization was poor but confident no longer actively bleeding from the vagina. Unable to visualize if possible prior laceration. Review of the SRI's filed by the facility revealed no SRI was filed with the State Agency related to the potential sexual assault alleged by the physician at the gynecologist office. Interview with the Administrator on 02/24/25 at 2:45 P.M. confirmed there had not been an SRI filed with the State Agency following the documented allegation of sexual assault from the gynecologist office. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, implemented on 09/15/21, revealed if the event that caused the allegation involves abuse or serious bodily injury, it should be reported to the State Agency immediately, but no later than two hours after the allegation was made. This deficiency represents non-compliance investigated under Complaint Number OH00162528.

Based on medical record review, review of the facility investigation, staff interview, and review of the facility handbook, the facility failed to ensure the resident environment was free of potentially hazardous substances/prescription medications. This affected one (Resident #130) of three residents reviewed for accidents and accident hazards. The facility census was 130. Findings include: Review of the medical record for Resident #130 revealed an admitted [DATE] with diagnoses including frontotemporal neurocognitive disorder, diabetes mellitus type two, rhabdomyolysis, dementia, anxiety, dehydration, falls, hematuria, and polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #130 dated 04/15/24 revealed the resident had severely impaired cognition. Review of the progress note for Resident #130 dated 05/24/24 timed at 10:35 A.M. revealed the resident was sent to the hospital for evaluation and possible treatment for ingestion of medications not prescribed for the resident. Review of facility investigation revealed on 05/02/24 staff found Resident #130 in his room with two medications that belonged to State tested Nursing Assistant (STNA) #30 in the resident's possession. The resident had found medication bottles containing Wellbutrin (an antidepressant) and Adderall ER (a stimulant medication and a controlled substance) in STNA #30's purse which had been left unattended in the resident dining room. Resident #130 had the bottles of Wellbutrin and Adderall in his possession with one bottle opened and the other remaining closed. Interview with STNA #30 confirmed she could not recall or verify how many individual medications were in either bottle, or how many were taken. STNA #30 further confirmed she had left her purse on the table in the resident dining room while she took her lunch break. A visiting family member had informed staff that Resident #130 was looking through the purse when no staff was around. Two staff members went searching for the resident and found him in his room with both medicine bottles. Review of facility transfer report revealed Resident #130 was sent to the hospital on 05/02/24 after possible ingestion of two medications that were not prescribed to him. Review of hospital records for Resident #130 dated 05/02/24 revealed the hospital conducted blood tests to determine if the resident had ingested Wellbutrin or Adderall and determined the resident's blood was negative for both substances. The resident returned to the facility with no new orders. Interview on 05/24/24 at 11:00 A.M. with the Director of Nursing (DON) and Administrator confirmed STNA #30 acknowledged she did not properly secure her personal belongings on 05/02/24 when she left her purse containing bottles of Wellbutrin and Adderall unattended in the resident dining area. Further interview confirmed Resident #130 was found in his room with STNA #30's purse and the bottles of Wellbutrin and Adderall in his possession with one pill bottle open. Interview on 05/24/24 at 12:15 P.M with Registered Nurse (RN) #10 confirmed she responded to the room of Resident #130 on 05/02/24 when staff reported the resident had taken two bottles of medication from a staff members' personal belongings. Review of the employee handbook undated under the section titled Personal Property on page 25 revealed all employees were responsible for securing/storing their own personal property. This deficiency represents noncompliance investigated under Complaint Number OH00153629.

Based on observations, medical record review, staff interviews, review of the facility's quality assurance investigation, review of hospital documentation and reports, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of a resident, without staff knowledge, who was cognitively impaired and assessed as being at risk for elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #136 eloped from the facility and the resident was found by a staff family member 600 feet away from the facility near a highway that had a 55 Miles Per Hour (MPH) speed limit. This affected one (Resident #136) of three residents reviewed of a total of seven identified by the facility as being at risk for elopement. The facility census was 134. On [DATE] at 1:47 P.M., the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) #610, and Clinical Operations Director #333 were notified Immediate Jeopardy began on [DATE] at 8:20 P.M., when Resident #136 was not provided adequate supervision and eloped from the facility. Resident #136 was assessed as being at risk for wandering and elopement. Resident #136 had a history of dementia and behaviors including exit seeking. On [DATE] around 7:20 P.M., the facility staff were unable to locate Resident #136 after completing a head count of all residents on the secured memory care unit. The resident was located approximately 600 feet from the facility after completing a search of the grounds and the surrounding area at 8:23 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:20 P.M., State tested Nursing Assistant (STNA) #111 last saw Resident #136 on Willow Hall unit. On [DATE] at 7:40 P.M., STNA #111 stated he was unable to locate Resident #136. On [DATE] at 7:40 P.M., Registered Nurse (RN) #399 was notified and implemented the Wandering/Missing Policy. On [DATE] from 7:42 P.M. to 7:50 P.M., Staff Notifications were made to the Administrator by RN #399, and notification to the DON, Maintenance Director #900, and Staffing Coordinator #140 were made by Administrator. On [DATE] from 7:40 P.M. to 8:04 P.M., staff searched inside and outside the building and surrounding locations by all available staff, from all departments. Minimal staff were left on each unit to manage care needs. On [DATE] at 8:00 P.M., all other residents were verified to be in the facility by RN #399, LPN #501, LPN #222, and LPN #849. On [DATE] at 8:04 P.M., police notifications were made by the Administrator. On [DATE] from 8:04 P.M. to 8:20 P.M., the search for Resident #136 was ongoing. On [DATE] at 8:23 P.M., Resident #136 was found by the husband of Staff Coordinator #140. On [DATE] from 8:23 P.M. to 9:03 P.M., Resident #136 was initially assessed, returned to the facility, and more fully assessed by Licensed Practical Nurse (LPN) #250, the DON and ADON #610. On [DATE] at 8:40 P.M., Doors on Willow Hall were checked and found to be operational by Maintenance Director #900. The gate was checked on the secure courtyard and was found to be operational; however, could be opened if it was pushed with enough force. On [DATE] at 8:40 P.M., Willow Hall door audits began and will continue daily for one week, and then weekly for four weeks. These audits will be completed by Maintenance Director #900 or his designee. Results will be provided to the Quality Assurance Team for review. On [DATE] at 9:03 P.M., Physician #89 was contacted and communicated status of events and assessments for Resident #136 by the DON, and an order was received to send the resident to the emergency room (ER) for evaluation and treatment. On [DATE] at 9:05 P.M., [NAME] Life Squad was contacted by LPN #250. The squad arrived at approximately 9:09 P.M. and assumed responsibility of Resident #136. On [DATE] at 9:15 P.M., in-servicing of staff was started for Review of Wandering/Missing Resident Policy by the Administrator and was completed by all staff on [DATE]. On [DATE], the power supply to the exterior courtyard gate was replaced. On [DATE], audits for residents deemed at high risk for elopement were completed and care plans reviewed per the DON and/or designee. This included seven residents (#17, #64, #66, #94, #107, #111, and #132) identified at high risk. No new concerns were identified. On [DATE] at approximately 11:00 A.M., the facility placed a staff monitor at the end of Willow Hall and will continue around the clock until the new door system is installed. On [DATE] and completed on [DATE], staff were interviewed to determine if there are any exit seeking behaviors for residents who are identified at high risk to elope. The interviews will be for each shift for one week and then once daily for an additional week. Once completed, the results will be reviewed by the Quality Assurance Team. On [DATE] at 11:50 A.M., interviews with STNA #776, LPN #779, and RN #777 revealed they have all been reeducated on the Elopement Policy and the residents who are at risk for elopement. On [DATE] at 12:45 P.M., observation of the facility revealed an outside contractor is providing maintenance to the outside door on the secured unit. STNA #776 is seated six feet from the door and monitoring. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Medical record review revealed Resident #136 was admitted to the facility on [DATE] with diagnoses including hypertension, falls, dementia, and unspecified psychosis with delusions. Further Review of Resident #136's record revealed she was discharged to the hospital on [DATE]. Review of Resident #136's elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility, the resident was confused to time and place and resident wandered, roamed and paced. The resident was also assessed to be a high risk for elopement. Review of Resident #136's admission nursing observation, dated [DATE], revealed Resident #136 was alert and oriented to person. Resident #136 was noted to be verbally incomprehensible and required limited assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and walking in room and locomotion on the unit. Resident #136 also required supervision with eating. Review of Resident #136's physician order dated [DATE] revealed Resident #136 was to have a Roam Alert bracelet in place and to check placement and function daily, every shift. Review of Resident #136's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and required limited assistance with bed mobility, transfers, eating, locomotion on and off the unit and walking in the room and in the corridor. Resident #136 also required limited assistance with dressing, toileting and personal hygiene and was reported to wander during the [DATE] MDS. Review of Resident #136's elopement care plan dated [DATE] revealed Resident #136 was at risk for elopement and wandering due to dementia. Interventions included Roam Alert bracelet, identifying patterns of wandering, provide structured activities, monitor for fatigue and weight loss, and distract resident from wandering with diversions. Review of Resident #136's cognition care plan dated [DATE] revealed Resident #136 was at risk for alterations in thought process due to dementia. Interventions included activities staff will provide resident with a calendar of events and invite the resident to attend those of interest, administer medications as ordered, allow ample time for resident to complete tasks, allow the resident the opportunity to make choices regarding daily routine, allow resident to complete as much personal hygiene and oral care as possible and always explain the activity being performed with a gentle voice. Review of Resident #136's progress note dated [DATE] at 5:10 P.M. revealed the facility received reports from Resident #136's hospice provider that the resident has a tendency to wander. A Roam Alert bracelet was placed. Review of Resident #136's progress note dated [DATE] at 5:12 A.M. revealed Resident #136 was found by staff to be wandering but was redirected back to her room with a snack. Review of Resident #136's progress note dated [DATE] at 3:24 A.M. revealed Resident #136 had wandered off the unit after being up wandering most of the night. Review of Resident #136's Social Services note dated [DATE] at 2:05 P.M. revealed Resident #136 has an extensive history of wandering prior to residing in the facility. The notes documented a discussion with the spouse of Resident #136 resulted in a decision to move the resident to a secured and locked unit with a room change due to recent wandering episodes. Review of Resident #136's progress note dated [DATE] at 8:23 P.M. revealed Resident #136 was located outside of the facility grounds after she had left the facility unaccompanied by staff. The resident was found by the husband of Staffing Coordinator #140, after a search of the area was initiated. The resident was located lying on the ground with a hematoma to the left side of her forehead. The resident was sent to the hospital for evaluation with transport arriving at 9:20 P.M. Review of Resident #136's hospital records revealed an admitted to the hospital on [DATE] to the emergency department trauma center. Hospital notes documented Resident #136 was admitted with diagnoses including parenchymal hematoma/contusion of the right inferior frontal lobe, a subarachnoid hemorrhage of the right frontal lobe, a left frontotemporal scalp hematoma, fractures of the posterior left 8th rib and non-displaced anterior ,d+[DATE] rib fractures, as well as left lateral ,d+[DATE] rib fractures. The resident also was diagnosed with a fracture of the left para symphyseal pubis and left inferior pubic ramus. Review of the Quality Assurance Note dated [DATE] revealed Resident #136 was last seen on her unit at approximately 7:20 P.M. A search of the unit was completed with RN #399 being notified. Staff implemented the Missing/Wandering Resident Policy at 8:40 P.M. The Administrator and Director of Nursing were notified. A search of the grounds and surrounding areas began, with Police being notified at 8:04 P.M. to assist in the search. At 8:20 P.M., Resident #136 was found on a gravel driveway of a neighbor adjacent to the facility. The note documented the facility suspects the resident eloped from the exit door at the end of the secured hallway by pushing the door open to the courtyard. The resident was able to exit the gated courtyard by pushing through a magnetic lock on the courtyard gate. The resident was assessed to have a hematoma to the left side of her forehead upon discovery. The resident was returned to the facility at approximately 8:40 P.M. by facility transport. Interview with the Director of Nursing on [DATE] at 9:30 A.M. revealed Resident #136 eloped from the facility on [DATE]. She stated she suspects the resident had walked out of the door to the outside courtyard and proceeded to leave the gated courtyard through a magnetically locked gate. She stated the resident then looped around the front of the building and driveway until she ended up in the driveway of a nearby, adjacent home. No outdoor cameras captured the resident eloping through the main front door as that is where the camera is located. She stated the resident was found by the husband of Staffing Coordinator #140, and nursing was notified. LPN #250 then assessed the resident to have a hematoma to her left forehead, and no other complaints of pain. She stated that after the resident was returned to the facility, staff were helping the resident clean up, when Resident #136 began complaining of hip pain at that time. She stated all notifications were made, and the resident was sent to the hospital at approximately 9:20 P.M. for evaluation. Interview with Maintenance Director #900 on [DATE] at 9:30 A.M. revealed the resident had more than likely eloped through the courtyard door on [DATE]. He stated he had checked function of the door and it was functioning properly that evening. He stated he also checked the function of the magnetic lock on the courtyard gate, which was found with a weak charge, which allowed for the gate to be pushed open easily. He stated a new door was ordered and scheduled to be installed the morning of [DATE]. He also stated he had adjusted the charge on the magnetic lock which is now functioning at full strength as of [DATE]. Interview with RN #399 on [DATE] at 9:30 A.M. revealed she was alerted to a possible elopement of Resident #136 on [DATE]. She stated the resident was an elopement risk and she alerted the Administrator and Director of Nursing at approximately 7:40 P.M. that evening. Interview on [DATE] at 10:29 A.M. with STNA #111 revealed he was working on the secured unit on [DATE]. He stated he last saw Resident #136 around 7:10 P.M. when she was in the resident lounge area. He stated he then went to assist another resident into her wheelchair and provide care. He stated at 7:20 P.M., another STNA arrived on the unit from her lunch break, and they completed a head count of all residents on the secured unit as he was leaving for his lunch break. He stated Resident #136 could not be located as the head count was one short. He stated no alarms were sounding that he could recall, and the exit door to the courtyard was closed. He then stated he notified RN #399 they could not locate Resident #136, and the Missing/Elopement Policy was enacted at 8:40 P.M. He stated he was not aware Resident #136 was at risk for elopement. Telephone Interview with the daughter of Resident #136 on [DATE] at 11:30 A.M. revealed the resident expired in the hospital on [DATE] with multiple brain bleeds, pelvic fractures, and rib fractures. She stated the death is being reported as an accidental death as a result of a fall. Observation of the facility on [DATE] at 1:15 P.M. revealed the exterior door on the secured unit opened freely to the courtyard with an alarm sounding through the hall. The alarm was located in the middle of the hall, with the shut off switch approximately two feet from the ceiling and must be manually switched off. The courtyard gate could not be opened due to the magnetic lock on the gate during this observation. STNA #776 is currently seated by the door to monitor for any resident who may try to elope. Review of an undated list of residents with Wander Guards revealed Residents #17, #64, #66, #94, #107, #111 and #132 had Wander Guards in place as these residents remain at risk for elopement. Review of the facility's wandering and elopement policy dated [DATE] revealed staff shall promptly report any resident who leaves or attempts to leave to the Charge Nurse or Director of Nursing. In the event an employee discovers a resident is missing from the facility, they should determine whether the resident is on a leave or pass; an immediate search of the facility if not authorized to leave; if the resident is not located in the facility, all parties will be notified including Administrator, DON, physician, law enforcement, and volunteer agencies as necessary; provide search teams with identification information and initiate an extensive search of the surrounding area. This deficiency represents noncompliance for Complaint Numbers OH00140058 and OH00140048.

Based on record review, observation and interview, the facility failed to prepare and serve the puree diet as planned by a Registered Dietitian for Residents #40, #28, # 22, #75, #68, #23, #2, and #20. The facility census was 134. Findings Include: Record review for Resident # 40 revealed admitted [DATE], medical diagnosis of Alzheimer's disease and No Added Salt puree diet order. Record review for Resident #28 revealed admitted [DATE], medical diagnosis of dementia with behavioral disturbance and Regular puree diet order. Record review for Resident # 22 revealed admitted [DATE], medical diagnosis of Alzheimer's Disease and Regular, puree, nectar consistency diet order. Record review for Resident # 75 revealed admitted [DATE], medical diagnosis of [CONDITION(S)] and No Added Salt, No Concentrated Carbohydrate and puree consistency diet order. Record review for Resident #68 revealed admitted [DATE], medical diagnosis of unspecified convulsions and No Added Salt puree diet order. Record review for Resident #23 revealed admitted [DATE], medical diagnosis of Alzheimer's Disease and Regular, nectar consistency, puree diet order. Record review for Resident #2 revealed admitted [DATE], medical diagnosis of dementia with behavioral disturbance and No Concentrated Sweets, honey consistency and puree diet order. Record review for Resident #20 revealed admitted [DATE], medical diagnosis of chronic [CONDITION(S)] and No Added Salt, No Concentrated Sugar, nectar consistency and puree diet order. Review of lunch menu spreadsheet dated 08/31/22 revealed the puree diet was to consist of six ounces of puree lasagna with two ounces sauce, a number eight scoop serving size of puree green beans and a number 12 serving size of puree roll. Observation on 8/31/22 at 9:35 A.M. revealed Cook #260 pureed the roll/bread with the green beans in the blender. There was no separate serving of roll/bread. Interview on 08/31/22 at 9:40 A.M., Cook #260 verified she had pureed the green beans with the bread. She stated she purees the vegetable with the bread because it dries out on the steam table during serving time. Interview on 08/31/22 at 11:35 the Registered Dietitian, (RD) #90 verified the puree roll/bread should have been pureed separately and served separately from the green beans. Review of the Puree Recipe Guidelines, undated, revealed directions to follow the spreadsheet when preparing puree foods.

Based on observation and interview, the facility failed to store foods, discard expired foods and monitor refrigerator temperatures. This had the potential to affect 133 residents who received food from the kitchen. The facility census was 134. Findings include: Observation on [DATE] at 10:05 A.M. revealed following sanitation violations in the main kitchen: 1. Open container of syrup dated [DATE] with no open or use by date in the dry storage area. 2. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date 3. Three reach-in refrigerators temperature monitoring logs not completed of random dates totaling 85 missing temperature entries. Observation on [DATE] at 10:30 A.M. revealed following sanitation violations in Parkview satellite kitchen: 1. In the reach in refrigerator, three containers of liquid, identified as juice, with no label or date. 2. One reach in refrigerator temperature monitoring log not completed of random dates totaling 54 missing temperature entries. Observation on [DATE] at 10:40 A.M. revealed following sanitation violations in the Birch satellite kitchen: 1. One reach in refrigerator temperature monitoring log not completed of random dates totaling 48 missing temperature entries. 2. In the dry storage area, an open loaf of bread with no open or use by date. 3. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date. 4. Opened, unlabeled bag of darkened, browned green vegetable, identified as lettuce, with no open or use by date. Interview on [DATE] at 10:40 Diet Manager Assistant, #98 verified the foods should have been labeled and dated, including the containers of juices, the lettuce and bread loaf. The refrigerator temperature monitoring logs should have been completed. She verified the skilled facility residents receive foods from the main kitchen, Parkview satellite and Birch satellite kitchens. Review of the facility policy, Food Storage, dated [DATE], revealed dry food will be labeled and dated. All foods stored in the refrigerator will be covered, labeled, and dated. Refrigerated food will indicate the date the food shall be consumed or discarded for a maximum of seven days. Functioning of the refrigeration will be monitored at designated intervals throughout the day.

Based on record review and staff interviews, the facility failed to ensure a resident's mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected two (#44, #96) of four residents reviewed for PASARR. The facility census was 134. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44 quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfer, dressing and toileting. Review of Resident # 44's PASARR dated 08/31/20 revealed Resident #44 did not have any mental health diagnoses. Review of Resident #44's face sheet dated 09/02/20 revealed Resident #44 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Social Worker (SW) # 204 on 09/01/22 at 10:11 A.M. verified Resident #44's mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SW #204 noted another PASSAR was not completed to reflect these changes. 2. Review of the medical record for Resident #96 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE] revealed Resident #96 had severe cognitive impairment with delusions, and physical and verbal behaviors directed towards others. The MDS indicated Resident #96 was not considered by state level II PASRR process to have a serious mental illness or related condition. Review of the PASRR dated 10/11/19 indicated Resident #96 had no indications of serious mental illness. An interview on 09/01/22 at 10:08 A.M. with Social Services #204 and #216 confirmed the PASRR for Resident #96 was not updated with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review the facility failed to ensure Resident #96 received appropriate nail care. This affected one of four residents reviewed for activities of daily living. The facility census was 134. Findings include: Review of the medical record for Resident #96 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #96 had severe cognitive impairment with delusions, physical and verbal behaviors directed towards others. Resident #96 required extensive assistance of two persons for personal hygiene and was totally dependent on two persons for bathing. Review of the plan of care revealed Resident #96 needed staff assistance to complete activities of daily living. Review of the shower sheets for Resident #96 from 07/04/22 through 08/29/22 revealed the nurses signature ensured the resident had been provided nail care with the shower. Observations on 08/30/22 at 9:33 A.M. and at 3:22 P.M. and on 08/31/22 at 9:55 A.M. revealed Resident #96 to have long, jagged fingernails with a brown and black substance underneath the fingernails. An interview on 08/31/22 at 10:05 A.M. with State tested Nursing Assistant (STNA) #8 confirmed Resident #96 fingernails were long and jagged with a brown and black substance underneath the fingernails. STNA #8 stated nail care would be provided with showers and as needed.

Based on staff interview, record review, and review of the facility discharge policy, the facility failed to provide notice of discharge in writing to a resident and/or legal guardian. This affected one (Resident #151) of three residents reviewed for discharges. The facility census was 132. Findings include: Review of the medical record for Resident #151 revealed he was admitted to the facility on [DATE] and discharged to the hospital on 06/09/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/22, revealed Resident #151 had impaired cognition. Review of the progress notes, dated 06/09/22 revealed Resident #151 was discharged to the hospital on 06/09/22. The reason for discharge was yelling, bleeding from the rectum, combative, and not eating or drinking. Review of Resident #151's medical record from 03/18/22 to 06/09/22 revealed there was no discharge notice provided to Resident #151 and/or Resident #151's legal guardian. There was no form the facility utilized titled Emergency Transfer to the Hospital Notice in Resident #151's medical record. Interview on 06/28/22 at 3:14 P.M. with the Director of Nursing (DON) revealed the facility will notify the resident or family member of discharge and will complete the facility's form titled Emergency Transfer to the Hospital Notice, at the time of discharge. However, the DON verified she was unable to find the one that should have been given to Resident #151 on the date of discharge to the hospital on 06/09/22. Review of the facility's form titled Emergency Transfer to the Hospital Notice, dated 09/09/20, revealed the form list the date, the resident name, how it was delivered, and transfer to location. The form details information on how to appeal and hearing of discharge. Review of the facility's policy titled Facility Initiated Discharge and Discharge Notification Policy, dated 09/02/21, revealed the resident or resident representative will be notified in writing of the reason for discharge. The facility will provide a resident and/or the resident's representative (Sponsor) with a (30)-day written notice of an impending facility-initiated discharge except in specific circumstances. This deficiency substantiates Master Complaint Number OH 454.

Based on staff interview, record review, and review of the facility's discharge policy, the facility failed to permit a resident to return to the facility following a hospital stay. This affected one (Resident #151) of three residents reviewed for discharges. The facility census was 132. Findings include: Review of the medical record for Resident #151 revealed he was admitted to the facility on [DATE] and discharged to the hospital on 06/09/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/22, revealed Resident #151 had impaired cognition. Resident #151 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the progress notes, dated 06/09/22 revealed Resident #151 was discharged to the hospital on 06/09/22. The reason for discharge was yelling, bleeding from the rectum, combative, and not eating or drinking. Review of Resident #151's medical record from 03/18/22 to 06/09/22 revealed there was no discharge notice provided to the resident and/or legal guardian. There was no form the facility's utilized titled Emergency Transfer to the Hospital Notice in Resident #151's medical record. Interview on 06/28/22 at 3:14 P.M. with the Director of Nursing (DON) revealed the facility will notify the resident or family member of discharge and will complete the facility's form titled Emergency Transfer to the Hospital Notice, at the time of discharge. However, the DON verified she was unable to find the one that should have been given to Resident #151 on the date of discharge to the hospital on 06/09/22. Interview on 06/28/22 at 2:43 P.M. with the Administrator confirmed the facility refused to allow Resident #151 to return from the hospital on 06/10/22 when the hospital called and inquired if Resident #151 could return. The Administrator stated Resident #151 had applied for Medicaid, however he owed a bill of $15,000 to the facility and she wanted some type of payment toward the bill. The Administrator stated the hospital was wanting to discharge Resident at 4:00 P.M. on 06/10/22 on a Friday and asked the hospital to allow the facility to revisit the option of Resident #151 returning the following week. The Administrator stated she was hoping the family would provide payment or the facility could obtain a status of the Medicaid pending case prior to return to the facility. Review of the facility's form titled Emergency Transfer to the Hospital Notice, dated 09/09/20, revealed the form list the date, the resident name, how it was delivered, and transfer to location. The form details information on how to appeal and hearing of discharge. Review of the facility's policy titled Facility Initiated Discharge and Discharge Notification Policy, dated 09/02/21, revealed the resident or resident representative will be notified in writing of the reason for discharge. The facility will provide a resident and/or the resident's representative (Sponsor) with a (30)-day written notice of an impending facility-initiated discharge except in specific circumstances. This deficiency substantiates Master Complaint Number OH 454.

Based on record review, staff interview, and facility policy review, the facility failed to obtain laboratory testing as ordered by a physician. This affected one (Resident #152) of three residents reviewed for laboratory testing. The facility census was 132. Findings include: Review of the medical record for Resident #152 revealed an admitted [DATE] and was discharged to the hospital on 06/03/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 05/29/22, revealed Resident #152 had intact cognition. Review of Resident #152's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no results of the c-diff culture in Resident #152's medical record from 05/23/22 to 06/03/22. Review of the nursing progress notes revealed Resident #152 was discharged to the hospital on 06/03/22 due to having complaints of pain in the abdomen and increased abdominal pain with any intake. Interview on 06/30/22 at 9:34 A.M. with Nurse Practitioner (NP) #500 stated Resident #152 was seen by the physician on 05/23/22 and the physician ordered a fecal lab. On 05/25/22, NP #500 received blood work back on Resident #152 (however not the fecal lab test results) and met with her to review and ordered fecal occult times three days. NP #500 confirmed she never received the results or was able to confirm the testing was completed to rule out C-Diff. Interview on 06/30/22 at 4:26 P.M. with the Administrator confirmed Resident #152's fecal sample on 05/24/22 was not picked up by the lab. The facility identified this oversight on 05/28/22. Another fecal sample was obtained and picked up on 05/28/22 for Resident #152, however, there were no results available. NP #500 ordered [MEDICATION(S)] (antibiotic) as a precaution given the abdominal pain may be related to diverticulitis. On 06/30/22 at 4:57 P.M., an interview with the Administrator at 4:57 P.M. confirmed the facility has never received any results from either fecal sample ordered for Resident #152. Review of the facility's policy titled Laboratory Test Results, dated 01/2022, revealed the facility will provide or arrange for diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. This deficiency substantiates Complaint Number OH 251.

Based on medical record review, resident and staff interview, the facility failed to notify the a resident of a change in medications. This affected one resident (#85) of one reviewed for care planning. The facility census was 135. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) assessment completed on 10/10/19 revealed Resident #85 was cognitively intact. Review of physician orders [REDACTED].#85 revealed the resident had a change from Ensure nutritional supplement to Glucerna nutritional supplement, before meals and at bedtime. The resident also had a change in Calcium [MEDICATION NAME] 950 milligrams (mg) every morning, from Calcium [MEDICATION NAME] 975 mg every morning. There was no documentation the resident was notified of the change. Interview with Resident #85 on 12/03/19 at 10:16 [NAME]M. revealed he was not notified of the medication changes. care. Interview with the Director of Nursing (DON) on 12/05/19 at 1:44 P.M. verified there was no notification to Resident #85 of the changes in medication and the supplement.

Based on observation, staff interview, facility policy review, and review of manufacture's guidelines, the facility failed to date open vials of medications. This had potential to affect one Resident (#231) identified by facility as a new admission. The facility further failed to remove expired medications out of active medication use, this had the potential to affect one Resident (#67) for who it was prescribed for. The facility census 135. Findings include: 1. Observation on 12/03/19 at 4:43 P.M. with Licensed Practical Nurse (LPN) #100 of the medication room on Unit One revealed there was an opened vial of [MEDICATION NAME] Protein Derivative Diluted [MEDICATION NAME] (TB) with no date when it was opened. Interview on 12/03/19 at 4:45 P.M. with LPN #100 verified the vial of [MEDICATION NAME] Protein Derivative Diluted [MEDICATION NAME] was opened and not dated. Review of the manufacturers recommendations for storage for [MEDICATION NAME] Protein Derivative Diluted [MEDICATION NAME], revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 2. Observation on 12/03/19 at 5:24 P.M. with the Director of Nursing (DON) of the Maple Unit medication room revealed a bottle of [MEDICATION NAME] (anti-anxiety) Oral Concentrate two milligrams (mg) per milliliter (ml) was opened with the only dose given date 07/26/19. The medication had a 90-day shelf life after opened. Review of the Controlled Drug Record for Resident #67 revealed the only dose of [MEDICATION NAME] Oral Concentrate 2 mg/ml was given on 07/26/19. Interview on 12/03/19 at 5:26 P.M. with the DON verified the [MEDICATION NAME] Oral Concentrate 2 mg/ml was opened with the only dose given on 07/26/19. Review of the [MEDICATION NAME] Oral Concentrate 2 mg/ml manufacturing guidelines revealed to discard opened bottle after 90 days. Review of the facility policy titled, Storage of Medications, dated 11/27/19 revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed, some drugs have a shelf life that is different than the expiration date after opening. These drugs shall be labeled with the date opened to ensure that no outdated or deteriorated drugs are stored.

Based on observation, staff interview, and record review, the facility failed to ensure a fall intervention was in place for one (#5) of five residents reviewed for falls. The facility census was 138. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with a re-entry dated of 04/03/16. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/11/18, revealed intact cognitive skills for daily decision making. Extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and limited assistance was required with eating. Review of care plan initiated 02/23/15 revealed Resident #5 was at risk for falls related to weakness. Interventions included a skid rug at bedside. Observation on 10/31/18 at 9:29 A.M. revealed Resident #5 was up in wheelchair in her room. A non skid rug was not in place to the floor beside the bed. Observation on 11/01/18 at 1:44 P.M. with Licensed Practical Nurse Unit Manger (LPNUM) #31 of Resident #5's room verified the non skid rug was not in place to the floor beside the bed. Interview on 11/01/18 at 4:30 P.M. with the Director of Nursing (DON) reported the non skid rug was an active fall intervention for Resident #5. The DON stated a nurse had last observed the non skid rug in place to Resident #5's floor on 10/25/18 and sometime after the housekeeper removed the rug without informing nursing staff.

Based on observation, staff interview, record review, review of Bed Frames User-Service Manual, and review of UltraWide Comfort Extension Accessories user-Service Manual, the facility failed to ensure an assessment was completed for the risk of entrapment with the use of side rails following a change in a mattress for one (#65) of seven residents reviewed for accidents. The facility identified 96 residents as having side rails. The facility census was 138. Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) assessment, dated 09/10/18, revealed intact cognitive skills for daily decision making. Resident #65 was totally dependent with transfers and required extensive assistance with bed mobility. Review of physician order [REDACTED]. Review of side rail assessment dated [DATE] revealed use of bilateral horizon assist rails which do not restrict the resident's freedom of movement and improved the resident's functional status. The side rails were not used to treat medical symptoms or used for staff convenience. The side rails were requested by an alert and oriented resident to aid in bed mobility and were used as an enabler. Risk related to use of side rails included risk of suffocation, strangulation, entrapment, risk of injury including fracture and death. Resident #65 required extensive assistance with bed mobility and a mechanical lift with assistance of two staff members for transfers. The assessment did not include any information or measurements of gaps between rails and mattress. Observation on 10/31/18 at 9:52 A.M. revealed Resident #65 was awake in bed. A large gap was observed between the right upper side rail and mattress. Interview with Resident #65 at the time of the observation reported he/she received a new mattress about three months ago and the new mattress didn't fit the bed. Observation on 10/31/18 at 10:08 A.M. of Resident #65's bed with Maintenance Supervisor (MS) #173 revealed a 5.25 inch gap between the right side rail and mattress. A warning sticker on the bed frame revealed use only the wider Joerns end panels provided with this accessory. Use appropriate sized mattress: consult user manual for dimensions. A warning sticker on the side rail attachment revealed creating too small or too large of a gap between the side rail or assist device can create an entrapment hazard. Death or serious injury may result. Prior to use read all instructions and warnings in the sure/safety manual. Interview on 10/31/18 at 11:04 A.M., the Director of Nursing (DON) reported bed extensions had been applied to Resident #65's bed which created the large gap between the side rail and mattress. The extensions had been removed to eliminate the gap. A larger mattress was ordered and once received the bed would be extended to facilitate the resident's comfort. Interview on 11/01/18 at 1:40 P.M., the Administrator reported Resident #65 had a 36 inch mattress with 42 inch bed extensions. An additional interview on 11/01/18 at 1:58 P.M., the DON reported Resident #65 had his/her mattress changed several times. Maintenance typically changed the mattress and a side rail assessment was not completed with each mattress change to assess for risks of entrapment. Review of Bed Frame User-Service Manual revealed an optimal bed system assessment should be conducted on each resident by a qualified clinician to ensure maximum safety of the resident. Use of properly sized mattress in order to minimize the gap between the side of mattress and assist device. The gap must be small enough to prevent resident/patient from getting his/her head or neck caught in this location. Make sure that raising or lowering bed, or contouring the sleep surface, does not create any hazardous gaps. Excessive gaps may result in injury or death. Review of UltraWide Comfort Extension Accessories user-Service Manual revealed use a mattress that is properly sized to fit mattress support platform which will remain centered on mattress support platform relative to State and Federal guidelines. Joerns Healthcare recommends the use of a mattress with minimum dimensions of 41.5 inches for a 42 inch extension.

Based on observation, staff interview, record review, review of Bed Frames User-Service Manual, and review of UltraWide Comfort Extension Accessories user-Service Manual, the facility failed to ensure bed rails and a bed extension were properly installed according to manufacturer requirements to ensure maximum Resident safety.for one (#65) of seven residents reviewed for accidents. The facility identified 96 residents as having side rails. The facility census was 138. Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) assessment, dated 09/10/18, revealed intact cognitive skills for daily decision making. Resident #65 was totally dependent with transfers and required extensive assistance with bed mobility. Review of physician order [REDACTED]. Review of side rail assessment dated [DATE] revealed use of bilateral horizon assist rails which do not restrict the resident's freedom of movement and improved the resident's functional status. The side rails were not used to treat medical symptoms or used for staff convenience. The side rails were requested by an alert and oriented resident to aid in bed mobility and were used as an enabler. Risk related to use of side rails included risk of suffocation, strangulation, entrapment, risk of injury including fracture and death. Resident #65 required extensive assistance with bed mobility and a mechanical lift with assistance of two staff members for transfers. The assessment did not include any information or measurements of gaps between rails and mattress. Observation on 10/31/18 at 9:52 A.M. revealed Resident #65 was awake in bed. A large gap was observed between the right upper side rail and mattress. Interview with Resident #65 at the time of the observation reported he/she received a new mattress about three months ago and the new mattress didn't fit the bed. Observation on 10/31/18 at 10:08 A.M. of Resident #65's bed with Maintenance Supervisor (MS) #173 revealed a 5.25 inch gap between the right side rail and mattress. A warning sticker on the bed frame revealed use only the wider Joerns end panels provided with this accessory. Use appropriate sized mattress: consult user manual for dimensions. A warning sticker on the side rail attachment revealed creating too small or too large of a gap between the side rail or assist device can create an entrapment hazard. Death or serious injury may result. Prior to use read all instructions and warnings in the sure/safety manual. Interview on 10/31/18 at 11:04 A.M., the Director of Nursing (DON) reported bed extensions had been applied to Resident #65's bed which created the large gap between the side rail and mattress. The extensions had been removed to eliminate the gap. A larger mattress was ordered and once received the bed would be extended to facilitate the resident's comfort. Interview on 11/01/18 at 1:40 P.M., the Administrator reported Resident #65 had a 36 inch mattress with 42 inch bed extensions. An additional interview on 11/01/18 at 1:58 P.M., the DON reported Resident #65 had his/her mattress changed several times. Maintenance typically changed the mattress and a side rail assessment was not completed with each mattress change to assess for risks of entrapment. Review of Bed Frame User-Service Manual revealed an optimal bed system assessment should be conducted on each resident by a qualified clinician to ensure maximum safety of the resident. Use of properly sized mattress in order to minimize the gap between the side of mattress and assist device. The gap must be small enough to prevent resident/patient from getting his/her head or neck caught in this location. Make sure that raising or lowering bed, or contouring the sleep surface, does not create any hazardous gaps. Excessive gaps may result in injury or death. Review of UltraWide Comfort Extension Accessories user-Service Manual revealed use a mattress that is properly sized to fit mattress support platform which will remain centered on mattress support platform relative to State and Federal guidelines. Joerns Healthcare recommends the use of a mattress with minimum dimensions of 41.5 inches for a 42 inch extension.

Based on medical record review, staff interviews, review of a facility Self-Reported Incident report and the facility's abuse policy, the facility failed to ensure a resident was protected from being physically abused by a staff member. This resulted in Immediate Jeopardy for one resident (#25) who was smacked on the arm and the mouth by a staff member during personal care. This affected one of three residents reviewed for abuse out of a current facility census of 138. On 12/23/14 at 1:30 P.M. the Administrator was notified Immediate Jeopardy began on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 was witnessed by two other staff members strike cognitively impaired Resident #25 on the arm and in the mouth and threaten to hit the resident when the resident became agitated during a transfer. The resident was later assessed by a nurse and found to have no visible injuries. STNA #209 continued to provide care to residents on the Dogwood hall until 1:51 P.M. The Immediate Jeopardy was removed on 12/11/14 when the facility initiated the following corrective actions: ? On 11/30/14 at 1:51 P.M. STNA #209 was escorted from the building by staff and did not return to the facility. ? ? On 11/30/14 at 1:51 P.M., Resident #25 was assessed and found without physical injury or emotional distress. The physician and family were notified of the incident. ? ? On 12/01/14 at 12:00 P.M., STNA #209's employment was terminated and STNA's #360 and #338 were disciplined for failing to report the incident timely. ? ? On 12/01/14 at 5:23 P.M., Resident #25 was evaluated by Licensed Social Worker (LSW) #66 and found not to recall the incident and without any change in mood or behaviors. ? ? On 12/02/14, all residents were interviewed and evaluated for possible abuse. ? ? Starting on 12/05/14 at 12:00 P.M. through 12/11/14, in-service training was conducted by the Administrator, Director of Nursing and Education Director for all staff on the facility's abuse policy, to include immediately reporting all instances and allegations of abuse. ? ? On 12/10/14, the facility added a checklist to the abuse policy to ensure staff followed abuse policy and procedures. Although the Immediate Jeopardy was removed on 12/11/14, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting ongoing weekly audits on 12/15/14 and was in the process of verifying the corrective action taken was effective. Findings include: Review of the medical record of Resident #25 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's plans of care revealed a plan of care for altered thought process dated 08/21/14 related to a [MEDICAL CONDITION] and dementia with agitation. The care planned interventions included to speak softly and distinctly in three to five word sentences. Further review of the plans of care revealed a plan of care for Risk for Violence against others dated 08/21/14 that indicated the resident was at risk due to his [DIAGNOSES REDACTED]. The care planned interventions included to attempt to divert the resident's attention, call for help at first sign of trouble, attempt to find out the reason for agitation if resident was agitated, and provide support and reassurance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short term memory problems and was severely impaired for decision making. During the seven day assessment period the resident displayed physical and verbal behavior symptoms four to six days, and other type of behavioral symptoms daily. The MDS further indicated Resident #25 required extensive assistance of two or more persons to dependent with activities of daily living and only one person extensive assistance for eating and locomotion on/off the unit. Review of a facility Self-Reported Incident report dated 11/30/14 revealed at approximately 1:50 P.M. on 11/30/14 RN #399 (building supervisor) was notified of an allegation of abuse regarding Resident #25. The abuse allegedly occurred on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 smacked Resident #25 in the mouth. As a result of an investigation, the facility concluded STNA #209 did smack Resident #25 in the mouth. STNA #209 denied the allegations and her employment was terminated. During interview on 12/03/14 at 11:23 P.M., Licensed Practical Nurse (LPN) #249 stated STNA #360 reported the abuse to her on 11/30/14 sometime after lunch. LPN #249 stated after the incident was reported she assessed Resident #25 and found no visible injuries. She stated the resident could not recall the incident. During interview on 12/03/14 at 11:43 A.M., State tested Nurse Aide (STNA) #360 stated on the morning of 11/30/14 at approximately 7:40 A.M. she and STNA's #209 and #338 went into Resident #25's room to get the resident up for breakfast. STNA #360 stated at that time Resident #25 was kicking and yelling obscenities as they tried to position him in the mechanical lift to transfer the resident. STNA #360 stated STNA #209 smacked Resident #25 on the arm and then a short time later smacked the resident in the mouth. STNA #360 further stated STNA #209 told Resident #25 if he kept screaming she was going to hit him like his parents did. STNA #360 stated she could hear the contact when STNA #209 hit Resident #25 on the arm and mouth. STNA #360 stated she felt the actions of STNA #209 were abusive; however she did not report the abuse immediately. STNA #360 stated she did not report the abuse right away because STNA #209 was around her and she was unable to get away from STNA #209 to report the abuse. STNA #360 stated later after lunch she reported the abuse to LPN #249. STNA #360 verified neither she nor STNA #338 attempted to stop STNA #209. During interview on 12/03/14 at 12:50 P.M., STNA #338 confirmed STNA #360's account of the abusive incident regarding Resident #25 and STNA #209. STNA #338 stated she had the opportunity to report the abuse to LPN #249 right after it happened when she left the room, but she did not. She further verified she did not report the allegation to any management staff. During interview on 12/03/14 at 3:46 P.M., the Administrator and the Director of Nursing (DON) stated the facility substantiated the abuse occurred because they felt both STNA #338 and STNA #360 were credible witnesses. During telephone interview on 12/04/14 at 11:10 A.M., STNA #209 confirmed she assisted Resident #25 up for breakfast on 11/30/14, and denied hitting Resident #25. STNA #209 confirmed she fed the resident breakfast and later went in the resident ' s room while STNA #360 was shaving the resident. STNA #209 further revealed she assisted STNA #238 transfer Resident #25 up for lunch and that she fed Resident #25 lunch that day in the lobby by herself. Review of the facility's Abuse Policy dated 06/01/12 revealed the policy stated all employees were responsible to promptly report any suspected, alleged, or report abuse, of any type to the nurse in charge of the resident and to the building supervisor. The policy further noted in accordance with the law the facility did not permit verbal, mental or physical abuse. This certification deficiency substantiates Master Facility Self Reported Incident Number OH 54 and Complaint Control Number OH 130.

Based on record review, staff interview, review of the facility's abuse policy and policy regarding care of combative residents, the facility failed to ensure staff to resident physical and verbal abuse was immediately reported to the Administrator, failed to ensure the resident was protected from further abuse and failed to ensure allegations of abuse were thoroughly investigated. This resulted in Immediate Jeopardy for one resident (#25) when two staff members did not immediately report the resident was smacked by another staff member and that staff member continued to provide care to the resident. The facility also failed to ensure a thorough investigation was completed when Resident (#3) who required two person assistance, was found with bruising after one state tested nurse aide provided incontinence care and alleged the resident was combative during the care. This had the potential to affect up to 37 residents (#86, #28, #88, #30, #90, #2, #1, #5, #3, #93, #91, #7, #89, #87, #85, #81, #83, #19, #77, #75, #69, #71, #73, #67, #65, #63, #61, #57, #59, #55, #53, #51, #49, #47, #45, #43 and #41) who resided on the facility's Station 2 units (Hickory and Maple) out of a facility census of 138. On 12/23/14 at 1:30 P.M. the Administrator was notified Immediate Jeopardy began on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 was witnessed by STNA #360 and STNA #338 strike cognitively impaired Resident #25 on the arm and in the mouth and threaten to hit the resident when the resident became agitated during a transfer. The resident was later assessed by a nurse and found to have no visible injuries. STNA#209 continued to provide care to residents on the Dogwood hall until 1:51 P.M. The Immediate Jeopardy was removed on 12/11/14 when the facility initiated the following corrective actions: ? On 11/30/14 at 1:51 P.M. STNA #209 was escorted from the building by staff and did not return to the facility. ? ? On 11/30/14 at 1:51 P.M., Resident #25 was assessed and found without physical injury or emotional distress. The physician and family were notified of the incident. ? ? On 12/01/14 at 12:00 P.M., STNA #209's employment was terminated and STNA's #360 and #338 were disciplined for failing to report the incident timely. ? ? On 12/01/14 at 5:23 P.M., Resident #25 was evaluated by Licensed Social Worker (LSW) #66 and found not to recall the incident and without any change in mood or behaviors. ? ? On 12/02/14, all residents were interviewed and evaluated for possible abuse. ? ? Starting on 12/05/14 at 12:00 P.M. through 12/11/14, in-service training was conducted by the Administrator, Director of Nursing and Education Director for all staff on the facility's abuse policy, to include immediately reporting all instances and allegations of abuse. ? ? On 12/10/14, the facility's abuse policy was updated. Although the Immediate Jeopardy was removed on 12/11/14, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting ongoing weekly audits on 12/15/14 and was in the process of verifying the corrective action taken was effective. Findings include: 1. Review of the medical record of Resident #25 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's plans of care revealed a plan of care for altered thought process dated 08/21/14 related to a [MEDICAL CONDITION] and dementia with agitation. The care planned interventions included to speak softly and distinctly in three to five word sentences. Further review of the plans of care revealed a plan of care for Risk for Violence against others dated 08/21/14 that indicated the resident was at risk due to his [DIAGNOSES REDACTED]. The care planned interventions included to attempt to divert the resident's attention, call for help at first sign of trouble, attempt to find out the reason for agitation if resident was agitated, and provide support and reassurance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short term memory problems and was severely impaired for decision making. During the seven day assessment period the resident displayed physical and verbal behavior symptoms four to six days, and other type of behavioral symptoms daily. The MDS further indicated Resident #25 required extensive assistance of two or more persons to dependence with activities of daily living and only one person extensive assistance for eating and locomotion on/off the unit. Review of a facility Self-Reported Incident report dated 11/30/14 revealed at approximately 1:50 P.M. on 11/30/14 Registered Nurse #399 (the building supervisor) was notified of an allegation of abuse regarding Resident #25. The abuse allegedly occurred on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 smacked Resident #25 in the mouth. As a result of an investigation, the facility concluded STNA #209 did smack Resident #25 in the mouth. STNA #209 denied the allegations and her employment was terminated. During interview on 12/03/14 at 11:23 P.M., Licensed Practical Nurse (LPN) #249 stated STNA #360 reported the abuse to her on 11/30/14 sometime after lunch. LPN #249 stated after the incident was reported she assessed Resident #25 and found no visible injuries. She stated the resident could not recall the incident. During interview on 12/03/14 at 11:43 A.M., State tested Nurse Aide (STNA) #360 stated on the morning of 11/30/14 at approximately 7:40 A.M. she and STNA's #209 and #338 went into Resident #25's room to get the resident up for breakfast. STNA #360 stated at that time Resident #25 was kicking and yelling obscenities as they tried to position him in the mechanical lift to transfer the resident. STNA #360 stated STNA #209 smacked Resident #25 on the arm and then a short time later smacked the resident in the mouth. STNA #360 further stated STNA #209 told Resident #25 if he kept screaming she was going to hit him like his parents did. STNA #360 stated she could hear the contact when STNA #209 hit Resident #25 on the arm and mouth. STNA #360 stated she felt the actions of STNA #209 were abusive; however she did not report the abuse immediately. STNA #360 stated she did not report the abuse right away because STNA #209 was around her and she was unable to get away from STNA #209 to report the abuse. STNA #360 stated later after lunch she reported the abuse to LPN #249. STNA #360 verified neither she nor STNA #338 attempted to stop STNA #209. During interview on 12/03/14 at 12:50 P.M., STNA #338 confirmed STNA #360's account of the abusive incident regarding Resident #25 and STNA #209. STNA #338 stated she had the opportunity to report the abuse to LPN #249 right after it happened when she left the room, but she did not. She further verified she did not report the allegation to any management staff. During interview on 12/03/14 at 3:46 P.M., the Administrator and the Director of Nursing (DON) stated the facility substantiated the abuse occurred because they felt both STNA #338 and STNA #360 were credible witnesses. The DON further revealed no other residents or staff was interviewed to determine if any other resident had been abused and/or mistreated. During telephone interview on 12/04/14 at 11:10 A.M., STNA #209 confirmed she assisted transfer Resident #25 up for breakfast on 11/30/14 and denied hitting Resident #25. STNA #209 confirmed she fed the resident breakfast and later went in the resident ' s room while STNA #360 was shaving the resident. STNA #209 further revealed she assisted STNA #238 transfer Resident #25 up for lunch and that she fed Resident #25 lunch that day in the lobby by herself. Review of the facility's Abuse Policy dated 06/01/12 revealed the policy stated all employees were responsible to promptly report any suspected, alleged, or report abuse, of any type to the nurse in charge of the resident and to the building supervisor. The policy further noted in accordance with the law the facility did not permit verbal, mental or physical abuse. 2. Review of the undated Kardex (resident's state tested nurse aide plan of care) for Resident #3 revealed the resident resided in the facility since 05/08/14. The Kardex indicated staff was to identify themselves before providing care and provide explanation of care (short and simple commands); always have two staff for assistance, speak distinctly, allow the resident time to respond, make sure the resident was safe and discontinue care when resident was combative with care and report it to the charge nurse. The Kardex further stated staff was to reapproach the resident after the resident had time to calm down. Review of the resident's Risk of Impaired Skin Integrity care plan dated 08/25/14 revealed the interventions included padded side rails, geri sleeves and monitor/document size. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated Resident #3 had short and long term memory problems with a severe impairment for daily decision making. The assessment further stated Resident #3 required extensive assistance for all activities of daily living and did not have any behavioral symptoms of physical, verbal, rejection of care, or any other behavior during this assessment period. Review of nursing notes dated 11/16/14 at 4:48 A.M. revealed Resident #3 was noted to have combative behavior when the nurse aides did their first round to check on the residents. The notes stated the nurse aides were attempting to change Resident #3 and he began hitting and scratching. The notes stated the resident ' s hand made contact with his face and a 5 centimeter (cm) by 3 cm bruise was noted when staff made their final round to check on the residents. Review of the resident's Treatment Record revealed there was sixteen new areas of bruising noted for Resident #3 on 11/15/14 and 11/16/14. The areas documented were a 5 cm by 3 cm bruise on the left side of the resident's face; a 4 cm by 3 cm bruise on the right cheek; a 2.5 cm by 2.5 cm and a 1.5 cm and 1.5 cm bruise on the right elbow; a 4 cm by 4 cm bruise on the top of the right hand; a 1 cm by 0.5 cm bruise on the right pinky finger; a 0.5 cm by 0.5 cm bruise on the right third digit; a 1 cm by 0.8 cm bruise on the right second digit; a 0.3 cm by 0.5 cm bruise on the right pointer finger; a 3 cm by 1 cm bruise on the right first knuckle; a 1.5 cm by 1 cm bruise on his nose; a 3 cm by 2.5 cm bruise on the left shoulder; a 2.5 cm by 1 cm bruise to the left ear; a 1 cm by 1 cm bruise to the left pointer finger; a 1 cm by 0.8 cm bruise to the left ring finger and a 1.5 cm by 0.5 cm bruise to the left thumb. Further review of Resident #3's Treatment Records revealed the only previous bruising documented was an 8 cm by 5 cm fading bruising to the right forearm that originated on 10/10/14. Review of nursing notes dated 11/16/14 at 1:51 P.M. revealed Resident #3 continued with multiple bruising to face and hands, left ear, left shoulder, right elbow, right cheek and nose. Review of a facility Self-Reported Incident report dated 11/16/14 revealed Resident #3 was on two blood thinners, [MEDICATION NAME] and Aspirin. Review of fax to Resident #3's physician on 11/17/14 at 12:01 P.M. revealed Resident #3 was reported as combative with care and sustained a bruise to the left side of the face. During interview on 12/04/14 at 11:57 A.M., State tested Nurse Aide (STNA) #403 stated she regularly worked on the first shift (6:00 A.M. to 2:00 P.M.) and cared for Resident #3. STNA #403 stated Resident #3 required two person assistance at all times and she would never walk into his room by herself to provide care. STNA #403 stated at times Resident #3 would kick, hit, or try to bite staff. STNA #403 stated Resident #3 never tried to hurt himself while combative. STNA #403 stated the resident could be easily redirected by talking with him and telling him what they were doing. STNA #403 stated she noted the multiple bruising on the resident while she was doing first round checks on the residents sometime after 6:00 A.M. on 11/16/14. STNA# 403 stated she immediately notified the nurse. Interview with the Administrator and Director of Nursing (DON) on 12/04/14 at 1:17 P.M. revealed STNA #201 did not follow the facility policy and provided care to Resident #3 without assistance as the resident was being combative. The Administrator stated two other STNA's who worked the night of the incident were given educational conferences regarding providing assist when a resident required two person for assistance regardless of what other aides directed them to do. The DON and Administrator stated STNA #201 reported when she initially went into the room she jerked the sheets off Resident #3 without explaining what she was going on and touched the resident and caused a static shock. During interview on 12/04/14 at 1:59 P.M., STNA #239 stated she generally worked night shift and cared for Resident #3. STNA #239 stated Resident #3 was generally not combative with her and only had one episode of combativeness with her in the past six months. STNA #239 stated she felt the resident was combative with her at that time because she tried to rush the resident during his care. STNA #239 stated on the evening of 11/15/14 during their first round of checking on the resident's she asked STNA #201 if she wanted assistance with Resident #3 and STNA #201 declined. STNA #239 stated STNA #201 had given care to Resident #3 by herself in the past. STNA #239 stated STNA #201 later called for assistance and when she went into Resident #3's room she noted the resident was out of breath " like he just ran a mile." STNA #239 stated the resident was not combative, but was trying to push their hands away. STNA #239 stated she held the resident's hand and told him what they were going to do and Resident #3 seemed to relax. STNA #239 stated when she arrived in the resident's room the resident already had a clean incontinence brief on with only the left side unfastened. STNA #239 stated she and STNA #201 later checked on Resident #3 during their fourth round of checking on the residents. STNA #239 stated it was then she saw the bruise to Resident #3's eye and pointed it out to STNA #201. STNA #239 stated STNA #201 denied seeing the bruise. During telephone interview on 12/04/14 at 2:38 P.M., STNA #201 stated Resident #3 helped staff with his care before so she felt she could give him incontinence care by herself, although she was aware he was assessed and care planned for two person assistance. STNA #201 stated she thought she caused a static electric shock when she initially touched the resident and her hands were cold which may have startled the resident. STNA #201 stated the resident was dressed in a sweatshirt. STNA #201 stated Resident #3 started swinging his arms and tried to hit, kick and bite her. She stated Resident #3 was incontinent of bowel and bladder. STNA #201 confirmed Resident #3 was combative when she started to provide the incontinence care. She stated she continued to provide the care until she could no longer handle the resident and she then asked STNA #239 for assistance when she was unable to finish the care and fasten the resident ' s incontinence brief. STNA #201 stated she had never seen Resident #3 " act " like that before. STNA #201 stated when Resident #3 became combative she should have covered the resident back up and given him some time to calm down. Interview with the Resident #3's Physician #801 on 12/09/14 revealed he was unsure if he actually visually assessed the resident. He stated he was made aware of the resident ' s multiple bruises by someone but he was unsure if it was by the resident ' s family or the facility. Physician #801 stated he had been Resident #3's physician for over [AGE] years and he did not recall the resident having any self-injurious behaviors. Physician #801 confirmed Resident #3 was on blood thinners and that the bruises would not just spontaneously appear as a result of the medication. Review of STNA #201's personnel file revealed the employee was hired on 04/07/08. Review of a facility Employee Memorandum dated 11/18/14 revealed STNA #201 was terminated due to violation of a facility code of conduct rule. The Employee Memorandum noted on 11/15/14 STNA #201 provided care to Resident #3 at approximately 10:30 P.M. and when initially asked by a co-worker (STNA #239) if she needed assistance with the resident, stated "no she thought she could handle it." After providing some care to Resident #3, STNA #201 decided to get assistance from STNA #239 due to Resident #3's level of combativeness. STNA #201 stated Resident #3 was short of breath, flailing his arms, kicking and when she went to put her hand on his arm, the resident reached forward in an attempt to bite her. STNA #201 then requested assistance from STNA #239. Per a statement from STNA #239, when she went to assist with the care Resident #3 was short of breath, and looked like he just ran a mile. STNA #239 indicated Resident #3 was not combative when she entered the room to assist STNA #201. Further review of the Memorandum revealed at 5:30 A.M. Resident #3 was noted to have a bruise on the corner of his left eye. On 11/16/14 Resident #3 was noted to have 16 bruises to various parts of his upper body. A significant bruise was noted to the resident's left shoulder. The resident had impaired mobility in his left shoulder due to an old injury therefore, he did not have full range of motion of that shoulder and it would be highly unlikely that he self-inflicted this type of bruising. The Memorandum indicated STNA #201 should not have provided care to Resident #3 by herself and she was aware the resident had a history of [REDACTED].#3's room than STNA#201 was willing to admit. The Memorandum stated based on the fact STNA #201 and the facility have the obligation to protect the resident from harm, the facility could not be sure what took place in the resident's room due to the resident's level of cognition and the facility terminated STNA #201 in order to protect all residents in the future. Review of the facility's undated new STNA training information regarding care for combative residents, revealed if a resident was combative staff was to first introduce themselves and use short simple commands. Allow the resident time to respond, and always use two persons for a resident with a history of combative behavior. If the resident becomes combative stop what you are doing, make sure the resident is safe, and do not have contact with the resident. This is to be reported to the nurse. This certification deficiency substantiates Master Facility Self Reported Incident Number OH 54 and Complaint Control Number OH 130.

Based on record review, staff interview, review of the facility's abuse policy and policy regarding care of combative residents, the facility failed to ensure staff followed the facility's abuse policy when staff to resident physical and verbal abuse was not immediately reported to the Administrator, when staff failed to ensure the resident was protected from further abuse and when the facility failed to ensure allegations of abuse were thoroughly investigated. This resulted in Immediate Jeopardy for one resident (#25) when two staff members did not immediately report the resident was smacked by another staff member and that staff member continued to provide care to the resident. The facility also failed to follow their policy to ensure a thorough investigation was completed when Resident (#3) who required two person assistance, was found with bruising after one state tested nurse aide provided incontinence care and alleged the resident was combative during the care. This had the potential to affect up to 37 residents (#86, #28, #88, #30, #90, #2, #1, #5, #3, #93, #91, #7, #89, #87, #85, #81, #83, #19, #77, #75, #69, #71, #73, #67, #65, #63, #61, #57, #59, #55, #53, #51, #49, #47, #45, #43 and #41) who resided on the facility's Station 2 units (Hickory and Maple) out of a facility census of 138. On 12/23/14 at 1:30 P.M. the Administrator was notified Immediate Jeopardy began on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 was witnessed by STNA #360 and STNA #338 strike cognitively impaired Resident #25 on the arm and in the mouth and threaten to hit the resident when the resident became agitated during a transfer. The resident was later assessed by a nurse and found to have no visible injuries. STNA#209 continued to provide care to residents on the Dogwood hall until 1:51 P.M. The Immediate Jeopardy was removed on 12/11/14 when the facility initiated the following corrective actions: ? On 11/30/14 at 1:51 P.M. STNA #209 was escorted from the building by staff and did not return to the facility. ? ? On 11/30/14 at 1:51 P.M., Resident #25 was assessed and found without physical injury or emotional distress. The physician and family were notified of the incident. ? ? On 12/01/14 at 12:00 P.M., STNA #209's employment was terminated and STNA's #360 and #338 were disciplined for failing to report the incident timely. ? ? On 12/01/14 at 5:23 P.M., Resident #25 was evaluated by Licensed Social Worker (LSW) #66 and found not to recall the incident and without any change in mood or behaviors. ? ? On 12/02/14, all residents were interviewed and evaluated for possible abuse. ? ? Starting on 12/05/14 at 12:00 P.M. through 12/11/14, in-service training was conducted by the Administrator, Director of Nursing and Education Director for all staff on the facility's abuse policy, to include immediately reporting all instances and allegations of abuse. ? ? On 12/10/14, the facility's abuse policy was updated. Although the Immediate Jeopardy was removed on 12/11/14, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting ongoing weekly audits on 12/15/14 and was in the process of verifying the corrective action taken was effective. Findings include: 1. Review of the medical record of Resident #25 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's plans of care revealed a plan of care for altered thought process dated 08/21/14 related to a [MEDICAL CONDITION] and dementia with agitation. The care planned interventions included to speak softly and distinctly in three to five word sentences. Further review of the plans of care revealed a plan of care for Risk for Violence against others dated 08/21/14 that indicated the resident was at risk due to his [DIAGNOSES REDACTED]. The care planned interventions included to attempt to divert the resident's attention, call for help at first sign of trouble, attempt to find out the reason for agitation if resident was agitated, and provide support and reassurance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short term memory problems and was severely impaired for decision making. During the seven day assessment period the resident displayed physical and verbal behavior symptoms four to six days, and other type of behavioral symptoms daily. The MDS further indicated Resident #25 required extensive assistance of two or more persons to dependence with activities of daily living and only one person extensive assistance for eating and locomotion on/off the unit. Review of a facility Self-Reported Incident report dated 11/30/14 revealed at approximately 1:50 P.M. on 11/30/14 Registered Nurse #399 (the building supervisor) was notified of an allegation of abuse regarding Resident #25. The abuse allegedly occurred on 11/30/14 at 7:40 A.M. when State tested Nurse Aide (STNA) #209 smacked Resident #25 in the mouth. As a result of an investigation, the facility concluded STNA #209 did smack Resident #25 in the mouth. STNA #209 denied the allegations and her employment was terminated. During interview on 12/03/14 at 11:23 P.M., Licensed Practical Nurse (LPN) #249 stated STNA #360 reported the abuse to her on 11/30/14 sometime after lunch. LPN #249 stated after the incident was reported she assessed Resident #25 and found no visible injuries. She stated the resident could not recall the incident. During interview on 12/03/14 at 11:43 A.M., State tested Nurse Aide (STNA) #360 stated on the morning of 11/30/14 at approximately 7:40 A.M. she and STNA's #209 and #338 went into Resident #25's room to get the resident up for breakfast. STNA #360 stated at that time Resident #25 was kicking and yelling obscenities as they tried to position him in the mechanical lift to transfer the resident. STNA #360 stated STNA #209 smacked Resident #25 on the arm and then a short time later smacked the resident in the mouth. STNA #360 further stated STNA #209 told Resident #25 if he kept screaming she was going to hit him like his parents did. STNA #360 stated she could hear the contact when STNA #209 hit Resident #25 on the arm and mouth. STNA #360 stated she felt the actions of STNA #209 were abusive; however she did not report the abuse immediately. STNA #360 stated she did not report the abuse right away because STNA #209 was around her and she was unable to get away from STNA #209 to report the abuse. STNA #360 stated later after lunch she reported the abuse to LPN #249. STNA #360 verified neither she nor STNA #338 attempted to stop STNA #209. During interview on 12/03/14 at 12:50 P.M., STNA #338 confirmed STNA #360's account of the abusive incident regarding Resident #25 and STNA #209. STNA #338 stated she had the opportunity to report the abuse to LPN #249 right after it happened when she left the room, but she did not. She further verified she did not report the allegation to any management staff. During interview on 12/03/14 at 3:46 P.M., the Administrator and the Director of Nursing (DON) stated the facility substantiated the abuse occurred because they felt both STNA #338 and STNA #360 were credible witnesses. The DON further revealed no other residents or staff was interviewed to determine if any other resident had been abused and/or mistreated. During telephone interview on 12/04/14 at 11:10 A.M., STNA #209 confirmed she assisted transfer Resident #25 up for breakfast on 11/30/14 and denied hitting Resident #25. STNA #209 confirmed she fed the resident breakfast and later went in the resident ' s room while STNA #360 was shaving the resident. STNA #209 further revealed she assisted STNA #238 transfer Resident #25 up for lunch and that she fed Resident #25 lunch that day in the lobby by herself. Review of the facility's Abuse Policy dated 06/01/12 revealed the policy stated all employees were responsible to promptly report any suspected, alleged, or report abuse, of any type to the nurse in charge of the resident and to the building supervisor. The policy further noted in accordance with the law the facility did not permit verbal, mental or physical abuse. 2. Review of the undated Kardex (resident's state tested nurse aide plan of care) for Resident #3 revealed the resident resided in the facility since 05/08/14. The Kardex indicated staff was to identify themselves before providing care and provide explanation of care (short and simple commands); always have two staff for assistance, speak distinctly, allow the resident time to respond, make sure the resident was safe and discontinue care when resident was combative with care and report it to the charge nurse. The Kardex further stated staff was to reapproach the resident after the resident had time to calm down. Review of the resident's Risk of Impaired Skin Integrity care plan dated 08/25/14 revealed the interventions included padded side rails, geri sleeves and monitor/document size. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated Resident #3 had short and long term memory problems with a severe impairment for daily decision making. The assessment further stated Resident #3 required extensive assistance for all activities of daily living and did not have any behavioral symptoms of physical, verbal, rejection of care, or any other behavior during this assessment period. Review of nursing notes dated 11/16/14 at 4:48 A.M. revealed Resident #3 was noted to have combative behavior when the nurse aides did their first round to check on the residents. The notes stated the nurse aides were attempting to change Resident #3 and he began hitting and scratching. The notes stated the resident ' s hand made contact with his face and a 5 centimeter (cm) by 3 cm bruise was noted when staff made their final round to check on the residents. Review of the resident's Treatment Record revealed there was sixteen new areas of bruising noted for Resident #3 on 11/15/14 and 11/16/14. The areas documented were a 5 cm by 3 cm bruise on the left side of the resident's face; a 4 cm by 3 cm bruise on the right cheek; a 2.5 cm by 2.5 cm and a 1.5 cm and 1.5 cm bruise on the right elbow; a 4 cm by 4 cm bruise on the top of the right hand; a 1 cm by 0.5 cm bruise on the right pinky finger; a 0.5 cm by 0.5 cm bruise on the right third digit; a 1 cm by 0.8 cm bruise on the right second digit; a 0.3 cm by 0.5 cm bruise on the right pointer finger; a 3 cm by 1 cm bruise on the right first knuckle; a 1.5 cm by 1 cm bruise on his nose; a 3 cm by 2.5 cm bruise on the left shoulder; a 2.5 cm by 1 cm bruise to the left ear; a 1 cm by 1 cm bruise to the left pointer finger; a 1 cm by 0.8 cm bruise to the left ring finger and a 1.5 cm by 0.5 cm bruise to the left thumb. Further review of Resident #3's Treatment Records revealed the only previous bruising documented was an 8 cm by 5 cm fading bruising to the right forearm that originated on 10/10/14. Review of nursing notes dated 11/16/14 at 1:51 P.M. revealed Resident #3 continued with multiple bruising to face and hands, left ear, left shoulder, right elbow, right cheek and nose. Review of a facility Self-Reported Incident report dated 11/16/14 revealed Resident #3 was on two blood thinners, [MEDICATION NAME] and Aspirin. Review of fax to Resident #3's physician on 11/17/14 at 12:01 P.M. revealed Resident #3 was reported as combative with care and sustained a bruise to the left side of the face. During interview on 12/04/14 at 11:57 A.M., State tested Nurse Aide (STNA) #403 stated she regularly worked on the first shift (6:00 A.M. to 2:00 P.M.) and cared for Resident #3. STNA #403 stated Resident #3 required two person assistance at all times and she would never walk into his room by herself to provide care. STNA #403 stated at times Resident #3 would kick, hit, or try to bite staff. STNA #403 stated Resident #3 never tried to hurt himself while combative. STNA #403 stated the resident could be easily redirected by talking with him and telling him what they were doing. STNA #403 stated she noted the multiple bruising on the resident while she was doing first round checks on the residents sometime after 6:00 A.M. on 11/16/14. STNA# 403 stated she immediately notified the nurse. Interview with the Administrator and Director of Nursing (DON) on 12/04/14 at 1:17 P.M. revealed STNA #201 did not follow the facility policy and provided care to Resident #3 without assistance as the resident was being combative. The Administrator stated two other STNA's who worked the night of the incident were given educational conferences regarding providing assist when a resident required two person for assistance regardless of what other aides directed them to do. The DON and Administrator stated STNA #201 reported when she initially went into the room she jerked the sheets off Resident #3 without explaining what she was going on and touched the resident and caused a static shock. During interview on 12/04/14 at 1:59 P.M., STNA #239 stated she generally worked night shift and cared for Resident #3. STNA #239 stated Resident #3 was generally not combative with her and only had one episode of combativeness with her in the past six months. STNA #239 stated she felt the resident was combative with her at that time because she tried to rush the resident during his care. STNA #239 stated on the evening of 11/15/14 during their first round of checking on the resident ' s she asked STNA #201 if she wanted assistance with Resident #3 and STNA #201 declined. STNA #239 stated STNA #201 had given care to Resident #3 by herself in the past. STNA #239 stated STNA #201 later called for assistance and when she went into Resident #3's room she noted the resident was out of breath "like he just ran a mile." STNA #239 stated the resident was not combative, but was trying to push their hands away. STNA #239 stated she held the resident ' s hand and told him what they were going to do and Resident #3 seemed to relax. STNA #239 stated when she arrived in the resident's room the resident already had a clean incontinence brief on with only the left side unfastened. STNA #239 stated she and STNA #201 later checked on Resident #3 during their fourth round of checking on the residents. STNA #239 stated it was then she saw the bruise to Resident #3's eye and pointed it out to STNA #201. STNA #239 stated STNA #201 denied seeing the bruise. During telephone interview on 12/04/14 at 2:38 P.M., STNA #201 stated Resident #3 helped staff with his care before so she felt she could give him incontinence care by herself, although she was aware he was assessed and care planned for two person assistance. STNA #201 stated she thought she caused a static electric shock when she initially touched the resident and her hands were cold which may have startled the resident. STNA #201 stated the resident was dressed in a sweatshirt. STNA #201 stated Resident #3 started swinging his arms and tried to hit, kick and bite her. She stated Resident #3 was incontinent of bowel and bladder. STNA #201 confirmed Resident #3 was combative when she started to provide the incontinence care. She stated she continued to provide the care until she could no longer handle the resident and she then asked STNA #239 for assistance when she was unable to finish the care and fasten the resident ' s incontinence brief. STNA #201 stated she had never seen Resident #3 "act" like that before. STNA #201 stated when Resident #3 became combative she should have covered the resident back up and given him some time to calm down. Interview with the Resident #3's Physician #801 on 12/09/14 revealed he was unsure if he actually visually assessed the resident. He stated he was made aware of the resident ' s multiple bruises by someone but he was unsure if it was by the resident ' s family or the facility. Physician #801 stated he had been Resident #3's physician for over [AGE] years and he did not recall the resident having any self-injurious behaviors. Physician #801 confirmed Resident #3 was on blood thinners and that the bruises would not just spontaneously appear as a result of the medication. Review of STNA #201's personnel file revealed the employee was hired on 04/07/08. Review of a facility Employee Memorandum dated 11/18/14 revealed STNA #201 was terminated due to violation of a facility code of conduct rule. The Employee Memorandum noted on 11/15/14 STNA #201 provided care to Resident #3 at approximately 10:30 P.M. and when initially asked by a co-worker (STNA #239) if she needed assistance with the resident, stated "no she thought she could handle it." After providing some care to Resident #3, STNA #201 decided to get assistance from STNA #239 due to Resident #3's level of combativeness. STNA #201 stated Resident #3 was short of breath, flailing his arms, kicking and when she went to put her hand on his arm, the resident reached forward in an attempt to bite her. STNA #201 then requested assistance from STNA #239. Per a statement from STNA #239, when she went to assist with the care Resident #3 was short of breath, and looked like he just ran a mile. STNA #239 indicated Resident #3 was not combative when she entered the room to assist STNA #201. Further review of the Memorandum revealed at 5:30 A.M. Resident #3 was noted to have a bruise on the corner of his left eye. On 11/16/14 Resident #3 was noted to have 16 bruises to various parts of his upper body. A significant bruise was noted to the resident's left shoulder. The resident had impaired mobility in his left shoulder due to an old injury therefore, he did not have full range of motion of that shoulder and it would be highly unlikely that he self-inflicted this type of bruising. The Memorandum indicated STNA #201 should not have provided care to Resident #3 by herself and she was aware the resident had a history of [REDACTED].#3's room than STNA#201 was willing to admit. The Memorandum stated based on the fact STNA #201 and the facility have the obligation to protect the resident from harm, the facility could not be sure what took place in the resident's room due to the resident's level of cognition and the facility terminated STNA #201 in order to protect all residents in the future. Review of the facility's undated new STNA training information regarding care for combative residents, revealed if a resident was combative staff was to first introduce themselves and use short simple commands. Allow the resident time to respond, and always use two persons for a resident with a history of combative behavior. If the resident becomes combative stop what you are doing, make sure the resident is safe, and do not have contact with the resident. This is to be reported to the nurse. This certification deficiency substantiates Master Facility Self Reported Incident Number OH 54 and Complaint Control Number OH 130.

Based on record review, review of a facility self reported incident, review of the facility's new hire training for caring for a combative resident and staff interviews, the facility failed to ensure one cognitively impaired resident assessed to require assistance of two staff for personal care was without injury after provided personal care by one staff member. Resident #3 was noted with bruising on the ear, face, nose, shoulder, elbow, hand and fingers after a state tested nurse aide (#201) alleged the resident was combative during incontinence care. This had the potential to affect all 37 (#86, #28, #88, #30, #90, #2, #1, #5, #3, #93, #91, #7, #89, #87, #85, #81, #83, #19, #77, #75, #69, #71, #73, #67, #65, #63, #61, #57, #59, #55, #53, #51, #49, #47, #45, #43 and #41) residents residing on Station 2 who could have potentially been cared for by that state tested nurse aide that shift. The facility census was 138. Findings include: Review of the undated Kardex (resident's state tested nurse aide plan of care) for Resident #3, revealed the resident resided in the facility since 05/08/14. The Kardex indicated staff was to identify themselves before providing care and provide explanation of care (short and simple commands); always have two staff for assistance, speak distinctly, allow the resident time to respond, make sure the resident was safe and discontinue care when resident was combative with care and report it to the charge nurse. The Kardex further stated staff was to reapproach the resident after the resident had time to calm down. Review of the resident's Risk of Impaired Skin Integrity care plan dated 08/25/14 revealed the interventions included padded side rails, geri sleeves and monitor/document size. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated Resident #3 had short and long term memory problems with a severe impairment for daily decision making. The assessment further stated Resident #3 required extensive assistance for all activities of daily living and did not have any behavioral symptoms of physical, verbal, rejection of care, or any other behavior during this assessment period. Review of nursing notes dated 11/16/14 at 4:48 A.M. revealed Resident #3 was noted to have combative behavior when the nurse aides did their first round to check on the residents. The notes stated the nurse aides were attempting to change Resident #3 and he began hitting and scratching. The notes stated the resident ' s hand made contact with his face and a 5 centimeter (cm) by 3 cm bruise was noted when staff made their final round to check on the residents. Review of the resident's Treatment Record revealed there was sixteen new areas of bruising noted for Resident #3 on 11/15/14 and 11/16/14. The areas documented were a 5 cm by 3 cm bruise on the left side of the resident's face; a 4 cm by 3 cm bruise on the right cheek; a 2.5 cm by 2.5 cm and a 1.5 cm and 1.5 cm bruise on the right elbow; a 4 cm by 4 cm bruise on the top of the right hand; a 1 cm by 0.5 cm bruise on the right pinky finger; a 0.5 cm by 0.5 cm bruise on the right third digit; a 1 cm by 0.8 cm bruise on the right second digit; a 0.3 cm by 0.5 cm bruise on the right pointer finger; a 3 cm by 1 cm bruise on the right first knuckle; a 1.5 cm by 1 cm bruise on his nose; a 3 cm by 2.5 cm bruise on the left shoulder; a 2.5 cm by 1 cm bruise to the left ear; a 1 cm by 1 cm bruise to the left pointer finger; a 1 cm by 0.8 cm bruise to the left ring finger and a 1.5 cm by 0.5 cm bruise to the left thumb. Further review of Resident #3's Treatment Records revealed the only previous bruising documented was a 8 cm by 5 cm fading bruising to the right forearm that originated on 10/10/14. Review of nursing notes dated 11/16/14 at 1:51 P.M. revealed Resident #3 continued with multiple bruising to face and hands, left ear, left shoulder, right elbow, right cheek and nose. Review of a facility Self-Reported Incident report dated 11/16/14 revealed Resident #3 was on two blood thinners, [MEDICATION NAME] and Aspirin. Review of fax to Resident #3's physician on 11/17/14 at 12:01 P.M. revealed Resident #3 was reported as combative with care and sustained a bruise to the left side of the face. During interview on 12/04/14 at 11:57 A.M., State tested Nurse Aide (STNA) #403 stated she regularly worked on the first shift (6:00 A.M. to 2:00 P.M.) and cared for Resident #3. STNA #403 stated Resident #3 required two person assistance at all times and she would never walk into his room by herself to provide care. STNA #403 stated at times Resident #3 would kick, hit, or try to bite staff. STNA #403 stated Resident #3 never tried to hurt himself while combative. STNA #403 stated the resident could be easily redirected by talking with him and telling him what they were doing. STNA #403 stated she noted the multiple bruising on the resident while she was doing first round checks on the residents some time after 6:00 A.M. on 11/16/14. STNA# 403 stated she immediately notified the nurse. Interview with the Administrator and Director of Nursing (DON) on 12/04/14 at 1:17 P.M. revealed STNA #201 did not follow the facility policy and provided care to Resident #3 without assistance as the resident was being combative. The Administrator stated two other STNA's who worked the night of the incident were given educational conferences regarding providing assist when a resident required two person for assistance regardless of what other aides directed them to do. The DON and Administrator stated STNA #201 reported when she initially went into the room she jerked the sheets off Resident #3 without explaining what she was going on and touched the resident and caused a static shock. During interview on 12/04/14 at 1:59 P.M., STNA #239 stated she generally worked night shift and care for Resident #3. STNA #239 stated Resident #3 was generally not combative with her only had one episode of combativeness with her in the past six months. STNA #239 stated she felt the resident was combative with her at that time because she tried to rush the resident during his care. STNA #239 stated on the evening of 11/15/14 during their first round of checking on the resident ' s she asked STNA #201 if she wanted assistance with Resident #3 and STNA #201 declined. STNA #239 stated STNA #201 had given care to Resident #3 by herself in the past. STNA #239 stated STNA #201 later called for assistance and when she went into Resident #3's room she noted the resident was out of breath "like he just ran a mile." STNA #239 stated the resident was not combative, but was trying to push their hands away. STNA #239 stated she held the resident ' s hand and told him what they were going to do and Resident #3 seemed to relax. STNA #239 stated when she arrived in the resident's room the resident already had a clean incontinence brief on with only the left side unfastened. STNA #239 stated she and STNA #201 later checked on Resident #3 during their fourth round of checking on the residents. STNA #239 stated it was then she saw the bruise to Resident #3's eye and pointed it out to STNA #201. STNA #239 stated STNA #201 denied seeing the bruise. During telephone interview on 12/04/14 at 2:38 P.M., STNA #201 stated Resident #3 helped staff with his care before so she felt she could give him incontinence care by herself, although she was aware he was assessed and care planned for two person assistance. STNA #201 stated she thought she caused a static electric shock when she initially touched the resident and her hands were cold which may have startled the resident. STNA #201 stated the resident was dressed in a sweatshirt. STNA #201 stated Resident #3 started swinging his arms and tried to hit, kick and bite her. She stated Resident #3 was incontinent of bowel and bladder. STNA #201 confirmed Resident #3 was combative when she started to provide the incontinence care. She stated she continued to provide the care until she could no longer handle the resident and she then asked STNA #239 for assistance when she was unable to finish the care and fasten the resident's incontinence brief. STNA #201 stated she had never seen Resident #3 "act" like that before. STNA #201 stated when Resident #3 became combative she should have covered the resident back up and given him some time to calm down. Interview with the Resident #3's Physician #801 on 12/09/14 revealed he was unsure if he actually visually assessed the resident. He stated he was made aware of the resident ' s multiple bruises by someone but he was unsure if it was by the resident ' s family or the facility. Physician #801 stated he had been Resident #3's physician for over [AGE] years and he did not recall the resident having any self-injurious behaviors. Physician #801 confirmed Resident #3 was on blood thinners and that the bruises would not just spontaneously appear as a result of the medication. Review of STNA's personnel file revealed the employee was hired on 04/07/08. Review of a facility Employee Memorandum dated 11/18/14 revealed STNA #201 was terminated due to violation of a facility code of conduct rule. The Employee Memorandum noted on 11/15/14 STNA #201 provided care to Resident #3 at approximately 10:30 P.M. and when initially asked by a co-worker (STNA #239) if she needed assistance with the resident, stated "no she thought she could handle it." After providing some care to Resident #3, STNA #201 decided to get assistance from STNA #239 due to Resident #3's level of combativeness. STNA #201 stated Resident #3 was short of breath, flailing his arms, kicking and when she went to put her hand on his arm, the resident reached forward in an attempt to bite her. STNA #201 then requested assistance from STNA #239. Per a statement from STNA #239, when she went to assist with the care Resident #3 was short of breath, and looked like he just ran a mile. STNA #239 indicated Resident #3 was not combative when she entered the room to assist STNA #201. Further review of the Memorandum revealed at 5:30 A.M. Resident #3 was noted to have a bruise on the corner of his left eye. On 11/16/14 Resident #3 was noted to have 16 bruises to various parts of his upper body. A significant bruise was noted to the resident's left shoulder. The resident had impaired mobility in his left shoulder due to an old injury therefore, he did not have full range of motion of that shoulder and it would be highly unlikely that he self-inflicted this type of bruising. The Memorandum indicated STNA #201 should not have provided care to Resident #3 by herself and she was aware the resident had a history of [REDACTED].#3's room than STNA#201 was willing to admit. The Memorandum stated based on the fact STNA #201 and the facility have the obligation to protect the resident from harm, the facility could not be sure what took place in the resident's room due to the resident's level of cognition and the facility terminated STNA #201 in order to protect all residents in the future. Review of the facility's undated new STNA training information regarding care for combative residents, revealed if a resident was combative staff was to first introduce themselves and use short simple commands. Allow the resident time to respond, and always use two persons for a resident with a history of combative behavior. If the resident becomes combative stop what you are doing, make sure the resident is safe, and do not have contact with the resident. This is to be reported to the nurse. This certification deficiency substantiates Complaint Control Number OH 130 and Facility Self Reported Incident Number OH 051.