Every finding on record at Ohio Veterans Home

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure infection control practices were followed for residents on enhanced barrier precautions and during medication administration. This affected three (#2, #33, and #192) of three residents directly observed for infection control practices. The facility census was 233.Findings include:1. Review of the medical record for Resident #233 revealed the resident was admitted on [DATE]. Diagnoses included Parkinson's disease, dementia, congestive heart failure (CHF), and peripheral vascular disease (PVD).Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #233 revealed an unhealed stage four pressure ulcer (full-thickness skin and tissue loss) present on admission.Review of the current physician orders for Resident #233 revealed he was ordered enhanced barrier precautions (EBP; infection control measures to protect individuals from cross infections for those that have either multi-drug resistant organisms and those that have areas of increased risk factors for infections such as wounds, catheters, and other artificial openings in the skin).Observation on 06/09/26 at 8:57 A.M. revealed two unknown staff members entered Resident #233's room. Observation revealed EBP signage was posted on the resident's door along with the personal protective equipment (PPE) that may be needed to wear during care. Continued observation revealed the staff that entered the room did not apply PPE.Observation on 06/09/26 at 9:08 A.M. revealed two staff members exited Resident #33's room holding a garbage bag with an incontinence brief inside. Concurrent interview with Certified Nurse Aide (CNA) #738 stated she provided oral care, peri-care, and repositioned Resident #233. CNA #738 verified the resident had a sign that identified the need to don PPE when care was provided in high contact areas and he had a wound on his buttocks. CNA #738 verified she did not wear gown and was in a hurry. Review of the facility policy titled, Enhanced Barrier Precautions, dated 02/23, revealed enhanced barrier precautions are infection control interventions designed to reduce the transmission of multi-drug resistant organism (MDRO) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for resident known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). Indications for use of EBP are those with MDRO, chronic wounds, and/or indwelling medical devices. Activities that require EBP are activities of daily living such as dressing, bathing/showering, providing hygiene, and toileting.2. Observation on 06/09/26 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #569 was at her medication cart in the hallway and Resident #2 approached the medication care. LPN #569 gathered the medications for the resident. Further observation of LPN #569 revealed she administered eye drops to Resident #2 without wearing gloves. Further observation of LPN #569 revealed no hand hygiene was completed following the administration of the eye drops. LPN #569 then collected a medication cup with pills in the cup and an insulin syringe and went to Resident #192's room and administered his oral medication and his insulin injection. Continued observation of LPN #569 revealed no gloves were worn to administer the insulin to Resident #192.Interview on 06/09/26 at 9:05 A.M. with LPN #569 verified she did wear gloves when she administered the eye drops to Resident #2 and verified she did not wear gloves when she administered the insulin to Resident #192. LPN #569 stated she washed her hands between the residents and used hand sanitizer. Review of the facility policy titled, Medication Administration Procedure, revised 10/24, revealed all prescribed medications are administered safely, accurately and timely by a qualified licensed nurse. The nurse preparing medication is responsible for being knowledgeable about the medication, side effects, medication order, method of preparation, administration, and documentation.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure meal intake strategies were followed in accordance with physician orders and failed to ensure residents were adequately supervised and smoking safety interventions were properly utilized during resident smoking. This affected two (#3 and #109) of six residents reviewed for accidents and hazards. The census was 233. Findings include: 1. Medical record review revealed Resident #3 admitted to the facility 02/11/22 with the diagnoses including, schizophrenia, peripheral vascular disease, gastroesophageal reflux disease with esophagitis, gastroparesis, dysphagia pharyngoesophageal phase, dyskinesia of esophagus, anemia, Barrett's esophagus, and type II diabetes mellitus. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #3 with intact cognition, no recorded behaviors, the utilized a walker or wheelchair independently for mobility, was independent with activities of daily living, had unplanned weight loss, received nutrition via feeding tube and by mouth, and was on a mechanical and therapeutic diet. Review of Resident #3's ordered revealed on 07/24/25 a physician order was implemented for intake/dysphagia recommendations to include encouraging the resident to consume gastroparesis-friendly food/drink items (lean proteins, soft vegetables, and water) instead of fried/greasy/high-fiber/acidic food/drink items (whole grains, salsa, and orange juice). Staff were to provide prompts/reminders for slowed rate of consumption, small bite sizes, and alternation of solids/liquids every two to three bites. Review of Resident #3's speech therapy Discharge summary dated [DATE], with dates of service between 07/24/25 and 09/11/25, revealed discharge recommendations including strategies to facilitate safety and efficiency, it was recommended the resident use the following strategies during oral intake: bolus size modifications, rate modification, alternation of liquid/solids, lingual sweep/re-swallow and hard throat clear/swallow, along with the following maneuvers including upright posture for greater than 30 minutes after meals. Review the medical record revealed on 02/18/26 a nursing plan of care was revised to address Resident #3 being at risk for malnutrition related to frequent emesis/regurgitating behaviors related to gastroparesis, esophageal dysmotility, dysphagia, etc. Gastroparesis guidelines are challenging for the resident to adhere to as he eats rapidly with large portions, purchases food/beverages outside of dietary recommendations, and often lays down right after meals. Interventions included the resident was able to dine with set up help and supervision; staff to determine food preferences and provide items within dietary limitations; honor food preferences whenever possible as the resident liked potato chips and many beverages and disliked ground meat; the resident purchased many unapproved snacks which cause gastric distress despite continual education efforts on appropriate items; a diet order including high protein, mechanical soft with chopped meat texture and thin consistency, and provide additional sauces/gravy and bite sized pieces; intake/dysphagia recommendations to include encouraging the resident to consume gastroparesis-friendly food/drink items (lean proteins, soft vegetables, and water) instead of fried/greasy/high-fiber/acidic food/drink items (whole grains, salsa, and orange juice); provide prompts/reminders for slowed rate of consumption, small bite sizes, and alternation of solids/liquids every two to three bites; and monitor for chewing/swallowing problems or choking. Observation on 06/10/26 between 6:53 A.M. and 7:14 A.M. revealed Resident #3 was seated at table in dining room with a large lidded cup and multiple Styrofoam cups, two bowls of ice cream, two containers of dry cereal, a whole breakfast burrito and hash browns, and two health shakes. There was no monitoring or instruction provided during the meal related to consumption strategies. No staff were observed monitoring the resident throughout the meal. Observation on 06/11/26 at 8:35 A.M. revealed Resident #3 was noted in the main dining room seated at a table alone. Resident #3 was consuming two large slices of banana bread with additional food items and multiple beverages. No staff were observed in the dining room or monitoring the resident during the meal. Resident #3 was noted to be regurgitating into a large Styrofoam cup following intake at intervals. On 06/11/26 at 8:42 A.M. Food Service Worker (FSW) #533 was observed providing food to residents seated in the main dining room. Interview with FSW #533 at that time verified Resident #3 ate each meal in main dining room. FSW #533 stated if residents require supervision during meals either nursing staff monitors or specific residents would eat on their residing unit. FSW #533 verified Resident #3 had multiple food and beverage items including large slices of banana bread being consumed by the resident and the resident frequently regurgitates following consumption. FSW #533 stated she was unaware Resident #3 required monitoring or mealtime consumption strategies and confirmed the resident was not monitored by any staff during the meals each day. On 06/11/26 8:50 A.M. interview with Licensed Practical Nurse (LPN) #595 verified Resident #3 ate each meal in the main dining room and was not monitored or prompted during the meals. LPN #595 went on to state she was unaware Resident #3 required prompting or supervision with or during meals. On 06/11/26 at 11:02 A.M. interview with Director of Therapy Services #790 during a review of Resident #3 most recent speech therapy treatment verified 09/11/25 was the most current recommendation and included the 07/24/25 meal time monitoring with instruction. 2. Review of the medical record for Resident #109 revealed the resident was admitted on [DATE]. Diagnoses included nicotine dependence and quadriplegia. Review of the quarterly MDS assessment dated [DATE] for Resident #109 revealed he was cognitively intact. Review of the care plan, revised February 2026, for Resident #109 revealed the resident was care planned for supervised smoking with smoking apron. Interventions included Resident #109 was to wear a smoking apron (supervised), and inform the resident of smoking policy and procedure. Further review of the care plan for Resident #109 revealed continued non-compliance with the smoking safety put into place for the resident. Further review of the care plan for Resident #109 revealed he was care planned for activities of daily living (ADLs) due to a diagnosis of quadriplegia. Review of the physician orders for June 2026 for Resident #109 revealed he was a supervised smoker with smoke apron. Review of the nursing progress note dated 02/17/26 for Resident #109 revealed he was found to have a burn on his leg from the cigarette ash falling on his leg earlier in the day while he was smoking. Further review of the nursing progress notes for Resident #109 revealed he was found to have ashy substance on his person after returning from smoking with no actual burn holes in his clothes or on his skin. Review of the resident safe smoking assessment dated [DATE] for Resident #109 revealed he required supervision and a smoke apron for smoking cigarettes. Observation on 06/08/26 at 4:15 P.M. of Resident #109 revealed the resident was observed smoking outside the [NAME] Lounge. The resident was alone and had a smoking apron on. Concurrent interview with Resident #109 stated he was found to have a burn hole in his clothes about four months ago and he was told he had to be supervised while he smoked and had to wear a smoking apron while he smoked. Observation on 06/09/26 at 10:44 A.M. of Resident #109 revealed he was sitting on the smoke deck outside D unit and had a spent cigarette in his hand. The resident was not wearing a smoke apron. Observation on 06/10/26 at 9:30 A.M. of Resident #109 revealed the resident was smoking a cigarette. Resident #109 did not have a smoking apron on and there were no staff for supervision. Interview on 06/10/26 at 9:33 A.M. with the Director of Nursing (DON) verified Resident #109 was a supervised smoker and required the use of a smoke apron. The DON further verified Resident #109 was smoking without his smoke apron in place and without supervision. Review of the facility policy titled, Smoking, dated 04/23, revealed the purpose of the policy is to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Residents who smoke will be further assessed to determine if it is safe to smoke unsupervised using the assessment form. All safe smoking measure will be documented in the care plan of each resident and communicated to the staff and visitors.

Based on observation, staff interview, resident interview, medical record review, review of an incident and accident log, and facility policy review, the facility failed to ensure a thorough assessment was completed for use of and residents were free from unnecessary physical restraints. This affected one (#91) of one residents reviewed for physical restraints. The facility census was 233.Findings include:Review of the medical record for Resident #91 revealed an admission date of 03/05/24. Diagnoses included chronic obstructive pulmonary disease (COPD), Parkinson's disease, and abnormalities of gait and balance.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #91 revealed he had moderate cognitive impairment.Review of the care plan revised June 2026 for Resident #91 revealed he was care planned for falls. Interventions included a standard wheelchair with Dycem (a sticky mat to prevent sliding) above and below the redistribution cushion with push button release seatbelt and encourage Resident #91 to buckle his seatbelt.Review of the fall assessment dated [DATE] for Resident #91 revealed no falls in the past assessment period. Further review of the fall risk assessment for Resident #91 revealed a balance problem while standing and required the use of an assist device.Review of the seatbelt review assessment dated [DATE] for Resident #91 revealed he was able to release the device.Review of the current orders for June 2026 for Resident #91 revealed he had an order to encourage the resident to buckle the seatbelt on the wheelchair.Review of the incident and accident log for the past six months revealed Resident #91 has not had a fall during the past six months.Observation on 06/08/26 at 10:44 A.M. revealed Resident #91 was sitting in his wheelchair with a seatbelt laying across his lap and unbuckled. Resident #91's truncal support was steady and was unwavering.Observation on 06/09/26 at 9:10 A.M. of Resident #91 revealed the resident was sitting in his room in his wheelchair with a seatbelt in place and fastened. Resident #91's truncal support was steady and was unwavering. Concurrent interview and observation with Resident #91 revealed he fumbled with the seatbelt and was not able to independently remove the seatbelt. Resident #91 stated, I can't take it off.Observation on 06/09/26 at 11:05 A.M. of Resident #91 revealed staff assisted the resident and the seatbelt remained in place and latched. Resident #91's truncal support was steady and was unwavering.Observation on 06/09/26 at 3:15 P.M. of Resident #91 revealed he was sitting in his room in his wheelchair with the seatbelt in place and latched. Resident #91's truncal support was steady and was unwavering.Observation on 06/10/26 at 9:45 A.M. of Resident #91 revealed he was sitting in his wheelchair with the seatbelt in place and latched. Resident #91's truncal support was steady and was unwavering.Interview on 06/09/26 at 3:16 P.M. with Certified Nurse Aide (CNA) #791 stated she applied the seatbelt to Resident #91 and stated he played with the buckle all day long.Interview and concurrent observation on 06/09/26 at 3:43 P.M. with Registered Nurse (RN) #625 stated Resident #91 utilized the seatbelt for positioning for poor trunk control. Continued observation of Resident #91 revealed a significant amount of prompting from RN #625 before he was able to unfasten the seatbelt. The time lapsed was approximately five minutes. RN #625 stated Resident #91 liked to lean forward and pick things up off the floor and can slide out (of the wheelchair). RN #625 was questioned about whether the seatbelt restrained him from falling on the floor and the nurse stated, Yes.Interview on 06/10/26 at 8:09 A.M. with Rehabilitation Director (RD) #790 stated Resident #91 had been in several different wheelchairs as his disease had progressed and he would not be in a seatbelt without therapy evaluation and recommendations.A follow up interview on 06/10/26 at 11:06 A.M. with RD #790 state the Occupational Therapist did not complete a formal assessment that was documented and must have just gone to the room of Resident #91 and made sure he was able to buckle and unbuckle the seatbelt and then an order was written.Review of the facility policy titled, Restraints and Plan of Care, revealed the resident has the right to be free from any physical and chemical restraints imposed for the purposes of discipline or convenience and not required to treat the residents medical symptoms.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure pain monitoring and pain relief interventions were effectively implemented. This affected one (#195) of three residents reviewed for effective pain control and monitoring in a facility census of 233. Findings include: Review of the medical record revealed Resident #195 admitted to the facility on [DATE] with the diagnoses including, type II diabetes mellitus, hypertension, end stage renal disease requiring hemodialysis, congestive heart failure, atrial fibrillation, and Charcot's joint of the bilateral ankle and foot. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #195 was assessed with intact cognition, had no recorded behavior or refusal of care, was dependent on staff for the completion of activities of daily living, received scheduled pain medication with no pain frequency identified, received a mechanically altered therapeutic diet, and received dialysis. Review of Resident #195's physician orders revealed an order dated 12/14/25 for acetaminophen 325 milligrams (mg) to give two tablets three times a day for pain, and order dated 06/13/25 to attend hemodialysis every Tuesday, Thursday, and Saturday, and an order dated 06/02/25 to document pain level and location, if applicable, every shift. Review of the medical record noted Resident #195 had a nursing plan of care, revised 11/26/25, to include the resident had the potential to be non-compliant with dialysis treatment. On 09/13/25, 11/01/25, and 11/25/25 the resident refused to go to dialysis. Interventions included to acknowledge the resident's right to refuse or choose against recommended treatment; document non-compliance in appropriate charts and notify the nurse/physician; offer education and reassurance to the resident and/or family/responsible party as needed; and re-attempt to offer declined interventions as needed. Further review revealed on 07/30/25, a nursing plan of care was revised to address Resident #195's pain due to diabetes mellitus with neuropathy and lumbar disk disease with claudication. Interventions included to administer medications as ordered, monitor for effectiveness of medications given, and notify the physician as needed; monitor for signs and symptoms of pain and when having pain try to determine cause of pain and attempt to eliminate it; position for comfort as needed; try alternative relief measures such as back rubs; and offer non-pharmacologic intervention for complaints of pain (such as reposition, offer food/fluids, assist to the toilet, use pillows for positioning, provide distraction through television/music/conversation) and if ineffective, medicate as ordered. Review of Resident #195's progress notes dated 06/06/26 at 7:15 A.M. revealed a late entry nursing note that Resident #195 refused dialysis. There was no documentation noted of a physician notification or attempts/interventions to determine why Resident #195 was refusing to attend dialysis. On 06/09/26 at 5:11 A.M., and nursing progress note was documented that Resident #195 refused to go to dialysis that morning. The resident was educated and the Registered Nurse supervisor (RNCC) was notified. No content of education was documented and no intervention or underlying cause was documented to be attempted. Additionally, no pain evaluation was recorded. Observation and interview on 06/09/26 at 10:25 A.M. noted Resident #195 seated in a wheelchair in his room. Resident #195 stated he had bilateral lower extremity pain since early morning and requested pain medication approximately at 7:00 A.M. The source of pain was the lower extremity neuropathy and resulted in him refusing dialysis that day due to pain. On 06/09/26 at 10:30 A.M. interview with Licensed Practical Nurse (LPN) #595 revealed no information was provided during shift report at 7:00 A.M. indicating the reason for Resident #195 refusing to attend dialysis. LPN #595 stated she assumed care of Resident #195 at 7:00 A.M.; however, she had not interacted or assessed the resident since assuming report from the off-going shift. LPN #595 confirmed she was not informed at anytime since assuming care Resident #195 was experiencing pain.

Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to report allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Further review of the investigation report revealed the facility had not interviewed all staff present in the dining room during lunch at the time of the allegation of verbal abuse. Further review of the staff witness statements revealed staff had reported additional allegations of resident abuse against CNA #400 with no documentation of an investigation and no Self-Reported Incidents submitted to the state agency regarding the allegations. Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurses' notes from 01/17/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Also, the facility implemented an intervention for a psychiatric consult but there was no documentation the facility had contacted psychiatric services for resident follow-up.2. Review of the closed medical record for Resident #244 revealed an admission date of 04/16/25 and a discharge date of 01/23/26. Diagnoses included dementia, type two diabetes mellitus, and aphasia.Review of the quarterly MDS dated [DATE] revealed the resident required substantial/maximal assistance for eating. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #244 revealed no documentation of the allegation of abuse. Review of the facility SRIs also revealed no reported allegations of physical abuse by staff for Resident #244.3. Review of the closed medical record for Resident #243 revealed an admission date of 08/01/23 and a discharge date of 01/27/26. Diagnoses include Alzheimer's disease, Parkinson's disease, dementia, aphasia, and dysphagia oral phase.Review of the significant change MDS dated [DATE] revealed Resident #243 had severe cognitive impairment. The resident was dependent on staff for meal assistance. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #243 revealed no documentation of alleged staff to resident abuse. Review of the facility SRIs revealed no reported allegations of abuse by staff for Resident #243. 4. Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the nurse's notes from 01/01/26 through 02/03/26 for Resident #93 revealed no documentation of allegations of abuse. Review of the facility SRIs revealed no allegations of staff to resident abuse had been submitted for Resident #93. 5. Review of the medical record for Resident #129 revealed an admission date of 04/07/25. Diagnoses include Alzheimer's disease, dementia, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident required set-up assistance for meals.Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #129 revealed no documentation of an abuse allegation. Review of the facility SRIs revealed no SRIs submitted for staff to resident abuse for Resident #129.6. Review of the medical record for Resident #6 revealed an admission date of 12/04/12. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #6 revealed no documentation of allegations of abuse. Review of the facility SRIs also revealed no reported allegations of staff to resident abuse for Resident #6. Review of a witness statement dated 01/28/26 by CNA #350 revealed on 01/27/26 Resident #193 was sleeping during lunch and CNA #400 went up to him and was yelling in his ear to keep waking him up to eat. CNA #350 noted CNA #400 was cursing in the dining room and yelling at the residents to wake up and eat. CNA #350 noted CNA #400 was not compliant with the resident's diet orders and it was not unusual for her to force feed the residents. There was no documentation CNA #350 was further questioned regarding the allegation of CNA #400 force feeding residents. Review of a witness statement dated 01/28/26 by CNA #374 revealed he responded yes when asked if he had witnessed any resident being mistreated or abused. CNA #374 revealed CNA #400 had yelled at Resident #6 and had force fed Resident #243. CNA #374 revealed the incidents were reported to the Assistant Director of Nursing (ADON) #370 and the Director of Nursing (DON). There was no documentation CNA #374 was further interviewed regarding the additional abuse allegations. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 CNA #400 was cursing at lunch and cursed at Resident #193 who was sleeping to wake up and eat. DS #367 revealed this had been going on for weeks/months. DS #367 revealed she had made reports of her yelling at the residents. DS #367 noted CNA #400 was mean to the residents. There was no documentation DS #367 was asked additional questions regarding her previous reports of CNA #400's treatment of residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed at the lunch meal on 01/27/26 CNA #400 was opening swearing at other staff members regarding personal frustration or for being suggested to follow specific diet orders/recommendations. Review of a witness statement dated 01/29/26 by CNA #400 revealed she had denied verbally abusing Resident #193. There was no documentation CNA #400 was questioned regarding the additional allegations of abuse for Resident #243, Resident #244, Resident #93, Resident #193 and Resident #6. Interview on 02/03/26 at 10:07 A.M., LPN #488 revealed he had not witnessed resident abuse and had no reports of resident abuse from staff.Interview on 02/03/26 at 3:12 P.M., Certified Nursing Assistant (CNA) #350 revealed CNA #400 was cursing in the dining room. CNA #350 revealed CNA #400 would yell at residents to eat, and had force fed Resident #129 and Resident #193. CNA #350 revealed CNA #400 would put a spoon to Resident #193's mouth and the resident shook his head no. CNA #350 revealed CNA #400 then forced the spoon inside the resident's mouth. CNA #350 also revealed CNA #400 had forced a spoon into the mouth of Resident #129. CNA #350 also reported CNA #400 would awaken former Resident #244 and Resident #93 during meal service with sternal rubs. CNA #350 revealed she told CNA #400 to stop her actions but it went in one ear and out the other. CNA #350 revealed the incidents were reported to LPN #488 and LPN #402. Interview on 02/03/26 at 3:31 P.M., CNA #374 revealed he had witnessed CNA #400 and Resident #6 yelling at each other outside the dining room. CNA #374 also revealed he saw CNA #400 force fed former Resident #243 by literally forcing the food in the resident's mouth. CNA #374 revealed he had reported the incidents to LPN #302 who then reported the incident to ADON #370.Interview on 02/03/26 at 3:50 P.M., LPN #302 revealed CNA #374 had never reported CNA #400 force feeding a resident or yelling at a resident. LPN #302 revealed she had not witnessed any resident abuse during the lunch meal on 01/27/26. LPN #302 revealed force feeding a resident was abusive and she would have immediately reported the abuse. Interview on 02/04/26 at 8:15 A.M., LPN #402 revealed he had never witnessed CNA #400 force feeding residents or performing sternal rubs on a resident. LPN #402 also revealed no staff had reported these allegations of abuse as they would have been immediately reported to a supervisor. Interview on 02/04/26 at 9:28 A.M., Supervisor RN #340 revealed anything significant from interviews conducted during an abuse investigation would be added to the summary report. RN #340 revealed the investigations were a team effort ultimately reviewed by the DON and the Administrator. RN #340 revealed he had interviewed CNA #374. RN #340 revealed CNA #374 had a meeting with the DON and had reported his concerns to her. RN #340 revealed the DON called me and told me to interview additional staff. RN #340 was not aware of any Self-Reported Incident or investigation for CNA #374's allegations. RN #340 revealed force feeding would be considered abusive. RN #340 revealed he could not recall staff reporting a nursing assistant completing a sternal rub. RN #340 revealed he had limited involvement in the investigation and was not familiar with CNA #400 or the involved residents. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed DS #367 had reported CNA #400 was at the meal service window cursing and had done so frequently. RN #342 revealed she asked ST #324 and CNA #400 to write statements. RN #342 revealed she notified the Director of Nursing and the Administrator. RN #342 revealed she was instructed to remove CNA #400 from the floor and begin an investigation. RN #342 revealed she spoke with Resident #193 who could not recall the incident. RN #342 revealed the residents on the unit were interviewed and skin sweeps were completed on the residents who could not be interviewed. RN #342 revealed the staff working the unit were asked to write statements. RN #342 revealed she was unaware the dietician was present on the unit during the meal service. RN #342 revealed the information for the investigation was gathered and the Administrator and DON completed the final review. RN #342 revealed force feeding a resident would be considered abuse and should be reported. RN #342 revealed she was not made aware of an allegation of CNA #400 waking up residents with a sternal rub which should not be completed by a nursing assistant. Interview on 02/04/26 at 11:05 A.M., Dietary Staff (DS) #367 revealed on 01/27/26 as staff were serving the lunch meal, CNA #400 was cursing at other staff and then went up Resident #193 and cursed at him to wake up. DS #367 revealed ST #324 told her they needed to do something about this and ST #324 needed her to back him up on this. DS #367 revealed the incident was reported to the head nurse. DS #367 revealed a couple months earlier that CNA #400 had yelled at a resident to sit down and shut up and had also yelled at another resident to get their head off of the table. DS #367 revealed she had reported the incidents to the nursing supervisor RN #602. DS #367 revealed she had discussed one incident in person with RN #602 and another incident over the phone with RN #602. DS #367 revealed she had not been asked to write a statement regarding the prior incidents.Interview on 02/04/26 at 1:46 P.M., the DON revealed the Administrator, and the DON should be notified when additional allegations of abuse were discovered during an abuse investigation. The DON revealed the nursing supervisors should be reviewing witness statements and additional allegations should be reported and additional investigations added. The DON revealed she had not reviewed the staff witness statements. The DON revealed she had not been notified of staff force feeding a resident. The DON verified the facility had not completed Self-Reported Incidents (SRI) for the additional allegations brought forward during the investigation of verbal abuse on 01/27/26. The DON revealed CNA #374 had talked to her on 01/30/26 and had never mentioned any abuse concerns during the two times she spoke with him. The DON also revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse. Interview on 02/04/26 at 2:39 P.M., RN #602 revealed he was aware of the allegation of CNA #400 force feeding residents. RN #602 revealed he had not reported the allegation as CNA #400 was already off from work on administrative leave. RN #602 revealed he should have reported the allegation as force feeding would be considered abusive. RN #602 revealed he could not recall if DS #367 had reported allegations of resident mistreatment by CNA #400 in the past. Interview on 02/04/26 at 4:15 P.M., Dietary Supervisor (DS) #610 revealed DS #367 had concerns regarding how a nursing assistant was treating the residents. DS #610 revealed he dialed RN #602's number for DS #367 to speak with RN #602. DS #610 revealed he heard DS #367 reporting to RN #602 about a nursing assistant being mean to the residents. Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse. Interview on 02/05/26 at 9:30 A.M., the Assistant Director of Nursing (ADON) #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later. Further interview with ADON #370 revealed she was aware of an allegation of former Resident #243 being force fed but she had talked to the resident's wife who said the resident had not been force fed. ADON #370 verified the allegation was not reported or further investigated. Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility would investigate all allegation of alleged violations by identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnessed, and others who might have knowledge of the allegations. The facility would provide complete thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents, remove the accused, notify the Administrator, notify the facility police department, notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed all alleged violations of any form of abuse would be reported immediately, but no later than two hours after the allegation was made if the events cause the involve abuse or serious bodily injury. The Administrator would report allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Only the Administrator in consultation with the Superintendent and Chief Compliance Office can determine if abuse occurred. The facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to implement their abuse policy to provide timely interventions and further failed to provide notification to the appropriate medical and support staff for follow-up services. This affected one (#193) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.Findings include:Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Also, the facility implemented an intervention for psychiatric services but there was no documentation the facility had timely contacted psychiatric services for resident care follow-up.Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurse's notes from 01/27/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Further review of the progress notes from 01/27/26 through 02/04/26 revealed no documentation psychiatric services was notified and no documentation the resident was seen by psychiatric services after the alleged abuse. Interview on 02/04/26 at 1:46 P.M., the Director of Nursing (DON) revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse.Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse.Interview on 02/05/26 at 9:30 A.M., the Assistant Director of Nursing (ADON) #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later.Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility the facility would provide complete and thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents. The facility would notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed the facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

Based on review of the medical record, review of staff statements, staff interview, and policy review, the facility failed to ensure food items were provided per physician orders. This affected one (#93) of three residents reviewed for dietary services and had the potential to affect 14 residents identified by the facility with physician orders for mechanically altered diet textures. The facility census was 242.Findings include:Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the care plan last revised 02/03/26 revealed the resident was at risk for aspiration due to a history of dysphagia. Interventions included to monitor for choking and for signs/symptoms of aspiration and notify physician as needed. Review of the nutritional care plan last revised 12/03/24 revealed the resident was at nutritional risk due to dementia, diabetes mellitus, chronic kidney disease, and dysphagia. Interventions included a high protein diet, pureed texture, nectar consistency via nosey cup with three to four pumps thickener. Additional interventions included to monitor for chewing/swallowing problems or choking. Also for direct one to one supervision with small bite sizes, slowed rate of consumption, and alternation of foods/drinks every two to three bites.Review of the physician orders dated 12/22/25 revealed Resident #93 was ordered a high protein, pureed texture diet with nectar consistency. Further review of physician orders dated 08/14/25 revealed the resident required direct one to one supervision with implementation of small bites, slowed rate of consumption, and alternation of foods/drinks every two to three bites. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 Certified Nursing Assistant (CNA) #400 was always telling her to do things other than what was on the meal tickets for the residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed on 01/27/26 he had been informed by a nursing assistant that CNA #400 had provided Resident #93 with a banana during snack time despite the resident being on a pureed diet and without his direct presence on the unit. ST #324 revealed the resident had an order for direct one to one assistance/supervision due to an extensive history of suspected aspiration/penetration episodes during intake. Review of a witness statement dated 01/29/26 by CNA #400 revealed CNA #400 was asked if she had given residents food or requested items not listed on the meal ticket. CNA #400 responded yes. CNA #400 was asked if she had given resident food items that had not followed their diet order such as giving a resident a banana who had a pureed diet order. CNA #400 responded yes and noted she had approval from ST #324 as long as the resident was awake and alert. Further review of the medical record, assessments, and nurse's notes dated 01/29/26 revealed no documentation Resident #93 had a respiratory assessment after receiving food with the incorrect texture per dietary orders. Interview on 02/03/26 at 1:36 P.M., ST #324 revealed CNA #350 had reported CNA #400 gave Resident #93 a whole banana despite prior education on following dietary orders. ST #324 revealed the resident was on a pureed diet and he had never okayed the resident getting a banana without his direct supervision. ST #324 revealed the resident was at risk for aspiration. ST #324 revealed he had not assessed the resident after he was notified the resident was given the banana. ST #324 revealed he reported the incident to a nursing supervisor. Interview on 02/03/26 at 3:12 P.M., CNA #350 revealed CNA #400 would serve residents the incorrect diet textures. CNA #350 revealed Resident #93 required a pureed diet but CNA #400 gave the resident a whole banana for breakfast on 01/27/26. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed ST #324 reported CNA #400 gave a resident the wrong food and had also done this in the past with the behavior continuing.Interview on 02/024/26 at 1:46 P.M., the Director of Nursing (DON) verified there was no documentation Resident #93 had a respiratory assessment completed on 01/27/26 after being given the wrong textured food item. Review of the facility policy Dysphagia, dated 08/19/24, revealed the food service manager would follow any written orders for diet and fluid consistency and educate staff and supervise preparation of altered consistency diets. The nursing staff would follow any written physician orders. This deficiency represents non-compliance investigated under Complaint Number 2731992.

Based on observation, review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to thoroughly investigate allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Further review of the investigation report revealed the facility had not interviewed all staff present in the dining room during lunch at the time of the allegation of verbal abuse. Further review of the staff witness statements revealed staff had reported additional allegations of resident abuse against CNA #400 with no documentation of an investigation and no Self-Reported Incidents submitted to the state agency regarding the allegations. Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurse's notes from 01/17/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Also, the facility implemented an intervention for a psychiatric consult but there was no documentation the facility had contacted psychiatric services for resident follow-up.2. Review of the closed medical record for Resident #244 revealed an admission date of 04/16/25 and a discharge date of 01/23/26. Diagnoses included dementia, type two diabetes mellitus, and aphasia. Review of the quarterly MDS dated [DATE] revealed the resident required substantial/maximal assistance for eating.Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #244 revealed no documentation of the allegation of abuse.Review of the facility SRIs also revealed no reported allegations of physical abuse by staff for Resident #244.3. Review of the closed medical record for Resident #243 revealed an admission date of 08/01/23 and a discharge date of 01/27/26. Diagnoses include Alzheimer's disease, Parkinson's disease, dementia, aphasia, and dysphagia oral phase.Review of the significant change MDS dated [DATE] revealed Resident #243 had severe cognitive impairment. The resident was dependent on staff for meal assistance. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #243 revealed no documentation of alleged staff to resident abuse. Review of the facility SRIs revealed no reported allegations of abuse by staff for Resident #243. 4. Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the nurse's notes from 01/01/26 through 02/03/26 for Resident #93 revealed no documentation of allegations of abuse. Review of the facility SRIs revealed no allegations of staff to resident abuse had been submitted for Resident #93. 5. Review of the medical record for Resident #129 revealed an admission date of 04/07/25. Diagnoses include Alzheimer's disease, dementia, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident required set-up assistance for meals. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #129 revealed no documentation of an abuse allegation. Review of the facility SRIs revealed no SRIs submitted for staff to resident abuse for Resident #129.6. Review of the medical record for Resident #6 revealed an admission date of 12/04/12. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #6 revealed no documentation of allegations of abuse.Review of the facility SRIs also revealed no reported allegations of staff to resident abuse for Resident #6. Review of a witness statement dated 01/28/26 by CNA #350 revealed on 01/27/26 Resident #193 was sleeping during lunch and CNA #400 went up to him and was yelling in his ear to keep waking him up to eat. CNA #350 noted CNA #400 was cursing in the dining room, and yelling at the residents to wake up and eat. CNA #350 noted CNA #400 was not compliant with the resident's diet orders and it was not unusual for her to force feed the residents. There was no documentation CNA #350 was further questioned regarding the allegation of CNA #400 force feeding residents. Review of a witness statement dated 01/28/26 by CNA #374 revealed he responded yes when asked if he had witnessed any resident being mistreated or abused. CNA #374 revealed CNA #400 had yelled at Resident #6 and had force fed Resident #243. CNA #374 revealed the incidents were reported to the Assistant Director of Nursing (ADON) #370 and the Director of Nursing (DON). There was no documentation CNA #374 was further interviewed regarding the additional abuse allegations. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 CNA #400 was cursing at lunch and cursed at Resident #193 who was sleeping to wake up and eat. DS #367 revealed this had been going on for weeks/months. DS #367 revealed she had made reports of her yelling at the residents. DS #367 noted CNA #400 was mean to the residents. There was no documentation DS #367 was asked additional questions regarding her previous reports of CNA #400's treatment of residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed at the lunch meal on 01/27/26 CNA #400 was opening swearing at other staff members regarding personal frustration or for being suggested to follow specific diet orders/recommendations. Review of a witness statement dated 01/29/26 by CNA #400 revealed she had denied verbally abusing Resident #193. There was no documentation CNA #400 was questioned regarding the additional allegations of abuse for Resident #243, Resident #244, Resident #93, Resident #193 and Resident #6. Further review of the witness statements revealed no documentation of a witness statement by Registered Dietitian (RD) #318. Observation on 02/03/26 at 11:27 A.M. with the DON and Police Chief (PC) #648 of video surveillance dated 01/27/26 during the lunch meal on Unit 3 South from 12:20 P.M. through 1:08 P.M. revealed residents were in the dining room with staff serving and assisting the residents with meals. Staff present during the meal service in the dining room identified by PC #648 and the DON included CNA #400, CNA #350, CNA #330, Licensed Practical Nurse (LPN) #302, ST #324, RD #318, CNA #308, and DS #367. The DON verified RD #318 had not been interviewed regarding the incident. Further observations of the video surveillance revealed CNA #400 sat down briefly by Resident #193 during the meal. The surveillance video contained no audio and it could not be determined if CNA #400 was cursing or yelling at Resident #193. Interview on 02/03/26 at 10:07 A.M., LPN #488 revealed he had not witnessed resident abuse and had no reports of resident abuse from staff.Interview on 02/03/26 at 3:12 P.M., CNA #350 revealed CNA #400 was cursing in the dining room. CNA #350 revealed CNA #400 would yell at residents to eat, and had force fed Resident #129 and Resident #193. CNA #350 revealed CNA #400 would put a spoon to Resident #193's mouth and the resident shook his head no. CNA #350 revealed CNA #400 then forced the spoon inside the resident's mouth. CNA #350 also revealed CNA #400 had forced a spoon into the mouth of Resident #129. CNA #350 also reported CNA #400 would awaken former Resident #244 and Resident #93 during meal service with sternal rubs. CNA #350 revealed she told CNA #400 to stop her actions but it went in one ear and out the other. CNA #350 revealed the incidents were reported to LPN #488 and LPN #402. Interview on 02/03/26 at 3:31 P.M., CNA #374 revealed he had witnessed CNA #400 and Resident #6 yelling at each other outside the dining room. CNA #374 also revealed he saw CNA #400 force fed former Resident #243 by literally forcing the food in the resident's mouth. CNA #374 revealed he had reported the incidents to LPN #302 who then reported the incident to ADON #370.Interview on 02/03/26 at 3:50 P.M., LPN #302 revealed CNA #374 had never reported CNA #400 force feeding a resident or yelling at a resident. LPN #302 revealed she had not witnessed any resident abuse during the lunch meal on 01/27/26. LPN #302 revealed force feeding a resident was abusive and she would have immediately reported the abuse. Interview on 02/04/26 at 8:15 A.M., LPN #402 revealed he had never witnessed CNA #400 force feeding residents or performing sternal rubs on a resident. LPN #402 also revealed no staff had reported these allegations of abuse as they would have been immediately reported to a supervisor. Interview on 02/04/26 at 9:28 A.M., Supervisor RN #340 revealed anything significant from interviews conducted during an abuse investigation would be added to the summary report. RN #340 revealed the investigations were a team effort ultimately reviewed by the DON and the Administrator. RN #340 revealed he had interviewed CNA #374. RN #340 revealed CNA #374 had a meeting with the DON and had reported his concerns to her. RN #340 revealed the DON called me and told me to interview additional staff. RN #340 was not aware of any Self-Reported Incident or investigation for CNA #374's allegations. RN #340 revealed force feeding would be considered abusive. RN #340 revealed he could not recall staff reporting a nursing assistant completing a sternal rub. RN #340 revealed he had limited involvement in the investigation and was not familiar with CNA #400 or the involved residents. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed DS #367 had reported CNA #400 was at the meal service window cursing and had done so frequently. RN #342 revealed she asked ST #324 and CNA #400 to write statements. RN #342 revealed she notified the Director of Nursing and the Administrator. RN #342 revealed she was instructed to remove CNA #400 from the floor and begin an investigation. RN #342 revealed she spoke with Resident #193 who could not recall the incident. RN #342 revealed the residents on the unit were interviewed and skin sweeps were completed on the residents who could not be interviewed. RN #342 revealed the staff working the unit were asked to write statements. RN #342 revealed she was unaware the dietician was present on the unit during the meal service. RN #342 revealed the information for the investigation was gathered and the Administrator and DON completed the final review. RN #342 revealed force feeding a resident would be considered abuse and should be reported. RN #342 revealed she was not made aware of an allegation of CNA #400 waking up residents with a sternal rub which should not be completed by a nursing assistant. Interview on 02/04/26 at 11:05 A.M., DS #367 revealed on 01/27/26 as staff were serving the lunch meal, CNA #400 was cursing at other staff and then went up Resident #193 and cursed at him to wake up. DS #367 revealed ST #324 told her they needed to do something about this and ST #324 needed her to back him up on this. DS #367 revealed the incident was reported to the head nurse. DS #367 revealed a couple months earlier CNA #400 had yelled at a resident to sit down and shut up, and had also yelled at another resident to get their head off of the table. DS #367 revealed she had reported the incidents to the nursing supervisor RN #602. DS #367 revealed she had discussed one incident in person with RN #602 and another incident over the phone with RN #602. DS #367 revealed she had not been asked to write a statement regarding the prior incidents.Interview on 02/04/26 at 1:46 P.M., the DON revealed the Administrator and the DON should be notified when additional allegations of abuse were discovered during an abuse investigation. The DON revealed the nursing supervisors should be reviewing witness statements and additional allegations should be reported and additional investigations added. The DON revealed she had not reviewed the staff witness statements. The DON revealed she had not been notified of staff force feeding a resident. The DON verified the facility had not completed Self-Reported Incidents (SRI) for the additional allegations brought forward during the investigation of verbal abuse on 01/27/26. The DON revealed CNA #374 had talked to her on 01/30/26 and had never mentioned any abuse concerns during the two times she spoke with him. The DON also revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse. Interview on 02/04/26 at 2:39 P.M., RN #602 revealed he was aware of the allegation of CNA #400 force feeding residents. RN #602 revealed he had not reported the allegation as CNA #400 was already off from work on administrative leave. RN #602 revealed he should have reported the allegation as force feeding would be considered abusive. RN #602 revealed he could not recall if DS #367 had reported allegations of resident mistreatment by CNA #400 in the past. Interview on 02/04/26 at 4:15 P.M., Dietary Supervisor (DS) #610 revealed DS #367 had concerns regarding how a nursing assistant was treating the residents. DS #610 revealed he dialed RN #602's number for DS #367 to speak with RN #602. DS #610 revealed he heard DS #367 reporting to RN #602 about a nursing assistant being mean to the residents. Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse. Interview on 02/05/26 at 9:30 A.M., the ADON #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later. Further interview with ADON #370 revealed she was aware of an allegation of former Resident #243 being force fed but she had talked to the resident's wife who said the resident had not been force fed. ADON #370 verified the allegation was not reported or further investigated. Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility would investigate all allegation of alleged violations by identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnessed, and others who might have knowledge of the allegations. The facility would provide complete and thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents, remove the accused, notify the Administrator, notify the facility police department, notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed all alleged violations of any form of abuse would be reported immediately, but no later than two hours after the allegation was made if the events cause the involve abuse or serious bodily injury. The Administrator would report allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Only the Administrator in consultation with the Superintendent and Chief Compliance Office can determine if abuse occurred. The facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of the medical record, review of a facility Self-Reported Incident (SRI), review of an SRI investigation, review of staff statements, review of the staffing schedule, review of employee time records, review of a police report, review of video surveillance, review of an incident report, staff interviews, resident interview, family interview, and review of facility policy, the facility staff failed to ensure Resident #241 was free from staff to resident verbal and physical abuse. This resulted in Immediate Jeopardy when Resident #241 was thrown from his wheelchair on 09/16/25 at approximately 7:50 P.M. by Licensed Practical Nurse (LPN) #602 placing the resident at risk for potential serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report resident abuse to the administrator placing 26 additional residents who resided on the Memory Care Unit at risk for abuse. On 09/16/25 beginning at approximately 7:50 P.M., Certified Nursing Assistant (CNA) #400 witnessed LPN #602 aggressively pushing Resident #241 out of his room and swearing at the resident while the resident was trying to stop the wheelchair by reaching out his arms, placing his feet on the ground and yelling no. LPN #602 then continued to push Resident #241 toward the nurses' station where LPN #602 hit the resident's arm and pulled on the back of the resident's shirt to keep the resident in the wheelchair. LPN #602 then aggressively pushed Resident #241 in his wheelchair into a recliner causing the resident to fly forward hitting the recliner and then landing on the floor. While Resident #241 was on the floor, LPN #602 tried to pick the resident up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 sat in the resident's wheelchair next to the resident on the floor and later kicked the back of the resident's right leg. CNA #400 failed to intervene to protect the resident and failed to call for additional help. LPN #614 arrived on the unit and LPN #602 reported the resident had fallen. Registered Nurse (RN) Supervisor #700 then arrived on the unit to assess Resident #241 all while LPN #602 remained working on the Memory Care Unit until CNA #400 reported the abuse to RN Supervisor #700 at approximately 9:15 P.M. This resulted in serious psychosocial harm as Resident #241 was agitated and upset attempting to get away from LPN #602. Resident #241 also sustained three skin tears to the bilateral upper extremities. Furthermore, all residents on the Memory Care Unit were placed at potential risk for serious injury and/or harm when LPN #602 continued to work on the unit until 9:15 P.M. This affected one (#241) of four residents reviewed for abuse and had the potential to affect 26 additional residents (#02, #08, #30, #33, #35, #49, #59, #87, #90, #91, #95, #99, #103, #109, #117, #121, #123, #152, #154, #165, #174, #188, #190, #209, #216, and #220) residing on the Memory Care unit. The facility census was 241. On 10/20/25 at 4:52 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 09/16/25 at 7:50 P.M., when Resident #241 was thrown from his wheelchair by LPN #602 placing the resident at risk for serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report resident abuse to the administrator placing 26 additional residents who resided on the Memory Care Unit at risk for abuse. On 09/16/25 beginning at approximately 7:50 P.M., CNA #400 witnessed LPN #602 aggressively pushing Resident #241 out of his room and swearing at the resident while the resident was trying to stop the wheelchair by reaching out his arms, placing his feet on the ground and yelling no. LPN #602 then continued to push Resident #241 toward the nurses' station where LPN #602 hit the resident's arm and pulled on the back of the resident's shirt to keep the resident in the wheelchair. LPN #602 then aggressively pushed Resident #241 in his wheelchair into a recliner causing the resident to fly forward hitting the recliner and then landing on the floor. While Resident #241 was on the floor, LPN #602 tried to pick the resident up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 sat in the resident's wheelchair next to the resident on the floor and later kicked the back of the resident's right leg. CNA #400 failed to intervene to protect the resident and failed to call for additional help. LPN #614 arrived on the unit and LPN #602 reported the resident had fallen. RN Supervisor #700 then arrived on the unit to assess Resident #241 all while LPN #602 remained working on the Memory Care Unit until CNA #400 reported the abuse to RN Supervisor #700 at approximately 9:15 P.M. This resulted in serious psychosocial harm as Resident #241 was agitated and upset attempting to get away from LPN #602. Resident #241 also sustained three skin tears to the bilateral upper extremities. Furthermore, all residents on the Memory Care unit were placed at potential risk for serious injury and/or harm when LPN #602 continued to work on the unit 9:15 P.M. Although the Immediate Jeopardy was removed on 09/19/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 09/25/25 when the facility implemented the following corrective actions: On 09/16/25 at 9:15 P.M., CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700. On 09/16/25 at 9:16 P.M., off duty RN Supervisor #772 called to report the allegation of abuse to the police department. On 09/16/25 at 9:18 P.M., RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor. On 09/16/25 at 9:22 P.M., Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse. On 09/16/25 at 9:23 P.M., ADON #549 notified the DON of the allegation of abuse. On 09/16/25 at 9:28 P.M., RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse. On 09/16/25 at 9:29 P.M., RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit. On 09/16/25 at 9:29 P.M., RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed on 09/18/25. On 09/16/25 at 9:29 P.M., Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400. On 09/16/25 at 10:09 P.M., the DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately. LPN #602 was also informed to report on 9/17/25 at 3:00 P.M. to the Police Department for questioning and interviewing. On 09/16/25 at 11:45 P.M., RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment at 7:55 P.M. On 09/17/25 at 12:28 A.M., RN #740 emailed a request for psychiatric services to evaluate Resident #241. On 09/17/25 at 6:00 A.M., ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit. On 09/17/25 at 6:00 A.M., LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before. On 09/17/25 at 6:00 A.M., RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift nursing staff. On 09/17/25 at 7:52 A.M., ADON #549 notified Resident #241's guardian of the allegation of abuse. On 09/17/25 at 8:37 A.M., ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241. On 09/17/25 at 9:00 A.M., the Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457. On 09/17/25 at 11:12 A.M., psychiatric services responded to an email indicating they would evaluate Resident #241 on 09/17/25; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention. On 09/17/25 at 11:17 A.M., ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education. On 09/17/25 at 3:00 P.M., LPN #602 reported to the police department and was interviewed by Lieutenant #457. On 09/17/25 at 3:15 P.M., the Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse. On 09/18/25, Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241. Resident #241's BIMS score was six out 15 indicating severe cognitive impairment. On 09/18/25, resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks. Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit. Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required. Subsequent document review revealed resident weekly skin assessments were completed 09/16/25 through 10/09/25. Resident Safety Monitoring was completed for five residents on 09/18/25, 09/19/25, 09/22/25, 09/24/25, 09/26/25, 09/29/25, 10/01/25, 10/03/25, 10/07/25, and 10/09/25. On 09/18/25, education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed by 09/25/25. On 09/19/25 at 9:00 A.M., the QAPI Committee (Superintendent #990, Administrator, DON, Social Services #433, ADON #464, ADON #634, Infection Preventionist #671, Chief Compliance Officer #994, Police Chief #409, Lieutenant #457, Medical Director #688, Pharmacy Staff #453, Activities Staff #570, Support Services #632, ADON #721, MDSRN #472, and Rehabilitation Staff #995 met via TEAMS to discuss this allegation of abuse and the mitigation items put into place. On 09/19/25 at 4:30 P.M., psychiatric services evaluated Resident #241 with no new recommendations. On 10/01/25 at 9:30 A.M., the Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy. On 10/15/25 and 10/16/25, interviews with 15 staff (RN #700, LPN #614, LPN #960, LPN #911, LPN #901, LPN #637, CNA #400, CNA #293, CNA #770, CNA #663, CNA #296, CNA #292, CNA #725, CNA #714, and CNA #684) verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge. Review of the medical record for Resident #241 revealed an admission date of 06/10/24. Diagnoses included Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident required substantial/maximal assistance with toileting and partial/moderate assistance with transfers. Review of Resident #241's plan of care for non-compliant behaviors initiated 10/09/24 and last revised 03/21/25 revealed the resident had the potential to be non-compliant with refusing his medications, treatments, and peri-care at times. Interventions included acknowledging the resident's right to refuse or choose against recommended treatment. Staff should offer education and reassurance to resident as needed. Staff would review non-compliance with the physician and other members of the Interdisciplinary Team (IDT) as needed. Further review of the care plan revealed the resident had anxiety at times. Interventions included attempting to find cause of anxiety, encouraging resident to voice needs and allowing resident time to do so and attempting to divert attention. Also, to maintain a calm manner while interacting with the resident and reduce sensory stimulation by maintaining a quiet environment. Staff were to monitor behaviors and notify the registered nurse and social worker as needed. Review of the resident's communication plan of care revealed the resident had difficulty finding words or finishing thoughts at times related to Alzheimer's disease. Interventions included explaining all procedures prior to beginning them, giving the resident simple one to two step commands while providing instructions. Also, for staff to monitor for non-verbal forms of communication such as smiling, facial grimaces, agitation, guarding, and pointing. Staff were to gain attention and eye contact before speaking to resident and ask simple questions that require yes or no answers, allowing time for response. Repeat or rephrase questions as needed to assure resident's understanding. Continued review of the care plan revealed the resident required placement in the Memory Care Unit due to cognitive impairment and dementia diagnoses and the resident could be resistive to care. Interventions included when the resident was upset, it would be helpful for him to feel better when someone listened to his concerns. Additionally, staff could show care/respect by being nice/friendly. Review of a skin observation report dated 09/15/25 revealed Resident #241 had bruising to the front right thigh, a scar to the front left lower leg, bruising to the left forearm, and skin tear to the right forearm measuring 3.8 centimeters (cm) in length by 0.3 centimeters in width. Review of video surveillance footage dated 09/16/25 beginning at approximately 7:50 P.M., revealed LPN #602 entered Resident #241's room. LPN #602 remained in the room for approximately 20 seconds then LPN #602 aggressively wheeled Resident #241 out of his room while the resident was attempting to stop the wheelchair by putting his feet down and grabbing the door. CNA #400 could be seen walking toward Resident #241 and LPN #602 as the incident occurred. LPN #602 continued to wheel the resident up to the nurse's station. LPN #602 can be seen hitting the resident's right arm and grabbing and pulling the back of the resident's shirt as he was attempting to move away from the nurse while the nurse continued to hold the wheelchair in place. LPN #602 can be seen moving his mouth and pointing and appeared to be speaking to the resident. Approximately a minute later, CNA #400 approached LPN #602 at the nurse's station while carrying a white packet which LPN #602 opened and handed back to her. CNA #400 then returned to the hallway. Resident #241 appeared agitated and in distress. Approximately 30 seconds later, LPN #602 then aggressively pushed Resident #241 in his wheelchair forcefully and directly slamming the resident's legs into the front of the recliner causing the resident to fly forward hitting the recliner then landing on the floor with CNA #400 present and witnessing the incident. LPN #602 attempted to pick Resident #241 up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 remained standing over the resident while he was on the floor. LPN #602 glanced at the camera several times then removed his name badge. Less than a minute after slamming the resident into the recliner, LPN #602 moved the resident's wheelchair back and then sat in the resident's wheelchair next to the resident on the floor. Approximately 25 seconds after sitting in the resident's chair as LPN #614 was walking down the hall looking toward the resident on the floor, LPN #602 lifted his left leg and kicked the back of the resident's lower right leg as LPN #614 arrived at her medication cart near the nurse's station. LPN #614 remained at the medication cart for over a minute looking at her computer screen while CNA #400 approached Resident #241 and LPN #602 as LPN #602 appeared to be speaking. CNA #400 stood there for one minute before leaving toward the hallway behind the nurse's station. LPN #614 was then seen at the desk using the phone about five minutes after the incident began. CNA #400 returned to the resident's hallway and continued cleaning up water from the floor in the hallway. CNA #400 was not seen intervening between the resident and the nurse to protect the resident and CNA #400 was not seen attempting to call for additional help. As LPN #614 was on the phone, about one minute later RN Supervisor #700 arrived on the unit and then began addressing Resident #241. Continued review of the video surveillance revealed on 09/16/25 at 8:09 P.M. and 8:13 P.M., LPN #602 was seen continuing to work on the unit. Review of an incident report dated effective 09/16/25 at 7:55 P.M. revealed RN Supervisor #700 received a statement of alleged physical and verbal abuse from CNA #400 towards Resident #241. Resident #241 was unable to give a description. ADON #549 was notified, the staff member was removed from the floor immediately, and the resident was assessed. Psychiatric services and social services were notified. No injuries observed at the time of the incident. The physician was notified on 09/17/25 at 8:37 A.M. and the resident's guardian notified on 09/17/25 at 7:52 A.M. Review of a late entry nurses note by RN #740 effective for 9/16/25 at 7:55 P.M. with the document created on 09/16/25 at 11:14 P.M revealed a skin assessment had been completed for Resident #241 and three skin tears were added to the skin editor. Review of a nurses note by LPN #614 dated effective for 9/16/25 at 7:58 P.M. with the documentation not created until 09/16/25 at 9:08 P.M., revealed Resident #241 stated he needed to go the bathroom. CNA #400 attempted to assist the resident who then refused care while cussing and yelling at the CNA. When leaving the room, Resident #241 then attempted to enter another resident's room causing that resident to yell at Resident #241. Resident #241 yelled this is my room. Resident #241 was redirected to his room with his name on it and the resident then stated, I know they invited me over there. Resident #241 then wheeled himself to the sink and started to brush his teeth. Review of a nurses note by LPN #614 with an effective date of 9/16/25 at 8:09 P.M. with the document not created until 09/16/25 at 9:21 P.M., revealed a nursing assistant observed water throughout the hallway and a few resident rooms with water on floors. The nurse noted Resident #241 was observed coming out of his bathroom from his room with a urinal he had just filled from the hopper on the back of the toilet. Resident #241 was then observed raising the urinal and throwing water all over the hallway floors and his room floor. Review of a nurses note dated 9/16/25 at 8:32 P.M., LPN #602 documented assisting Resident #241 to a stationary chair in the common area. Resident #241 attempted to stand up from the wheelchair and landed on the floor on his knees. Resident noted clothed and wearing shoes in good condition. Resident denied pain. The floor was dry and free of debris. Range of motion times four and resident assessed. LPN #602 noted no injuries to the resident's knees. Staff assisted resident to the stationary chair. Interventions included a bladder scan and toileting assistance. LPN #602 initiated an incident report on 09/16/25 at 8:00 P.M. noting the resident had no injuries. LPN #602 notified the guardian on 09/16/25 at 8:12 P.M. and the physician at 8:32 P.M. Review of a facility Self-Reported Incident (SRI) dated 09/16/25 at 9:47 P.M. and review of the subsequent investigation reports revealed on 09/16/25 at approximately 9:15 P.M., the facility became aware of an allegation of staff to resident abuse on the Memory Care Unit. The facility noted the incident affected the resident causing agitation. The police were notified on 09/16/25 at 9:20 P.M. Resident #241 sustained skin injuries from fall occurring during the incident. The resident representative was notified on 09/17/25 at 7:52 A.M. Resident #241 was unable to provide useful information. Further review of the SRI investigation revealed CNA #400 informed the facility that LPN #602 was pushing Resident #241 in his wheelchair and yelling at the resident. The resident's knees struck the front of the recliner, causing him to fall forward out of the wheelchair and onto the floor because of LPN #602 pushing the resident aggressively in the wheelchair and during transfer the resident fell onto the floor. LPN #602 admitted to using inappropriate language while assisting the resident and spoke loudly due to the resident being hard of hearing. LPN #602 admitted to using excessive force when transferring the resident into the recliner by grabbing the resident's waistband and shorts. A head-to-toe assessment of Resident #241 was completed by RN #740 revealing skin injuries including an abrasion. During RN #740's assessment the resident had stated the nurse had hit him. Further review of the facility SRI investigation revealed the resident had one skin tear to the left upper arm, one skin tear to the left upper forearm, and one skin tear to the left upper arm above elbow and it was unknown if the injuries were caused by LPN #602. The resident displayed expressions of anger while in the presence of LPN #602. Review of a description of the incident revealed LPN #602 was removed from the resident care area and escorted out of the facility. Further review of the follow-up SRI investigation report noted upon further review and confirmation by video surveillance, LPN #602 was arrested by the police department and transported to the county jail awaiting further court proceedings at this time related to pending charges of patient abuse and assault. The facility completed skin sweeps for all residents on the Memory Care Unit and requested a psychiatric evaluation for the resident. Review of the SRI facility conclusion revealed the allegation of abuse was substantiated and verified by evidence. Review of CNA #400's statement dated 09/16/25 at 9:15 P.M. revealed Resident #241 was filling the urinal with water and throwing water around the floor. CNA #400 revealed when she noticed the water she grabbed a spill kit/mop to attempt to get the water up per the nurse request. When returning, LPN #602 was pushing Resident #241 through the door very aggressively while calling the resident expletive names (vulgar or profane words used to express strong emotion). CNA #400 revealed she tried to take over and get Resident #241 to the common area, but LPN #602 kept pushing him in the wheelchair very aggressively while yelling at the resident. CNA #400 noted she believed the resident was not in his right mind, his sentences were not making sense, and he was scared. CNA #400 revealed when LPN #602 got the resident to the recliner in the common area he slammed his knees in the chair and body, and the resident fell. CNA #400 revealed LPN #602 had not carefully transferred the resident like we were instructed to do. CNA #400 revealed during report she was told Resident #241 was a stand lift, so when she saw how LPN #602 manhandled him, she was very scared. CNA #400 revealed she walked over to try and help get the resident up, but LPN #602 told her to keep cleaning the spill. CNA #400 revealed she had not wanted to leave Resident #241 as she was scared for him. CNA #400 revealed he had two bloody sores on his right and left arm. CNA #400 stated Resident #241 was stating how he thought LPN #602 was his friend and CNA #400 revealed that just broke my heart. CNA #400 revealed yes the resident was throwing water, but she had removed the urinal, it did not have to go that way. CNA #400 revealed LPN #602 stated Resident #241 climbed out of the chair to the other nursing assistant which was not true. Further review of CNA #400's interview dated and initialed 09/16/25 revealed CNA #400 indicated she had been educated on the abuse policy, had worked on the Memory Care Unit on 09/16/25 on second shift, had witnessed Resident #241 throw water on the floor, and had witnessed staff use inappropriate language and excessive force while assisting Resident #241. CNA #400 also documented when assisting Resident #241 to bed, the resident stated, that nurse hit me. Review of staff statements for four additional staff (LPN #614, CNA #997, CNA #998, and CNA #999) working on the unit at the time of the alleged abuse revealed the four employees were not present in the common area during the incident and had not witnessed the fall or abusive mistreatment of the resident. Review of LPN #602's employee timecard dated 09/16/25 revealed the nurse began their work shift at 2:43 P.M. and then punched out at 10:16 P.M. after being placed on administrative leave. Review of a nurses note by LPN #614 effective for 09/16/25 at 10:59 P.M. with the documentation not created until 09/16/25 at 11:43 P.M. revealed LPN #614 had observed Resident #241 coming out of the bathroom from his room in his wheelchair holding a urinal filled with water that was filled using the hopper from the toilet. The resident was asked what he was doing when he raised the urinal and started to throw water on the floor in the hallways and his room. LPN #614 documented the resident had three skin tears with skin flaps observed. One to the right upper arm measuring one centimeter (cm) in length by one cm in width; a second skin tear to the left back of upper arm measuring three cm in length by five cm in width; and a third skin tear to the left lower arm measuring two cm in length by three cm in width. The resident denied pain or discomfort with range of motion within normal limits to the bilateral upper extremities. LPN #614 noted the skin tears were cleansed with normal saline and a dressing was applied to all three skin tears with skin flap. A new intervention was initiated for padding for the pole behind the toilet. Review of a late entry nurses note by RN #740 effective for 09/16/25 at 11:45 P.M. with the documentation created on 09/18/25 at 11:16 A.M. revealed Resident #241 had a head-to-toe skin assessment completed with no new findings since previous assessment at 7:55 P.M. Review of a police report dated 09/16/25 through 09/24/25 revealed after reviewing witness statements and video surveillance there was overwhelming evidence beyond a reasonable doubt that LPN #602's actions warranted criminal charges. On 09/17/25, LPN #602 was charged with assault and patient abuse and taken to the county jail. On 09/24/25 the police department was notified LPN #602 had resigned his position from the facility. Further review of the police report revealed photographs of Resident #241 showing two wound treatment dressings to the right upper arm above the elbow dated 09/16/25 3-11 shift, and one wound dressing to the right upper forearm dated 09/16/25 7-3 shift. On the resident's left posterior upper arm above the elbow was a wound dressing dated 09/16/25 3-11 shift and a second wound dressing to the left lower arm dated 09/16/25 3-11 shift visible. The resident had multiple bruised areas from a previous fall. Review of the staffing schedule dated 09/16/25 for the Memory Care Unit revealed there were two nurses (LPN #602 and LPN #614) and four CNA's assigned to the unit on the 3:00 P.M. to 11:30 P.M. shift. CNA #400 was assigned to Resident #241. Review of a skin observation report dated 09/17/25 revealed the resident had a skin tear to the right upper arm measuring 1 cm in length by one cm in width by 0.1 cm in depth. A second skin tear to the left lower arm measuring two cm in length by three cm in width by 0.1 cm in depth. A third skin tear to the left posterior upper arm measuring three cm in length, five cm in width, with a depth of 0.1 cm. Review of a notification letter dated 09/17/25 revealed LPN #602 was informed and acknowledged placement on administrative leave. Review of an interdisciplinary progress note by ADON #549 revealed she had been called on 09/16/25 at 9:18 P.M. about a statement received by a nursing supervisor of a nursing assistant alleging physical and verbal abuse towards Resident #241 by his nurse. ADON #549 instructed the supervisor to remove the charge nurse from the floor immediately, and requested an RN assessment of the resident, skin sweeps on all residents on the unit and for psychiatric services to be notified. Review of a progress note by ADON #549 dated 09/17/25 at 7:58 A.M. revealed the social worker and herself spoke with the resident's representative about the incident of alleged abuse. Review of a medical provider progress note dated 09/17/25 at 10:21 A.M. revealed the resident was assessed with new orders to send to the emergency room for an acute urology evaluation due to urinary urgency, retention, and hematuria. Further review of the progress notes revealed Resident #241 was sent to the emergency room (ER) and treated for a urinary tract infection and ordered antibiotic treatment. The resident returned to the facility on [DATE] at 6:00 P.M. Subsequent review of the ER laboratory final urinalysis results revealed the resident had no urinary tract infection. Review of a progress note by LSW #473 dated 09/17/25 at 10:49 A.M. revealed Resident #241 was in good spirits and recognized the social worker. The social worker inquired how the resident was doing after the incident from the previous evening and the resident stated everything was fine yesterday and he felt good. Review of an IDT progress note by ADON #549 dated 09/17/25 at 12:09 P.M. and 12:14 P.M. revealed the IDT team met to discuss the resident's skin injury from 09/16/25 and to discuss the alleged incident between the resident and staff member. Interventions were noted as in place and the care plan was reviewed and revised. Review of a documented interview dated 09/17/25 with LPN #602 revealed LPN #602 stated and initialed yes he had been educated on the policy related to abuse, neglect, and misappropriation. LPN #602 documented yes and initialed he had worked on the Memory Care Unit on 09/16/25 on second shift. LPN #602 documented and initialed no he had not witnessed Resident #241 throwing water on the floor in his room. LPN #602 documented and initialed yes he had used inappropriate language while assisting Resident #241, additionally noted was spoke loud because resident hard of hearing. LPN #602 documented and initialed yes to using excessive force that could be viewed as aggressive while assisting Resident #241 and noted grabbed waist band of shorts to help transfer. LPN #602 documented and initialed yes to attempting to assist Resident #241 in/out of the common area recliners during the shift. LPN #602 documented and initialed yes Resident #241 had skin injuries prior to the fall and noted there were two skin injuries and LPN #614 had stated there were three total. LPN #602 documented and initialed no to kicking Resident #241 while he was on the floor. LPN #602's interview statement was signed and dated by him on 09/17/25. Review of a statement dated 09/18/25 at 12:23 P.M. by RN Supervisor #700 revealed he had not witnessed the fall or any abuse. RN Supervisor #700 revealed he arrived on the unit shortly after the incident and was not aware of any allegations of abuse until CNA #400 came to his office to report concerns. RN Supervisor #700 revealed he had entered the Memory Care Unit to complete rounds. LPN #614 requested help as RN Supervisor #700 observed Resident #241 on the floor with LPN #602 standing nearby. RN Supervisor #700 stated LPN #614 and LPN #602 reported the resident was throwing water from a urinal in the hallway. LPN #602 stated Resident #241 had climbed out of his wheelchair and sustained multiple skin tears in his room when he was throwing water. RN Supervisor #700 approached Resident #241 and LPN #[TRUNCATED]

Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, review of a hospital record, review of an employee skills checklist, and policy review, the facility failed to complete resident transfers using a mechanical lift with appropriate assistance as care planned and as ordered. Actual Harm occurred on 04/29/25 when Resident #2, who was care planned for two-person assistance with all personal care and had a physician order to always be transferred using two people, was transferred in her room by one staff member using a mechanical lift without assistance. Resident #2 sustained a right femur fracture as a result of the improper transfer. This affected one (#2) of three residents reviewed for accidents. The facility census was 223. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, peripheral vascular disease, and constipation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs) including transfers. Review of the care plan for Resident #2 dated 08/04/21 revealed Resident #2 required two staff persons for all personal care. Review of Resident #2's physician orders revealed an order dated 03/17/23 for Resident #2 to always be transferred by two persons. Review of an SRI and related investigation documentation dated 04/29/25 revealed on 04/29/25 Resident #2 was observed at dinner at approximately 7:45 P.M. and was noted to be not be acting right. Registered Nurse Clinical Care Coordinator (RNCCC) #200 documented noticeable painful facial grimacing and bruising to Resident #2's left leg and left facial abrasions, which RNCCC #200 felt was consistent with Resident #2 bumping her leg on the wall and rubbing her face with her hand as she often did. Upon further assessment, RNCCC #200 observed a deformity to Resident #2's right knee. Resident #2 was unable to verbalize to staff how she obtained the injuries. RNCCC #200 placed a call to Resident #2's primary care physician (PCP) and received orders to obtain x-rays of Resident #2's right knee and right hip. The facility was informed by the x-ray company that Resident #2 had a fracture to her right femur and new orders were obtained to send Resident #2 to a local hospital for evaluation. Further review of the SRI investigation dated 04/29/25 revealed common area video camera footage was reviewed by the facility's police department, the Administrator, and nursing administration. On the video, Certified Nurse Aide (CNA) #101 was seen entering Resident #2's room by herself around 5:10 P.M., bringing in a non-weight bearing lift inside the room. Approximately two minutes later, CNA #101 was seen exiting Resident #2's room with the non-weight bearing lift and placing the lift by the wall. CNA #101 then proceeded to interact with an unknown visitor. Once the interaction between the two was complete, video camera footage showed CNA #101 entered Resident #2's room by herself again, bringing the non-weight bearing lift with her. Approximately twelve (12) minutes later, CNA #101 was seen exiting the room, pushing Resident #2 in the cradle chair, and leaving the room with the non-weight bearing lift. The facility concluded after conducting interviews and statements from nursing staff and other interviews conducted by the facility police department that video footage and other investigation findings revealed CNA #101 failed to follow Resident #2's plan of care and physician orders, and failed to follow the facility policy and procedure for two staff members for all transfers with non-weight bearing residents. CNA #101 was escorted out of the building and the facility notified her staffing agency that she was placed on the do not return list. Review of the hospital x-ray evaluation dated 04/29/25 revealed Resident #2 had a supracondylar femur fracture (a fracture of the thigh bone just above the knee) with minimal comminution (a type of bone fracture where the bone breaks into three or more pieces, but the fragments are relatively small and relatively stable) and posterior displacement. Review of the document titled, Skills Checklist for State Tested Nurse Aide (STNA)/CNA, for CNA #101 dated 01/17/25, revealed CNA #101 was deemed capable to perform resident transfers. Interview with Lieutenant #300 from the facility's police department on 06/06/25 at 2:00 P.M. verified the events of the SRI dated 04/29/25 and CNA #101's failure to follow Resident #2's plan of care and physician order related to transferring the resident with resulting in the fracture of Resident #2's right femur. Interview with the Director of Nursing (DON) on 06/06/25 at 3:00 P.M. revealed, as a result of the incident when CNA #101 transferred Resident #2 by herself using a mechanical lift resulting in a fractured right femur on 04/29/25, the facility was engaging staff with re-education of the proper techniques of how to mechanical (Hoyer) lift transfer and the facility had not completed all staff education as of 06/06/25. Interview with the Assistant Director of Nursing (ADON) on 06/06/25 at 3:30 P.M. revealed she was the primary clinical investigator and during interview with CNA #101 and confirmed CNA #101 stated Resident #2's injury occurred during the transfer on 04/29/25. The ADON further stated CNA #101 did not identify she had any assistance transferring Resident #2 on 04/29/25. Review of the policy titled, Full Body Mechanical Lift Bed to Chair Transfer Work Instructions, dated 04/01/25, revealed all transfers involving the use of full body mechanical lift require two-assist for transfer. This deficiency represents non-compliance investigated under Master Complaint Number OH00165363.

Based on medical record review, review of facility self-reported incidents (SRIs) and investigation documents, staff and resident interview, and review a facility policy, the facility failed to ensure residents were free from verbal and physical abuse. This affected three (#3, #4, and #5) of five residents reviewed for abuse. The facility census was 223. Findings Include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported that Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing Resident #3 a shower. Resident #3 was noticeably upset because of CNA #102's deliberate attempts at agitation and spit in CNA #102's face to which CNA #102 threw a towel at Resident #3, striking him in the face and head area. Upon investigation by facility administrative staff that included resident interviews, staff interviews, and record reviews, the allegation of abuse by CNA #102 to Resident #3 was substantiated. CNA #102's employment was terminated on 03/20/25. 2. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #4 was severely cognitively impaired and required hand on assistance of two staff persons for completing his ADLs. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and wandering diseases. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required hand on assistance of two staff persons for completing his ADLs. Review of an SRI and corresponding investigation documentation dated 03/21/25 revealed CNA #103 informed administrative staff that between the dates of 03/05/25 and 03/10/25, at around 11:30 P.M., he and CNA #102 were putting Resident #5 to bed and while changing Resident #5's incontinence care products, CNA #102 took an inhalation off his nicotine vaping pen and exhaled the vapor into Resident #5's face. Further review revealed while continuing care for Resident #5, Resident #4 was heard in the hallway shouting, I do not know where to go. Upon hearing Resident #4, CNA #102 left the room and told Resident #4 to, go find a bridge to jump off of. CNA #103 confronted CNA #102 about his actions toward Resident #4 and Resident #5 and was ignored. CNA #102 was already on suspension from a previous SRI investigation and his employment was terminated subsequent to the two incidents reported on 03/20/25 and 03/21/25. Interview with Lieutenant #300 from the facility's police department on 06/06/25 at 2:00 P.M. verified both incidents of CNA #102 being verbally and physically abusive toward Resident #3, exhaling vapor into Resident #5's face during incontinence care, and being verbally abuse to Resident #4. Lieutenant #300 described CNA #102 as someone who thought they could do whatever he wanted to. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the facility will prohibit and prevent abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00163793.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility self-reported incidents (SRI) and related investigation documents, staff and resident interview, review of local new reports, and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#1) of five residents reviewed for misappropriation. The facility census was 223. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and gout. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 was cognitively intact and required hands on assistance from one staff person for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documentation dated 03/31/25 revealed the facility was made aware of a claim that Resident #1 was missing between $1000 and $1500. Resident #1 alleged that theft was done by an African American staffing agency nurse aide. An investigation was immediately initiated which included resident interviews, staff interviews of all staff on-site at the time of the alleged theft, and medical record reviews. During an interview with the facility's police force, Certified Nurse Aide (CNA) #100 confessed to the theft of Resident #1's money from the wallet that was hanging on Resident #1's wheelchair while CNA #100 was in the room. The facility's police force obtained consent to search CNA #100's vehicle and a bag with $1050 was noted in the middle console of CNA #100's vehicle in dominations of $20 bills and $50 bills. Review of a statement completed by Lieutenant #300 with the facility's police department dated 04/03/25 revealed CNA #100 was questioned about Resident #1's money and confessed to take $1050 out of the resident's bag/wallet hanging over his chair while she was in his room. Review of a local news report dated 04/30/25 revealed CNA #100 was booked into the local county jail on 04/04/25 and charged with theft from the elderly which was classified as a fourth-degree felony and carried at minimum a six-month jail sentence to a maximum of 18 months. Interview with the Administrator on 06/06/25 at 10:00 A.M. verified the facility was made aware of an allegation of misappropriation of Resident #1's funds and immediately began an investigation. The Administrator stated through investigation it was determined CNA #100 was responsible for stealing Resident #1's money. Interview with Resident #1 on 06/06/25 at 10:30 A.M. stated he had money taken from his room and it was reported to the facility. Resident #1 stated the facility conducted and investigation and caught the person that stole it. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the facility will prohibit and prevent abuse, neglect, exploitation or mistreatment, including injuries of of unknown origin and misappropriation of resident property. As a result of the incident, the facility took the following actions to correct the deficient practice by 04/08/25: • On 03/31/25, all staff working at the time of the alleged incident were interviewed and questioned by both facility clinical staff and the police department. • On 03/31/25, CNA #100 was escorted off the property upon confession of the theft. • On 03/31/25, CNA #100's employer was contacted and CNA #100 was put on the do not return list for the facility. • On 03/31/25, CNA #100 was reported to the Nurse Aide Registry. • On 03/31/25, all residents with a Brief Interview for Mental Status (BIMS) score of eight (indicating moderate cognitive impairment) or higher were interviewed regarding concerns with CNA #100 or any other staff related to misappropriation with no negative findings. All residents with BIMS scores indicating they were cognitively impaired had their medical records reviewed for concerns of misappropriation with no issues identified. The interviews and medical record reviews were completed by 04/01/25. • On 04/03/25, Resident #1's stolen funds were returned to the resident after processing for the criminal investigation into CNA #100's actions. • Immediately after the incident, all staff were assigned an online education regarding abuse, neglect, and misappropriation with all staff completing the in-service as of 04/08/25. • Review of facility SRIs on 06/06/25, completed between 04/01/25 and 05/19/25, revealed no further confirmed allegations of misappropriation and no trends or patterns were identified. • On 06/06/25, review of four (#2, #3, #4, and #5) additional resident medical records revealed no concerns related to misappropriation. This deficiency represents non-compliance investigated under Complaint Number OH00164401.

Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, staff interview, and review of a facility policy, the facility failed to timely report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#3) of five residents reviewed for abuse. The facility census was 223. Findings Include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing Resident #3 his shower. Resident #3 was noticeably upset and spit in CNA #102's face, to which CNA #102 threw a towel at the resident striking Resident #3's in the face and head area. Further review revealed the alleged incident was reported to the State Survey Agency more than a month after it occurred. Interview with the current Administrator on 06/06/25 at 3:45 P.M. verified the previous Administrator did not report the allegation which occurred on 02/06/25 involving Resident #3 and CNA #102 to the State Survey Agency in a timely manner. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the nursing home administrator shall be designated the Abuse Prevention Coordinator at the facility. This employee is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will report to the Administrator immediately but no later than two (2) hours after the allegation was made, if the events of the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not results in serious bodily injury. The facility will also report to the state agency, adult protective services, law enforcement, and to all other required agencies, as applicable. This deficiency represents non-compliance investigated under Master Complaint Number OH00165363.

Based on review of the medical record, review of a police report, review of an incident report, observation, staff interview, and policy review, the facility failed to ensure a resident was adequately assessed for unsupervised smoking and failed to follow the smoking policy. This affected one (#84) of three residents reviewed for smoking safety. The facility identified 38 residents who smoked. The facility census was 223. Findings include: Review of the medical record revealed Resident #84 had an admitted [DATE] and a readmitted [DATE]. Diagnoses included paranoid schizophrenia, type two diabetes mellitus, osteoarthritis, anxiety disorder, depression, unspecified psychosis, insomnia, and polyneuropathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required supervision for walking and was independent in wheelchair. Review of the care plan initiated 10/29/23 for Resident #84 revealed the resident had schizophrenia with potential for delusions and hallucinations. Interventions included administering medications as ordered and monitoring for adverse effects and effectiveness of medications, to monitor and record episodes of hallucinations or delusions, and psychiatric consults as ordered. Further review of the care plan revealed Resident #84 had episodes of agitation raising voice and yelling at staff. Interventions included to immediately intervene if altercation with another resident, notify physician as needed, one to one visits as needed, find cause of agitation and rectify, encourage resident to vent feelings. Review of a physician order dated 01/31/24 revealed an order for oxygen two liters per minute per nasal cannula, if using oxygen mask adjust flow meter to at least five liters per minute for pulse oximeter of less than 88 percent as needed for shortness of breath. Review of a physician order dated 10/24/24 revealed the resident had order for quetiapine 25 milligrams (mg), one tablet by mouth in evening for insomnia and schizophrenia. Review of psychiatric progress notes dated 11/21/24 revealed the resident had been taken off most of his psychiatric medications due to a physical illness. The resident had recovered physically and had more mental health signs and symptoms. The nursing staff stated the resident had become more paranoid and agitated. The resident was started on quetiapine 25 milligrams (mg) daily after last visit. The resident denied hallucinations and paranoid beliefs at the time of the visit. Review of a nurses note dated 12/31/24 at 7:55 A.M. revealed Resident #84 had hallucinations. The resident's antipsychotic medication quetiapine was increased to 50 mg at bedtime. Review of a psychiatric progress note dated 01/09/25 revealed nursing had reported increased paranoia and agitation in the resident. The resident denied paranoia and hallucinations at the time of the visit. The resident was noted as more stable on quetiapine and to continue current medications. Review of social service progress note dated 01/15/25 revealed the resident requested a carton of cigarettes. The social worker asked the resident what made him decide to smoke and the resident replied he used to smoke and missed it. Review of a nurses note dated 01/16/25 at 7:16 A.M. revealed the resident pulled out his indwelling urinary catheter and yelled at nurse it was not needed and refused to have it replaced. Review of a physician order dated 01/16/25 at 11:35 A.M. revealed Resident #84 was an unsupervised smoker. Review of a smoking assessment dated [DATE] at 11:36 A.M., revealed the resident smoked in the designated smoking area and displayed safe smoking. Further review of the smoking assessment revealed the assessment evaluated the functional ability to smoke. The smoking assessment form had not indicated if other pertinent safety factors were evaluated including medical conditions (i.e. oxygen use), mental health symptoms, and cognition level before determining if a resident required supervision or no supervision while smoking. Review of a police report dated 01/16/25 at 1:15 P.M. revealed Housekeeper #250 reported a fire in an auditorium on the second floor. Staff #260 reported exiting his office and noticing a small flame in the auditorium as Resident #84 was exiting the room. Housekeeper #250 grabbed a fire extinguisher while Staff #260 grabbed the bin with flames and carried to the open area in the room. Staff #260 stated the fire was put out using the fire extinguisher. Video footage was later observed and confirmed Resident #84 entered the auditorium at 1:07 P.M. in his wheelchair. Resident #84 proceeded to a table with tissues and blew his nose. Resident #84 then removed five tissues from the box then wheeled to the pool table and scattered the balls on the table. Resident #84 then went to the north corner of the room touching items on the shelf with his back to the camera. At 1:11 P.M. Resident #84 turns and looks around the room. At 1:12 P.M. a small fire flames/illuminating light appeared near the area the resident was located. Resident #84 placed a tissue that was lit on fire into the bin. Smoke was observed in the air. Resident #84 placed what was believed to be tissues on the shelf where the flame was located. At 1:13 P.M. Staff #260 entered the auditorium noticed the flames, requested a fire extinguisher from Housekeeper #250 who was walking by. Staff #260 confronted Resident #84 who threw his hands in the air saying he does not know what happened as he exited the room. Staff #260 picked up and carried the bin with flames to an open area. Housekeeper #250 brought a fire extinguisher and Staff #260 used the extinguisher to put the fire out. The police were called and the fire department was notified. There was very little property damage. The police asked Resident #84 for his cigarettes and lighter and the resident provided them. Resident #84 was interviewed and denied starting the fire even after watching the video and stated it was not me. The Administrator stated the resident would be placed on one-on-one staff supervision until he could be evaluated at the hospital. It was noted in the police report the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 showing cognitive impairment. The resident's St. Louis University Mental Status (SLUMS) score was 16 out of 30 showing signs of dementia. The resident was also diagnosed with paranoid schizophrenia. Review of an incident report dated 01/16/25 at 1:29 P.M. revealed Resident #84 was not burned and had no injuries. The resident was burning items and witnessed by the police department on video surveillance. The resident's smoking materials were brought to the nurse by the police department. The resident was placed on one-one-supervision. Notifications were made to the physician, nurse practitioner, social worker, Administrator, Director of Nursing, and family. Review of a nurses note dated 01/16/25 at 1:29 P.M., revealed the police department was on the unit looking for Resident #84 for starting a fire in the auditorium with cards. Nurse took possession of the resident's cigarettes and lighter. Review of a progress note dated 01/16/25 at 1:55 P.M. revealed the resident set a fire and would now be a supervised smoker. Review of a progress note dated 01/16/25 at 2:25 P.M., revealed a BIMS was completed and the resident scored 11 out of 15 indicating cognitive impairment. Review of a social service note dated 01/16/25 at 2:47 P.M. revealed the social worker met with the resident. The resident denied starting a fire and stated he was playing pool. Resident continued to deny starting the fire even after he was told the incident was on camera. The social worker completed a slums assessment with the resident scoring a 16 out of 30 noting the resident had an eight grade education. Review of a progress note dated 01/16/25 at 3:06 P.M. revealed the physician approved of the resident on one-on-one supervision. Review of a social service note dated 01/16/25 at 5:12 P.M. revealed the resident agreed to go to the hospital for an evaluation for a psychiatric evaluation. Observation on 01/27/25 at 8:46 A.M. revealed there was a camera in the auditorium on the second floor. There were tables in the room and a pool table. Along the back wall there were shelves with books and activities like cards and puzzles. Further observation revealed no signs of fire, smoke or fire damage. Later observation of the grey plastic bin the fire was started in revealed the bin was melted on one end. Inside the bin were partially burned playing cards. Interview on 01/27/25 at 9:37 A.M., with the Administrator and Director of Nursing (DON) revealed after the fire incident on 01/16/25, the facility reviewed the smoking policy and smoking assessment with no changes made. Prior to the incident unsupervised/independent smokers could keep their lighters and cigarettes in their possession. The Administrator revealed staff were reeducated on the fire policy and smoking policy with new instructions to assess cognitive function using BIMS and SLUMS. Those with low scores were evaluated for supervised smoking. The Administrator revealed all smoking residents were reevaluated and all were now supervised while smoking. The DON revealed Resident #84 last used the as needed oxygen on 12/31/24. Further interview with the DON on 01/27/25 at 12:35 P.M. revealed she could not determine if Resident #84 had an oxygen concentrator in place for use on 01/16/24 when he was determined to be an unsupervised smoker in possessions of his cigarettes and lighter. The DON revealed the resident should not have had an oxygen concentrator in his room when he was allowed to have a lighter and cigarettes. Observation on 01/27/25 beginning at 10:40 A.M. in the designated smoking area outside the building revealed there were two extinguished cigarettes on the ground in the resident smoking area. Further observations revealed Resident #129 and Resident #40 were supervised by video surveillance while smoking. Licensed Practical Nurse (LPN) #300 had also been present in the smoking area. Registered Nurse (RN) #302 provided the residents with cigarettes and lit the resident's cigarettes. Interviews on 01/27/25 at 10:40 A.M., LPN #300 and at 10:43 A.M. with RN #302 each verified an extinguished cigarette was on the ground and had not been properly disposed of in the ash container. Further observation on 01/27/25 at 12:54 P.M., in Resident #84's room revealed there was an oxygen in use no smoking sign on the resident's door to the room. Resident #84 had no oxygen concentrator on his side of the shared room. Resident #84's roommate (Resident #12) had an oxygen concentrator on his side of the room and was ordered four liters of oxygen per nasal cannula continuous. Interview on 01/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) #200 verified Resident #84's roommate had an oxygen concentrator in the room and required continuous oxygen use. Interview on 01/28/25 at 6:55 A.M., the DON revealed supervision for smoking was determined by the smoking assessment. The DON verified the smoking assessment form does not instruct the nurse to evaluate medical condition (i.e. oxygen use), mental health symptoms or cognition when determining if a resident was considered a supervised or unsupervised smoker. The DON revealed there was nowhere to document those things on the form. The DON revealed supervised smokers were not allowed to keep their cigarettes and lighter. Unsupervised smokers could always keep their own cigarettes and lighters with them. The DON revealed some residents just need supervision to get to and from the smoking area and were observed from a distance. Other residents required staff to be present with them. The DON revealed RN #490 had completed Resident #84's smoking assessment how the nurses were told to do it and the resident demonstrated safe smoking. The DON revealed RN #490 should have evaluated the resident's order for oxygen and discontinued the order if the resident was not using the oxygen. The DON revealed the resident was not on the radar for behavioral concerns. The DON revealed staff thought it was odd that Resident #84 wanted to start smoking and provided education to the resident about smoking. The DON verified the facility was not evaluating the residents' cognition at the time of the smoking assessment as stated in the smoking policy. The DON also revealed prior to the fire they had not been considering current medical conditions and a in determining supervision level. Interview on 01/28/25 at 7:08 A.M., RN #490 revealed completing the smoking assessment for Resident #84 on 01/16/25. RN #490 revealed a resident's supervision level was determined by the smoking assessment form and nothing else. RN #490 revealed Resident #84 had an order for oxygen but was not using it. RN #490 revealed the resident smoked safely, and knew where to go to smoke so he was an unsupervised smoker and was allowed to keep his cigarettes and lighter. RN #490 was not having any hallucinations at the time of the smoking assessment. Interview on 01/28/25 at 7:47 A.M. RN #492 revealed for a smoking assessment the resident was taken outside to smoke and observed for hand dexterity, not dropping ashes and distinguishing the cigarette in the bin. RN #492 revealed health conditions and mental health conditions were not considered when evaluating the resident's level of supervision needed. RN #492 revealed the smoking policy stated nothing in regard to medical conditions. Interview on 01/28/25 at 7:53 A.M., RN #494 revealed a function smoking assessment along with a resident's diagnoses, medical conditions, mental health issues and cognition were evaluated to determine if a resident was a supervised or unsupervised smoker. RN #494 revealed residents on oxygen could not have smoking materials. RN #494 revealed residents with hallucinations would need to be supervised especially if they are going through an adjustment period with medications. RN #494 revealed everyday something changes regarding smoking. RN #494 revealed the policy should be clearer and more direct with more training. RN #494 revealed the facility had not been proactive just reactive when something happens. Interview on 01/28/25 at 8:19 A.M., RN #496 revealed the smoking assessment form was used to determine if a resident needed supervision while smoking. RN #496 revealed we check if the resident can hold and dispose of the cigarette. RN #496 revealed some need direct one on one assistance and some were just watched through a camera but we should be a little closer. RN #496 revealed if a resident or the resident's roommate was on oxygen then the resident should not have a lighter. RN #496 revealed if a resident had an increase in delusions or hallucinations then they should not have a lighter or smoke unsupervised. RN #496 revealed the smoking policy was confusing and does not clearly state things. Interview on 01/28/25 at 8:33 A.M., Registered Nurse (RN) #498 revealed smoking assessments were completed upon admission, readmission, and quarterly. RN #498 revealed they would observe the resident smoke. RN #498 revealed if the resident knew where to smoke, could hold, light, and ash the cigarette and where to extinguish the cigarette and not put on the ground then the resident was an independent smoker. RN #498 revealed she was not sure if a resident experiencing increases in mental health symptoms like delusions or hallucinations should be supervised or independent or have a lighter. RN #498 revealed previously she had not allowed one resident to keep his lighter because both his roommate and next door neighbor were on oxygen. RN #498 revealed the policy had some grey areas. RN #498 revealed after the fire the residents were now monitored more closely. Interview on 01/28/25 at 9:06 A.M., the Administrator revealed the facility was still in the process of evaluating the smoking policy and the smoking assessment forms as part of their performance improvement plan. Interview on 01/28/25 at 9:15 A.M., Licensed Social Worker (LSW) #600 revealed on 01/14/25 Resident #84 asked for cigarettes. LSW #600 revealed the resident was not a current smoker. LSW #600 revealed the resident stated he had smoked in the past and wanted a cigarette to smoke. LSW #600 revealed the cigarettes were purchased on 01/15/25 and given to the nurses on 01/16/25. LSW #600 revealed the resident had no alarming behaviors and she had not witnessed the resident having delusions or hallucinations. LSW #600 revealed after the fire she had evaluated the resident's cognition which was low which could be due to the resident's eighth grade education. LSW #600 further revealed Resident #94 denied starting the fire. Review of the policy Smoking, dated 02/02/24, revealed the provision of ashtrays but no direction to ensure cigarettes were extinguished in the provided ashtrays. No smoking signs would be maintained where oxygen was used. Resident who smoke would be assessed to determine if it was safe to smoke unsupervised using the assessment form. Smoking materials of supervised smoking resident would be maintained by the nursing staff. Unsupervised smokers could maintain smoking materials if stored safely and only used in designated smoking areas. All resident's on oxygen would be supervised smokers. If a resident who smokes experiences any decline in condition or cognition, they would be reassessed for ability to smoke and/or evaluate whether any additional safety measures were required. Documentation/information to support decision making of the assessment would be included in the medical record including assessment of relevant functional and cognitive factors affecting ability to smoke safely. Further review of the policy revealed no guidelines if an unsupervised smoker was allowed to maintain smoking materials if there roommate was on oxygen. Review of the policy Oxygen Safety, revised 03/18/24, revealed No Smoking signs would be used to identify oxygen in use and would remain in place until oxygen administration had been discontinued. No smoking rules would be strictly enforced while oxygen was in use including the removal of smoking materials from resident receiving oxygen. This deficiency represents non-compliance investigated under Complaint Number OH00161827.

Based on observations, medical record review, review of facility policy, and resident and staff interviews, the facility failed to provide adequate pain management which resulted in actual harm to Resident #111 who continued to have uncontrolled pain at a level of 8 out of 10 (with 10 being the highest level). This affected one (#111) of two residents reviewed for pain management. The facility census was 186. Findings include: Review of Resident #111's medical record revealed an admitted [DATE]. Diagnoses included chronic pain, chronic obstructive pulmonary disease (COPD), anxiety, depression, and mental and behavioral disorders. Review of Resident #111's quarterly pain assessment, dated 11/16/23, revealed pain over the last five days making it hard to sleep at night, which is frequently limiting his day to day activities. Resident has indicated his pain was moderate and rated as an eight out of 10. The care planning interventions included for the physician to check mark which interventions to utilize in helping the resident's pain revealed no pain interventions were checked and were left blank. Review of Resident #111's Medication Administration Record (MAR) for January 2024 revealed an order for ibuprofen 200 milligrams (mg) twice a day for pain. Nothing was ordered for pain to be given as needed (PRN). Review of the Physician-Patient Encounter Note dated 11/29/2023 revealed the resident was assessed by Physician #553 for an evaluation. Review of the physician's encounter note revealed question number nine on this form asked for the resident's most recent pain level, pain scale and date. All those questions were left blank. The note revealed the resident complained of new onset left hand pain. He reported the pain had been going on for a couple weeks. The pain was more severe in his third digit at the metacarpophalangeal (MCP) joint. The resident also complained of bilateral knee pain. The resident was offered a topical treatment and an occupational therapy evaluation, which he refused. The note revealed to continue current treatment with no changes in medications. Observation of Resident #111 on 01/08/24 at 11:26 A.M. revealed resident sitting in his recliner chair appearing irritated and anxious. Interview on 01/08/24 at 11:26 A.M. with Resident #111 revealed he was angry as he has been in frequent and uncontrolled pain since he admitted and the facility staff have done nothing to address it. He further stated he has notified multiple staff, including Physician #553. Upon his admission Physician #553 decreased his ibuprofen and this dosage is ineffective in relieving his pain. Resident #111 stated he wants his ibuprofen dosage back to what he was originally taking before coming to this facility, which consisted of ibuprofen 400 mg three times a day. Resident #111 stated he was currently receiving ibuprofen 200 mg twice a day and he has been in pain since the dosage decrease. He further stated Physician #553, along with all the other facility staff, were aware of how he has been feeling regarding his pain and they are well aware of how he feels about the decrease in this pain medication. He stated he has been offered Tylenol and has told the nursing staff, along with Physician #553, that Tylenol upsets his stomach and he cannot take it. Interview on 01/10/24 at 1:00 P.M. with Registered Nurse (RN) #436 confirmed Resident #111's quarterly pain assessment dated [DATE] was accurate. RN #436 confirmed the resident was not receiving any PRN pain medications. Interview with Licensed Practical Nurse (LPN) #396 on 01/10/24 at 08:40 A.M. revealed the medical team has discussed with Resident #111 other options. The medical team reviewed his labs and only wanted to put him on one ibuprofen due to his labs indicating there was a decline in his kidney function. Resident #111 wants his medications given his way and not the way the physician has ordered. LPN #396 stated Resident #111 currently has an order for ibuprofen 200 mg to be given in the morning and at bedtime. LPN #396 stated this is the only pain medication Resident #111 can have at this time. Interview on 01/10/24 at 11:11 A.M., LPN #396 stated she called Physician #553 and notified her Resident #111 wanted to be seen today regarding his pain and to increase his ibuprofen. LPN #396 stated Physician #553 said Resident #111's pain was all well documented regarding his ibuprofen order and complaints of his pain. Physician #553 stated she would try to see Resident #111 today, but if she was not able to see Resident #111 today, she would see him when she became available. Additional review of the medical record revealed a progress note dated 01/10/2024 revealed Nurse Practitioner (NP) #551 was asked to see this resident for multiple complaints. Resident #111's first complaint was pain in his hands and knees which he rated as a six out of 10 on the pain scale, stating this pain was an ache. The resident stated that he was diagnosed with arthritis and had been taking ibuprofen 400 mg three times a day, which provided relief. Resident #111 stated he was upset that when he was admitted into this this facility, the ibuprofen was decreased to 200 mg twice a day. Further review of this note reveals he did not want any arthritis cream or muscle rub, no K-Pad, or any acetaminophen. Resident #111 was adamant he had tried all of these things in the past and they were ineffective. Resident #111 insisted the ibuprofen at 400 mg three times a day was all that would work. He had been taking it that way for over twenty years without any problems and it reduced his pain down to a two or three, which was tolerable. Resident #111 stated to NP #551 he was left-handed and opening and doing things etc., was difficult for him. NP #551 thanked the resident for his time, and stated the ibuprofen would be looked at. NP #551 documented after evaluating Resident #111's laboratory (lab) results for his basic metabolic panel from December 2023, as well as his lab results for his comprehensive metabolic panel from August 2023, his kidney function was good on those two occasions. NP #551 increased the ibuprofen to 400 mg three times a day. Review of the January 2024 MAR revealed ibuprofen 400 mg three times a day was ordered on 01/10/24. Review of the facility policy titled Pain Management Work Instructions,dated 05/13/08, revealed a pain assessment and treatment program is used to evaluate the resident's pain consistently and accurately. For 4-6 (moderate pain) give Tylenol 650 mg and reassess. If unrelieved in one hour but minimized, attempt diversional activities. If pain persists beyond 48 hours and/or the condition worsens, notify physician for standing orders. Further review of this policy reveals if the pain is a 7-10 (severe pain) give Tylenol 650 mg per standing order or specific ordered pain medication for severe pain. Reassess and if unrelieved notify physician. The policy further reveals the process of treating acute or chronic unrelieved pain is to notify the physician with consideration of a referral to neurologist, pain clinic, or other. Unit Supervisor to evaluate use of PRN pain medication and refer to physician if needed when the PRN medication is used routinely. For moderate to severe pain that occurs every day, formulate a pain management program with specific interventions that address the resident's individual needs.

Based on observations, medical record review and staff interviews, the facility failed to provide the resident with a table of appropriate height to ensure proper eating for one (#139) of 40 sampled residents. The facility census was 186. Finding include: Review of Resident #139's medical record identified admission to the facility occurred on 05/18/23. Diagnoses included Parkinson's disease, dementia, major depression, diabetes and prostate cancer. Review of Resident #139's record identified on 06/01/23 his weight was 161 pounds and on 01/02/24 his weight was 141 pounds, which was a 12.4% loss. Review of Resident #139's plan of care for nutritional concerns identified Resident #139's goal was to ensure adequate intake to prevent weight loss. The plan included interventions for dining which included to ensure the resident was in an upright posture for oral intake and alternating solids and liquids with each bite. Observation of Resident #139 on 01/10/24 at 8:29 A.M., revealed the resident was in the dining room. The dining room was observed with tables of varying heights. Resident #139 was observed at a table that was higher than others located in the room. Resident #139 was observed with his neck area at the same height as the top of the table. Resident #139 was observed to be reaching up to attempt to eat foods in front of him. Interview with Registered Nurse (RN) #436 on 01/10/24 at 8:29 A.M. confirmed Resident #139's chair was too low to the ground to comfortably eat. The interview confirmed Resident #139's wheelchair had a lowered seat, therefore when in front of a table he was positioned to low. Observation of Resident #139 on 01/11/24 at 9:04 A.M. revealed the resident was in his wheelchair at the dining table. Resident #139 had to reach up to get to his food and was poorly positioned. Interview with Therapeutic Program Worker (TPW) #710 on 01/11/24 at 9:04 A.M. confirmed Resident #139 was positioned poorly to the table in the dining room. TPW #710 confirmed since his wheelchair was so low when he was sitting up to the table he had to reach up to try and eat.

Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed allow a resident the choice to utilize their personal electric wheelchair and failed to ensure and follow their policy to complete an individualized assessment to determine the resident's ability to use their electric wheelchair. This affected one (#41) of 40 sampled resident. The facility census was 186. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included dementia, psychotic disturbance, and diabetes mellitus with diabetic neuropathy. The resident was receiving hospice services. Review of the admission Minimum Data Set (MDS) assessment, dated 07/21/23, revealed Resident #41 was identified with intact cognition. The care area assessment (CAA) identified Resident #41 was non ambulatory, required the use of a non-weight bearing lift for all transfers, and used a manual wheelchair for mobility with staff pushing him to desired destinations. Review of a quarterly social service note dated 07/25/23 revealed Resident #41 was admitted to the nursing home on 07/13/23. The resident ambulates with a Power Motorized Device (PMD) but needs to be evaluated before he can use it. The note stated for now he was using a manual wheelchair. Resident #41 was able to communicate on his own. Review of a St. Louis University Mental Status (SLUMS) test (a screening tool to identify cognitive impairment), dated 08/01/23, revealed Resident #41's score was 17/30 demonstrating dementia. Review of the social service note dated 08/03/2023 at 3:07 P.M. revealed the social worker talked to Resident #41 and let him know that he cannot use his PMD because he scored a 17/30 on the testing. Resident #41 was upset and stated he thinks he should be given a different test. The social worker educated Resident #41 on the policy of obtaining a PMD at the facility and explained the SLUMS test is a facility cognitive test they must use. The social worker explained therapy could fit him for a manual wheelchair. Resident #41 stated If I can't get my electric wheelchair, I don't want no damn chair. Review of the social service progress note dated 10/23/23 revealed Resident #41's most recent MDS assessment identified the resident with cognitive impairment. Review of social services progress notes dated 01/08/24 revealed Resident #41 was asking to get his PMD back. The social worker completed the SLUMS with the Resident and he scored a 17/30, which puts him in the dementia category. The medical record contained no evaluation from therapy regarding the resident's ability to safely utilize his PMD, no interdisciplinary team assessment and recommendation regarding the use of the PMD, and no evidence the PMD team met to determine if Resident #41 was able to utilize a PMD safely. Observation and interview with Resident #41 on 01/08/24 at 12:19 P.M. revealed Resident #41 was lying in bed. A power chair was located in the room. Resident #41 stated he prefers to stay in bed because his manual wheelchair was too uncomfortable to sit in for any period of time. Observation of Resident #41 on 01/09/24 at 10:21 A.M., 01/10/24 at 9:15 A.M., and 2:10 P.M. and 01/11/24 at 8:51 A.M. identified he was in bed during all observations. Interview on 01/11/24 at 8:51 A.M. Resident #41 stated he rode his motorized wheelchair into the facility and they took it away when he got here. The resident stated the facility told him he wasn't smart enough and took away his motorized wheelchair. Resident #41 stated he feels like a prisoner. He stated he is worried about losing the function in his legs. If he has his motorized wheelchair he wouldn't be in bed all the time, and he would get up and get out of his room. If he had his wheelchair he could get around by himself and now he can't do anything. Interview with Licensed Practical Nurse (LPN) #418 on 01/10/24 at 8:25 A.M. confirmed Resident #41 was dependent and he refuses to get out of bed because he doesn't have his motorized scooter. LPN #418 stated residents have to meet the cognitive score to meet the criteria to have a motorized scooter as a qualification. Resident #41 has a wheelchair and he is pushed around by staff. LPN #418 stated he just stays in his room because he wants his motorized scooter but he didn't meet the qualification. Interview with the Director of Nursing (DON) on 01/11/24 at 8:30 A.M. confirmed once a resident fails the SLUMS test, they stop the evaluation process for use of a PMD. The DON confirmed Resident #41 was never evaluated by therapy to determine if he was safe to use his PMD device. The DON confirmed Resident #41 has not been permitted to use his device since his admission of 07/13/23. Review of the facility policy titled Power Mobility Device (PMD), dated 09/01/2019, revealed to be eligible to use a PMD a resident must: 1.) Be physically unable to use a manual wheelchair or similar device or have a medical condition that warrants the use of a PMD. 2.) Have a sufficient mental/cognitive and physical functioning to operate a PMD which includes no active mental health disorder, which may endanger him/herself or others and must have a recent St. Louis University Mental Status (SLUMS) score of 25 or higher if he/she completed high school or 22 or higher if he/she did not complete high school. Prior to approval to use a PMD, a resident must demonstrate safe and responsible proficiency in handling a PMD. For a nursing home resident, this is determined by an occupational therapist in the therapy department. The policy approval process includes the resident must inform the social worker of their interest in using a PMD. The social worker must bring the request to the IDT team. The IDT will discuss the issue and gather information as necessary (SLUMS exam, eye exam, physical therapy exam) to determine the resident's eligibility for a PMD. The IDT will then make a recommendation to the PMD team and make a notation of the recommendation in the record. The PMD team will evaluate the IDT recommendation and determine whether to recommend the use of the PMD to the physician.

Based on review of medical records, resident and staff interviews, the facility failed to ensure residents were included in their care plan meetings. This affected two (#17 and #95) of 40 sampled residents. The facility census was 186. Findings include: 1. Review of Resident #17's medical record identified admission to the facility occurred on 05/24/19. Diagnoses included major depression, diabetes, obesity and anxiety. The records identified Resident #17 with intact cognition. Review of care meeting notes dated 07/27/23 at 11:54 A.M. identified no participation including Resident #17 in his care plan choices. Review of Resident #17's most recent care meeting notes dated 11/09/23 at 12:15 P.M. identified the meeting was held on a phone conference; however, the conference did not include the resident. Interview with Resident #17 on 01/08/24 at 11:51 A.M. revealed he has not attended any care plan meetings, but would like to. Interview with Licensed Social Worker (LSW) #700 on 01/11/24 at 10:04 A.M. revealed residents were not being invited to their care meetings because I share an office with another LSW. LSW #700 confirmed she never thought about going to Resident #17's private room to do the meeting. 2. Review of Resident #95's medical record identified admission to the facility occurred on 01/22/19. Diagnoses included dementia, diabetes, high blood pressure and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #95 had moderately impaired cognition. Review of Resident #95's social services notes dated 10/25/23 at 11:48 A.M. identified his care conference was held. The notes identified Resident #95 was out of the building attending a facility activity at the time the meeting was held. Review of social services notes dated 07/26/23 at 11:29 A.M. identified a care meeting was held and Resident #95 was out of the facility at a baseball game. Interview on 01/08/24 at 10:40 A.M., Resident #95 stated he has not participated in any meetings about his care and would like to. Interview with LSW #560 on 01/10/24 at 1:49 P.M. confirmed the facility has not been working to ensure care meetings are being held at a time convenient for residents and they were not working around planned activities. The interview confirmed Resident #95 has not been able to participate in his last two meetings because they were scheduled when he was on facility initiated activities.

Based on record review, resident and staff interviews, the facility failed to ensure residents receive proper treatment and assistive devices to maintain their hearing abilities. This affected one (#79) of one resident identified with hearing issues. The facility census was 186. Findings include: Review of Resident #79's medical records revealed he was admitted on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment and hearing difficulties. Observation on 01/10/24 at 9:48 A.M. revealed Therapeutic Program Worker (TPW) #460 pushing Resident #79 in a wheelchair. TPW #460 was leaning close towards his ear saying Can you hear me? Resident #79 did not respond. During an interview with Resident #79 on 01/08/24 at 11:46 A.M., Resident #79 was observed at that time with no hearing aides and his television was very loud. Resident #79 stated he has a hard time hearing sometimes and he doesn't have any hearing aides. Interview with Licensed Practical Nurse (LPN) #418 on 01/10/24 at 8:21 A.M. identified she has never known Resident #79 not to be able to hear that well. LPN #418 confirmed Resident #79 has had no audiology exams since his admission oo 06/06/19.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure safe smoking. This affected two residents (#43 and #171) of two residents reviewed for smoking. The facility census was 186. Findings include: 1. Review of the medical record for Resident #171 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia. Review of the Minimum Data Set (MDS) assessment, dated 11/03/23, revealed Resident #171 had cognition impairment. Review of the MDS assessment revealed Resident #171 utilized oxygen. Review of the care plan, dated 11/16/23, revealed Resident #171 was a smoker and smoked unsupervised. Interventions included following smoking policy and procedure, smoking only in designated areas, storing cigarettes and lighter in medication room, and may keep one or two cigarettes on his person. Further review of the care plan revealed Resident #171 had a history of chronic respiratory failure with hypoxia and hypercapnia with interventions in place to apply two liters of oxygen via nasal cannula when going to bed and remove in the morning. Review of the physician orders dated 12/30/22 revealed Resident #171 had an order in place for two liters oxygen via nasal cannula every evening and night shift when resident goes to bed and remove in the morning. Review of the physician orders dated 07/18/23 revealed Resident #171 had an order in place to be an unsupervised smoker, have cigarettes and lighter stored in medication room, and may have one or two cigarettes at a time. Review of the quarterly Smoking Safety Evaluation dated 10/29/23 revealed Resident #171 was a smoker and did not require supervision. Observation and interview on 01/08/24 at 10:34 A.M. revealed Resident #171 was a smoker and went to the designated smoking area multiple times a day. Resident #171 revealed he kept his smoking paraphernalia in his pockets. Observation revealed multiple cigarettes and a lighter located in his coat pocket. An oxygen concentrator was located adjacent to the bed. Interview on 01/08/24 at 12:14 P.M. with Licensed Practical Nurse (LPN) #424 revealed cigarettes and lighter were to be kept locked in the medication room per the smoking policy. LPN #424 revealed Resident #171 kept his lighter on him and asked for two cigarettes at a time when going to smoke. LPN #424 revealed Resident #171 had a history of being caught smoking in his room and he utilized oxygen. Interview on 01/10/24 at 9:06 A.M. with LPN #422 revealed Resident #171 utilized oxygen only at night. He was an independent smoker but his cigarettes and lighter were locked in the medication room. Observation on 01/10/24 at 10:04 A.M. revealed Resident #171 exited his room and exited the facility to the designated smoking area without stopping at the nursing station. Resident #171 was observed retrieving his cigarette and lighter from his coat pocket, lit the cigarette, and started smoking. Observation and interview on 01/10/24 at 10:15 A.M. with LPN #422 revealed Resident #171 entered the facility placing cigarettes and lighter in his pocket and returned to his room. LPN #422 confirmed Resident #171 had a smoke break without retrieving any cigarettes and lighter from her or the medication room. LPN #422 also verified he kept his cigarettes and lighter on his person after entering the building. 2. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), bilateral age-related cataracts, and nicotine dependence. Review of the MDS quarterly assessment, dated 12/22/23, revealed Resident #43 had intact cognition. Review of a physician's order, dated 04/21/23, identified Resident #43 as an independent, unsupervised smoker with use of a protective smoke apron. Review of Resident #43's care plan, revised 07/08/23, revealed Resident #43 was able to smoke independently and unsupervised with the use of a smoke apron. Review of Resident #43's Smoking Safety Evaluation, dated 12/16/23, revealed Resident #43 had no burns to his skin or clothing and did not drop ashes on himself. Observation on 01/09/24 at 10:12 A.M. revealed Resident #43 seated in his motorized wheelchair. Cigarette ashes were noted on his lap. He had his smoking supplies, a pack of cigarettes and a lighter, in the left breast pocket of his jacket. There were multiple circular burns observed in his clothing. Observation on 01/10/24 at 9:27 A.M. revealed Resident #43 mobilized himself in his motorized wheelchair down the elevator and out the main entrance to the designated smoking area. He did not have on a smoke apron. Resident #43 retrieved his smoking supplies out of his left breast pocket and proceeded to smoke. Interview on 01/10/24 at 9:35 A.M. with Housekeeper #351, stationed near the main entrance, verified Resident #43 was not wearing a smoke apron. Housekeeper #351 stated he never wore a smoke apron. Observation and interview on 01/10/24 at 9:53 A.M. with Resident #43 revealed he mobilized himself back up to the nursing unit. Resident #43 was observed with ashes on his lap and no smoke apron on. Resident #43 verified he never wore a smoke apron when he went outside to smoke. Resident #43 stated the smoke apron was overkill and he did not need it, nor did he wear it. Resident #43 stated he only dropped a few ashes here and there. Interview on 01/10/24 at 9:57 A.M. with Therapeutic Program Worker (TPW) #461 verified Resident #43 had ashes on his lap. TPW #461 stated she believed he had a smoking apron but he did not routinely wear it. Interview on 01/10/24 at 9:53 A.M. with LPN #407 revealed Resident #43 had a smoke apron in his room but refused to wear it. LPN #407 stated the staff occasionally reminded him to wear it. LPN #407 verified he was still able to go out to smoke independently whether he wore the smoke apron or not. Interview on 01/11/24 at 9:19 A.M. with Registered Nurse Clinical Care Coordinator (RNCCC) #433 verified Resident #43 had holes in his clothing from cigarette burns but believed them to be old holes. RNCCC #433 stated his family recently sent him new clothing and the staff are monitoring the new clothing for new holes. RNCCC #433 verified Resident #43's care plan and physician's orders identified the need for a smoke apron while out smoking independently but he did not consistently wear it. Review of the facility policy titled Smoking, dated 04/26/23, revealed all residents who smoke will be assessed to determine if the resident is safe to smoke unsupervised. Any resident deemed safe to smoke using the assessment form will be allowed to smoke in designated smoking areas, at designated times, and in accordance with their care plan with supervision as per facility policy. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking. If a resident does not abide by the policy or their care plan, including refusal to wear protective gear, the resident's care plan may be revised to include additional measures such as prohibited smoking or even discharge. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by developing a safe smoking plan. Documentation to support decision making will be included in the medical record, including resident's wishes, assessment of relevant functional and cognitive factors affecting ability to smoke safely, response to smoking cessation intervention and compliance with the smoking policy.

Based on review of facility documents, review of facility policy, review of a personnel file, review of a Self-Reported Incident (SRI), and staff interview, the facility failed to protect residents from potential further abuse once the facility was made aware that an allegation of staff to resident abuse had occurred. This resulted in Immediate Jeopardy for three (Residents #07, #59, and #89) residents when the facility was notified on 03/25/22 that State tested Nursing Assistant (STNA) #155 was alleged to have taken inappropriate photographs of residents. The facility did not immediately remove STNA #155 from providing direct resident care. On 03/30/22, STNA #155 confessed to taking inappropriate photographs of Residents #07 and #59 and confessed to sexually assaulting Resident #89 on two separate occasions. This affected three of three residents reviewed for abuse and placed an additional 50 residents, who resided on the 2-South Unit, at potential risk for further abuse, when STNA #155 was allowed to continue to provide care for residents on 03/25/22 and 03/28/22 after an allegation of staff to resident abuse had been made. The facility census was 203. The Administrator was notified on 04/05/22 at 5:08 P.M. that the Immediate Jeopardy began on 03/25/22 at 11:30 A.M. when the facility received a complaint alleging STNA #155 had taken and shared inappropriate nude photographs of residents that resided in the facility. STNA #155 was not immediately removed from providing direct resident care on 03/25/22 and continued to work in the capacity of an STNA providing resident care on 03/25/22 and 03/28/22 after the allegation of abuse was made. On 03/30/22, STNA #155 confessed to taking inappropriate photographs of Residents #07 and #59 and confessed to sexually assaulting Resident #89 on two separate occasions. The Immediate Jeopardy was removed on 04/12/22 at 4:30 P.M. when the facility implemented the following corrective actions: · On 03/30/22 and 03/31/22, the affected residents, along with every other resident, received head-to-toe assessments with no findings. Residents who were interviewable were also interviewed at the time of their head-to-toe assessment with no findings. · On 03/30/22, STNA #155 was arrested and removed from the facility. On 04/08/22, STNA #155 resigned from employment at the Ohio Veterans Home. · On 03/30/22, staff education began on the facility's abuse policy. · During an interview with Licensed Practical Nurse (LPN) #305 on 04/04/22 at 11:35 A.M., it was confirmed he was trained on abuse proceedings, would protect a resident in an abuse situation and report to the supervisor immediately. · During an interview with LPN #340 on 04/04/22 at 11:05 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report to supervisor immediately. LPN #340 denied ever seeing abuse or knowing about abuse at the facility. · During an interview with STNA #335 on 04/04/22 at 11:37 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report the situation to the supervisor immediately. · During an interview with LPN #345 on 04/05/22 at 8:35 A.M., it was verified she was trained on abuse and verified she had not noted any changes in resident behaviors that indicated they had been abused at the facility. LPN #345 stated if there was any indication of resident abuse, she would have reported it. · During an interview with STNA #300 on 04/05/22 at 8:40 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report to supervisor immediately. STNA #300 denied ever seeing abuse or knowing about abuse at the facility. · During an interview with LPN #320 on 04/05/22 at 8:45 A.M., LPN #320 verified she was trained on abuse and verified she had not noted any changes in resident behaviors that indicated they had been abused. LPN #320 stated she was only aware of one allegation of abuse at the facility and that was the incident from last week. LPN #320 stated the residents in her care have not had any indications that would have made her think something had happened to them, and if there had been indications of abuse, she would have reported it. · On 04/12/22, staff re-education began on clarification of the facility's current abuse policy under Section 6 titled protection that an alleged perpetrator is to be immediately removed from the building pending outcome of the investigation in order to protect residents from harm. Police, Therapy, Pharmacy, Nursing, Dietary, Housekeeping, Laundry, Administration and Human Resources Staff were educated by the Administrator/Designee. · On 04/12/22, revisions were made to the SRI checklist to clarify any alleged perpetrator is to be immediately removed from the building upon receipt of an allegation of abuse, neglect, exploitation, mistreatment, including injuries of unknown source, misappropriation of resident property and resident to resident altercation. · On 04/12/22, every SRI will be audited on an on-going basis, as they occur, for the immediate removal of the alleged perpetrator. · On 04/12/22, the Administrator was educated by the Superintendent on the Abuse policy and included reporting responsibility, definitions of abuse including exploitation, prevention and identification. Although the Immediate Jeopardy was removed on 04/12/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the facility document titled Factual Timeline, provided by the facility via e-mail on 04/11/22, documented on the afternoon of 03/25/22, a senior employee of the Ohio Department of Job and Family Services (ODJFS) contacted the facility's Chief of Police to relay information alleging an employee of the facility had taken and shared nude photographs of residents. (The employee was identified as STNA #155). The Chief immediately met with the healthcare leadership at the facility, including the facility Superintendent and Nursing Home Administrator to discuss the nature of the allegations and how to proceed. STNA #155 was placed under enhanced surveillance. On 03/27/22, the facility's police department interviewed the individual who reported the allegations to ODJFS. The individual had no personal knowledge of the photographs. On 03/28/22, the facility police contacted the Ohio State Highway Patrol (OSHP) due to their original jurisdiction over investigations. At the recommendation of the facility police department and the OSHP, the facility did not proceed with the administrative investigation and continued to keep STNA #155 under enhanced surveillance for the remainder of the workday on 03/28/22. On 03/29/22, STNA #155 was interviewed at his residence and denied all allegations. He permitted a voluntary search of his telephone. Although the search of STNA #155's telephone did not reveal any images consistent with the allegations shared by ODJFS, the pictures did demonstrate the suspect had an interest in explicit images of older males. Based on this limited corroboration, the facility immediately removed the suspect from providing direct care to residents. After the interview at his home, STNA #155 called off work for his shift on 03/29/22. On 03/30/22, STNA #155 was reassigned to dietary so he would have no access to residents. Enhanced surveillance of him continued. That same day, the facility's police department interviewed STNA #155 again, which led to a full confession of a sexual assault of one resident on two occasions. The alleged events occurred sometime in November 2021. STNA #155 was immediately arrested and removed from the facility. Review of the punch detail for hours worked revealed STNA #155 worked on 03/25/22 from 3:00 P.M. to 11:30 P.M., 03/28/22 from 2:55 P.M. to 11:30 P.M. and on 03/30/22 from 2:46 P.M. to 8:00 P.M. Review of the personnel file for STNA #155 revealed he had a Bureau of Criminal Investigation (BCI) background check completed on 01/31/18. STNA #155 was hired on 02/20/18 and was current on the state nurse aide registry. The facility provided no evidence of references being checked for STNA #155. STNA #155 had signed the acknowledgement of the facility's management information technology compliance form and compliance training dated 02/23/18. STNA #155 completed all the training provided during orientation to include reporting abuse of resident, resident abuse neglect misappropriation of property, and relationships with residents/professional boundaries training. STNA #155 received abuse, neglect and misappropriation training on 02/20/18 and 02/06/19. The only disciplinary action in STNA #155's file was dated 04/03/22 documented as a no call no show for his shift. STNA #155 was incarcerated on this date. During an interview on 04/04/22 at 9:46 A.M., the Administrator stated she had minimal information as the alleged incident is criminal in nature and the facility cannot conduct a criminal and administrative investigation at the same time. The Administrator stated a call came into the Oho Veterans Home Police Department (OVHPD) on 03/25/22 from Adult Protective Services (APS) of [NAME] County. The call alleged one of the facility staff had potentially taken inappropriate pictures of residents. The Administrator stated the facility police obtained the name of the complainant from APS on 03/28/22. They were able to interview the complainant who provided the name of the staff member who was alleged of taking pictures of residents. The Administrator stated on 03/28/22 when the facility got the name of the alleged staff member, STNA #155, the staff member was placed on enhanced police surveillance (watching the staff member through live camera feed from the hallways, but not in resident rooms as the cameras are not in care areas). The Administrator stated on 03/28/22 the Police only had information alleging pictures were taken of residents and no firsthand knowledge of pictures having been taken as the complainant had not seen the pictures. The Administrator verified STNA #155 was a second shift employee who worked on 03/25/22 and 03/28/22 providing care to residents at the facility. On 03/29/22, OSHP and the facility police went to the home of STNA #155 to interview him. During this voluntary interview, STNA #155 provided his phone for the two police departments to review. The administrator stated no photographs of residents were found on STNA #155 's phone; however, the Administrator was notified there were inappropriate pictures on the STNA's phone. STNA #155 called off for his shift on 03/29/22. The Administrator revealed the facility police were able to identify and speak to an individual who had seen the alleged inappropriate pictures of residents that were taken by STNA #155. The individual interviewed also provided the facility police the name of the phone application where the pictures were taken and stored according to the Administrator. The Administrator stated STNA #155 was scheduled to work on 03/30/22, and due to the firsthand verification of residents having had their picture taken by STNA #155, his assignment was changed from providing resident care to working in dietary services washing pots and pans. The Administrator verified STNA #155 reported to work on 03/30/22 and worked in the dietary department from approximately 3:00 P.M. to 4:30 P.M. at which time the facility police took STNA #155 in for or further questioning. During this time of questioning, it was stated STNA #155 confessed to taking inappropriate pictures of Resident #07 and #59 in November 2021 and sexually assaulting Resident #89 on two separate occasions in December 2021. The Administrator stated after the STNA confessed to the resident abuse, OVHPD arrested STNA #155 and took him to the county jail. The Administrator stated as soon as it was confirmed STNA #155 had taken pictures of Resident #07 and #59 and sexually assaulted Resident #89 on 03/30/22, all residents were then assessed. There were no negative findings on any of the head-to-toe assessments. During an interview with the Administrator on 04/04/22 at 12:05 P.M., the Administrator stated that she had reviewed STNA #155's personnel file and other documents and found STNA #155 had a background check completed with no red flags, annual education on abuse, and was not named in any self-reported incidents at the facility. Additionally, there was no resident behavior changes or complaints to indicate any issue concerning STNA #155 or to show a deviation from standard work practices. The Administrator stated No, the facility did not find any gaps in their processes related to the abuse allegation. During an interview on 04/04/22 at 2:45 P.M., the Administrator confirmed STNA #155 worked on 03/25/22, the day the facility was made aware of the abuse allegation. The Administrator stated no other staff were interviewed regarding the allegation of abuse involving STNA #155 as there was no claim that others witnessed the pictures being taken or the abuse was occurring. The Administrator stated if there had been a statement that another staff member was in the room when STNA #155 had supposedly abused a resident then the other staff member would have been interviewed, but the facility does not interview others who are not involved in an incident as to keep it private to the alleged perpetrator. The Administrator was questioned who APS called at the facility and what time the call was made with the initial complaint and she stated she was on vacation on 03/25/22 and did not know. She also stated she did not know the time the police department was made aware of STNA #155 being named on 03/28/22. During an interview on 04/05/22 at 8:02 A.M., Facility Police Officer (FPO) #310 stated he was not familiar with the term enhanced surveillance. He stated there is a person who watches the camera monitors all the time. FPO #310 stated he was not on duty on the day of 03/28/22 when the facility had stated STNA #155 was put on enhanced surveillance and he did not know if there was an extra person called in to specifically monitor STNA #155 during his shift. FPO #310 stated the new camera system that is live in some parts of the building can tag an individual and that person can be tracked wherever they go in range of the cameras. The cameras do not extend into resident care areas. During an interview on 04/05/22 at 10:15 A.M., FPO #315 stated he was the officer on duty on 03/28/22 during the evening shift. FPO #315 stated he was not sure what nursing considered enhanced surveillance as that is not a term the facility police department uses. He stated due to the allegations against STNA #155 and the fact he was providing resident care, the facility police were mindful of STNA 155's presence in the facility and increased foot patrol on the floors to have a more visible presence. FPO #315 stated there is dispatch that monitors the camera feed 24 hours a day, seven days a week. FPO #315 stated he did not notice an extra person on the shift monitoring the camera feed. The officer also verified the new camera system does have the ability to tag an individual via facial recognition; however, the department has not been trained on that function. During an interview on 04/05/22 at 2:27 P.M. with Police Department Employee (PDE) #355 stated she was monitoring the surveillance camera feed on the evening shift on 03/28/22. PDE #355 verified there was no additional employee watching the monitors during that shift. PDE #355 stated she received no instruction to watch anyone or anything specific on this shift. There are 20 monitors with each monitor divided into 16 squares of surveillance feed. During an interview on 04/11/22 at 11:30 A.M., FPO #370 stated APS called the facility on 03/25/22 at 11:30 A.M. with the complaint about STNA #155. FPO #370 stated the complainant was interviewed on 03/25/22 from 6:30 P.M. to 8:00 P.M. via telephone. At this point, STNA #155 was placed on extra surveillance. FPO #370 explained enhanced surveillance as having extra foot patrol on the floors of the facility and the employee who monitors the camera feed will bring up the floor the STNA is working on and concentrate on that unit and see if they see anything suspicious is occurring. FPO #370 verified the cameras are only in common areas and are not in resident care areas or resident rooms. Review of the facility policy titled Administration Procedure No. Admin-3 Subject: Abuse, Neglect, Exploitation; Mistreatment, Including Injuries of Unknown Source, Misappropriation of Resident Property, and Resident to Resident Altercations, revised 07/19/17 revealed the investigative process for any reports of Abuse, Neglect, Exploitation, Mistreatment, Including Injuries of Unknown Source, Misappropriation of Resident Property, and Resident to Resident Altercations follows a systematic approach and meets the ODH seven requirements as listed below. I. Screening: Screen potential employees for a history of abuse, neglect, exploitation or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. II Training: Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices. III. Prevention: Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. IV. Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. V. Investigation: Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting as results to the proper authorities VI. Protection: Protect residents from harm during an investigation. VII. Reporting/Response: Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. Report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences All Staff: 2. Upon receiving a report of known, alleged, or suspected abuse neglect or misappropriation of property regarding a resident immediately contact the charge nurse. Charge Nurse: 1. Upon receiving a report of known, alleged, or suspected abuse, neglect or misappropriation of property regarding a resident immediately contacts the nurse supervisor. Clinical Care Coordinator: 1. Immediately ensures resident safety; 2. Immediately notifies Nurse Supervisor of incident; 3. Immediately completes assessments of all involved residents and documents in the medical record. Nurse Supervisor: 1. Upon receiving a report of known, alleged or suspected abuse, neglect, misappropriation of property, or injury of unknown source regarding a resident immediately address the situation by 1. ensuring resident safety; 2. Immediately notify the Licensed Nursing Home Administrator, Director of Nursing or designee; and 3. Start a thorough investigation with those parties who may have knowledge relevant to the situation. This deficiency substantiates Complaint Number OH 528.

Based on review of facility documents, staff and police interviews, policy review, and review of Self-Reported Incidents (SRI), the facility failed to ensure residents were free from sexual abuse by facility staff. This resulted in Immediate Jeopardy for Residents #07, #59, and #89 when State tested Nursing Assistant (STNA) #155 confessed to taking inappropriate pictures of Residents #07 and #59 and sexually assaulting Resident #89 on two separate occasions. This affected three of three residents reviewed for sexual abuse. The facility census was 203. The Administrator was notified on 04/11/22 at 2:20 P.M. that Immediate Jeopardy began on 03/25/22 when a senior employee of the Ohio Department of Job and Family Services (ODJFS) contacted the facility's Chief of Police to relay information alleging an employee of the facility had taken and shared nude photographs of residents. The employee was identified as STNA #155 and subsequently confessed to the Ohio Veterans Home police department on 03/30/22, during an interview, that he took inappropriate pictures of Residents #07 and #59 and sexually assaulted Resident #89 on two separate occasions while working in the facility. STNA #155 was then arrested and taken to jail. The Immediate Jeopardy was removed on 04/12/22 when the facility implemented the following corrective actions: · On 03/30/22 and 03/31/22, the affected residents, along with every other resident, received head-to-toe assessments with no findings. Residents who were interviewable were also interviewed at the time of their head-to-toe assessment with no findings. · On 03/30/22, STNA #155 was arrested and removed from the facility. On 04/08/22, STNA #155 resigned from employment at the Ohio Veterans Home. · On 03/30/22, staff education began on the facility's abuse policy. · During an interview with Licensed Practical Nurse (LPN) #305 on 04/04/22 at 11:35 A.M., it was confirmed he was trained on abuse proceedings, would protect a resident in an abuse situation and report to the supervisor immediately. · During an interview with LPN #340 on 04/04/22 at 11:05 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report to supervisor immediately. LPN #340 denied ever seeing abuse or knowing about abuse at the facility. · During an interview with STNA #335 on 04/04/22 at 11:37 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report the situation to the supervisor immediately. · During an interview with LPN #345 on 04/05/22 at 8:35 A.M., it was verified she was trained on abuse and verified she had not noted any changes in resident behaviors that indicated they had been abused at the facility. LPN #345 stated if there was any indication of resident abuse, she would have reported it. · During an interview with STNA #300 on 04/05/22 at 8:40 A.M., it was confirmed she was trained on abuse proceedings, would protect a resident in an abuse situation and report to supervisor immediately. STNA #300 denied ever seeing abuse or knowing about abuse at the facility. · During an interview with LPN #320 on 04/05/22 at 8:45 A.M., LPN #320 verified she was trained on abuse and verified she had not noted any changes in resident behaviors that indicated they had been abused. LPN #320 stated she was only aware of one allegation of abuse at the facility and that was the incident from last week. LPN #320 stated the residents in her care have not had any indications that would have made her think something had happened to them, and if there had been indications of abuse, she would have reported it. · On 04/12/22, staff re-education began on clarification of the facility ' s current abuse policy under Section 6 titled protection that an alleged perpetrator is to be immediately removed from the building pending outcome of the investigation in order to protect residents from harm. Police, Therapy, Pharmacy, Nursing, Dietary, Housekeeping, Laundry, Administration and Human Resources Staff were educated by the Administrator/Designee. · On 04/12/22, revisions were made to the SRI checklist to clarify any alleged perpetrator is to be immediately removed from the building upon receipt of an allegation of abuse, neglect, exploitation, mistreatment, including injuries of unknown source, misappropriation of resident property and resident to resident altercation. · On 04/12/22, every SRI will be audited on an on-going basis, as they occur, for the immediate removal of the alleged perpetrator. · On 04/12/22, the Administrator was educated by the Superintendent on the Abuse policy and included reporting responsibility, definitions of abuse including exploitation, prevention and identification. Although the Immediate Jeopardy was removed on 04/12/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the facility's document titled Factual Timeline, provided by the facility on 04/11/22, documented on the afternoon of 03/25/22, a senior employee of the Ohio Department of Job and Family Services (ODJFS) contacted the facility's Chief of Police to relay information alleging an employee of the facility had taken and shared nude photographs of residents. (The employee was identified as STNA #155) On 03/29/22, STNA #155 was interviewed at his residence and denied all allegations. He permitted a voluntary search of his telephone. Although the search of STNA #155's telephone did not reveal any images consistent with the allegations shared by ODJFS, the pictures did demonstrate the suspect had an interest in explicit images of older males. Based on this limited corroboration, the facility immediately removed STNA #155 from providing direct care to residents. After the interview at his home, STNA #155 called off work for his shift on 03/29/22. On 03/30/22, STNA #155 was reassigned to dietary so he would have no access to residents. Enhanced surveillance of him continued. That same day, the facility's police department interviewed STNA #155 again, which led to a full confession of a sexual assault of one resident on two occasions. The alleged events occurred sometime in November 2021. STNA #155 was immediately arrested and removed from the facility. During an interview on 04/04/22 at 9:46 A.M., the Administrator stated she had minimal information about the incident with STNA #155, as the alleged incident is criminal in nature and the facility cannot conduct a criminal and administrative investigation at the same time. The Administrator stated a call came into the Ohio Veterans Home Police Department (OVHPD) on 03/25/22 from Adult Protective Services (APS) of [NAME] County. The call was very brief indicating one of the staff at the facility had potentially taken inappropriate pictures of residents. The Administrator stated the facility police obtained the name of the complainant from APS on 03/28/22 in the evening hours. OVHPD was able to interview the complainant, who provided the name of the staff member on that date who was alleged to have taken pictures of residents. The Administrator stated the complainant was not an employee of the facility. The Administrator stated when the facility got the name of the alleged staff member, STNA #155, the staff member was placed on enhanced police surveillance (watching the staff member through live camera feed from the hallways, but not in resident rooms as the cameras are not in care areas.) STNA #155 was a second shift employee who worked on 03/25/22 and 03/28/22 providing care to residents at the facility. On 03/29/22, the Ohio State Highway Patrol along with OVHPD went to the home of STNA #155 to interview him. During this interview, STNA #155 provided his phone for the two police departments to review. The Administrator stated no photographs of facility residents were found on STNA #155's phone. On 03/29/22, STNA #155 called off work. On 03/30/22, STNA #155 was moved from resident care to the kitchen, washing pots and pans. The Administrator verified STNA #155 reported to work on 03/30/22 and worked in the dietary department from approximately 3:00 P.M. to 4:30 P.M. at which time the facility police took STNA #155 in for further questioning. During this questioning, STNA #155 confessed to taking inappropriate pictures of Resident #07 and #59 in November 2021 and sexually assaulting Resident #89 on two separate occasions in December 2021. The Administrator stated after STNA #155 confessed to the resident abuse, the facility police arrested STNA #155 and took him to the county jail. The Administrator stated there was minimal information related to this incident for review except for the head-to-toe assessments, resident interviews, and the education of staff. The Administrator stated Resident #89, who had moderate cognitive impairment, had been interviewed on 03/30/22 and denied having been touched inappropriately at the facility. The Administrator stated the other two residents, Residents #07 and #59, were not able to provide meaningful information on interview. The Administrator stated when responsible parties were notified, they were offered to have their resident receive psychological services related to the incident. Only Resident #59's family desired the resident to receive psychological services. The Administrator stated the family of Resident #89 was very upset over the allegations and were in the process of discharging Resident #89 home. During an interview on 04/11/22 at 11:30 A.M., Police Officer #370 stated on 03/25/22 at approximately 11:30 A.M., APS called with the complaint regarding pictures being allegedly taken of facility residents. The name of the alleged employee taking the pictures was divulged as STNA #155. Police Officer #370 stated they interviewed the complainant via phone on 03/25/22 from 6:30 P.M. to 8:00 P.M. at which point STNA #155 was placed on extra surveillance. During the conversation, the complainant stated he had not seen the alleged pictures, but he had spoken to the roommate of STNA #155, who had seen the photos. Police Officer #370 explained enhanced surveillance as having extra foot patrol on the floors of the facility and the employee who monitors the facility camera feed will bring up the floor the employee is working on and concentrate on that unit to see if they see anything suspicious occurring. The surveillance cameras are only in common areas and medication rooms, not in resident care areas or resident rooms. Police Officer #370 was present for part of the interview with STNA #155 on 03/30/22 and stated STNA #155 confessed to taking pictures of Residents #07 and #59 and sexually assaulting Resident #89. Police Officer #370 stated the details of the confession could not be shared. Review of the facility policy titled Administration Procedure No. Admin-3 Subject: Abuse, Neglect, Exploitation; Mistreatment, Including Injuries of Unknown Source, Misappropriation of Resident Property, and Resident to Resident Altercations, revised 07/19/17, documented the investigative process for any reports of Abuse, Neglect , Exploitation, Mistreatment, Including Injuries of Unknown Source, Misappropriation of Resident Property, and Resident to Resident Altercations follows a systematic approach and meets the ODH seven requirements as listed below. I. Screening: Screen potential employees for a history of abuse, neglect, exploitation or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. II. Training: Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices. III. Prevention: Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. IV. Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. V. Investigation: Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting as results to the proper authorities VI. Protection: Protect residents from harm during an investigation. VII. Reporting/Response: Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. Report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences All Staff: 2. Upon receiving a report of known, alleged, or suspected abuse, neglect or misappropriation of property regarding a resident, immediately contact the charge nurse. Charge Nurse: 1. Upon receiving a report of known, alleged, or suspected abuse, neglect or misappropriation of property regarding a resident, immediately contacts the nurse supervisor. Clinical Care Coordinator: 1. Immediately ensures resident safety; 2. Immediately notifies Nurse Supervisor of incident; 3. Immediately completes assessments of all involved residents and documents in the medical record. Nurse Supervisor: 1. Upon receiving a report of known, alleged or suspected abuse, neglect, misappropriation of property, or injury of unknown source regarding a resident immediately address the situation by 1. ensuring resident safety; 2. Immediately notify the Licensed Nursing Home Administrator, Director of Nursing or designee; and 3. Start a thorough investigation with those parties who may have knowledge relevant to the situation. This deficiency substantiates Complaint Number OH 528.

Based on medical record review, staff interview, resident interview, review of hospital documentation, review of mechanical lift manufacturer instructions, review of facility mechanical lift policy, and review of facility incident investigation documentation, the facility failed to ensure residents were provided with appropriate supervision during a transfer using a mechanical lift. This resulted in actual harm when Resident #433 sustained a 5.0 centimeter (cm) laceration to the right anterior shin which required suturing. The resident was being transferred with a mechanical lift with only one staff person. This affected one (Resident #433) of three residents reviewed for use of mechanical lift for transferring. Facility census was 390. Findings include; Review of the medical record revealed Resident #433 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #433 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living (ADL), and required extensive physical assistance of two staff for bed mobility, transfer, and personal hygiene. The resident utilized a wheelchair for mobility. Review of a a physician order [REDACTED]. Review of a nursing plan of care dated 07/24/19 was initiated to address fall risk. Interventions included the resident was an assist up in manual wheelchair daily. Additionally, a plan of care was developed on 07/24/19 to address the residents need for assistance with ADLs. Interventions included two staff assist with ADLs. There was no documentation on the care plans that indicated the number of staff to support the resident during a mechanical Hoyer lift for transfer. Review of an evaluation report for skin injury form, located in the medical record, revealed on 10/03/19 at 6:30 P.M. the resident was alert and oriented times two. The nurse was attempting to transfer Resident #433 with the mechanical Hoyer lift. The lift got stuck and the residents leg was stuck between the bed and the lift (Hoyer). The nurse attempted to remove the residents leg and the corner of the box on the Hoyer lift sliced the residents leg open, resulting in a laceration to the lateral right lower extremity. The lift indicated the battery was full but the lift would not go up. Review of nursing notes dated 10/03/19 at 7:16 P.M. revealed Resident #433's right anterior shin had an open area measuring 5.0 cm in length with adipose tissue exposure. Non-weight bearing Hoyer lift malfunctioned while licensed practical nurse (LPN) #400 was assisting the resident to bed. The resident sustained [REDACTED]. Pressure was placed to the laceration for over five minutes until bleeding stopped. The resident was subsequently sent to the emergency room for treatment. Review of nursing notes dated 10/03/19 at 7:25 P.M. noted the resident was being transferred to bed by LPN #400 when his leg hit on part of the Hoyer. State tested Nurse Aide (STNA) #300 reported the Hoyer was not working properly. The maintenance staff were informed and removed the lift from service. Review of hospital documentation dated 10/03/19 noted the resident was treated for [REDACTED]. The resident was placed on an antibiotic Keflex 500 milligrams (mg) every six hours for seven days and had six sutures placed to close the injury. On 10/24/19 at 8:15 [NAME]M. interview with STNA#302 revealed residents were transferred either using one assist or two assist depending on their functional status and ability to comply with instructions while using the lift. Some residents were transferred using one staff member. On 10/24/19 at 9:10 [NAME]M. interview with the Director of Nursing (DON) during a review of the facility full body mechanical lift instructions (policy) updated 04/04/19 noted in red print indicating all transfers involving the use of full body mechanical lift require two assist for transfer. The DON was unaware the mechanical lift policy required two staff to be utilized during a mechanical (Hoyer) lift transfer. On 10/24/19 at 11:04 [NAME]M. interview with Resident #433, in his room, revealed when he sustained the laceration to his leg only one staff member performed the mechanical lift. Since that incident single staff members have provided transfers using the Hoyer lift from bed to chair and chair to bed. On 10/24/19 at 11:15 [NAME]M. interview with LPN #401 and LPN #402 revealed they would use one person for transferring residents during a Hoyer lift transfer. The LPN's were unaware the facility policy indicated two staff were required. Further interview during a review of nursing and STNA care plans identified no documentation to direct staff on a specific number of staff to assist with Hoyer lift transfers. On 10/24/19 at 11:44 [NAME]M. interview with STNA #301 during a review of STNA care plan intervention verified no directive was listed for Resident #433 referring to the number of staff to be present during a Hoyer lift transfer. On 10/24/19 at 1:43 P.M. interview with Assistant DON #101 verified she was unaware the Hoyer lift policy indicated two staff were to be utilized with mechanical lift transfers. According to the skin injury status [REDACTED].#400 was transferring Resident #433 using the full body mechanical lift. LPN#400 was alone when the lift malfunctioned causing Resident #433's leg to become stuck between the bed frame and the lift. When LPN#400 attempted to remove Resident #433's leg from between the bed and lift, Resident #433's leg struck the corner of the Hoyer lift box and caused a laceration to his leg. The laceration resulted in Resident #433 being transported to the hospital emergency room to have six sutures put into place to close the wound. As a result of the incident corrective action was noted to remove the broken Hoyer lift from service. No documentation included staff utilized the appropriate number of staff when transferring residents while using the full body mechanical lift or the timely reporting of malfunctioning equipment. Review of manufacturer instructions for EZ Way Smart Lift (mechanical lift) revised 06/13/11 revealed the lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patients condition, two caregivers may be necessary. Review of facility policy entitled Full Body Mechanical Lift Bed To Chair Transfer Work Instructions with a revised date of 04/04/19 revealed all transfers involving the use of full body mechanical lift require two assist for transfer.

Based on observation, staff interview, medical record review, review of facility skin integrity policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure one resident had appropriate interventions in place to prevent skin breakdown. Actual harm occurred when the facility placed Resident #447 in a wheel chair which was not assessed for proper application and the resident subsequently developed a deep tissue injury to the right lower extremity. This affected one (#447) of three residents reviewed for skin breakdown. The facility identified 21 residents with pressure ulcers. Facility census was 413. Findings include: Review of Resident #447's medical record revealed an admission date of [DATE], with the [DIAGNOSES REDACTED]. On 03/28/17, a Braden skin risk assessment scored the resident with no risk for skin breakdown. On 03/28/17, a nursing plan of care was developed to address the resident being at risk for further skin breakdown. Interventions were as follows: pressure redistribution cushion to wheel chair seat, inspect skin while applying lotion daily on 3:00 P.M. to 11:00 P.M. shift, monitor skin each shift for signs/symptoms of potential skin breakdown (redness, discoloration, open area). Additionally, on 03/28/17, a nursing plan of care was developed to address residents complaints of bilateral knee pain. Interventions included, medications as ordered, monitor for effectiveness, monitor signs and symptoms of pain, when having pain assess for cause of pain and try to eliminate, position for comfort and try alternative measures. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed the resident was identified as alert and able to make needs known with highly impaired vision. The resident required total assistance of one staff for dressing, supervision with set-up help regarding transfer and one person physical assist with locomotion by wheelchair. The assessment also recorded the resident with a stage 2 pressure ulcer. On 05/04/17, a global cushion was added to the care plan while the resident was in bed to off load heels and on 05/25/17 the intervention was added to off load heels by placing a pillow behind the ankles while in bed. No intervention addressed the residents lower extremities while in the wheel chair. Review of nurses notes documented on 03/28/17 at 4:24 P.M., revealed Resident #447 was noted with stage 2 (II) wound intact, serum filled blister to left lower shin noted upon admission assessment. Blister measures 1.8 centimeters (cm) long by 1.2 cm wide. Peri-wound dark pink/brown as is almost entire lower shin of his left leg. Resident states that whole area opens and drains with blisters from time to time. Resident has diabetic [MEDICAL CONDITION] and verbalizes he has very little feeling in fingers. Nurses notes continue to document the resident up in a wheel chair and transfers with stand pivot method. Review of nurses notes from 04/12/17 noted the resident to experience pain to the bilateral legs. Frequent request for pain medication included the administration of narcotic medications, [MEDICATION NAME] 5/325 milligram (mg) one tablet, administered resulting in relief. On 04/13/17 at 6:09 P.M., a new order for [MEDICATION NAME] one tab administered at bedtime (hs) was obtained. On 04/15/17 at 11:43 A.M., medicated pain in legs. On 04/22/17 at 4:32 P.M., the stage II pressure area to the left lower shin healed and a new order was obtained at 9:43 P.M. for A&D ointment bilateral legs and feet every night. Nurses notes documented on 04/24/17 at 2:28 P.M., a new order to increase [MEDICATION NAME] (diuretic) to 60 mg every day due to lower extremity [MEDICAL CONDITION] and a new [DIAGNOSES REDACTED]. According to the physical therapy (PT) evaluation dated 03/29/17 the resident was referred to PT to evaluate and treat as indicated due to increased bilateral lower extremity weakness and decreased ability to transfer and ambulate placing him at significant risk for falling. The assessment did note the use of a wheel chair. However, no documentation indicated the wheelchair was assessed for proper size or foot pedal placement. On 04/25/17, the resident was discharged from physical therapy with recommendations including activities or an exercise group. No mention of the wheel chair use or application were noted. Further review of nurses notes on 04/26/17 at 6:45 P.M. returned from nephrology appointment with orders to see an orthopedic specialist to recheck the bilateral knees. The Resident continued with frequent request for [MEDICATION NAME] pain medication due to bilateral knee pain. On 05/04/17, a physician order [REDACTED]. On 05/09/17 at 10:15 A.M., the resident returned from a vascular specialist appointment and instruction revealed no need to be seen there any longer due to the bilateral knees not being vascular related and to refer to orthopedics. On 05/10/17 at 3:32 P.M. a new order to discontinue the [MEDICATION NAME] pain medication and start [MEDICATION NAME] 5/325 mg([MEDICATION NAME]) two tablets every eight hours (q 8 h) as needed for legs. The medical record continued to document use of the [MEDICATION NAME] pain medication for bilateral knee pain. On 05/25/17 at 9:21 P.M., a physician order [REDACTED]. According to nurses notes on 05/31/17 at 6:46 A.M., the nurse discovered the resident with a fluid filled and ruptured blister to right lateral shin. The proximal right lateral shin with a blood-serum filled blister measuring 5.5 cm by 3.5 cm. The Distal right lateral shin ruptured blister measures 5.7 cm by 2.0 cm by less than 0.1 cm. The area was cleansed with normal saline, padded and protected with an Abdominal (ABD) dressing and wrapped with kerlix (gauze wrap). The nurse documented the location of injury matches up with footrest of the wheel chair. The resident stated does not know how injury occurred. Interventions included lambswool to the footrest of wheelchair to prevent skin injury. Observation on 07/26/17 at 11:00 A.M. during the dressing change to the right lateral knee with Licensed Practical Nurse (LPN) #22 noted the resident in bed with feet elevated. The wound was noted with black eschar intact. Review of wound measurement documentation noted measurements as follows: on 06/04/17 area was 4.25 cm by 2.0 cm and depth less than 0.1 cm; on 06/24/17 became unstageable 8.2 cm by 4.3. cm color black without drainage. On 07/12/17 are was 7.0 cm by 4.4 cm by depth of less than 0.1 cm; on 07/15/17 area was 7.0 cm by 5.0 cm unknown depth with moderate amount of serous drainage; on 07/26/17 area was 8.0 cm by 4.4 cm and black in color with small amount of serosanguinous drainage. On 07/27/17 at 10:45 A.M. interview with Registered Nurse (RN) #44 unit manager during review of Resident #447's medical record stated the cause of the open area to the right lateral leg was due to pressure from the footrest on the wheelchair. No assessment of the residents wheel chair was documented. RN #44 then contacted the therapy department and verified at 11:10 A.M. during telephone conversation therapy was unable to provide an assessment regarding the appropriate application of the wheelchair and associated devices including the use of the footrests. Further review of the medical record lacked documentation indicating the residents skin was assessed each shift in accordance with the nursing plan of care. According to the facility maintenance of skin integrity policy dated May 13, 2008 measures to prevent skin breakdown include protecting the skin from scratching, rubbing, or other trauma, keep bed and chair seats free of objects that could cause irritation. Additionally, be observant to any reddened areas or breaks in skin. Information from the NPUAP was reviewed. According to the NPUAP revealed a deep tissue is persistent non-blanchable deep red, maroon or purple discoloration. The area is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatological conditions.

Based on surveyor observation, staff and police interviews, medical record review, review of police reports, review of employee personnel files, review of staffing schedules, review of a facility self-reported incident (SRI) and review of facility policy, the facility failed to ensure one resident (#30) was free from abuse by a staff member. This resulted in actual harm to Resident #30 when State tested Nurse Aide (STNA) #92 was observed to use his forearm to shove the resident forcibly while seated in his wheel chair causing the front wheels of his wheel chair to be lifted off the floor. These actions resulted in bruising to the left temple, chest area and the opening of a previous skin tear on the right elbow. Additionally, STNA #92 was observed to spit on Resident #30 during the incident. This affected one (#30) of three residents reviewed for allegations of abuse. The unit census was 38. Findings include: Review of a facility SRI dated 05/03/14 at 10:27 AM. revealed an allegation of physical abuse to Resident #30 (the victim) by a facility staff member. The (SRI) named the alleged perpetrator, State tested Nurse Aide (STNA) #92. Review of Resident #30's medical record revealed he was admitted on [DATE] and was receiving Hospice services for Alzheimer's since 05/23/13. The resident's [DIAGNOSES REDACTED]. Resident #30 resided on a locked dementia unit. Resident #30's medical record revealed his speech was nonsensical and he was not interviewable. His care plan documented he had episodes of agitation (verbally abusive and resistive to care at times). Interventions included to identify cause of agitation and to leave him alone and come back later, use two assist with all care, one to one visits and to medicate as directed. Review of STNA #92's employee file revealed he began employment as a STNA at the facility on 06/25/07. There was documentation of appropriate background checks, reference checks and nurse aide registry verifications having been completed. New employee orientation included: behavior monitoring, reality versus validation, diversional training and validation. His last performance evaluation was completed on 10/22/12 which did not document any concerns other than complaining about changes at the facility to families of residents. He was permanently assigned to One North (1N) and normally worked afternoon shift (where Resident #30 resided). Review of the staff schedule revealed STNA #92 worked a double shift (1st and 2nd shift) on 05/02/14. Review of the facility investigation revealed on 05/02/14, STNA #85 and another STNA #87 had gotten Resident #30 up. The resident had been combative but they had changed his brief, dressed him for the day and put him in his wheel chair. The only thing they had left to do was change his shirt. At approximately 7:10 A.M., STNA #92 (day shift aide) entered the room to inform STNA #87 she had a phone call. STNA #85 stated STNA #92 approached the resident and was aggressive. Resident #30 was resisting the shirt change and STNA #92 was shouting at the resident. On 05/03/14, the facility administration was made aware of an alleged incident of abuse that had happened on 05/02/14. STNA #85's statement documented she observed STNA #92 hit Resident #30 with his hand and she observed STNA #92 shove Resident #30 in the chest, using his right forearm, causing the resident's wheel chair's front wheels to come off the floor. STNA #85 stated she was scared. Then she observed Resident #30 spit on STNA #92 with STNA #92 spitting back at the resident. STNA #85 stated, STNA #92 then left the room. STNA #85 stated she observed blood on Resident #30's shirt after the incident occurred. On 05/03/14 at 7:20 A.M., a head to toe assessment was completed for Resident #30. There was a maroon colored, three centimeter (cm) by one cm discoloration to the resident's left temple, yellow discoloration to left outer corner of the left eye, a small open area to the back of the right ear with scabbing, small round yellow bruises noted to the left chest area, and yellow bruise noted to right scapular area. Resident #30 did have a fall and skin tears in the weeks preceding. Resident #30 had fallen from the wheelchair on 04/16/14. The resident also had obtained a skin tear to the right elbow on 04/26/14 and a skin tear to the right biceps on 04/28/14. It was determined the bleeding at the time of this incident had come from an existing skin tear that had reopened. The facility substantiated the allegation of abuse. Review of STNA #85's employee file revealed she was hired on 01/06/14. She was a new STNA as of 10/22/13 and all pre-employment checks were done. There were no issues (meets all expectations) on her "mid-probationary" evaluation done on 03/25/14. Review of the staff schedule revealed STNA #85 was a night aide. On 05/08/14 at approximately 10:00 A.M., the director of nursing (DON) and assistant director of nursing (ADON) #18 were interviewed. ADON #18 oversaw the unit where Resident #30 resided. They stated Resident #30 was not interviewable and could be combative and verbally abusive, especially with care. They verified there was a delay in staff reporting the abuse allegation. The witness was afraid of retaliation by STNA #92. The DON and ADON #18 felt the bruises on the temple and chest were possibly related to the abuse allegation. On 05/08/14 at 10:35 A.M., Chief of Police #170 was interviewed due to the facility's investigation involving the facility's own police department. He stated the police department had been notified on 05/03/14 in the morning of resident abuse. They investigated and interviewed the alleged perpetrator several times over the weekend. STNA #92 denied the incident and had no prior incidents with the facility police. The police chief (#170) stated STNA #92 was arrested on 05/07/14 and charged with patient abuse, felony of the fourth degree (F4) and STNA #92 pled not guilty on 05/07/14. On 05/08/14 at 11:23 A.M., STNA #85 was interviewed by telephone. She reported the same information as she did during the facility investigation. She stated she did not report the incident immediately. She stated she had worked nights and went home after the incident. She stated she reported it the next night after discussing with a co-worker who told her she had to report it. She stated she was too uncomfortable and scared to say anything. She stated she had not talked with STNA #92 since the incident. She stated she did not know STNA #92 but she reported it because it was wrong. She stated she has had abuse education during her orientation but again stated, "I was too scared." On 05/08/14 at 11:35 A.M., STNA #87 was interviewed by telephone. She stated she was not in the room when it happened. She stated the police officer told her about it. She stated STNA #92 had came to Resident #30's room and told her she had a phone call so she had left the room. She stated they had him ready except for his shirt. She stated she had started working in March and she was able to explain abuse reporting. On 05/12/14 at 1:25 P.M., during an interview with Licensed Practical Nurse (LPN) #65 she stated she and LPN #68 were the day nurses on 05/02/14. She stated she was never aware of any abuse allegations. She stated Resident #30 can be resistant to care. On 05/12/14 at 1:35 P.M., LPN #68 was interviewed by telephone. He stated STNA #92 had mentioned he had helped the girls because Resident #30 was "beating the hell out of the girls". He stated he observed Resident #30 at approximately 7:20 A.M. He stated there was no staff in the room and the resident was quiet. There had been no report of abuse. On 05/08/14 at 10:35 A.M., Resident #30 was observed seated in his wheelchair in the common area. He was taken to his room by staff, but attempts to do an assessment was met with him swinging at the staff. He did not speak but just struck out at them. The left temple had scaly skin without clear bruising observed. At 2:20 P.M., he was observed sleeping quietly in his bed. There was dried blood in his left ear which was related to a skin tear obtained during care on 05/07/14. On 05/12/14 at 11:55 A.M., Resident #30 was observed in a group activity. He was seated calmly in his wheelchair. He was nonverbal but shook his head "yes" in response to questions. However, he was distracted by scaly skin on right hand. Review of the facility policy, revised 09/02/09, entitled "Abuse, Neglect, and Misappropriation of Resident Property, Injuries of Unknown Origin and Resident to Resident Altercations", directed a witness to an event is to intervene immediately to ensure resident safety and to then report immediately to the charge nurse/supervisor. This deficiency substantiates complaint OH 593.