Every finding on record at Overbrook Center

Based on review of facility schedule, and interview the facility failed to ensure a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 69 residents residing in the facility. Findings Include:Review of the facility schedules from 04/03/26 to 04/09/26 revealed on 04/05/26 the scheduled dayshift RN had called off and was not replaced with an RN. On 05/07/26 at 2:43 P.M., an interview with Licensed Practical Nurse (LPN) #528 verified the facility had not met required eight consecutive hours of RN coverage for 04/05/26. This deficiency represents noncompliance investigated under Complaint Number 3006363.

Based on record review, resident interview, review of resident rights, and staff interview, the facility failed to ensure each resident was treated with respect and dignity and was given care in an environment that promoted enhancement of quality of life. This affected one of 20 sampled residents (Resident #39). The facility census was 69.Review of the record for Resident #39 revealed an admission date of 04/24/26 and diagnoses including diabetes, bipolar disorder, anxiety disorder, hypertension, and depression. Review of an admission Minimum Data Set completed on 04/29/26 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident required partial/moderate assistance with showers. Interview with Resident #39 on 05/04/26 at 3:13 P.M. revealed there was a nursing assistant on evening/night shift (she only knew the first letter of her name who was later determined to be Nursing Assistant #555) who was loud and rude to her. She stated that last evening she had put her call light on because she needed a pain pill and Nursing Assistant #555 responded. She stated Nursing Assistant #555 said the nurse was on another hall and she would get it when she gets it. Resident #39 stated LPN #513 came and gave her the pain pill and said she was sorry for the way the nursing assistant talked to her and she had heard that the nursing assistant talked to other residents that way. Resident #39 stated she had reported this to LPN #519 around lunch time on 05/04/26. Resident #39 stated another incident had occurred on Friday 05/01/26 when she asked Nursing Assistant #555 for a shower since she was going out to a church function the next day and wanted her hair to look nice. She stated Nursing Assistant #555 told her she was not on the shower list, she had eight other showers to do, and she could not do it. Resident #39 stated she washed her own hair in her bathroom sink. Resident #39 stated the way Nursing Assistant #555 talked to her made her feel bad and downgraded. She stated that she felt she had Post Traumatic Stress Disorder (PTSD) due to her ex-husband being verbally and physically abusive to her. She stated that he had stabbed her and broke her nose and the PTSD caused her to have nightmares and panic attacks with anxiety. She stated she felt the treatment by Nursing Assistant #555 might cause her to have a trigger of her PTSD. She stated no one from the facility had followed up with her since reporting it to LPN #519. Interview with LPN #513 on 05/05/26 at 1:50 P.M. confirmed she worked the evening/night shift (7:00 P.M. to 7:00 A.M.) on 05/01/26, 05/02/26, and 05/03/26. She stated the Resident #39 does not get along with Nursing Assistant #555. She stated that Resident #39 told her she didn't think Nursing Assistant #555 liked her. LPN #513 said she did not pursue why Resident #39 felt that way. She stated she told Resident #39 that Nursing Assistant #555 was young and that is just her personality. She stated she was not aware of what Resident #39 reported about how Nursing Assistant #555 responded to her needing a pain pill or shower. She stated she was aware Resident #39 washed her own hair in the sink and another resident (Resident #5 ) also said Nursing Assistant #555 was cranky and did not smile. She stated she did not report any of this to Administration or anyone else. Interview with LPN #519 on 05/05/26 at 2:10 P.M. revealed Resident #39 reported to him on 05/04/26 that Nursing Assistant #555 was rude. He stated Resident #39 described her as a (expletive). Resident #39 said she asked for a pain pill and Nursing Assistant #555 was rude when saying the nurse would come. He stated he reported this to Unit Manager LPN #532 on 05/04/26. Interview with Unit Manager LPN #532 on 05/05/26 at 2:30 P.M. revealed she did not remember LPN #519 reporting anything to her about Resident #39 or Nursing Assistant #555. She stated Resident #39's showers are scheduled on Monday, Wednesday, and Friday on dayshift. She stated it was documented Resident #39 refused her shower on dayshift on Friday, 05/01/26. Interview with Nursing Assistant #537 on 05/06/26 at 9:00 A.M. revealed she documented on the shower sheet on dayshift on Friday 05/01/26 the resident refused her shower. She stated Resident #39 had asked for a shower on evening shift as she was going on an outing. A message was left on 05/05/26 at 2:15 P.M. for Nursing Assistant #539 (who worked with Nursing Assistant #555 on 05/01/26, 05/02/36, and 05/03/26) but she did not return the call. Interview with the Administrator and Director of Nursing on 05/05/26 at 2:40 P.M. revealed they had not received any reports of any staff being rude or any concerns related to Nursing Assistant #555. They stated they would begin an investigation at that time. Interview with the Administrator on 05/06/26 at 9:03 A.M. revealed the facility did not have a policy on Dignity and Respect. He stated the facility followed Resident Rights and he would provide a copy. Review of a Resident/Family/Staff Concern form dated 05/05/26 revealed Resident #39 reported to state that she has PTSD and that a nursing assistant was rude to her. Trauma informed care completed during social service admission assessment where resident denied experiencing any frightening, horrible, or traumatic event. However on 05/05/26 the resident reported to state she has PTSD. No diagnosis present. Social Services followed up with resident and resident reports her last husband physically abused her and triggers are loud noises and rude people. The resident was asked about the nursing assistant being rude to her and the resident reports when she asked for a shower the nursing assistant reported you're not getting one today because it's not your shower day. The resident also asked for her pain medication and the same nursing assistant reported you're going to have to wait because your nurse is on another hall right now. The concern form stated the nursing assistant was suspended at this time pending investigation. It stated that once the investigation was completed, if the facility retained the nursing assistant, she will be reassigned to the other wing of the facility and provided with disciplinary action. Interview with the Administrator and Director of Nursing on 05/06/26 at 12:30 P.M. confirmed Nursing Assistant #555 was suspended during the investigation. They stated other residents were interviewed with no other concerns except Resident #5. They stated they were starting staff education on customer service and if Nursing Assistant #555 returned, they would move her to a different hall and monitor her interactions. They stated they instructed Resident #39 to report any additional issues to Administration. Review of the undated Resident Rights provided revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on record review and interview the facility failed to document that quarterly care conferences were conducted and who attended the meetings. This affected three Residents (#2, #8, and #53) of three sampled for care conferences. The facility census was 69. 1. Review of Resident #2's medical record revealed an admission date of 04/08/19, a re-entry date of 05/20/2025 and diagnoses including chronic obstructive pulmonary disease, diabetes, chronic kidney disease stage 4, unspecified diastolic (congestive) heart failure, hypothyroidism, anemia, bipolar disorder, paroxysmal atrial fibrillation, peripheral vascular disease, schizoaffective disorder, unspecified mood disorder, major depressive disorder, and anxiety disorder. Review of Resident #2's annual Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review of Resident #2's MDS revealed the resident was dependent on facility staff for toileting hygiene, required substantial/maximal assistance for bed mobility, and was always incontinent of bladder and bowel. Review of Resident #2's social services quarterly/annual/significant change assessment dated [DATE] and completed by the Director of Social Services (DSS) #550 revealed a summary note that read the resident and resident' power of attorney were invited to a care conference and declined. Further review of Resident #2's medical record revealed no further mention of a care conference or who attended the care conference. In an interview on 05/05/2026 at 8:26 A.M. with Resident #2 revealed the resident didn't recall a recent care conference. In an interview on 05/05/2026 at 10:44 A.M. DSS #550 revealed social services quarterly/annual/significant change assessments are done quarterly and care conferences are offered to residents and families with notices sent to families by mail but most do not respond. In an interview on 05/05/2026 at 2:22 P.M. with the Director of Nursing (DON) revealed staff do have a care conference assessment and a quarterly assessment and it is documented if the resident and family decline to attend. He said the care conference is documented in the assessments by discipline and the care conference is an ongoing process and is discussed daily during morning meeting for updates and acute changes. However, there was no information about the care conference or who attended. 2. Review of the record for Resident #53 revealed an admission date of 10/24/25 and diagnoses including cerebral infarction, diabetes, chronic obstructive pulmonary disorder, seizures, and migraines. Review of a Minimum Data Set assessment completed 03/27/26 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of a care conference summary dated 10/30/25 revealed- met with resident and sister this date. Goal to return home with sister and home health care. It was not documented what staff were part of the care conference at that time. Review of a Social Service Quarterly/Annual/Significant change assessment dated [DATE] revealed resident and POA invited to care conference but declined. Resident encouraged to reach out to Social Service if any concerns and/or questions arise. It did not indicate that a care conference was still held and what staff attended to review the plan of care. Interview with Resident #53 and her sister on 05/04/26 at 11:00 A.M. revealed there had been one care conference since she was admitted (in October 2025). She stated there had been none since and she would like to have one. Interview with Director of Social Services #550 on 05/05/26 at 10:47 A.M. revealed that letters are sent out quarterly regarding care conferences. She stated a letter is sent to Resident #53's sister. She stated when quarterly assessments are done, they ask the resident if they want to meet. She stated Resident #53's sister is here frequently and stops up at the front desk and speaks with her. Interview with Resident #53's sister on 05/05/26 at 10:55 A.M. revealed she had not received any letters pertaining to care conferences. She stated she brings in any mail that she gets pertaining to Resident #53 and lets her look at it also. Resident #53 confirmed she had not seen any letters related to a quarterly care conference. Interview with the Director of Nursing on 05/05/26 at 2:22 P.M. confirmed there was no evidence or documentation to indicate that a care conference was held quarterly to review the quarterly assessment and plan of care or who attended the care conference. He confirmed there was no evidence a care conference was held with the interdisciplinary team even if the resident/family declined to attend. 3. Review of the medical record for Resident #8 revealed an admission date of 05/17/25. Diagnoses included chronic obstructive pulmonary disease, cirrhosis of liver, bipolar disorder, current manic severe with psychotic features, schizoaffective disorder, post-traumatic stress disorder, pain in left hip, Raynaud's syndrome, hypertension, hyperlipidemia, intervertebral disc degeneration, lumbar region, chronic viral hepatitis C, anxiety disorder, osteoarthritis, gastro-esophageal reflux disease, obesity, nonrheumatic tricuspid valve insufficiency, mood disorder, congestive heart failure, cervical disc degeneration, chronic gastric ulcer, peripheral vascular disease, anemia and chronic kidney disease. Review of the medical record revealed a care conference was held on 05/20/25 with Social Services, the resident and her son via phone. Further review revealed the only discipline in attendance was social services. Review of the care conference letter dated 03/01/26 and sent to the resident's guardian (son) revealed a care conference was scheduled for 03/17/26 between 10:00 A.M. and 1:00 P.M. and to call to confirm reservation for care conference. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the medical record revealed no documented evidence a care conference had been held quarterly since the initial care conference of 05/20/25. On 05/05/26 at 10:41 A.M., an interview with Social Service Designee (SSD) #550 verified she does not document quarterly care conferences in the medical record and not all disciplines attend all the care conferences.

Based on observation, interview, and medical record review the facility failed to ensure routine shaving, nail care, and/or showers were provided for Resident #4 and #6. This affected two residents (#4 and #6) of three residents reviewed for activities of daily living (ADL). The facility census was 69. Findings Include:1. Review of the medical record for Resident #6 revealed an initial admission date of 08/17/22 with the latest readmission of 06/18/24. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, benign prostatic hyperplasia, protein calorie malnutrition, major depressive disorder, acquired absence of right foot, anemia, cirrhosis of liver, ascites, hypertension, ischemic cardiomyopathy, retention of urine, chronic obstructive pulmonary disease, dysphagia, insomnia, and atrial fibrillation. Review of the care plan dated 08/18/22 revealed the resident had an activity of daily living (ADL) self-care performance deficit and potential for fluctuations in ADL related to congestive heart failure, weakness, reduced mobility, depression, physical debility, difficulty walking and need for assistance with personal care. Interventions included resident requires maximum assistance with personal hygiene and shower twice weekly with hair and nail care per resident's preference. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors including rejection of care. The resident required substantial/maximal assistance with personal hygiene and bed mobility. On 05/04/26 at 1:26 P.M., observation of Resident #6 revealed the resident had several days of facial hair growth. The resident stated, not purposely, when as if he was growing a beard. Further observation revealed the resident's fingernails were long, jagged and dirty with a brown substance under the nail. The resident stated, they need cut, when asked if the liked his nails long. On 05/05/26 at 10:08 A.M., observation of the resident revealed the resident's facial hair remained long and his fingernails remained long, jagged and dirty with a brown substance under the nail. On 05/06/26 at 11:20 A.M., observation of the resident revealed the resident's facial hair remained long and his fingernails remained long, jagged and dirty with a brown substance under the nail. On 05/06/26 at 11:30 A.M., an interview with Licensed Practical Nurse (LPN) #523 verified the resident had several days of facial hair growth and his fingernails were long, jagged and dirty with a brown substance under the nail. 2. Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with the latest readmission date of 10/10/25. Diagnoses included Parkinson's disease, obstructive sleep apnea, dementia, atrial fibrillation, anemia, chronic pulmonary embolism, hypertension, dysphagia, retention of urine, cervical disc degeneration, benign prostatic hyperplasia, chronic kidney disease, gout, osteoarthritis, fatty liver, chronic pain, insomnia, malignant neoplasm of prostate, cerebral aneurysm, depression and diabetic mellitus. Review of the care plan dated 08/31/25 the resident had an ADL self-care performance deficit and potential for fluctuations in ADLs related to muscle wasting and atrophy, weakness, lack of coordination, difficulty walking, need for assistance with personal care, unsteadiness on feet, reduced mobility, age related physical debility and will refuse showers when offered at times. Interventions included Assist with bathing body parts that resident cannot do, requires partial assistance with bathing and honor resident's choices and preferences whenever possible. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors including rejection of care. The resident required partial/moderate assistance with bathing. On 05/04/26 at 9:53 A.M., an interview with Resident #4 revealed he was upset because he did not receive his shower on Saturday 05/02/26 and he stated, I stink. The resident stated, The aide said they were too busy to do showers. Review of the shower documentation for 05/02/26 by Certified Nursing Assistant (CNA) #537 revealed the resident's shower was documented as the resident refused the shower. Review of the resident's progress notes revealed no documented evidence the resident had refused his scheduled shower on 05/02/26. Review of the requested shower sheet for 05/02/26 revealed CNA #562 had filled out a shower sheet for 05/04/26 and the provided shower sheet had a two heavily marked over the four indicating the resident had received a shower on 05/02/26. On 05/07/26 at 11:17 A.M., an interview with CNA #537 revealed the resident had not refused the shower on 05/02/26 and she had not provided the resident with his scheduled shower on 05/02/26. CNA #537 revealed she must have marked the refusal on accident due to being in a hurry. On 05/07/26 at 1:04 P.M., interview with CNA #562 revealed she did not work at the facility on 05/02/26. She revealed she worked 05/04/26 and the resident was upset he had not received his scheduled shower on 05/02/26 so she ensured he had a shower on 05/04/26.

Based on observation, record review, and interview, the facility failed to ensure Resident #55's peripheral inserted central catheter (PICC) dressing was changed as ordered. This affected one (Resident #55) of one resident reviewed for PICC dressings. The census was 69.Findings include:Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses that include but are not limited to localization-related idiopathic epilepsy and epileptic syndromes with seizures of localized onset, paroxysmal fibrillation, and atherosclerosis atrial fibrillation. Review of the physician's orders for Resident #55 revealed an order dated 04/25/2026 to change the dressing to the midline weekly and as needed every night shift every Thursday until 05/05/2026 at 11:59 P.M.Review of the Medication Administration Record (MAR) revealed that the dressing change was signed off as completed by the LPN on 04/30/2026.On 05/05/2026 at 9:40 A.M. during medication observation Resident #55 was observed with a PICC line dressing dated 04/24/2026 on the right arm.Interview on 05/05/2026 at 10:30 A.M. with the LPN revealed that the date on the right arm PICC line dressing was dated 04/24/2026 and is to be changed per the order every Thursday during night Shift. During this interview, Resident #55 confirmed the dressing had not been since it was applied on 04/24/2026.Interview on 05/06/2026 at 6:45 A.M. with the LPN revealed the PICC line dressing change for Resident #55 was signed off on 04/30/2026 but did not get completed as ordered. The LPN stated she was going to do it in the evening, but the resident asked her to wait until morning, and she forgot to do the dressing as requested but should not have signed off until the treatment was completed.The facility did not have a policy specific to dressing changes for PICC lines.

Based on observations, medical record review and interviews, the facility failed to ensure pressure relieving interventions were implemented as ordered. This affected one resident (#6) of three residents reviewed for pressure ulcer. The facility census was 69. Findings Include: Review of the medical record for Resident #6 revealed an initial admission date of 08/17/22 with the latest readmission of 06/18/24. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, benign prostatic hyperplasia, protein calorie malnutrition, major depressive disorder, acquired absence of right foot, anemia, cirrhosis of liver, ascites, hypertension, ischemic cardiomyopathy, retention of urine, chronic obstructive pulmonary disease, dysphagia, insomnia, and atrial fibrillation. Review of the care plan dated 03/30/26 revealed the resident had the potential for pressure ulcer development related to decreased mobility and incontinence. Interventions included air mattress to bed, administer treatments as ordered, encourage/assist resident as needed to elevate heels off the mattress as tolerated, heel protector boot to bilateral feet and preventative treatments as ordered. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors including rejection of care. The resident required substantial/maximal assistance with personal hygiene and bed mobility. The resident was assessed to be at risk for skin breakdown and had no skin issues. Review of the resident's physician orders for May 2026 identified orders dated 09/03/24 to apply skin prep to right heel for skin breakdown for prevention, encourage/assist to elevate heels when in bed, use two or more pillows to assist with elevating and 04/24/25 soft boots while in bed, check placement every shift and document any noncompliance. Review of the resident's progress notes from 05/04/26 to 05/05/26 revealed no documented evidence the resident refused the soft boots while in bed. On 05/04/26 at 1:39 P.M., observation of Resident #6 revealed the resident was in bed and the soft boots while in bed were not in place as physician ordered. On 05/05/26 at 3:25 P.M., observation of the resident revealed he was in bed and the soft boots while in bed were not in place as physician ordered. On 05/05/26 at 3:30 P.M., an interview with the Director of Nursing (DON) verified the soft boots while in bed were not in place as physician ordered.

Based on observation, interview and medical record review, the facility failed to ensure contracture maintenance devices were in place as physician ordered. This affected one resident (#5) of one resident reviewed for range of motion (ROM). The facility census was 69. Findings Include:Review of the medical record for Resident #5 revealed an initial admission date of 07/30/16 with the latest readmission of 01/12/26. Diagnoses included cerebrovascular accident with left sided hemiplegia, chronic respiratory failure, diabetes mellitus, bipolar disorder, anemia, benign prostatic hyperplasia, hypertension, chronic obstructive pulmonary disease, anxiety disorder, diverticulosis of intestine, insomnia, hyperlipidemia, dysphagia, mood disorder, contracture of left foot, pseudobulbar affect, major depressive disorder and contracture of left hand. Review of the care plan dated 02/13/25 revealed the resident had an alteration in musculoskeletal status related to contracture left foot and left hand. Interventions included apply ankle foot orthosis (AFO) to left lower extremity every morning for transfers, remove every night, perform skin inspection every shift, hand roll left hand apply during bedtime care, remove with morning care, perform range of motion (ROM) and skin care prior to applying hand roll for 15 minutes, resting hand splint to left upper extremity apply with morning care remove after four hours, perform gentle passive range of motion prior to applying for 15 minutes, check skin after removal. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed verbal behaviors directed towards others and had not rejected care. The resident had impaired functional limitation in range of motion on one side to both upper and lower extremities. Review of the resident's monthly physician orders for May 2026 identified an order dated 01/12/26 to encourage resting hand splint to left upper extremity, applied with morning care and remove in four hours, perform gentle passive range of motion prior to applying resting hand splint daily for 15 minutes, check skin after removal everyday shift for maintenance. On 05/04/26 at 1:15 P.M., observation and interview of Resident #5 revealed he was supposed to wear a hand brace and leg brace, but the aides never put it on. The blue brace was observed laying in a bucket on the resident's nightstand. On 05/05/26 at 10:14 A.M., observation of the resident revealed the resting hand splint was not in place. On 05/06/26 at 8:26 A.M., observation of the resident revealed the resting hand splint was not in place. On 05/06/26 at 10:05 A.M., observation of the resident revealed the resting hand splint was not in place. On 05/06/26 at 3:15 P.M. an interview with Certified Nursing Assistant (CNA) #537 verified the resting hand splint had not been in place for the physician ordered four hours. The CNA revealed she thought nightshift applied the splint.

Based on observation, interview, and record review the facility failed to ensure adequate staffing levels to meet the total care needs of residents. This affected five residents (Resident #6, #39, #43, #44 and one anonymous resident) of 69 residents residing in the facility. Findings Include:1. On 05/04/26 at 9:53 A.M., an interview with Resident #4 revealed he was upset because he did not receive his shower on Saturday 05/02/26 and he stated, I stink. The resident stated, The aide said they were too busy to do showers. On 05/07/26 at 1:04 P.M., interview with Certified Nursing Assistant (CNA) #562 revealed she did not work at the facility on 05/02/26. She revealed she worked 05/04/26 and the resident was upset he had not received his scheduled shower on 05/02/26 so she ensured he had a shower on 05/04/26. 2. On 05/06/26 at 2:35 P.M.Resident #43 asked for assistance to get out of bed. The resident was informed the surveyor could not assist her out of bed but would alert someone to assist her and the resident's call light was activated. Licensed Practical Nurse (LPN) #528 was notified the resident was requesting to get up and she stated, The aides are in rooms so she will have to wait. On 05/06/26 at 3:15 P.M. Resident #43 remained in bed. Interview with CNA #537 revealed residents that require two person assistance, they have to wait until the other aides are available to help. On 05/06/26 at 3:46 P.M. Resident #43 remained in bed. 3.On 05/06/26 at 2:42 P.M., and observation of Resident #6 revealed he was sitting in his wheelchair at the nurse's station and asked the CNA #537 to be put to bed. The CNA stated he would have to wait because the other two aides on the unit were doing showers. On 05/06/26 at 3:15 P.M., observation of Resident #6 revealed he remained up in his chair. Interview with CNA #537 revealed residents that require two person assistance, they have to wait until the other aides are available to help. On 05/06/26 at 3:46 P.M., observation of Resident #6 revealed staff were now assisting the resident to bed more than an hour after requesting to go to bed. 4.Review of the record for Resident #39 revealed an admission date of 04/24/26 and diagnoses including diabetes, bipolar disorder, anxiety disorder, hypertension, and depression. Review of an admission Minimum Data Set completed on 04/29/26 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident required partial/moderate assistance with showers. Interview with Resident #39 on 05/04/26 at 3:13 P.M. revealed on Friday 05/01/26 she asked Nursing Assistant #555 for a shower since she was going out to a church function the next day and wanted her hair to look nice. She stated Nursing Assistant #555 told her she was not on the shower list, she had eight other showers to do, and she could not do it. Resident #39 stated she washed her own hair in her bathroom sink. Interview with Unit Manager LPN #532 on 05/05/26 at 2:30 P.M. revealed Resident #39's showers are scheduled on Monday, Wednesday, and Friday on dayshift. She stated it was documented that Resident #39 refused her shower on dayshift on Friday, 05/01/26. Interview with Nursing Assistant #537 on 05/06/26 at 9:00 A.M. revealed she documented on the shower sheet on dayshift on Friday 05/01/26 that the resident refused her shower. She stated Resident #39 had asked for a shower on evening shift as she was going out on an outing. Interview with LPN #513 on 05/05/26 at 1:50 P.M. revealed she was aware that Resident #39 washed her own hair in her sink. She stated there was not enough staff to meet resident needs in the area of showers. She stated Resident #4 went two days past his regular scheduled shower day because of this. She stated they normally have two nurses and four aides on the evening/night shift for the building. She stated ideally they would have five aides. 5.Interview with LPN #511 on 05/06/26 at 6:45 A.M. revealed she normally works the evening/night shift (7:00 P.M. to 7:00 A.M.) She stated they usually have two nurses and four aides in the building on that shift. She stated with only two aides per side of the building, they can't always do showers when the residents want them, so the residents will refuse. She stated that if a resident takes two for a shower, that leaves just the nurse on the floor and if the nurse is passing medications, it makes it difficult to do that and answer call lights. She stated it gets very hectic with only two aides per side of the building. (four total). She stated that when there is a fifth aide to work as a float between sides, it makes it much better. She stated that does not happen very often. 5.Interview with a resident who wished to remain anonymous on 05/04/26 at 10:55 A.M. revealed he/she routinely has to wait for hours for his/her call light to be answered. He/she stated at these times he/she needs to be changed after being incontinent. He/she stated there is usually only two aides for the evening/night shift on each side of the building (four total). He/she stated if a resident needs two staff for care, they have to wait until both staff are available. He/she stated staff will say put your call light on but it may be awhile before they can assist them. This deficiency demonstrates noncompliance investigated under Complaint Number 3006363. 3. Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses that include but are not limited to localization-related idiopathic epilepsy and epileptic syndromes with seizures of localized onset, paroxysmal fibrillation, and atherosclerosis atrial fibrillation. Interview with Resident #55 on 05/04/2026 at 1:31 P.M. revealed that there is not enough staff to provide all needs, especially nurses aides. Call lights are not answered in a timely manner and the care received is lacking because they are all in a hurry. Resident #55 stated that there is a need for more nurses aids and that they are provided with more training.

Based on observation, record review and interview, the facility failed to accurately document resident care in the medical record. This affected two residents (Resident #4 and #55) of 20 residents reviewed for accurate medical records.The facility census was 69. Findings include:1.On 05/05/2026 at 9:40 A.M. during medication observation Resident #55 was observed with a PICC line dressing date 04/24/2026 on the right arm. Review of the Medication Administration Record (MAR) on 05/05/2026 revealed that the dressing change was signed off as completed by LPN on 04/30/2026. Interview on 05/05/2026 at 10:30 A.M. with LPN revealed the date on the right arm PICC line dressing was dated 04/24/2026 and is to be changed per the order every Thursday during night Shift. During this interview, Resident #55 confirmed that the dressing had not been since it was applied on 04/24/2026. Interview on 05/06/2026 at 6:45 A.M. with the LPN revealed that the PICC line dressing change for Resident #55 was signed off on 04/30/2026 but did not get completed as ordered. LPN stated that she was going to do it in the evening, but the resident asked her to wait until morning, and she forgot to do the dressing as requested but should not have signed off until the treatment was completed. The facility did not have a policy related to documentation. 2. Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with the latest readmission date of 10/10/25. Diagnoses included Parkinson's disease, obstructive sleep apnea, dementia, atrial fibrillation, anemia, chronic pulmonary embolism, hypertension, dysphagia, retention of urine, cervical disc degeneration, benign prostatic hyperplasia, chronic kidney disease, gout, osteoarthritis, fatty liver, chronic pain, insomnia, malignant neoplasm of prostate, cerebral aneurysm, depression and diabetic mellitus. Review of the care plan dated 08/31/25 the resident had an ADL self-care performance deficit and potential for fluctuations in ADLs related to muscle wasting and atrophy, weakness, lack of coordination, difficulty walking, need for assistance with personal care, unsteadiness on feet, reduced mobility, age related physical debility and will refuse showers when offered at times. Interventions included Assist with bathing body parts that resident cannot do, requires partial assistance with bathing and honor resident's choices and preferences whenever possible. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors including rejection of care. The resident required partial/moderate assistance with bathing. On 05/04/26 at 9:53 A.M., an interview with Resident #4 revealed he was upset because he did not receive his shower on Saturday 05/02/26 and he stated, I stink. The resident stated, The aide said they were too busy to do showers. Review of the shower documentation for 05/02/26 by Certified Nursing Assistant (CNA) #537 revealed the resident's shower was documented as the resident refused the shower. Review of the resident's progress notes revealed no documented evidence that the resident had refused his scheduled shower on 05/02/26. Review of the requested shower sheet for 05/02/26 revealed CNA #562 had filled out a shower sheet for 05/04/26 and the provided shower sheet had a two heavily marked over the four indicating the resident had received a shower on 05/02/26. On 05/07/26 at 11:17 A.M., an interview with CNA #537 revealed the resident had not refused the shower on 05/02/26 and she had not provided the resident with his scheduled shower on 05/02/26. CNA #537 revealed she must have marked the refusal on accident due to being in a hurry. On 05/07/26 at 1:04 P.M., interview with CAN #562 revealed she did not work at the facility on 05/02/26. She revealed she worked 05/04/26 and the resident was upset he had not received his scheduled shower on 05/02/26 so she ensured he had a shower on 05/04/26. On 05/07/26 at 3:49 P.M., an interview with the Director of Nursing (DON) verified Resident #4's shower sheet had been altered from 05/04/26 to 05/02/26.

Based on observations, record review, staff interview, and policy review, the facility failed to implement infection control procedures related to maintaining enhanced barrier precautions and glove use. This affected three of 20 sampled residents (Residents #6, #39, and #55). The facility census was 69.1. Record review revealed a physician's order for Resident #39 to receive insulin (Lispro) 15 units subcutaneous. Observations on 05/04/26 at 4:00 P.M. revealed LPN #519 to administer an insulin injection to Resident #39's abdomen. LPN #519 did not wear gloves to administer the injection. Interview with LPN #519 on 05/04/26 at 4:05 P.M. revealed he was supposed to wear gloves to give an injection but did not. Interview with the Director of Nursing on 05/05/26 at 1:25 P.M. confirmed staff were to wear gloves when administering insulin. Review of the facility policy titled Medication Administration : Subcutaneous insulin dated 01/23 revealed staff were to put on gloves prior to giving the injection. 2. Observations on 05/05/26 at 9:40 A.M. revealed LPN #526 to prepare IV antibiotics (Meropenem 2 grams) for Resident #55. She applied gloves. Then, after priming the IV tubing, she used hand sanitizer on the gloves she was wearing and proceeded to connect the IV tubing to the IV in the resident's arm. Interview with the Director of Nursing on 05/05/26 at 1:25 P.M. revealed LPN #526 should have changed her gloves, not used hand sanitizer on the gloves. He stated using hand sanitizer on gloves was not part of the facility policy. 3. Review of the medical record for Resident #6 revealed an initial admission date of 08/17/22 with the latest readmission of 06/18/24. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, benign prostatic hyperplasia, protein calorie malnutrition, major depressive disorder, acquired absence of right foot, anemia, cirrhosis of liver, ascites, hypertension, ischemic cardiomyopathy, retention of urine, chronic obstructive pulmonary disease, dysphagia, insomnia, and atrial fibrillation. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the resident's physician orders for May 2026 identified orders dated 08/14/24 enhanced barrier precautions due to history of extended-spectrum beta-lactamases (ESBL), check placement of sign and cart, stock every shift. On 05/04/26 at 1:31 P.M., observation of the resident being assisted into bed revealed a sign on the door alerting staff the resident was in enhanced barrier precautions (EBP). Further observation revealed the Certified Nursing Assistants (CNA) had not donned gowns while providing the resident care. On 05/04/26 at 1:35 P.M., an interview with CNA #562 verified the CNA had not donned the appropriate personal protective equipment (PPE) while providing care to Resident #6 as required for EBP. Review of the facility policy titled, Enhanced Barrier Precautions, last revised 04/15/24 revealed the facility will implement enhanced barrier precautions for the prevention of multidrug-resistant organisms (MDRO). PPE for EBP is only needed when performing high-contact activities and may not be needed prior to entering a resident's room. Facility will ensure that gowns, gloves and hand hygiene are available. High contact activities include transferring, personal hygiene, change briefs, linens and assisting on commode.

Based on record review, review of Medicare (MCR) liability notice letters, and staff interview, the facility failed to ensure residents, whose skilled nursing services ended with days remaining, received at least a 48 hour notice of their skilled service ending prior to their last covered day. They also failed to ensure those residents, whose skilled service ended and remained in the facility, were provided an Advanced Beneficiary Notice (ABN) as required. This affected three residents (#1, #17, and #56) of three residents reviewed for liability notices. Findings include: 1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with a readmitted [DATE]. Her diagnoses included schizophrenia, unspecified dementia, delusional disorder, and Bipolar disorder. Her payer status was MCR Part A before being switched to Medicaid (MCD). Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Checklist revealed Resident #1 had a MCR Part A skilled service episode start date of 05/03/24. Her last covered day of Part A service was on 05/09/24. The facility staff indicated on the checklist that a CMS Notice of MCR Non-Coverage (NOMNC) CMS form 10123 was provided to the resident or their representative. They indicated a SNF ABN (CMS form 10055) was not provided to the resident/ representative, despite the resident remaining in the facility, after their skilled service ended. An explanation added, as to why an ABN was not provided, indicated the facility expected all charges to be covered by MCR. Review of Resident #1's NOMNC (CMS form 10123) revealed her current skilled service would end on 05/09/24. The form did not specify what skilled service was ending or the reason why. The notice was provided to the resident's representative over the phone on 05/09/24 (same day skilled service ended) and did not provide at least a 48 hour notice as required. 2. Review of Resident #17's medical record revealed she was originally admitted to the facility on [DATE] with a re-admission on 04/08/19. Her diagnoses included schizo-affective disorder, major depressive disorder, anxiety disorder, congestive heart failure, and chronic obstructive pulmonary disease. Review of Resident #17's SNF Beneficiary Protection Notification Review checklist revealed the resident had a MCR Part A skilled services episode start date of 07/09/24. Her last covered day of MCR Part A services was on 07/14/24. The checklist indicated a NOMNC (CMS 10123 form) was provided to the resident. Again, the facility indicated on the checklist that an ABN (CMS form 10055) was not provided to the resident, as the facility expected all charges to be covered by MCR. Resident #17 remained in the facility, after their skilled service ended, which would have required an ABN form to be provided. 3. Review of Resident #56's medical record revealed the resident was initially admitted to the facility on [DATE], with a re-admitted [DATE]. Her diagnoses included metabolic encephalopathy, hallucinations, and hypertension. Review of Resident #56's SNF Beneficiary Protection Notification Review checklist revealed the resident had a MCR Part A skilled services episode start date of 05/19/24. Her last covered day of MCR Part A services was on 07/23/24. The checklist indicated a NOMNC (CMS 10123 form) was provided to the resident. Again, the facility indicated on the checklist that an ABN (CMS form 10055) was not provided to the resident, as the facility expected all charges to be covered by MCR. Resident #56 remained in the facility after her skilled service ended and should have received an ABN (CMS form 10055) as required. On 07/30/24 at 9:50 A.M., an interview with Business Office Manager (BOM) #109 revealed the facility's social worker was the one that handled liability notices, but was off this week and she was filling in. Resident #1, #17, and #56's liability notices were reviewed with the BOM, as provided by the facility. She confirmed all three residents remained in the facility, after their skilled services ended, and should have received an ABN notice (CMS form 10055). She further confirmed none of the three residents were provided an ABN and the explanation given on the SNF Beneficiary Protection Notification Review was the facility expected all charges to be covered by MCR, as was written on those forms. She acknowledged the ABN allowed the resident or their representative to indicate whether they wanted to continue to receive the skilled service while appealing the decision to end their skilled service. It was not intended to only be completed if the facility felt MCR would not cover all charges for the skilled services that had previously been received. She was not sure if the facility had the CMS 10055 that should have been used for all residents whose skilled services ended, had MCR days remaining, and remained in the facility. She further acknowledged Resident #1's representative was not provided a 48 hour notice prior to the end of the resident's last covered day of MCR Part A services as required. The facility's administrator denied they had a policy that directed them on how and when to complete liability notices when a resident's MCR Part A services ended.

Based on observations, staff and representative interviews, and record reviews, the facility failed to ensure timely and adequate nail care was completed for a resident who was dependent upon staff for Activities of Daily Living (ADLs). This affected one resident (#18) out of the three residents reviewed for ADL's during the annual survey. The facility census was 61. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including senile degeneration of the brain, encounter for palliative care, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed the resident was assessed to be rarely/never understood. The resident was assessed to be dependent upon staff for personal hygiene. Review of the care plan, revised 09/18/23, revealed the resident had an ADL self-care performance deficit. Interventions included showers two times a week with hair and nail care. Review of the care plan, dated 04/03/24, revealed the resident had skin impairment. Interventions included to keep the residents nails cut short to reduce the risk of scratching or injury from picking at skin. Telephone interview with Resident #18's representative on 07/29/24 at 10:52 A.M. confirmed staff at the facility did not trim and clean the fingernails of Resident #18. Representative #500 stated family completed nail care for the resident but had not been able to visit the facility in almost three weeks due to medical issues. Observation on 07/29/24 at 12:24 P.M. revealed Resident #18 was being assisted with the lunch meal by a facility nurse. Resident #18 was eating chips out of a bag with bare fingers. The resident's fingernails were long and jagged and had a layer of dark brown debris caked underneath them. Observation on 07/30/24 at 10:39 A.M. revealed Resident #18 was lying in bed and had a small area of dried blood to the right corner of the mouth. The resident's fingernails continue to be long and jagged with a layer of dark brown debris caked underneath them. Interview with Licensed Practical Nurse (LPN) #173 at the time of the observation confirmed the resident's fingernails were long and jagged and were in need of being trimmed and cleaned. LPN #173 additionally confirmed the resident had dried blood on the right corner of the mouth likely caused by the resident scratching or picking at the area.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was assessed weekly for signs of healing/ infection as per the plan of care. This affected one resident (#59) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included a stroke with hemiplegia/ hemiparesis affecting his left, non-dominant side, peripheral vascular disease status post peripheral vascular angioplasty, muscle weakness, need for assistance with personal care, cognitive communication deficit, aphasia, attention and concentration deficit, unspecified protein-calorie malnutrition, adult onset diabetes mellitus, congestive heart failure and anemia. Review of Resident #59's nursing admission assessment dated [DATE] revealed the resident was admitted to the facility with some bruising and skin tears to his upper extremities. He was not known to have any pressure ulcers when he was admitted to the facility. Review of Resident #59's progress notes revealed a nurse's note dated 07/15/24 at 11:45 A.M. that indicated the resident was found to have a suspected deep tissue injury ( a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/ or shearing) to his left heel. The pressure ulcer measured 4.2 centimeters (cm) by 4.0 cm. Review of Resident #59's care plans revealed he had a care plan in place for having the potential for the development of a pressure ulcer related to his diagnoses. The care plan was updated to reflect the development of a pressure ulcer to his left heel on 07/15/24. The goal was for the pressure ulcer to show signs of healing and remain free from infection. The interventions included the need to administer treatments as ordered and to monitor the effectiveness of the treatments. They were to assess/ record/ monitor the wound healing weekly and prn to include measuring the length, width and depth where possible, assess and document status of wound perimeter/ wound bed and healing progress. They were to report improvements and declines to the physician. Review of Resident #59's wound assessments, under the assessment tab of the electronic medical record, revealed a skin observation tool was completed on 07/15/24, when the pressure ulcer was first noted. There was not a second wound assessment documented as having been completed until 07/30/24, when a pressure ulcer weekly observation tool was completed. There was a total of 15 days in between the date the pressure ulcer was first noted and documented on the skin observation tool and when it was further assessed as documented on the pressure ulcer weekly observation tool completed on 07/30/24. There was no documented evidence of the pressure ulcer being assessed the week of 07/22/24. Findings were verified by Licensed Practical Nurse (LPN) #156. On 07/31/24 at 10:45 A.M., an interview with LPN #156 revealed she was the facility's wound nurse. She was also the nurse that assessed, measured, and documented the wound's healing progress by doing weekly wound assessments. They previously were being conducted on Mondays, but she changed it to Tuesday to coincide with when the contracted wound company visited. She verified she had no documented evidence to show Resident #59's pressure ulcer was assessed the week of 07/22/24. She could not explain why the resident's pressure ulcer went 15 days between assessments. She confirmed wounds were to be assessed weekly to monitor for healing and signs of infection as per the resident's plan of care. The facility's Director of Nursing (DON) revealed they did not have a pressure ulcer policy that directed the staff on the ongoing monitoring of existing pressure ulcers. He reviewed the pressure ulcer policy that was provided, but confirmed it did not provide direction on ongoing monitoring of the pressure ulcer through weekly assessments.

Based on observations, interviews, and record reviews, the facility failed to ensure oxygen tubing was changed according to physician orders. This affected one resident (#43) reviewed for respiratory care during the annual survey. The facility census was 61. Findings include: Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/15/24, revealed the resident was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to have been administered oxygen therapy during the review period. Review of the care plan, dated 06/13/24, revealed the resident had altered respiratory status. Interventions included oxygen administration at two to four liters per minute by nasal cannula. Review of the active physician order, dated 03/29/24, revealed an order to change oxygen tubing weekly on night shift. Observation on 07/29/24 at 9:24 A.M. revealed Resident #43 was lying in bed with oxygen being administered by nasal cannula. The oxygen tubing had a piece of tape adhered to it with a date of 05/30/24. Interview with Resident #43 on 07/29/24 at 9:25 A.M. confirmed staff changed oxygen tubing but the resident could not recall the last time it had been changed. Observation and interview with Unit Manager #157 on 07/29/24 at 9:33 A.M. confirmed the oxygen tubing for Resident #43 was labeled with a date changed of 05/30/24 and would be changed immediately by facility staff.

Based on record reviews and staff interviews, the facility failed to ensure orders for as needed psychotropic medications included a duration of therapy and additionally failed to ensure psychotropic medications were administered for appropriate indications. This affected two residents (#18 and #25) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 61. Findings include: 1. Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including senile degeneration of the brain, encounter for palliative care, anxiety, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed the resident was assessed to be rarely/never understood. The resident was assessed to have received anti-anxiety medications during the review period. Review of the active physicians order, dated 02/07/24, revealed an order for 0.5 milligrams (mg) of Ativan (an anti-anxiety medication) to be administered every eight hours as needed for anxiety. The order did not include a date for which the order was to be stopped. Interview with Unit Manager #157 on 07/31/24 at 11:53 A.M. confirmed the order for Resident #18's as needed Ativan did not include a date for which the medication was to be stopped. 33023 2. Record review of Resident #25 on 07/30/24 at 10:56 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: otitis externa, chronic obstructive pulmonary disease, dementia with behavioral disturbance, right femur fracture, auditory hallucinations, cognitive communication deficit, mild intellectual disabilities, chronic kidney disease stage 3B, hearing loss, dysphagia, peripheral vascular disease, depression, benign prostatic hyperplagia, hypertension, and macular degeneration Review of the Minimum Data Set(MDS) assessment completed on 07/05/24 revealed this resident had moderate cognitive impairment. Review of Physician Orders revealed this resident received the following medications: Risperidone 0.5 mg 1 tablet by mouth twice daily for unspecified dementia. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical record. Interview with Registered Nurse (RN) #901 on 07/30/24 at 11:37 A.M. verified Risperidone is to have an actual diagnosis and not just treating a symptom such as agitation. Interview with the Director of Nursing on 07/30/24 at 1:04 P.M., verified unspecified dementia is not an acceptable diagnosis for the use of Risperidone.

Based on staff interview, resident interview, medical record review, and policy review, the facility failed to ensure that all allegations of abuse/mistreatment were reported immediately to the administrator of the facility. This affected one of 69 residents (Resident #15). Findings include: Interview with Licensed Practical Nurse (LPN) #75 on 01/29/24 at 5:03 A.M. revealed that, approximately a week prior, State tested Nursing Assistant (STNA) #76 had bragged to her about cursing at Resident #15 because he cursed at her. LPN #75 stated she had reported this to Registered Nurse (RN) #77, who was working that night and was her supervisor. LPN #75 stated she did not know if the administrator was aware of the allegation or not. Review of the medical record for Resident #15 revealed an admitted [DATE] and diagnoses including hemiplegia following a cerebral infarction, diabetes, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment completed 12/08/23 revealed a brief interview for mental status score of 15, indicating intact cognition. Review of the record did not reveal any allegations of abuse/mistreatment documented prior to 01/29/24. The plan of care dated 12/13/23 included that the resident had periods of anger if he had to wait and would curse at staff. Interview with Resident #15 on 01/29/24 at 6:10 A.M. revealed he denied any abuse/mistreatment by staff and stated he was never cursed at by staff. He stated he felt comfortable reporting if something did happen. Interview with RN #77 on 01/29/24 at 10:00 A.M. revealed she denied that LPN #75 had reported anything to her regarding STNA #76. Interview with STNA #76 on 01/29/24 at 10:26 A.M. revealed she denied stating that she had cursed at Resident #15. She stated that she had never cursed at a resident. Interview with the Director of Nursing on 01/29/24 at 7:03 A.M. revealed there had been no reported allegations of abuse/mistreatment in the past two months. He stated facility administration was not aware of the allegation reported to the surveyor by LPN #75. Review of the facility policy (dated November 2016) titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property must be reported immediately to the Administrator or designee. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00150297 and Complaint Number OH00149873.

Based on observation, interview and facility policy review the facility failed to store, prepare, and serve food in a sanitary manner and resident refrigerator temps were not monitored and adjusted as needed for increased temperatures. The food storage issue had the potential to affect all 74 residents receiving food from the facility kitchen (Residents #48 and # 276 do not receive food from the kitchen). The preparing and serving of food issue had the ability to affect all ten residents (Residents #6, #20, #25, #28, #31, #32, #40, #46, #51, and #69) who received pureed corn and one Resident (#30) who received a meatloaf sandwich. The resident refrigerator issue affected all thirteen residents (Residents #2, #5, #11, #19, #30, #32, #39, #41, #52, #60, #65, #67 and #68) who had personal refrigerators in their rooms. The nursing unit refrigerator issues had the potential affected all residents receiving items from those refrigerators in the facility. The facility census was 76. Findings included: 1. Observation on 10/25/22 at 11:10 A.M. of the walk-in refrigerator in the facility kitchen revealed a one-gallon container, 1/4 filled, with green beans. The date on the container was to discard by 10/24/22. There was also a plastic bag of bologna with a date on the bag to discard by 10/22/22 and another bag of bologna with a date on the bag to discard by 10/15/22. This was verified at the time of the observation by Dietary Staff #87 that the green beans and two bags of bologna should not be stored in the refrigerator due to having discard dates prior to the date of observation. Review of policy titled, Food Storage, undated, revealed all foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 2. Observation on 10/25/22 at 11:00 A.M. revealed Dietary Staff #100 touching 5 and 1/2 pieces of bread for pureed corn with her bare hands after touching multiple items in the work area and the bag with the bread in it. Observation on 10/25/22 at 11:20 A.M. revealed Dietary Staff #100 touching the bun for a meatloaf sandwich with her bare hands after touching serving utensil handles and the bag the buns were in. On 10/25/22 at 11:22 A.M. interview with Dietary Staff #100 verified she touched the bread and buns with her bare hands after touching items in the kitchen and the bags the bread and buns came in. Review of policy titled, General Food Preparation and Handling, undated, revealed food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. 3. Review of the October 2022 Refrigerator Logs for Residents #11, #41, #65, and #68 revealed no record of temperature for the 9th or the 12th to the 24th. Review of October 2022 Refrigerator Log for Residents #11 and #65 also revealed temperatures ranging from 46 degrees Fahrenheit to 48 degrees Fahrenheit on multiple occasions and no adjustment to lower the temperature. Review of the October 2022 Refrigerator Logs for Residents #2, #5, #19, #32, #39, #52, and #60 revealed no record of temperature for the 1st, 2nd, 5th, 11th, 14th, and the 19th. Review of the October 2022 Refrigerator Log for Resident #67 revealed no record of temperature from the 1st to the 14th and from the 16th to the 24th. Review of the October 2022 Refrigerator Log for Resident #30 revealed no record of temperature for the 9th, 12th, 13th, and 17th to the 24th. Review of the October 2022 Refrigerator Log for the East nursing refrigerator revealed no record of temperature for the dayshift or nightshift on the 13th. Review of the October 2022 Refrigerator Log for the West nursing refrigerator revealed no record of temperature for the dayshift or nightshift on the 1st, 2nd, 11th, 14th, 16th, or 19th. An interview on 10/25/22 at 4:25 P.M. with Registered Nurse (RN) #39 revealed the nurses on midnights are responsible for the temperature checks on the individual resident refrigerators. She verified the nurses should know proper temperature levels for refrigerators are less than 41 degrees. On 10/25/22 at 4:38 P.M. an interview with RN #80 verified the staff nurses are not consistent with documenting on temperature logs for resident refrigerators or unit refrigerators. She also verified that there was no intervention for the two refrigerators which were consistently out of range for Residents #11 and #65. Observation on 10/25/22 at 4:40 PM with RN #80 of Resident #65's refrigerator revealed a temperature of 50 degrees Fahrenheit and contents of drinks, Jell-O, and fruit. Observation on 10/25/22 at 4:42 P.M. with RN #80 of Resident #11's refrigerator revealed a temperature of 50 degrees Fahrenheit and contents of drinks, Jell-O, and chocolate candies. An interview on 10/25/22 at 5:03 P.M. with the Director of Nursing (DON) verified the nursing staff were to follow the Food Storage policy for resident refrigerators and the temperatures were not being monitored correctly. Review of policy titled, Food Storage, undated, revealed temperatures for refrigerators should be between 35 to 39 degrees Fahrenheit. Thermometers should be checked at least two times each day.

Based on record review and staff interview, the facility failed to ensure new Pre-admission Screening and Resident Review (PASARR's) were completed for residents receiving new mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #46's PASARR Identification Screen dated 09/13/18 revealed the resident was not identified as having had any mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A mood disorder was not marked despite the resident having the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR review results dated 10/10/18 revealed the Preadmission Screen (PAS) Determination was not applicable and an in- person assessment was not required. Resident #46's medical record was absent for any evidence of a new PASARR being completed after the resident was diagnosed with schizo-affective disorder on 10/26/21. On 10/26/22 at 10:22 A.M., an interview with Registered Nurse (RN) #80 revealed the facility did not have a policy specific to PASARR's. She reported they followed the Ohio Administrative Code regarding PASARR's. She provided a copy of the Ohio Administrative Codes that pertained to PASARR's but it only included the definitions. She stated she would check Resident #46's medical record to see if she could find evidence another PASARR being completed, after the resident's initial admission into the facility. On 10/26/22 at 10:50 A.M., a follow up interview with RN #80 revealed she was not able to find any evidence of the resident having a new PASARR completed since the initial PASARR was completed on 09/13/18. She confirmed a new PASARR should have been submitted after a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR Identification Screen dated 01/22/19 revealed Section (D.) identified indications of serious mental illness. The screener was to mark any of the seven mental disorders ([CONDITION(S)], mood disorder, delusional/ paranoid disorder, panic/ severe anxiety disorder, personality disorder or other psychotic disorders) included in that section the resident was known to have. There was an eighth option to mark another mental disorder other than mental [CONDITION(S)] that may lead to a chronic disability. The screener marked to reflect Resident #65 had recurrent major depressive disorder. Resident #65's medical record was absent for any evidence a new PASARR Identification Screen was completed, after 01/22/19, despite the resident receiving the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/22 at 11:45 A.M., an interview with Social Service Director (SSD) # 205 and the Director of Nursing (DON) revealed the facility's Admissions Director was the one who ensured PASARR's were completed for new admissions. If a resident received a new mental illness diagnosis (after they were admitted to the facility), the facility's previous Admissions Coordinator/ social worker was responsible for the completion of a new PASARR Identification Screen. They reported the Admission's Coordinator/ social worker no longer worked at the facility and the facility's Administrator was trying to keep up with those new PASARR's that needed to be completed. They stated they would look to see if they could find evidence of a more recent PASARR Identification Screen being completed. On 10/25/22 at 1:03 P.M., a follow up interview with the DON revealed they were not able to find evidence of Resident #65 having a new PASARR Identification Screen completed, after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged a new PASARR Identification Screen should have been completed after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of the medical record for Resident #40 revealed an initial admitted [DATE] with the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed on 10/26/21 the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed the most recent PASARR was completed on 04/12/21. On 10/26/22 at 10:36 A.M. interview with Registered Nurse (RN) #80 verified the significant change PASARR for the [CONDITION(S)] disorder added on 10/26/21 was not completed. 4. Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #14's most recent PASARR dated 11/25/19 revealed in Section D no boxes marked for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 10/25/22 at 1:46 P.M. with Social Services Designee (SS) #205 verified she does not do the PASARRs, the previous Admission person did those and at the time of the survey the Administrator was doing the PASARRs. SS #205 verified the most recent PASARR for Resident #14 was the one dated 11/25/19 and it was not accurate based on current diagnoses. An interview on 10/26/22 at 10:25 AM with Registered Nurse (RN) #80 reported the facility does not have a PASARR policy and they refer to the Ohio Revised Code for guidance. 5. Review of Resident #28's medical record revealed he was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #28's quarterly MDS dated [DATE] revealed he was not cognitively independent and had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's most recent PASARR dated 05/29/14 revealed in Section D no boxes marked for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 10/25/22 at 1:46 P.M. with SS #205 verified she does not do PASARRs, the previous Admission person did those and at the time of the survey the Administrator was doing the PASSARs. SS #205 verified the most recent PASARR for Resident #28 was the one dated 05/29/14 and it was not accurate based on current diagnoses. An interview on 10/26/22 at 10:25 AM with RN #80 reported the facility does not have a PASARR policy and they refer to the Ohio Revised Code for guidance. 6. Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) assessment 08/22/22 revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Resident #23 was admitted with [CONDITION(S)] Disorder, however PASARR dated 08/17/22 revealed the resident was not identified as having had any mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Mood disorder was not marked despite the resident having the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/22 at 1:34 P.M. interview with Social Service Designee #205 revealed she does not do PASARR's, the previous Admission person did those, however this one was not updated. On 10/26/22 at 10:22 A.M., an interview with Registered Nurse (RN) #80 revealed the facility did not have a policy specific to PASARR's. They followed the Ohio Administrative Code and she provided a copy of that but it only included the definitions.

Based on observation, interview and facility policy review the facility failed to maintain proper hand hygiene while providing care services to Resident #48's gastrostomy tube and during dining observation. This affected one Resident (#48) of one resident reviewed for tube feeding and 23 residents receiving meals in their room on the 200 hall (Residents #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). The facility census was 76. Findings included: 1. Review of Resident #48's medical record revealed he was initially admitted on [DATE] with a readmission on 01/25/13 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #48's annual Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition and an abdominal gastrostomy tube. Observation on 10/25/22 at 10:48 A.M. of Licensed Practical Nurse (LPN) #75 cleaning Resident #48's feeding tube insertion site revealed LPN #75 did not wash his hands or use alcohol-based hand rub prior to donning (putting on) gloves or after doffing (removing) his gloves. After cleaning Resident #48's feeding tube insertion site LPN #75 touched the bed controls and the tube feeding pump with his gloved hands. After removing his gloves and not washing his hands, LPN #75 walked down the hallway to the soiled linen room and used the key hanging beside the door to open it. On 10/25/22 at 10:55 A.M. an interview with LPN #75 verified he did not wash his hands prior to donning or after doffing his gloves. He also verified he should have removed his gloves and washed his hands prior to touching the bed controls and touching the tube feed pump. Review of the facility policy titled, Handwashing/Hand Hygiene revised 08/19, revealed alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and waster are used for the following situations: before and after direct contact with residents, after contact with objects (e.g., medical equipment) in immediate vicinity of the resident, and after removing gloves. 2. On 10/26/22 at 12:11 P.M., an observation of the dining process for the lunch meal served to the residents on the 200 hall noted three State tested Nursing Assistants (STNA's) passing the lunch trays to the residents eating their meals in their rooms. STNA #47, #79, and #105 were the three STNA's that were passing trays to the 23 residents (Resident #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). None of the three STNA's were noted to perform hand hygiene by washing their hands with soap and water or using alcohol based hand rub (ABHR) between tray passes. The STNA's were noted to assist the residents who needed it with repositioning in bed. They were observed to touch the residents' bed linen and bed controls while providing positioning assistance. They were also noted to come into contact with environmental surfaces such as bedside tables while in the rooms. The STNAs then returned to the food cart to retrieve another lunch tray to be passed to other residents. Several residents required feeding assistance and the STNA's were noted to only don disposable gloves to feed the residents and were not noted to wash their hands first before donning the gloves. Findings were verified by STNA #105. On 10/26/22 at 12:38 P.M., an interview with STNA #105 revealed she had a bottle of hand sanitizer (ABHR) in her pocket that she should be using as part of the meal delivery process. She denied she used the hand sanitizer between tray passes and did contact environmental surfaces, bed controls and bed linen when in resident rooms assisting them with positioning. She also denied washing her hands with soap and water before leaving the residents' room and proceeding to pass the next meal tray. When asked if that was something they should be doing, she confirmed they should be. She stated she was frazzled during the meal delivery process and it has been a week. A review of the facility's policy on Assistance with Meals revised March 2022 revealed all employees who provided assistance with meals would be trained and should demonstrate competency in the prevention of foodborne illnesses. That should include personal hygiene practices and safe food handling.

Based on medical record review, staff interview and facility policy and procedure review, the facility failed to notify a resident's physician of a change in condition related to a significant weight gain. This affected one (Resident #23) of 24 resident records reviewed. The census was 76. Findings include: Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Review of physician orders revealed an order dated 09/24/22 for daily weights due to [CONDITION(S)] (CHF) and notify physician if greater than three pounds. Review of Resident #23's weights revealed on 10/03/22 a weight of 216.3 and on 10/04/22 a weight of 220.7 which is a gain of 4.4 pounds. On 10/14/22 a weight of 206.7 pounds and on 10/15/22 a weight of 212.1 pounds, a gain of 5.4 pounds. On 10/22/22 a weight of 214.6 pounds and on 10/24/22 a weight of 219.8 pounds which is a 5.2 pound gain. Review of the plan of care dated 08/18/22 and revised 08/23/22 revealed the Resident #23 has a history of CHF and monitor vital signs and report abnormalities to the physician. On 10/26/22 at 2:05 P.M. interview with Licensed Practical Nurse (LPN) #25 revealed that she puts the daily weights in the computer, they are not documented any other place. On 10/26/22 at 2:07 P.M. interview with Registered Nurse (RN) #80 verified missing weights and the lack of physician notification with weight gain. Review of the facility policy and procedure Change in a Resident's Condition or Status dated 2001 and revised 02/21 revealed the nurse will notify the resident's attending physician when or physician on call when there has been a(an) specific instruction to notify the physician of change's in a resident's condition.

Based on medical record review, facility self-reported incident (SRI) history, facility witness statements, personnel file review, facility Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and procedure, and staff interviews, the facility failed to ensure an allegation of resident mistreatment by State tested Nursing Assistant (STNA) #1 was reported immediately, but no later than two hours after the allegation was made to a facility representative and to the State Agency (SA) as required. This resulted in likelihood of serious harm that is Immediate Jeopardy on 07/04/21 at 05:00 A.M. when STNA #106 observed STNA #1 pull her pants downs and show her genitalia to Resident #1 while using intimidating explicit language. The allegation was reported on 07/04/21 at 12:44 P.M. allowing STNA #1 to continue to work the rest of her shift on 07/04/21. During the course of investigating STNA #1 exposing herself to Resident #1, it was discovered STNA #1 also exposed herself to Resident #37 on an unknown date prior to 07/04/21, after stating she needed to urinate and check herself. Staff failed to immediately report the observed mistreatment to administration and a report of the event was not immediately made to the SA and a final reporting to the SA was not received within five working days. An additional concern was also identified when the facility failed to timely report an allegation of sexual abuse towards Resident #4. This affected three residents (Resident #1, Resident #4, and Resident #37) of three residents reviewed for abuse, but had the potential to affect all 71 residents in the facility who were at risk for potential harm or injury related to incidents of resident abuse and mistreatment. On 07/21/21 at 5:01 P.M. the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #105 (a unit manager at the facility) were notified Immediate Jeopardy began on 07/04/21 when the facility failed to immediately report an observed incident of staff to resident mistreatment on 07/04/21 STNA #1 exposed her genitalia to Resident #1 when she called her a boy and STNA #1 stated, Do I look like (expletive) boy to you? The incident was observed by a second STNA, STNA #106, that was in the room and STNA #106 did not immediately report it to a nurse on the hall. Furthermore, it was the discovered this was the second witnessed exposure by STNA #1. On an unknown date prior to 07/04/21, STNA #1 stated she had to pee and check myself, then pulled her pants down exposing her genitalia to Resident #37. This incident was witnessed by STNA #101 and was not reported to the administration and to the State Agency as required. The Immediate Jeopardy was removed on 07/23/21 when facility implemented the following corrective action: · On 07/22/21 at 1:10 P.M. STNA #1 was terminated for inappropriate behavior by the DON. · On 07/22/21 by 11:00 P.M. all facility Staff inserviced on the Abuse policy and procedure including reporting of staff exhibiting inappropriate behavior in front of residents and the staff member needing to be removed from facility until the investigation is complete. The inservice re-educated staff on timely and thorough investigation of any allegation. Supervisors must report immediately to nurse on call, DON, or Nursing Home Administrator (NHA) so the state agency can be notified within two hours and investigation started. As of 07/22/21 at 6:00 P.M., all but nine employees completed education. If a staff member was on vacation and/or could not be reached, they would be in serviced before going on the floor and performing job duties. Education was completed by DON, LPN #105, LPN #120, MDS Coordinator #121, Certified Dietary Manager #115, Business Office Manager #116, Rehab Director #117, and Director of Maintenance #118. · On 07/22/21 at 2:15 P.M., DON inserviced by Administrator on timeliness of reporting and doing a thorough investigation. · Starting 07/22/21, the Administrator or designee will review SRI progress each weekday morning at the facility stand up meeting. Administrator will audit all SRI's for timeliness and thorough investigation weekly for three weeks. Administrator will interview residents and staff weekly for three weeks. The data collected will be presented to QAPI for further direction. · On 07/22/21 by 5:30 P.M. current residents were asked if they have had any experience with inappropriate behavior. Residents who were cognitively impaired would have medical records reviewed to see if any change in behaviors or activities or other signs which may indicate resident may have been witness to inappropriate behavior. This review was completed by DON/designee, LPN #105, MDS Coordinator #121, and LPN #120. · On 07/22/21 by 5:00 P.M. an SRI of inappropriate behavior by STNA #1 towards Resident #1 and Resident #37 would be completed and submitted by DON. · On 07/22/21 by 11:00 P.M. Resident #1 and Resident #37's families were notified by LPN #105 and/or designee of the allegation of mistreatment towards the resident. · Beginning 07/23/21 continued monitoring by DON and/or designee will be completed with staff and residents if they have seen or experienced inappropriate behavior. This monitoring will be completed three times per week for three weeks. The data will then be presented to the QAPI team to determine if further action is needed. · On 07/26/21 from 1:16 P.M. through 1:30 P.M. interview with Registered Nurse (RN) #112, STNA #113, and STNA #114 revealed they were knowledgeable of the inservice completed on 07/23/21 regarding the facility abuse prohibition policy and procedures. Although the Immediate Jeopardy was removed on 07/23/21, the deficiency 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 continued to provide staff education and monitoring of corrective actions. Findings include: Record review for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's annual Minimum Data Set (MDS) assessment, dated 04/06/21, revealed this resident's cognition was severely impaired and required extensive two person assistance with toileting, transfer, and mobility. Resident #1's care plan, dated 09/08/20, revealed due to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included giving non-judgmental support, explain all treatments and procedures to help reduce anxiety, and provide calm/quiet atmosphere as needed. Staff were educated to use a different approach if the resident did not want changed at that moment, and to wait and try different approach or get a team partner for assistance. Resident #1's care plan, dated 07/21/21, revealed the resident was resistive of care, curses at staff, and slaps at staff when providing care. Interventions included allowing the resident to make decisions about treatment regime as applicable/appropriate, to the provide sense of control. If the resident resists assistance with activities of daily living (ADL), reassure resident, leave, and return five to ten minutes later and try again, and provide consistency in care to promote comfort with ADL's, caregivers, and routine, as much as possible, and provide resident with opportunities for choice during care provision. Record review for Resident #37 revealed this resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's quarterly Minimum Data Set (MDS) assessment, dated 06/06/21, revealed the resident's cognition was severely impaired and require two persons assist with toileting, mobility, and transfer. Review of Resident #37's care plan, dated 12/14/20, revealed the resident had severely impaired cognitive function/impaired thought processes due to dementia. The resident is rarely/never understood/understands. Interventions included but were not limited to not showing impatience/annoyance, and self-expression to ensure needs are met. Interview on 07/19/21 at 2:49 P.M. with STNA #106 revealed she worked with STNA #1 the morning of 07/04/21. She revealed around 5:00 A.M. she and STNA #1 were completing two hour rounds and were in the process of changing Resident #1. STNA #106 revealed this resident called STNA #1 a boy, which was not unusual for this resident to call staff names. She stated Resident #1 does not like to be changed and whenever staff attempt to change her, she starts to curse at staff. STNA #106 stated the next thing she saw was STNA #1 pull her pants down showing Resident #1 her genitalia area and stated, do I look like a (expletive) boy to you? She revealed at that point this resident gasped. STNA #106 revealed she did not report the incident to the supervisor on that floor because she always blows everything off. She revealed she did not report the incident until 12:44 P.M. when she reported the incident to the unit manager, LPN #105. She revealed the facility did not call her for further information regarding the incident until 07/06/21 when the DON called her on the phone and interviewed her regarding the incident. STNA #106 also revealed this was not first time STNA #1 had exposed herself to a resident. She revealed she heard another staff saying that STNA #1 had done this before in the presence of another resident. Interview on 07/19/21 at 3:45 P.M. with STNA #101 revealed the DON called her on 07/06/21 over the phone regarding the alleged incident on 07/04/21. She stated she informed the DON this was the second time STNA #1 pulled her pants down in front of a resident. STNA #101 revealed STNA #1 first exposed herself not too long ago, prior to 07/04/21, but could not remember the exact date and time. STNA #101 revealed while in Resident #37 room, STNA #1 said I have to pee very bad; I have to check myself. STNA #101 revealed STNA #1 proceeded to pull her pants down, exposing her genitalia in front of the resident. STNA #101 revealed she reported the incident to LPN #107 but did not do anything about it. Interview on 07/19/21 at 4:06 P.M. with LPN #105 revealed STNA #106 informed her of the alleged incident that had occurred on the 07/04/21 at 5:00 A.M. LPN #105 revealed that STNA #106 stated STNA #1 pulled her pants down in front of this resident in her room while providing care because this resident called her a boy. She further stated STNA #106 reported she did not notify the supervisor on the hall that day because whenever there was an issue and staff report it to this nurse, she does not do anything about it. LPN #105 revealed she reported the allegation immediately to the DON. She also stated STNA #1 was off 07/05/21, 07/06/21, and was taken off the schedule on 07/07/21. She revealed STNA #1 was back on the schedule and was on the floor working on 07/13/21. She revealed she was not sure of the outcome of that investigation. Review of the facility internal investigation revealed witness statements dated 07/06/21 confirmed STNA #106 witnessed STNA #1 expose herself to Resident #1 on 07/04/21 and STNA #101 witnessed STNA #1 expose herself to Resident #37 on an unknown date. Review of STNA #1's personnel file revealed on 07/13/21 STNA #1 received a disciplinary action report with a discharge warning for improper conduct. Review of STNA #1's assignment sheet, dated 07/04/21, revealed she and STNA #106 were assigned to the area Resident #1 resided. Review of STNA #1's timecard report sheet, revealed she was clocked in to work at the facility on 07/04/21 from 4:14 P.M. to 7:06 A.M., on 07/13/21 from 6:57 P.M. to 7:15 A.M., on 07/16/21 from 10:41 P.M. to 7:06 A.M., on 07/17/21 from 6:59 P.M. to 7:11 A.M., and on 07/18/21 from 7:01 P.M. to 5:00 A.M. Review of the facility SRI history revealed no allegations of mistreatment or abuse toward Resident #1 or Resident #37 had been reported to the State Agency. Review of Resident #1 and Resident #37's medical record contained no evidence the allegation of mistreatment was made. The residents were not assessed to determine if they were affected by the alleged mistreatment. The medical record contained no evidence Resident #1 and Resident #37's families were notified of the allegations. An attempt to reach STNA #1 and LPN #107 for interview was unsuccessful. Interview on 07/20/21 at 2:50 P.M. with the DON revealed the allegation made on 07/04/21 was brought to her attention by LPN #105 on the 07/06/21. The DON revealed LPN #105 informed her that STNA #106 notified her that STNA #1 pulled her pants down exposing her genitalia to Resident #1 and stated, see I am not a boy, and this happened because this resident called her a boy. She stated STNA #1 was pulled off the schedule until the investigation was completed on 07/13/21. The DON revealed during the investigation of STNA allegedly exposing herself to Resident #1, STNA #101 reported that she witnessed STNA #1 pull her pants down exposing her genitalia in presence of resident #37, after STNA #1 stated she needed to pee and needed to check herself. DON could not specify when this allegation was reported to have occurred. The Resident #1 and Resident #37 was not assessed or interviewed because there was no physical contact, and the resident was not mentally with it. DON revealed STNA #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON revealed she did not think the allegation towards Resident #1 was abuse because the resident was not with it and the incident was he said, she said. The DON revealed the allegation had not been reported to the state at the time of the interview. On 07/19/21 at 3:40 P.M. an attempt to interview Resident #37 was unsuccessful as the resident was nonverbal. On 07/20/21 at 3:16 P.M. an attempt to interview Resident #1 was unsuccessful as the resident was not able to answer questions. Interview on 07/21/21 at 11:47 A.M. with Physician #111 revealed no knowledge about the allegation. He revealed if an incident like this should be brought to his attention, he would talk with the DON and the perpetrator would be removed from the facility. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated November 2016, the facility should immediately report all alleged violations involving abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In cases of where a crime is suspected, staff should also report the same to local law enforcement. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enable through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. 2. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident's cognition was intact and required two person assistance with transfer and mobility. Review of Resident #4's care plan dated 04/01/21 revealed the resident had anxiety and depression with targeted behaviors of restlessness, fidgeting, complaints of nervousness, and dyspnea. The resident reported feeling depressed and decreased energy/feeling tired. Interventions included allow resident to ventilate feelings and offer realistic feedback. Review of Resident #4's nurses progress notes, dated 07/14/21 at 11:00 A.M., revealed Resident #4 reported to RN #102 at 3:30 A.M. that Resident #31 opened the door and came into her room and closed the door behind him and began touching her all over. Resident #4 began to yell out and pushed the light for assistance. STNA #110 entered the room and escorted Resident #31 out of her room. Physician #111, DON, and Administrator were notified of the incident. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 05/15/21, revealed the resident had severely impaired cognition and required one person assistance with mobility and transfers. Resident #31's care plan, dated 05/14/21 revealed the resident was an elopement risk/wanderer and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . and wandering the streets prior to admission. Interventions includes distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books of the resident's preference. The facility was to monitor the resident's location every 30 minutes, and to document wandering behavior and attempted diversional interventions in behavior log. Resident #31's care plan, dated 06/22/21, revealed the resident has a behavior problem of being sexual inappropriate and urinates/defecates in other places then the toilet at times. Interventions included administer medication as ordered, monitor/document for side effects and effectiveness, and if reasonable, discuss the resident's behavior. The facility should explain/reinforce why the behavior was inappropriate and/or unacceptable to the resident. The facility should intervene as necessary to protect the rights and safety of others and approach/speak in a calm and take the resident to alternate location as needed. Review of Resident #37's nurses progress notes, dated 07/14/21 at 11:00 A.M., revealed Resident #4 reported that at 3:30 A.M. Resident #31 came into her room, shut the door behind him and began touching her all over. Resident #4 began to yell and put the call light on. STNA #110 entered the room and escorted Resident #31 out of room. Resident #31 placed on 15-minute location checks and one to one. The resident's daughter and physician were notified, and a referral was made to geriatric psychiatric unit. Review of a facility submitted SRI on 07/14/21 at 10:58 A.M. for an allegation of sexual abuse. The SRI revealed Resident #4 reported Resident #31 wandered into her room and touched her breasts. Resident #4 redirected Resident #31 with success and he left her room. Resident #31 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It was dark in Resident #4's room and it could not be verified if Resident #31 was trying to find his way around room or feeling Resident #4 in a sexual way. Resident #31 stopped when Resident #4 told him to do so. Resident #31 was placed on one on one until he was accepted at an [NAME] psych unit. Resident #4 showed some anxiety the day after the occurrence but reported she felt less nervous knowing someone was with him at all times. The facility unsubstantiated the allegation. Interview at 07/19/21 at 1:37 P.M. with Resident #4 revealed about 3:00 A.M. to 3:30 A.M. in the morning she had turned off her light and television and was asleep. She revealed the next thing she felt was a hand all over her. She stated she started screaming for help, but the door was shut. The perpetrator then headed towards the door and then turned back. He then held his pant and she was not sure what he was trying to do. She revealed she continued to scream and then one of the staff came and took him out of her room. She stated she knew the man wandered around the facility, so she knew he did not know what he was doing. Resident #4 revealed after the incident the facility did not complete any form of assessment on her, nobody talked to her about the incident, or asked how she was feeling until later that day. She revealed it was later that morning around 10:00 A.M. when the nurse passing medication came to give her meds, and she asked the nurse would there be any follow up to the incident that occurred. The nurse then told her that she was not aware of the incident, but she was going to find out and let her know. She revealed Registered Nurse (RN) #102 came to her and asked her questions about the incident and how she felt. She revealed the nurse assured her that they will keep an eye on Resident #31, so he won't bother her. Resident #4 revealed that later that evening around 8:00 P.M., Resident #31 came back to her room. Resident #4 revealed she yelled and told him to get out, and that was when another staff came and took him out of her room and had him on one on one observation. Resident #4 revealed since the incident she had been having problems sleeping. She keeps getting up during the night scared Resident #31 may come back. She verified that now that Resident #31 is out of the facility she is felt better but wondered what the facility will do with him when he comes back. Interview at 07/19/2021 at 2:01 P.M. with STNA #110 revealed she was the aide assigned on that hall the night Resident #31 entered Resident #4 room. She revealed around 4:00 A.M. on 07/14/21 she saw Resident #4 call light on and when she went to help her, she saw Resident #31 standing at Resident's #4 doorway. She revealed she immediately took him back to his room. She stated Resident #4 was very upset and shaking. STNA #110 revealed Resident #4 stated this resident came to her room had the door close and was touching her all over. STNA #110 revealed she notified the two nurses (RN #103 and LPN #104) who were sitting at the nurse's station but they did nothing as always. She revealed STNA's do not have access to document in the medical record or any other place except to notify the supervisor or charge nurse of any incidents, and that was exactly what she did. She revealed nothing was done until that 12:00 P.M. when the nurse informed her she would be providing one on one supervision of Resident #31. Telephone interview at 07/20/21 at 10:21 A.M. with LPN 104 revealed she worked a different hall the morning the incident happened between Resident #4 and Resident #37. She revealed she was on break and out of the building when alleged incident happened. LPN #104 revealed she was unaware of the incident until later during shift change. Telephone interview on 07/20/21 at 12:22 P.M. with RN #102 (Assistant Director of Nursing) revealed the allegation was brought to her attention at 10:00 A.M. by the morning nurse on that hall She revealed night shift did not mentioned the allegation during shift change report. She revealed she immediately went to Resident #4 to talk with her and making sure she was fine. RN #102 verified she did not complete any form of physical assessment. Interview at 07/20/21 at 2:50 P.M. with the DON revealed RN#102 notified her about the allegation later that morning after night shift had left. She revealed the night shift nurse did not give report on anything happening during their shift. She stated she was very disappointed that the nurse on that hall did not check on the resident after the incident and did not inform administration of what had happened. The DON further revealed Resident #31 has always be on some sort of check because he wanders the facility and has made several attempts to get out of the building. She confirmed this resident was supposed to be on 15 minutes check and later was switched to one on one supervision. She revealed this resident was on one on one until he was transferred to the psychiatric hospital. She revealed the physician also had him on Stagnant to reduce his sexual behaviors. She states she believed social services completed a psychosocial evaluation on Resident #4 but was not certain. She revealed Resident #31 was not sent out immediately because all the hospitals they wanted to send him were full at that time. She also confirmed that he has bed hold and is going to come back. Telephone interview on 07/20/21 at 3:13 P.M. with RN #103 revealed he was informed by the STNA #110 that Resident #31 was in Resident #4's room and she got him out. He stated Resident #31 wanders a lot in the facility, so this was not out of the norm for him. RN #103 revealed if the aide would have told him that Resident #4 complained that Resident #31 was in her room touching her, he would have been in there to assess the situation. RN #103 revealed usually when this resident is found wandering staff redirect him back to his room. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriate of Resident Property, dated November 2016, revealed it is the facility policy to investigate all alleged violations involving abuse, neglect, exploitation mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health. In cases of where a crime is suspected, staff should also report the same to local law enforcement. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enable through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Complaint Number OH 160

Based on medical record review, staff interviews, review of facility witness statements, review of the facility Self-Reported Incident (SRI) history, and review of the facility Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and procedure, the facility failed to ensure allegations of resident mistreatment by State tested Nursing Assistant (STNA) #1 were immediately and thoroughly investigated. This resulted in likelihood of serious harm that is Immediate Jeopardy on 07/04/21 at 05:00 A.M. when STNA #106 observed STNA #1 pull her pants downs and show her genitalia to Resident #1 while using intimidating explicit language. The allegation was reported on 07/04/21 at 12:44 P.M. allowing STNA #1 to continue to work the rest of her shift on 07/04/21. During the course of investigating STNA #1 exposing herself to Resident #1, it was discovered that STNA #1 also exposed herself to Resident #37 on an unknown date prior to 07/04/21, after stating she needed to urinate and check herself. The facility failed to immediately investigate the observed mistreatment and failed to assess and/or interview all the residents to ensure they were free from mistreatment. An additional concern was also identified when the facility failed to timely investigate an allegation of sexual abuse towards Resident #4 and failed to ensure Resident #4 was protected against the alleged perpetrator. This affected three residents (Resident #1, Resident #4, and Resident #37) of three residents reviewed for abuse, but had the potential to affect all 71 residents in the facility who were at risk for potential harm or injury related to incidents of resident abuse and mistreatment. On 07/21/21 at 5:01 P.M. the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #105 (a unit manager at the facility) were notified Immediate Jeopardy began on 07/04/21 when the facility failed to timely investigate an observed incident of staff to resident mistreatment. On 07/04/21 STNA #1 exposed her genitalia to Resident #1 when she called her a boy and STNA #1 stated, Do I look like (expletive) boy to you?. The incident was observed by a second STNA, STNA #106, that was in the room and STNA #106 did not immediately report it to the nurse on the hall for investigation. Furthermore, it was discovered this was the second witnessed exposure by STNA #1. On an unknown date prior to 07/04/21, STNA #1 stated she had to pee and check myself, then pulled her pants down exposing her genitalia to Resident #37. This incident was witnessed by STNA #101 and was not investigated immediately as required. The Immediate Jeopardy was removed on 07/23/21 when facility implemented the following corrective action: · On 07/22/21 at 1:10 P.M. STNA #1 was terminated for inappropriate behavior by the DON. · On 07/22/21 by 11:00 P.M. all facility Staff inserviced on the Abuse policy and procedure including reporting of staff exhibiting inappropriate behavior in front of residents and the staff member needing to be removed from facility until the investigation is complete. The inservice re-educated staff on timely and thorough investigation of any allegation. Supervisors must report immediately to nurse on call, DON, or Nursing Home Administrator (NHA) so the state agency can be notified within two hours and investigation started. As of 07/22/21 at 6:00 P.M., all but nine employees completed education. If a staff member was on vacation and/or could not be reached, they would be in serviced before going on the floor and performing job duties. Education was completed by DON, LPN #105, LPN #120, MDS Coordinator #121, Certified Dietary Manager #115, Business Office Manager #116, Rehab Director #117, and Director of Maintenance #118. · On 07/22/21 at 2:15 P.M., DON inserviced by Administrator on timeliness of reporting and doing a thorough investigation. · Starting 07/22/21, the Administrator or designee will review SRI progress each weekday morning at the facility stand up meeting. Administrator will audit all SRI's for timeliness and thorough investigation weekly for three weeks. Administrator will interview residents and staff weekly for three weeks. The data collected will be presented to QAPI for further direction. · On 07/22/21 by 5:30 P.M. current residents were asked if they have had any experience with inappropriate behavior. Residents who were cognitively impaired would have medical records reviewed to see if any change in behaviors or activities or other signs which may indicate resident may have been witness to inappropriate behavior. This review was completed by DON/designee, LPN #105, MDS Coordinator #121, and LPN #120. · On 07/22/21 by 5:00 P.M. an SRI of inappropriate behavior by STNA #1 towards Resident #1 and Resident #37 would be completed and submitted by DON. · On 07/22/21 by 11:00 P.M. Resident #1 and Resident #37's families were notified by LPN #105 and/or designee of the allegation of mistreatment towards the resident. · Beginning 07/23/21 continued monitoring by DON and/or designee will be completed with staff and residents if they have seen or experienced inappropriate behavior. This monitoring will be completed three times per week for three weeks. The data will then be presented to the QAPI team to determine if further action is needed. · On 07/26/21 from 1:16 P.M. through 1:30 P.M. interview with Registered Nurse (RN) #112, STNA #113, and STNA #114 revealed they were knowledgeable of the inservice completed on 07/23/21 regarding the facility abuse prohibition policy and procedures. Although the Immediate Jeopardy was removed on 07/23/21, the deficiency 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 continued to provide staff education and monitoring of corrective actions. Findings include: Record review for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#1's annual Minimum Data Set (MDS) assessment, dated 04/06/21, revealed this resident's cognition was severely impaired and required extensive two-person assistance with toileting, transfer, and mobility. Resident #1's care plan, dated 09/08/20, revealed due to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included giving non-judgmental support, explain all treatments and procedures to help reduce anxiety, and provide calm/quiet atmosphere as needed. Staff were educated to use a different approach if the resident did not want changed at that moment, and to wait and try different approach or get a team partner for assistance. Resident #1's care plan, dated 07/21/21, revealed the resident was resistive of care, curses at staff, and slaps at staff when providing care. Interventions included allowing the resident to make decisions about treatment regime as applicable/appropriate, to the provide sense of control. If the resident resists assistance with activities of daily living (ADL), reassure resident, leave, and return five to ten minutes later and try again, and provide consistency in care to promote comfort with ADL's, caregivers, and routine, as much as possible, and provide resident with opportunities for choice during care provision. Record review for Resident #37 revealed this resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's quarterly Minimum Data Set (MDS) assessment, dated 06/06/21, revealed Resident #37's cognition was severely impaired and require two persons assist with toileting, mobility, and transfer. Review of Resident #37's care plan, dated 12/14/20, revealed the resident had severely impaired cognitive function/impaired thought processes due to dementia. The resident is rarely/never understood/understands. Interventions included but were not limited to not showing impatience/annoyance, and self-expression to ensure needs are met. Interview on 07/19/21 at 2:49 P.M. with STNA #106 revealed she worked with STNA #1 the morning of 07/04/21. She revealed around 5:00 A.M. she and STNA #1 were completing two-hour rounds and were in the process of changing Resident #1. STNA #106 revealed this resident called STNA #1 a boy, which was not unusual for this resident to call staff names. She stated Resident #1 does not like to be changed and whenever staff attempt to change her, she starts to curse at staff. STNA #106 stated the next thing she saw was STNA #1 pull her pants down showing Resident #1 her genitalia area and stated, do I look like a (expletive) boy to you? She revealed at that point this resident gasped. STNA #106 revealed she did not report the incident to the supervisor on that floor because she always blows everything off. She revealed she did not report the incident until 12:44 P.M. when she reported the incident to the unit manager, LPN #105. She revealed the facility did not call her for further information regarding the incident until 07/06/21 when the DON called her on the phone and interviewed her regarding the incident. STNA #106 also revealed this was not first time STNA #1 had exposed herself to a resident. She revealed she heard another staff saying that STNA #1 had done this before in the presence of another resident. Interview on 07/19/21 at 3:45 P.M. with STNA #101 revealed the DON called her on 07/06/21 over the phone regarding the alleged incident on 07/04/21. She stated she informed the DON this was the second time STNA #1 pulled her pant down in front of a resident. STNA #101 revealed STNA #1 first exposed herself not too long ago, prior to 07/04/21, but could not remember the exact date and time. STNA #101 revealed while in Resident #37 room, STNA #1 said I have to pee very bad; I have to check myself. STNA #101 revealed STNA #1 proceeded to pull her pants down, exposing her genitalia in front of the resident. STNA #101 revealed she reported the incident to LPN #107 but did not do anything about it. Interview on 07/19/21 at 4:06 P.M. with LPN #105 revealed STNA #106 informed her of the alleged incident that had occurred on the 07/04/21 at 5:00 A.M. LPN #105 revealed that STNA #106 stated STNA #1 pulled her pants down in front of Resident #1 in her room while providing care because this resident called her a boy. She further stated STNA #106 reported she did not notify the supervisor on the hall that day because whenever there was an issue and staff report it to this nurse, she does not do anything about it. LPN #105 revealed she reported the allegation immediately to the DON. She also stated STNA #1 was off 07/05/21, 07/06/21, and was taken off the schedule on 07/07/21. She revealed STNA #1 was back on the schedule and was on the floor working on 07/13/21. She revealed she was not sure of the outcome of that investigation. Review of the facility internal investigation revealed witness statements dated 07/06/21 confirmed STNA #106 witnessed STNA #1 expose herself to Resident #1 on 07/04/21 and STNA #101 witnessed STNA #1 expose herself to Resident #37 on an unknown date. The internal investigation contained no evidence any residents were interviewed or assessed to determine if they were free from staff mistreatment. Review of STNA #1's personnel file revealed on 07/13/21 STNA #1 received a disciplinary action report with a discharge warning for improper conduct. Review of STNA #1's assignment sheet, dated 07/04/21, revealed she and STNA #106 were assigned to the area Resident #1 resided. Review of STNA #1's timecard report sheet, revealed she was clocked in to work at the facility on 07/04/21 from 4:14 P.M. to 7:06 A.M., on 07/13/21 from 6:57 P.M. to 7:15 A.M., on 07/16/21 from 10:41 P.M. to 7:06 A.M., on 07/17/21 from 6:59 P.M. to 7:11 A.M., and on 07/18/21 from 7:01 P.M. to 5:00 A.M. Review of the facility SRI history revealed no allegations of mistreatment or abuse toward Resident #1 or Resident #37 had been reported to the State Agency with the final outcome of an investigation. Review of Resident #1 and Resident #37's medical record contained no evidence the allegation of mistreatment was made. The residents were not assessed to determine if they were affected by the alleged mistreatment. The medical record contained no evidence Resident #1 and Resident #37's families were notified of the allegations. An attempt to reach STNA #1 and LPN #107 for interview was unsuccessful. Interview on 07/20/21 at 2:50 P.M. with the DON revealed the allegation made on 07/04/21 was brought to her attention by LPN #105 on the 07/06/21. The DON revealed LPN #105 informed her that STNA #106 notified her that STNA #1 pulled her pants down exposing her genitalia to Resident #1 and stated, see I am not a boy, and this happened because this resident called her a boy. She stated STNA #1 was pulled off the schedule until the investigation was completed on 07/13/21. The DON revealed during the investigation of STNA #1 allegedly exposing herself to Resident #1, STNA #101 reported that she witnessed STNA #1 pull her pants down exposing her genitalia in presence of Resident #37, after STNA #1 stated she needed to pee and needed to check herself. DON could not specify when this allegation was reported to have occurred. DON revealed Resident #1 and Resident #37 were not assessed or interviewed because there was no physical contact, and the residents were not mentally with it. DON revealed STNA #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON revealed she did not think the allegation towards Resident #1 was abuse because the resident was not with it and the incident was he said, she said. On 07/19/21 at 3:40 P.M. an attempt to interview Resident #37 was unsuccessful as the resident was nonverbal. On 07/20/21 at 3:16 P.M. an attempt to interview Resident #1 was unsuccessful as the resident was not able to answer questions. Interview on 07/21/21 at 11:47 A.M. with Physician #111 revealed no knowledge about the allegation. He revealed if an incident like this should be brought to his attention, he would talk with the DON and the perpetrator would be removed from the facility. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriate of Resident Property, dated November 2016, revealed it is the facility policy to investigate all alleged violations involving abuse, neglect, exploitation mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must have evidence that all alleged violations are thoroughly investigated and will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. The facility will report the results of all investigations to the administrator or her designated representative and to other officials in accordance with State Law, including to the State Survey Agency, within five working days of the incident. 2. Review of a facility submitted SRI revealed on 07/14/21 at 10:58 A.M. an allegation of sexual abuse was reported. The SRI revealed Resident #4 reported Resident #31 wandered into her room and touched her breasts. Resident #4 redirected Resident #31 with success and he left her room. Resident #31 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It was dark in Resident #4's room and it could not be verified if Resident #31 was trying to find his way around room or feeling Resident #4 in a sexual way. Resident #31 stopped when Resident #4 told him to do so. Resident #31 was placed on one on one until he was accepted at an [NAME] psych unit. Resident #4 showed some anxiety the day after the occurrence but reported she felt less nervous knowing someone was with him at all times. The facility unsubstantiated the allegation. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident's cognition was intact and required two-person assistance with transfer and mobility. Review of Resident #4's care plan dated 04/01/21 revealed the resident had anxiety and depression with targeted behaviors of restlessness, fidgeting, complaints of nervousness, and dyspnea. The resident reported feeling depressed and decreased energy/feeling tired. Interventions included allow resident to ventilate feelings and offer realistic feedback. Review of Resident #4's nurses progress notes, dated 07/14/21 at 11:00 A.M., revealed Resident #4 reported to RN #102 at 3:30 A.M. that Resident #31 opened the door and came into her room and closed the door behind him and began touching her all over. Resident #4 began to yell out and pushed the light for assistance. STNA #110 entered the room and escorted Resident #31 out of her room. Physician #111, DON, and Administrator were notified of the incident. Resident #4's medical record contained no evidence a physical or psychosocial assessment was completed after the allegation of abuse was made on 07/14/21. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 05/15/21, revealed the resident had severely impaired cognition and required one person assistance with mobility and transfers. Resident #31's care plan, dated 05/14/21 revealed the resident was an elopement risk/wanderer and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . and wandering the streets prior to admission. Interventions includes distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books of the resident's preference. The facility was to monitor the resident's location every 30 minutes, and to document wandering behavior and attempted diversional interventions in behavior log. Resident #31's care plan, dated 06/22/21, revealed the resident has a behavior problem of being sexual inappropriate and urinates/defecates in other places then the toilet at times. Interventions included administer medication as ordered, monitor/document for side effects and effectiveness, and if reasonable, discuss the resident's behavior. The facility should explain/reinforce why the behavior was inappropriate and/or unacceptable to the resident. The facility should intervene as necessary to protect the rights and safety of others and approach/speak in a calm and take the resident to alternate location as needed. Review of Resident #31's Resident Location Log dated 07/14/21 revealed the resident was on 30 minute checks from 12:00 A.M. to 7:00 A.M. An additional Resident Location Log dated 07/14/21 revealed the resident's checks were increased from 30 minutes to 15 minutes at 11:00 A.M. There was no evidence the resident was observed from 07/14/21 at 7:15 A.M. through 10:45 A.M. The logs did not indicate the resident was ever on one on one observation. Review of Resident #31's nurses progress notes, dated 07/14/21 at 11:00 A.M., revealed Resident #4 reported that at 3:30 A.M. Resident #31 came into her room, shut the door behind him and began touching her all over. Resident #4 began to yell and put the call light on. STNA #110 entered the room and escorted Resident #31 out of room. Resident #31 placed on 15-minute location checks and one to one. The resident's daughter and physician were notified, and a referral was made to geriatric psychiatric unit. Review of Resident #31's progress note dated 07/14/21 at 9:45 P.M. revealed the resident was walking out in the hallway attempting to go to Resident #4's room. The resident was redirected without incident. Although Resident #31 should have been on one on one observation, the progress note indicated 15 minute checks would continue. Interview at 07/19/21 at 1:37 P.M. with Resident #4 revealed about 3:00 A.M. to 3:30 A.M. in the morning she had turned off her light and television and was asleep. She revealed the next thing she felt was a hand all over her. She stated she started screaming for help, but the door was shut. The perpetrator then headed towards the door and then turned back. He then held his pants, and she was not sure what he was trying to do. She revealed she continued to scream and then one of the staff came and took him out of her room. She stated she knew the man wandered around the facility, so she knew he did not know what he was doing. Resident #4 revealed after the incident the facility did not complete any form of assessment on her, nobody talked to her about the incident, or asked how she was feeling until later that day. She revealed it was later that morning around 10:00 A.M. when the nurse passing medication came to give her meds, and she asked the nurse would there be any follow up to the incident that occurred. The nurse then told her that she was not aware of the incident, but she was going to find out and let her know. She revealed Registered Nurse (RN) #102 came to her and asked her questions about the incident and how she felt. She revealed the nurse assured her that they will keep an eye on Resident #31, so he won't bother her. Resident #4 revealed that later that evening around 8:00 P.M., Resident #31 came back to her room. Resident #4 revealed she yelled and told him to get out, and that was when another staff came and took him out of her room and had him on one-on-one observation. Resident #4 revealed since the incident she had been having problems sleeping. She keeps getting up during the night scared Resident #31 may come back. She verified that now that Resident #31 is out of the facility she is felt better but wondered what the facility will do with him when he comes back. Interview at 07/19/2021 at 2:01 P.M. with STNA #110 revealed she was the aide assigned on that hall the night Resident #31 entered Resident #4 room. She revealed around 4:00 A.M. on 07/14/21 she saw Resident #4 call light on and when she went to help her, she saw Resident #31 standing at Resident's #4 doorway. She revealed she immediately took him back to his room. She stated Resident #4 was very upset and shaking. STNA #110 revealed Resident #4 stated this resident came to her room had the door close and was touching her all over. STNA #110 revealed she notified the two nurses (RN #103 and LPN #104) who were sitting at the nurse's station, but they did nothing as always. She revealed STNA's do not have access to document in the medical record or any other place except to notify the supervisor or charge nurse of any incidents, and that was exactly what she did. She revealed nothing was done until that 12:00 P.M. when the nurse informed her, she would be providing one on one supervision of Resident #31. Telephone interview at 07/20/21 at 10:21 A.M. with LPN 104 revealed she worked a different hall the morning the incident happened between Resident #4 and Resident #37. She revealed she was on break and out of the building when alleged incident happened. LPN #104 revealed she was unaware of the incident until later during shift change. Telephone interview on 07/20/21 at 12:22 P.M. with RN #102 (Assistant Director of Nursing) revealed the allegation was brought to her attention at 10:00 A.M. by the morning nurse on that hall. She revealed night shift did not mentioned the allegation during shift change report. She revealed she immediately went to Resident #4 to talk with her and making sure she was fine. RN #102 verified she did not complete any form of assessment on the resident. Interview at 07/20/21 at 2:50 P.M. with the DON revealed RN #102 notified her about the allegation later that morning after night shift had left. She revealed the night shift nurse did not give report on anything happening during their shift. She stated she was very disappointed that the nurse on that hall did not check on the resident after the incident and did not inform administration of what had happened. The DON further revealed Resident #31 has always been on some sort of check because he wanders the facility and has made several attempts to get out of the building. She confirmed this resident was supposed to be on 15 minutes check and later was switched to one on one supervision, but the observation form did not specify one on one. DON confirmed the staff did not document observation of the resident on 07/14/21 form 7:15 A.M. to 10:45 A.M. She revealed this resident was on one on one until he was transferred to the psychiatric hospital. She revealed the physician also had him on [MEDICATION(S)] to reduce his sexual behaviors. She stated she believed social services completed a psychosocial evaluation on Resident #4 but was not certain. She revealed Resident #31 was not sent out immediately because all the hospitals they wanted to send him were full at that time. She also revealed he has bed hold and was going to come back. Telephone interview on 07/20/21 at 3:13 P.M. with RN #103 revealed he was informed by the STNA #110 that Resident #31 was in Resident #4's room and she got him out. He stated Resident #31 wanders a lot in the facility, so this was not out of the norm for him. RN #103 revealed if the aide would have told him that Resident #4 complained that Resident #31 was in her room touching her, he would have been in there to assess the situation. RN #103 revealed usually when this resident is found wandering staff redirect him back to his room. Interview on 07/21/21 at 3:20 P.M. with STNA #110 revealed when she returned to work on 07/15/21 at 3:00 A.M. she received report that Resident #31 entered Resident #4's room again and had to be escorted back to his room. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriate of Resident Property, dated November 2016, revealed it is the facility policy to investigate all alleged violations involving abuse, neglect, exploitation mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must have evidence that all alleged violations are thoroughly investigated and will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. The facility will report the results of all investigations to the administrator or her designated representative and to other officials in accordance with State Law, including to the State Survey Agency, within five working days of the incident. This deficiency substantiates Complaint Number OH 160

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facilities daily census reports, review of the facilities floor plan, observations, staff and the local health department interviews, and record reviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy when five residents (Resident #19, #32, #35, #70 and #72) who tested negative for COVID-19 remained in a semi-private room occupied by a roommate who had tested positive for COVID-19. Seven residents (Resident #19, #32, #35, #48, #62, #70 and #72) were noted to reside on the designated COVID-19 unit despite testing negative for COVID-19. Six residents (Resident #15, #22, #28, #55, #64 and #68) were not moved to the designated COVID-19 unit for more than 24 hours after a positive COVID-19 test result was received. Observations made on [DATE] revealed the designated COVID-19 unit had equipment leaving the unit without being disinfected prior to going to non-COVID-19 units. Staff exited the COVID-19 unit into the facility's common areas prior to exiting the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 69 residents at risk for the likelihood of harm, complications and/or death. The facility census was 69 residents. On [DATE] at 10:50 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when five residents (Resident #19, #32, #35, #70 and #72) who tested negative for COVID-19 remained in a semi-private room occupied by a roommate who had tested positive for Covid-19. of COVID-19. Additionally, seven residents (Resident #19, #32, #35, #48, #62, #70 and #72) were noted to have resided on designated COVID-19 units despite testing negative for COVID-19. Furthermore, Residents #15, #22, #28, #55, #64 and #68 were not moved to the designated COVID-19 unit for over 24 hours after positive COVID-19 test result was obtained. Observations on [DATE] revealed the designated COVID-19 unit had equipment, including a medication and dining cart, leaving the COVID-19 unit without being disinfected before going to the non-COVID-19 units, and staff were observed exiting the COVID-19 unit into facility common areas and restrooms prior to exiting the facility. The facility's failure to effectively implement infection control practices likely contributed to the COVID-19 outbreak that spread throughout the facility infecting 53 residents with COVID-19 resulting in nine deaths. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE], Resident #19 was moved to a non-COVID unit. On [DATE], Resident #72 expired at the facility. On [DATE], Resident #15 was hospitalized and when she returned from the hospital on [DATE], she was placed on the COVID-19 unit. On [DATE], Resident #70 expired at the facility and Resident # 22, #28, #55, #64 and #68 were moved to a COVID-19 unit. On [DATE], Resident #35 expired at the facility. · On [DATE], all residents who previously tested negative for COVID-19 will be retested by a Nurse Manager by [DATE] and processed by the Ohio Department of Health (ODH) Lab. If the results for Resident #48 and #62 are negative, they will be moved from the COVID-19 unit upon confirmation of results. Resident #32 resides in a room with his spouse and has chosen to remain on the COVID-19 unit. Resident #32 will be re-educated on [DATE] regarding potential risks and consequences of remaining on the COVID-19 unit. Resident #35 expired on [DATE]. · Beginning on [DATE], licensed nurses will be re-educated by the Administrator, DON or designee by [DATE] regarding isolating residents with an onset of symptoms in place, in a single room, as available until a positive case of COVID-19 is confirmed through testing and then will be moved to the COVID-19 unit as soon as possible but within 24 hours; moving residents whose roommate has an onset of symptoms to a single room, as available with isolation precautions in place. · Beginning on [DATE], licensed nurses, stated tested nursing aides (STNAs) and housekeepers will be re-educated by the Administrator, DON or designee by [DATE], regarding medication carts to remain on the COVID-19 units and disinfected prior to removal from unit if removal is necessary; dining carts to be disinfected prior to removal from the COVID-19 units; staff to enter facility through service hallway, remain on the COVID-19 unit for the duration of the shift with the exception of breaks and exit COVID-19 units through end hall door for break and end of shift. · On [DATE] at 6:00 P.M., Residents #4, #5, #6, #11, #12, #32, #34, #50, #52, #54, #56, #58, #61 and #62 received positive COVID-19 test results and will remain in place on ,[DATE] halls designated as a COVID-19 unit. Residents #20, #41, #51, and #57 received negative results and were moved from 400 hall to 200 hall (non-COVID-19 hall). Resident #48 received a negative COVID-19 test result at 7:00 P.M. on [DATE] and was moved from 100 hall (COVID-19 hall) to 200 hall (Non-COVID-19). · Beginning on [DATE], the Administrator and/or DON will monitor placement of residents to ensure residents with an onset of symptoms are isolated in place, in a single room, as available until a positive case of COVID-19 is confirmed through testing and then moved to the COVID-19 unit as soon as possible but within 24 hours and residents whose roommate has an onset of symptoms are moved to a single room, as available with isolation precautions in place. Monitoring will begin the week of [DATE] and will continue weekly for four weeks, then as needed as determined by the Quality Assurance and Performance Improvement (QAPI) committee. Negative findings will be addressed immediately, and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed. · Beginning on [DATE], the medication carts will remain on the COVID-19 units and will be disinfected by the nurses prior to removal from the units daily to be checked and stocked. Dining carts will be disinfected by the STNAs prior to removal from the COVID-19 units. · Beginning on [DATE], staff working the COVID-19 units will enter the facility through the service hallway, remain on the COVID-19 unit for the duration of the shift with the exception of breaks and will exit the COVID-19 unit through the end hall door for breaks and end of shift. · On [DATE] at 10:00 A.M., a barrier was installed separating the West Wing (300 and 400 COVID-19 halls) from the rest of the facility. · On [DATE], the DON and/or Unit Manager (UM) will monitor the medication carts to remain on the COVID-19 units and are disinfected prior to removal from unit if removal is necessary; dining carts to be disinfected prior to removal from the COVID-19 units; and to staff enter the facility through the service hall, remain on the COVID-19 units for the duration of the shift with the exception of breaks and exit through the end hall doors for breaks and end of shift. The monitoring will continue weekly for four weeks, then as needed as determined by the QAPI committee. Negative findings will be addressed immediately, and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed. · On [DATE], onsite observations of the facility revealed staff were appropriately wearing and removing PPE, hand hygiene was in place, staff were utilizing outside entry/exit to the COVID-19 units, medication/dietary carts were not removed from the designated area without proper sanitization and residents requiring isolation and quarantine were residing on the appropriate unit. · On [DATE] between 9:47 A.M. and 11:07 A.M., five staff members (one state tested nursing aide (STNA), one licensed practical nurse (LPN), and three registered nurses (RN)) were interviewed and found to be knowledgeable of the facility's COVID-19 practices and general infection control practices. Staff confirmed that they received education at the facility that included: appropriate use of PPE, areas of the facility where isolation and quarantined residents would be placed, not to enter the facility after entering the COVID-19 unit, and proper disinfecting of dietary cart/medication cart when leaving the COVID-19 unit. Although the Immediate Jeopardy was removed on [DATE], 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 is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). 1(a). Review of Resident #37's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #37 was tested for COVID-19 on [DATE] with positive results received by the facility on [DATE]. Review of the facility's census records revealed the resident had not changed rooms. Review of Resident #70's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #70 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed Resident #70 remained roommates with Resident #37, who had tested positive for COVID-19, and remained in the room until she expired on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:45 A.M. verified the facility received a positive COVID-19 test result for Resident #37 and a negative COVID-19 result for Resident #70 on [DATE] and both residents continued to occupy the same room until Resident #70 expired on [DATE]. The DON also verified the facility had empty beds on [DATE]. Interview with the Local Health Department Director of Nurses (LHD) #225 on [DATE] at 2:48 P.M. reported Resident #70 was identified as a probable COVID-19 positive case; however, they had not received the death certificate at of [DATE] to confirm the death diagnosis. 1(b). Review of Resident #71's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE], revealed Resident #71 was tested for COVID-19 on [DATE] with positive results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room until she expired on [DATE]. Review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #19 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed Resident #19 remained in the same room with Resident #71 who had tested positive for COVID-19 until a room change on [DATE]. Interview with the DON on [DATE] at 10:45 A.M. verified the facility received a positive COVID-19 test result for Resident #71 and a negative COVID-19 result for Resident #37 on [DATE] and the residents continued to occupy the same room until Resident #71 expired on [DATE]. The DON also verified the facility had empty beds on [DATE]. 1(c). Review of Resident #73's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #73 was tested for COVID-19 on [DATE] with positive results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room until she expired on [DATE]. Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #72 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room with Resident #73 until she expired on [DATE]. Interview with the DON on [DATE] at 10:45 A.M. verified the facility received a positive COVID-19 test result for Resident #73 and a negative COVID-19 result for Resident #72 on [DATE] and the residents continued to occupy the same room until Resident #73 expired on [DATE]. The DON also verified the facility had empty beds on [DATE]. Interview with the LHD #225 on [DATE] at 2:48 P.M. reported Resident #72 was considered presumptive positive for COVID-19 on [DATE] and COVID-19 was listed as other causative factor on her death certificate. 1(d). Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed the resident was tested for COVID-19 on [DATE] with positive results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE] through [DATE], revealed Resident #35 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed Resident #35 remained in the same room with Resident #49 who had tested positive. Interview with the DON on [DATE] at 10:45 A.M. verified the facility received a positive COVID-19 test result for Resident #49 and a negative COVID-19 result for Resident #35 on [DATE] and the residents continued to occupy the same room. The DON also verified the facility had empty beds on [DATE]. 1(e). Review of Resident #31's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE], revealed Resident #31 was tested for COVID-19 on [DATE] and a positive result was received by the facility on [DATE]. Review of the facility's census records revealed Resident #31 remained in the same room through [DATE]. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes, dated [DATE], revealed the resident was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed Resident #32 remained in the same room with Resident #31, who had tested positive, until [DATE]. Interview with the DON on [DATE] at 10:45 A.M. verified the facility received a positive COVID-19 test result for Resident #32 and a negative COVID-19 result for Resident #31 on [DATE] and the residents continued to occupy the same room as of [DATE]. The DON also verified the facility had empty beds on [DATE] and [DATE]. Review of the CDC guidelines indicated for residents with new-onset suspected or confirmed COVID-19 test results the facility should: · Ensure the resident is isolated and cared for using all recommend COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. o Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). o If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. · If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. · Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). o Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. 2(a). Resident #19 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained on the COVID-19 positive unit from [DATE] through [DATE]. 2(b). Resident #72 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room on the COVID-19 positive unit until she expired on [DATE]. 2(c). Resident #70 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed Resident #70 remained in the same room on the COVID-19 positive unit until she expired on [DATE]. 2(d). Resident #32 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of Resident #31's census revealed he remained in the same room on the COVID-19 positive unit until [DATE]. 2(e). Resident #35 was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained in the same room on the COVID-19 positive unit until [DATE]. 2(f). Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained on the COVID-19 positive unit until [DATE]. 2(g). Review of Resident #48's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was tested for COVID-19 on [DATE] with negative results received by the facility on [DATE]. Review of the facility's census records revealed the resident remained on the COVID-19 positive unit until [DATE]. Interview with the DON on [DATE] at 10:45 A.M. verified Resident #19, #33, #35, #48, #62, #70 and #72 had remained on a designated COVID-19 unit after testing negative for COVID-19. Interview with the Administrator on [DATE] at 12:35 P.M. revealed she did not want to move residents who tested negative off the designated COVID-19 unit due to the resident being exposed to active COVID-19 and having a high risk of infecting other residents in the facility. The Administrator stated this decision was not the recommendation of the local health department, but rather the decision of the facilities interdisciplinary team. Review of the CDC guidelines with new-onset suspected or confirmed COVID-19 revealed the facility should ensure the resident is isolated. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. 3(a). Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #15. The medical record revealed Resident #15 remained in her room, which was not a designated COVID-19 unit, until [DATE]. On [DATE], she was transferred to the emergency room and admitted to an acute care facility due to elevated temperature, decreased oxygen concentration and elevated blood pressure. 3(b). Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #22. The medical record revealed Resident #15 remained in her room which was not a designated COVID-19 unit through [DATE]. On [DATE], Resident #22 was transferred and admitted to the local emergency room due to a change of condition. 3(c). Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #28. The medical record revealed Resident #28 remained in her room for three days before being transferred to the designated COVID-19 unit on [DATE]. 3(d). Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #55. The medical record revealed Resident #55 remained in her room for three days until being transferred to the designated COVID-19 unit on [DATE]. (e). Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #64. The medical record revealed Resident #64 remained in her room for three days before being transferred to the designated COVID-19 unit on [DATE]. (f). Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the facility received results of a positive COVID-19 test for Resident #68. The medical record revealed Resident #68 was not moved to a room on the COVID-19 unit until [DATE]. Interview with the DON on [DATE] at 10:45 A.M. verified Resident #15, #22, #28, #55, #64 and #68 were not transferred to a designated COVID-19 unit for three days following notification of the facility of the residents having positive COVID-19 test results. Interview with the Administrator on [DATE] at 12:35 P.M. revealed the facility did not move residents who tested positive for COVID-19 to the designated COVID-19 units until after all the test results were received. Interview with the LHD #225 on [DATE] at 3:17 P.M. reported the facility had not reported residents were not immediately moved to a COVID-19 designated area. LHD #225 reported the residents should be transferred within 24 hours to a COVID-19 unit to help prevent the spread of the disease. 4(a). During a tour of the designated COVID-19 hall on [DATE] between 10:30 A.M. to 1:00 P.M., staff were observed obtaining resident meal trays from a meal cart and delivering the trays to the residents' rooms. The meal cart was positioned in the hallway of the COVID unit. Interview on [DATE] at 12:15 P.M. with RN #172 revealed the meal cart was delivered from dietary to outside the COVID-19 unit, then staff would open the door and pull the tray onto the unit. RN #172 reported when residents were finished eating, all trays were placed on the cart and taken off the unit where they would pass the meal cart out to a dietary staff member and the cart was returned to the kitchen area. Interview on [DATE] at 12:30 P.M. with the Administrator confirmed the meal carts were taken on the COVID-19 unit, meals were served from the cart, dirty trays were placed back inside the cart and the cart was then taken from the COVID-19 unit and returned to the kitchen. The dietary cart traveled past the nurse's station, through a designated non-COVID-19 resident hallway, the main entry hall, the DON's office and then down the service corridor which also contained the therapy department and linen services before arriving at the kitchen. The Administrator stated the facility did not have a policy addressing the need to sanitize the meal cart when leaving the COVID-19 unit. Interview with Dietary Staff (DS) #203 on [DATE] at 2:30 P.M. reported the meal carts were taken from the kitchen to the nurse's station outside the COVID-19 unit. DS #203 stated someone from nursing would take the cart to the COVID-19 unit and staff on the unit would pull the cart inside. When everyone was finished with their meal, the cart was placed outside the COVID-19 unit and dietary staff obtained the cart near the nurse's station and proceeded down the hall to the kitchen wash area. After the cart was inside the kitchen, the cart was emptied and then sanitized. Interview with LHD #225 on [DATE] at 2:36 P.M. reported she was not aware that the meal carts were being taken to the COVID-19 unit and then returned to the kitchen before sanitization. LHD #225 stated no type of cart should be taken from the COVID-19 unit unless it was sanitized before leaving the unit. 4(b). During tour of the designated COVID-19 unit on [DATE] between 10:30 A.M. to 1:00 P.M., the medication cart was observed sitting outside the COVID unit adjacent to the nurse's station. Interview with RN #180 on [DATE] at 12:08 P.M. reported when the medication cart was not in use for administering medication, it was located outside the COVID-19 unit. RN #180 stated she would get the cart as needed and bring it on the unit and when finished, would return it to the location outside the COVID-19 unit located in an open area that was by another nurse's station, which was not a designated COVID-19 unit. RN #180 reported it was not disinfected when taken off the COVID-19 unit. Interview with the DON on [DATE] at 9:53 A.M. revealed the medication cart was removed from the unit when not in use. When asked why the cart had to be off the COVID-19 hall, the DON stated that the Unit Manager would restock medication every morning. The DON stated disinfecting wipes were available for staff to clean the medication carts anytime they deemed necessary. The DON stated there was no facility policy she was aware of regarding disinfecting the medication cart when taken off the unit. Review of the CDC guidelines Sparkling Surfaces: Stop COVID-19's Spread indicated [MEDICAL CONDITION] that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that are touched frequently increase the change that germs could be spread to residents and staff. Surfaces which look clean, pathogens may be present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. 5. During tour of the facility on [DATE] between 10:00 A.M. to 1:00 P.M., interviews with RN #168, #172 #180 and #210, and State tested Nursing Assistant (STNA) #216 who worked the COVID-19 units, reported when they left the facility at the end of their shift, when they went on break or when they needed to go to the restroom, they would remove their personal protective equipment (PPE) and enter the non COVID-19 designated area and then return to the COVID-19 unit. When leaving the building, going to the restroom or on a break, the employees stated they would exit the COVID-19 unit to the main shared corridor where residents who did not have COVID-19 resided, walk past the nurse's station to a common hallway, and then could exit the front door if going on a break or would continue down the hallway and exit after clocking out through the employee entrance/exit after their shift was completed. Interview with the Administrator on [DATE] at 12:30 P.M. confirmed all staff entered and exited the building by using the employee entrance. The Administrator confirmed all facility staff did utilize the same restrooms in the common area and in break area. Interview with LHD #225 on [DATE] at 2:36 P.M. reported she was not aware employees working the COVID-19 unit were using the same restroom as staff who were not assigned to the unit and were exiting the building through the common hallway. LHD #225 stated if staff were leaving the COVID-19 unit during their shift, and utilizing common areas, this would not contain the isolation area and could possibly spread [MEDICAL CONDITION]. Review of the CDC guidelines revealed the facility should identify a space that could be dedicated to monitor and care for residents with COVID-19, such as a dedicated floor, unit or wing in the facility. The CDC considerations for establishing a designated COVID-19 unit for residents with confirmed COVID-19 included ideally the unit should be physical separated from other rooms/units housing residents without confirmed COVID-19, assign dedicated staff to work the COVID-19 care unit, the unit should have a restroom, break room and work area that are separate from staff working in other areas of the faci (TRUNCATED)

Based on observation, staff interview, and medical record review, the facility failed to provide adequate supervision for each resident to prevent accidents including falls. Actual Harm occurred to Resident #90 when she fell and sustained a right hip fracture. This affected two (Residents #90, #70) of three sampled residents reviewed for falls. Findings include: 1. Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE], and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] revealed this resident was at risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident was cognitively impaired, and required extensive assistance of two or more staff for bed mobility and to transfer. Review of Resident #90's plan of care for falls dated 06/06/14, and updated on 06/14/14, 08/08/14, 08/12/14, 08/20/14 and 08/23/14 revealed this resident was at risk for falls. The interventions listed to prevent falls included assist with transfers and ambulation as needed, educate to lock wheels on four wheeled walker before sitting down. On 06/14/14 an intervention was added to send the resident's personal walker home with family and the resident to use a facility walker. On 08/08/14 an intervention was added to continue therapy. On 08/12/14 an intervention was added to be up as desired in wheelchair. On 08/20/14 restorative nursing was to provide range of motion to all extremities and ambulate 25 feet twice a day was added to the care plan. On 08/23/14 the plan of care was updated calling for non-skid strips to floor beside bed. Review of Resident #90's nursing notes revealed on 06/14/14 the resident was found sitting on the floor at the end of her bed. Resident #90 stated she was trying to sit on the seat of her walker and it rolled out from under her. This fall resulted in a skin tear to the resident's left hand. Review of the facility's Found On Floor/Fall Reassessment dated [DATE] listed new interventions of educating the resident to use the brakes on her four wheeled walker before sitting down and to send the resident's four wheel walker home with her family. Review of nursing notes dated 08/08/14 revealed at 7:30 A.M. the resident attempted to stand up and she lost her balance, fell and hit the right side of her forehead against the wall. Neurological checks were completed and found within normal limits. The resident sustained [REDACTED]. Review of the Found On Floor/Fall Reassessment dated [DATE] recommended continuing therapy. Review of the nursing notes revealed on 08/12/14 the use of a walker for this resident was discontinued and the resident was to use a wheel chair. A nursing note dated 08/12/14 at 9:00 P.M. revealed bruising was noted to Resident #90's right shoulder and the resident complained of pain. The note stated the resident had a recent fall. An x-ray was ordered and obtained on 08/13/14 that showed the resident had a fracture to her right distal clavicle (collar bone). Review of the nursing notes dated 08/20/14 revealed on 08/19/14 this resident had been discharged from therapy and placed on a restorative nursing program. Review of the nursing notes dated 08/23/14 at 9:30 A.M. revealed Resident #90 was trying to walk without assistance and bumped the right side of her forehead on her room door. A bruised area was noted on her right forehead. Neurological checks were completed and were within normal limits. Review of the Found On Floor/Fall Reassessment dated [DATE] listed new interventions of active listening, explain procedures well, speak clearly and slowly, offer food/warm beverage, non-skid strips to floor beside bed. Review of Resident #90's nursing notes dated 08/26/14 at 11:45 A.M. revealed the resident had an unwitnessed fall in the east wing lounge. The resident stated she was trying to get up by herself. The note revealed the resident complained of right hip and foot pain. This resident was sent to a local hospital. On 08/26/14 at 3:00 P.M. the facility was notified the resident was admitted to the hospital due to a right hip fracture. Interview of the East Unit Manager, Registered Nurse (RN) #200 on 09/05/14 at 4:00 P.M. revealed on 08/26/14 she had taken Resident #90 to the east wing lounge for her lunch. This nurse stated another resident's family member was asking her questions and Resident #90 was left unsupervised for only a few minutes when the resident fell . This nurse stated the facility had increased Resident #90's level of supervision by having her in therapy, attending more activities, and when the resident was out of her room she was placed by the nurses station. Review of Resident #90's record revealed no evidence to support the resident's level of supervision was increased. The record contained no evidence that the facility assessed the resident for the reason she was getting up unassisted in an effort to provide for her needs. Review of the activity plan of care revealed no intervention to increase the resident's activity participation. Review of the resident's activity participation logs for June 2014 and August 2014 revealed the resident attended one more activity but not on a regular basis. The July activity participation log was requested on 09/05/14 at 4:10 P.M. RN #200 reported it could not be located. The resident had been discontinued from therapy on 08/19/14. There was no documentation in the nursing notes or plan of care to indicate the resident was to be placed at the nursing station when she was out of her room. Interview of RN #200 confirmed there was no evidence in the resident's record that demonstrated an increased level of supervision. 2. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of this resident's fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of Resident #70's MDS 3.0 assessment dated [DATE] revealed this resident was cognitively impaired, required extensive assistance of one staff for bed mobility and to transfer, required limited assistance with set up help of staff to walk in his room, and limited assistance of one staff to walk in the corridor, and the resident used a walker. Review of Resident #70's plan of care dated 07/09/14 revealed this resident was at risk for falls because he was unaware of safety needs, confusion, gait/balance problems, and had a history of [REDACTED]. Review of Resident #70's nurse notes dated 08/07/14 revealed this resident was seen sitting on the floor next to his bed leaning against a chair. The resident stated he was going to the bathroom. Review of the Found On Floor/Fall Reassessment dated [DATE] recommended the addition of non-skid strips to the floor beside his bed. Review of the nursing notes dated 08/16/14 revealed Resident #70 was observed laying on the floor next to his bed. The resident stated he was getting up and fell backward. Review of the Found On Floor/Fall Reassessment dated [DATE] added to toilet Resident #70 every two hours. Observations of Resident #70 on 09/05/14 at 10:48 A.M. revealed the resident was in bed and his call light out of reach. It was tied to the back of the arm of bed side chair. The resident was observed in bed on 09/05/14 at 11:59 A.M. and at 1:06 P.M. and his call light was tied to the back of the arm of his bed side chair. Interview of State tested Nurse Aide (STNA) #400 on 09/05/14 at 1:38 P.M. revealed staff encouraged Resident #70 to use his walker and the staff took him to the bathroom frequently. This STNA stated the resident used his call light to call for assistance. Interview with RN #201 on 09/05/14 at 1:45 P.M. confirmed Resident #70's call light was to be within his reach. This nurse stated he liked it tied to the arm of the chair. When she was asked if he could reach the call light when tied to the back of the chair arm, she did not answer. Resident #70 was up walking in his room without use of his walker. The resident plopped down on the foot of bed over the foot board. This deficiency substantiated Complaint Number OH 216.