Every finding on record at Park Center Healthcare and Rehabilitation

Based on observation, record review and interview, the facility failed to ensure Resident #80 was provided privacy while being changed. This affected one (Resident #80) of three residents reviewed for privacy. The facility census was 93. Findings include:Review of the medical record for Resident #80 revealed an admission date of 11/08/19. Diagnoses included Alzheimer's disease, stroke affecting right dominant side, diabetes, right hand contracture, depression, arthritis and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired. He required setup help for eating, supervision for oral and personal hygiene, partial assistance for showering, and substantial or maximum assistance for toileting. Observation on 08/06/25 at 2:48 P.M. revealed Resident #80's bedroom door was open. Certified Nurse Aide (CNA) #619 was assisting Resident #80 in being cleaned up after having a bowel movement. Resident #80 was rolled onto his right side, facing the door with no clothing on. The privacy curtain was not drawn. Interview on 08/06/25 at 2:53 P.M. with CNA #619 confirms she was assisting in cleaning and changing Resident #80 and did not close the door or draw the privacy curtain. Review of the facility policy titled Dignity, dated February 2021, revealed the facility would promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care.

Based on record review, observation, interview and facility policy review, the facility failed to ensure a comprehensive assessment, and periodic reassessments of a seatbelt restraint were completed for Resident #88. This affected one (Resident #88) of one resident reviewed for restraints. The facility census was 93. Findings include: Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS), chronic pain syndrome, migraine, anxiety, and major depressive disorder. Review of the 07/04/25 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #88 was alert and oriented to person, place, and time (A&Ox3). The assessment indicated Resident #88 did not have any restraints, including chair or trunk restraints. She was dependent on her wheelchair for movement around the facility. Review of the current physician orders revealed no orders for a seatbelt for Resident #88. Review of the current care plans revealed no mention of Resident #88 using a seatbelt or trunk restraint. Initial observation of Resident #88 on 08/04/25 at 10:02 A.M. revealed she was in her wheelchair with a seatbelt fastened around her stomach/abdomen. Interview on 08/05/25 at 11:34 A.M. with the Administrator and Assisting Administrator #700 revealed both agreed Resident #88 does not have a seatbelt. Interview on 08/05/25 at 3:45 P.M. with Clinical Manager #510 confirmed Resident #88 did not have a seatbelt on her wheelchair. Review of progress notes prior to 08/06/25 revealed no mention of Resident #88 utilizing a seatbelt. Observation on 08/06/25 at 1:34 P.M. of Resident #88 revealed she was in bed, relaxing after her shower. There was a seat belt on her wheelchair. Interview on 08/06/25 at 1:34 P.M. with Resident #88 reported she liked wearing the seat belt, it made her feel more secure. She sometimes felt like she was going to slide out of her chair. She stated she easily takes the seatbelt off and on herself. Interview on 08/06/25 at 1:45 P.M. with Licensed Practical Nurse (LPN) #547 and Certified Nursing Assistant (CNA) #562 revealed they were aware Resident #88 had a seatbelt on her wheelchair and liked to use it to feel more secure. They admitted there was no assessment or direction to ask Resident #88 to release the seatbelt as it was her choice to wear it. LPN #547 and CNA #562 confirmed Resident #88 could self-release the seatbelt, as she would get in and out of it multiple times a day. Interview on 08/06/25 at 2:22 P.M. with the Administrator and Assisting Administrator #700 to advise both on the presence of a seatbelt, confirmed with a second observation and staff interview. Physician order dated 08/06/25 initiated Resident #88's seat belt use. The order specified the seat belt was per resident request and preference. Resident #88 shall demonstrate the ability to effortlessly self-release the seatbelt at will and verbalize understanding of appropriate use. Record review on 08/07/25 revealed the care plan for Resident #88's Functional Status deficit added an intervention on 08/06/25 asserting the self-releasing seatbelt was per resident request/preference. Resident #88 demonstrated the ability to release the seatbelt at will. Review of the facility policy Use of Restraints, updated April 2017, asserted prior to placing a resident in restraints, there shall be a pre-restraining assessment and review. Also, an ongoing, periodic review of the resident's ability to self-release the restraint.

Based on record review, observation, interview and facility policy review, the facility failed to ensure safe smoking practices for Resident #83. This affected one (Resident #83) of five residents reviewed for smoking. In addition, the facility failed to ensure there was a fire blanket or fire extinguisher was observed in the designated smoking area. This had the potential to affect 30 (Residents #2, #4, #7, #10, #19, #23, #27, #28, #30, #31, #32, #36, #38, #42, #43, #46, #52, #65, #73, #75, #76, #78, #79, #83, #85, #86, #91, #92, #93, #94 and #96) identified by the facility as residents who smoked. The facility census was 93. Findings include:Review of the medical record for Resident #83 revealed an admission date of 11/07/19. Diagnoses included traumatic brain injury, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), dementia, alcohol use, depression, cocaine abuse and tobacco use. Review of the smoking evaluation dated 06/06/25 revealed Resident #83 required supervision for smoking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact. He was independent in all activities of daily living and functional abilities. Review of the care plan dated 07/17/25 revealed Resident #83 was at an increased risk for health issues due to tobacco use. Interventions included educating about the risks associated with smoking, providing smoking cessation, and always providing supervision for smoking. Interview on 08/05/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #547 revealed Resident #83 could smoke without supervision but was expected to do so at the designated smoke times. She revealed he was non-compliant with this expectation and smoked whenever he chose. Interview on 08/05/25 at 3:15 P.M. with Resident #83 revealed he could smoke whenever he chose, and he did not believe he needed supervision to do so. Interview on 08/06/25 at 9:40 A.M. with Activity Director #508 confirmed Resident #83 was a supervised smoker. Observation on 08/06/25 at 1:59 P.M. revealed Resident #83 was outside smoking in the pavilion. Activities Assistant #507 remained in the pavilion with Resident #83 as well as other residents who were smoking for approximately 20 minutes. No fire blanket or fire extinguisher was observed in the designated smoking area. Interview on 08/06/25 at 2:31 P.M. with Activities Assistant #507 confirmed she had been outside supervising smokers and when she came in she did not ask Resident #83 to come in with her. She confirmed he required supervision for smoking but left without asking him to come inside because he was often noncompliant with the policy. Interview on 08/07/25 at 7:16 A.M. with the Administrator confirmed there was no smoke blanket or fire extinguisher in the smoking pavilion. Review of the facility policy titled Smoking Policy - Residents, dated August 2010, revealed any resident with restricted smoking privileges requiring monitoring would have direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on record review, interview and facility policy review, the facility failed to ensure lab work was obtained as ordered for Resident #5. The affected one (Resident #5) of three residents reviewed for laboratory services. The facility census was 93. Findings include:Review of the medical record for Resident #5 revealed an admission date of 10/18/21. Diagnoses included respiratory failure, kidney failure, dementia, heart failure, schizoaffective disorder, bipolar disorder and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. He was independent in eating, required supervision or touch assistance for oral and personal hygiene and partial to moderate assistance for showering and toileting. He had no psychosis or delusions. Review of the physician's orders for August 2025 revealed an order for a Depakote level and Hemoglobin A1c to be drawn every six months which began on 06/20/24, and liver function tests (LFT)'s to be drawn every three months which began on 04/09/24. Review of the lab work completed in the last year revealed a Hemoglobin A1c for Resident #5 was completed 12/23/24, a Depakote level was drawn 04/11/25 and LFT's were drawn 04/11/25. Interview on 08/07/25 at 9:37 A.M. with Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #510 confirmed labs had not been drawn as ordered for Resident #5. Review of the facility policy titled Labs and Diagnostic Test Results - Clinical Protocol, dated November 2018, revealed the physician would identify and order lab testing based on the residents' diagnostic and monitoring needs and the staff would process test requisitions and arrange for tests and lab results.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #80's medical record was accurate to reflect the refusal of the right-hand splint. This affected one (Resident #80) of three residents reviewed for split use. The facility census was 93. Findings include:Review of the medical record for Resident #80 revealed an admission date of 11/08/19. Diagnoses included Alzheimer's disease, stroke affecting the right dominant side, diabetes, right hand contracture, depression, arthritis and muscle weakness. Review of the care plan dated 05/08/25 revealed Resident #80 was at risk for contractures. Interventions included administering pain medication as ordered, encouraging and assisting with repositioning as needed, and reporting nonverbal expressions of pain such as moaning, grimacing, crying or thrashing. The care plan did not include anything regarding the physician's order for the right hand splint. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired. He required setup help for eating, supervision for oral and personal hygiene, partial assistance for showering, and substantial or maximum assistance for toileting. He had functional limitations in range of motion to upper and lower extremities on one side. Review of the physician's orders for August 2025 revealed Resident #80 was to wear a right hand splint during the day with it being removed at night for effective contracture management. The order began 12/01/21. Review of the Treatment Administration Record (TAR) for July 2025 revealed the splint was documented as applied to Resident #80's right hand each day and removed each night. There was no documented evidence of refusals. Observation on 08/04/25 at 9:22 A.M. revealed Resident #80 was lying in bed with his right hand contracted. No splint was observed to be in use. Interview on 08/05/25 at 12:47 P.M. with Registered Nurse (RN) #584 confirmed Resident #80 had a contracture to his right hand. She confirmed he has had it for more than one year. She revealed he used to have a splint but has not had one in at least one year because he refused to use it. Interview on 08/06/25 at 2:48 P.M. with Certified Occupational Therapy Assistant (COTA) #519 revealed Resident #80 was ordered a splint for his right-hand contracture, which would be in his bedroom. Observation at the time of the interview confirmed a right-hand splint in the top drawer of Resident #80's bedside table. Interview on 08/06/25 at 2:51 P.M. with Certified Nurse Aide (CNA) #619 revealed she had no knowledge of the splint in Resident #80's bedside table. She was not aware he was supposed to have one; she had never seen it and had never assisted him in applying it. Interview on 08/06/25 at 2:53 P.M. with CNA #561 and staffing coordinator/CNA #564 revealed CNA #561 was aware Resident #80 had a hand splint in his bedside drawer. CNA #564 said he was not required to wear it all the time and often refused to do so. She confirmed refusals would be documented in the medical record. CNA #564 also revealed if staff had attempted to apply the splint and it was removed by the resident; it would also be noted in the medical record that an attempt had been made but was unsuccessful. Interview on 08/07/25 at 8:09 A.M. with Resident #80 revealed he was sitting up in bed eating breakfast. He confirmed he had used a splint for his hand before, but it was not comfortable, and he would not wear it if asked. He could not confirm if he was consistently offered the use of the splint. Interview on 08/11/25 at 10:46 A.M. with Rehab Director #582 confirmed she was aware Resident #80 had a hand splint but stated he hated it and would not wear it for very long. She confirmed staff should be documenting attempts to apply the splint and resident refusals. She also confirmed the use of the splint should be included in the residents' care plan. Review of the undated facility policy titled Resident Splint Use Policy and Procedure revealed the facility would ensure splints were used according to medical orders and care plans. The use of a splint would be incorporated in the residents' care plan including goals reflecting the purpose of the splint. The care plan team, including therapy and nursing, would review splint use at least quarterly or with significant changes in condition. Residents had the right to refuse the use of a splint, and refusals would be documented, reported to the nurse and provider and the care plan updated to reflect interventions or education provided.

Based on record review, observation, interview and facility policy review, the facility failed to utilize enhanced barrier precautions (EBP) during wound care when required. This affected one (Resident #6) of two residents reviewed for EBP. There were eight (Residents #6, #24, #68, #70, #76, #82, #88 and #92) who required EBP. The facility census was 93. Findings include:Review of the medical record for Resident #6 revealed an admission date of 05/28/21 with diagnoses including vascular dementia and diabetes mellitus with hyperglycemia. A wound progress note dated 08/04/25 indicated the resident had a diabetic ulcer to the left lateral foot which began on 05/06/25 and required wound dressing changes three times weekly. Review of Resident #6's physician orders dated 07/07/25 revealed to cleanse the left lateral foot wound with normal saline, paint with betadine (antiseptic solution), apply calcium alginate (a dressing used to help maintain a moist wound environment), then cover with an abdominal dressing and gauze wrap three times weekly and as needed. Observation on 08/06/25 at 11:10 A.M. of wound care for Resident #6 with Assistant Director of Nursing (ADON) #510 revealed an EBP sign posted on Resident #6's door with a supply of personal protective equipment (PPE) including gowns and gloves nearby for staff use. ADON #510 entered the room, set-up the wound supplies on a clean barrier and proceeded to engage in the removal of Resident #6's left foot soiled dressing using gloved hands but did not don a gown for EBP. ADON #510 then cleansed the wound after changing gloves and handwashing but continued to conduct the wound care without wearing a gown for EBP. ADON #510 completed the wound care by applying the ordered clean dressings after again changing gloves and handwashing but did so without wearing a gown for EBP. Interview at the time of the observation with ADON #510 verified a gown was not worn for EBP as required while performing wound care for Resident #6. Review of the facility policy, Enhanced Barrier Precautions, revised December 2024 revealed EBP apply when a resident has a wound. Gloves and a gown are applied prior to performing high contact resident care activity which includes wound care (any skin opening requiring a dressing).

Based on observation, record review and interview the facility did not ensure palatable food was served at residents meals. This affected four residents (Resident #11, #32, #69 and #90) of six residents reviewed for food/nutrition. The facility census was 92. Findings include: Interview was conducted on 01/21/25 at approximately 9:25 A.M. with Licensed Practical Nurse (LPN) #577 who stated the residents do complain about the food being served cold and not hot enough. Interviews were conducted on 01/21/25 from 9:30 A.M. to 10:10 A.M. with Resident #69, #90, #32 and #11. Resident #69, #90 and #11 stated the hot food was served cold and was not always palatable. Resident #32 stated she had received spoiled milk and the food is sometimes too hard. Observation of tray line on 01/21/25 from 12:15 P.M. through 12:47 P.M. revealed food was above 165 degrees Fahrenheit ( F) at the start of tray line. A test tray was requested as the last resident's food was plated. The food cart left the kitchen at 12:47 P.M. and arrived at the unit at 12:48 P.M. When the last tray on the cart was delivered on 01/21/25 at 1:06 P.M., the test tray was removed from the food cart and placed on a table when food temperatures were taken. Dietary Manager (DM) #634 took the temperatures of the food and verified the temperature for the iced tea was 48 degrees F, two percent milk was 52 degrees F, mandarin oranges 59 degrees F, pasta with sausage 138 degrees F and brussels sprouts were 120 degrees F. Upon taste test of the brussel sprouts the temperature was barely warm and not hot. Review of the facility policy titled Food and Nutrition Services, dated 10/2017, revealed each resident would be provided a nourishing, palatable diet and food service staff would ensure attractive food was served at palatable temperatures. The policy did not indicate a temperature range to maintain palatable food temperatures. This deficiency represents non-compliance investigated under Complaint Number OH00160967.

Based on record review, interview and review of the facility policy the facility failed to ensure Resident #45's responsible party was included in the development and revision of the care plan for Resident #45. This affected one resident (Resident #45) out of three residents reviewed for participation in care planing. The facility census was 92. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, white matter disease (damage to the brain's white matter caused by reduced blood flow to the tissues), anxiety disorder, chronic ischemic heart disease and type two diabetes without complications. Review of Resident #45's Annual Minimum Data Set 3.0 assessment dated [DATE] included Resident #45 had severe cognitive impairment. Resident #45 required supervision or touching assistance for toileting hygiene and setup or clean-up assistance with personal hygiene. Resident #45 was independent for eating, upper and lower body dressing, bed mobility and walking ten feet. Resident #45 required supervision or touching assistance for transfer from bed to chair or wheelchair, and toilet transfer. Resident #45 was always continent of urine and bowel. Review of Resident #45's care plan dated 11/07/23 and revised on 11/19/24 included neurological deficiencies related to white matter signal abnormalities which were likely the sequela of chronic small vessel disease, Alzheimer's dementia. Resident #45 would have ADL (Activity of Daily Living) needs met with staff assistance. Resident #45 would maintain the ability to participate in all ADL's and activities of choice as condition permitted. Interventions included to obtain labs and diagnostic tests as ordered and notify the physician of results; to obtain vital signs as clinically needed; to report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness and slurred speech. Review of Resident #45's care plan dated 11/07/23 and revised on 12/16/24 included Resident #45 had an ADL self care deficit related to cognitive loss in dementia, generalized muscle weakness, unsteady gait, ischemic heart disease, type two diabetes and moderate malnutrition. Resident #45 would be clean, dressed and well groomed daily to promote dignity and psychosocial well-being. Interventions included toileting required supervision and verbal cues; Resident #45 was independent for bed mobility and ambulation required supervision and verbal cues. Review of Resident #45's social services notes dated 02/15/24, 05/16/24 and 08/16/24 revealed Resident #45 was reviewed for quarterly assessments and the notes included Resident #45's care plan was reviewed and updated and Resident #45 and her family were made aware of any changes to the care plan. Review of Resident #45's social services notes and progress notes dated 08/16/24 through 01/23/25 did not reveal evidence Resident #45 was reviewed for a quarterly assessment related to planning care which included the resident representative. Interview on 01/23/25 at 9:47 A.M. of Family Member (FM) #672 revealed she was Resident #45's Power of Attorney and Resident #45 had a change in condition and decline in Activity of Daily Living's and no one from the facility called her to discuss these issues or to set up a care conference. FM #672 stated when she was at the facility it was hard to find a nurse or aide to ask questions and address her concerns. FM #672 stated she did not think Resident #45 required a secured unit now, and would prefer her to be off the unit and would like to discuss the possibility with facility staff, but no one ever called her. FM #672 indicated she was only invited by the facility to one care conference and that was close to when Resident #45 was first admitted to the facility. FM #672 stated she had not been invited to a care meeting for about a year. Interview on 01/23/25 at 11:04 A.M. of Social Services Director (SSD) #617 revealed care conferences were completed every three months and per request. SSD #617 stated she worked with Registered Nurse/Minimum Data Set (RN/MDS) #624 to plan and conduct resident care conferences. SSD #617 stated RN/MDS #624 either placed a phone call or sent an email to invite responsible parties to resident care conferences. SSD #617 indicated Power of Attorney's were included and invited to resident care conferences. SSD #617 confirmed Resident #45 did not have a care conference since 08/16/24. Interview on 01/23/25 at 10:15 A.M. of RN/MDS #624 revealed she sent letters and made phone calls to invite resident's responsible parties to the care conferences. RN/MDS #624 stated if she did not have an address to send a letter then she made a phone call to the responsible party. RN/MDS #624 stated care conferences were documented in the progress notes, and she documented if she mailed letters or made phone calls to responsible parties. RN/MDS #624 indicated she reviewed Resident #45's medical record including progress notes and did not see where she documented she placed a phone call, left messages or sent a letter to FM #672 who was Resident #45's POA for care conferences on 02/15/24, 05/16/24 and 08/16/24 . RN/MDS #624 confirmed there should have been a care conference in October 2024 and there wasn't. RN/MDS #624 stated Resident #45's last care conference was 08/16/24. Review of the facility policy titled Care Planning Interdisciplinary Team, dated 12/2008, revealed the resident and resident representative are encouraged to participate in the development of and revisions to the resident care plan. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family. Care plans shall incorporate goals and objectives that lead to the resident's highest attainable level of independence. This deficiency represents noncompliance identified during investigation of Complaint Number OH00161689

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #45's change in condition was reported to Resident #45's primary care physician and responsible party in a timely manner. This affected one resident (Resident #45) out of three residents reviewed for change of condition. The facility census was 92. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and diagnoses included Alzheimer's disease, white matter disease (damage to the brain's white matter caused by reduced blood flow to the tissues), anxiety disorder, chronic ischemic heart disease and type two diabetes without complications. Review of Resident #45's Annual Minimum Data Set 3.0 assessment dated [DATE] included Resident #45 had severe cognitive impairment. Resident #45 required supervision or touching assistance for toileting hygiene and setup or clean-up assistance with personal hygiene. Resident #45 was independent for eating, upper and lower body dressing, bed mobility and walking ten feet. Resident #45 required supervision or touching assistance for transfer from bed to chair or wheelchair, and toilet transfer. Resident #45 was always continent of urine and bowel. Review of Resident #45's care plan dated 11/07/23 and revised on 11/19/24 included neurological deficiencies related to white matter signal abnormalities which were likely the sequela of chronic small vessel disease, Alzheimer's dementia. Resident #45 would have ADL (Activity of Daily Living) needs met with staff assistance. Resident #45 would maintain the ability to participate in all ADL's and activities of choice as condition permitted. Interventions included to obtain labs and diagnostic tests as ordered and notify the physician of results; to obtain vital signs as clinically needed; to report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness and slurred speech. Review of Resident #45's care plan dated 11/07/23 and revised on 12/16/24 included Resident #45 had an ADL self care deficit related to cognitive loss in dementia, generalized muscle weakness, unsteady gait, ischemic heart disease, type two diabetes and moderate malnutrition. Resident #45 would be clean, dressed and well groomed daily to promote dignity and psychosocial well-being. Interventions included toileting required supervision and verbal cues; Resident #45 was independent for bed mobility and ambulation required supervision and verbal cues. Review of Resident #45's progress notes dated 01/12/25 at 12:51 P.M. included Resident #45 needed increased assistance with ADL's. Extensive assistance was needed with all transfers, Resident #45 was incontinent of bladder and incontinence care was provided as needed. Resident #45 required extensive assistance with feeding. Much cueing was provided and was ineffective. Staff fed Resident #45 breakfast and lunch. Therapy services informed. There was no evidence Resident #45's physician or responsible party were notified. Review of Resident #45's progress notes dated 01/13/25 at 8:11 A.M. revealed on 01/13/25 at 12:04 A.M. Resident #45 appeared fatigued during medication administration, and signs of lethargy despite having vital signs within normal limits. Resident #45 reported feeling more tired than usual but had no complaints of pain or discomfort. The on call Nurse Practitioner (NP) (unidentified) was notified to discuss the situation and the NP ordered laboratory tests including Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) in the morning. There was no evidence Resident #45's responsible party was notified. Review of Resident #45's physician progress notes dated 01/13/25 written by Nurse Practitioner (NP) #670 included nursing endorsed Resident #45 had increased fatigue, confusion, weakness and needed increased assistance with ADL's. The on call NP was contacted and a CBC and CMP were ordered STAT (immediately). Upon exam Resident #45 denied shortness of breath, chest pain, lightheadedness, dizziness, headache, nausea, vomiting, diarrhea. Resident #45 endorsed she had constipation with no tenderness upon palpation to abdomen. There was no mention of Resident #45's bladder incontinence. Review of Resident #45's physician progress notes dated 01/14/25 written by NP #670 included Resident #45 was seen yesterday and noted to have tachycardia, electrocardiogram (EKG) was ordered and was pending. Resident #45's kidney, ureter, bladder (KUB) test ordered on 01/13/25 for complaints of constipation and hypoactive bowel sounds revealed gas and a normal amount of stool was scattered throughout the colon into the rectum and the impression was nonspecific nonobstructed bowel gas pattern by plain radiography. There was no mention of Resident #45's bladder incontinence. Review of Resident #45's physician progress notes dated 01/16/25 written by NP #670 included labs were ordered due to increased muscle weakness, increased need for assistance with ADL's as well as trouble feeding self. Upon exam Resident #45 denied shortness of breath, chest pain, lightheadedness, dizziness, headaches, blurred vision, nausea, vomiting, diarrhea. There was no mention of Resident #45's bladder incontinence. Observation on 01/23/25 at 8:56 A.M. of Resident #45 sitting at a table in the common area, her head was down and resting on her arms which were placed on the table in front of her. Resident #45's hair was clean and tied back into a ponytail and her face could not be seen. Interview on 01/23/25 at 9:47 A.M. of Family Member (FM) #672 revealed she visited Resident #45 on 01/12/25 around 3:00 P.M. and she was way worse than I have ever seen her. FM #672 stated she did not receive a call from the facility about Resident #45's change of condition. FM #672 stated she was Resident #45's Power of Attorney and she was not notified by the facility nor physician that Resident #45 was incontinent and needed incontinent briefs. Interview on 01/23/25 at 11:04 A.M. of Social Services Director (SSD) #617 confirmed FM #672 contacted her on 01/13/25 and told her she visited Resident #45 over the weekend and had some concerns. SSD #617 stated FM #672 told her Resident #45 was lethargic, was not doing well, and the nurse told her labs and a urinalysis were supposed to be ordered. SSD #617 indicated FM #672 was concerned about Resident #45's overall health, and there was also a concern about her medications, but she was not sure what the issue was. SSD #617 stated she documented the concerns and reported them to to Clinical Director (CD) #506. Interview on 01/23/25 at 11:38 A.M. of Certified Nursing Assistant (CNA) #538 revealed Resident #45 used to be independent and now she was confused, incontinent, not eating, sleepy, always tired and this was a big change for her. CNA #538 confirmed the nurses were aware of it. Interview on 01/23/25 at 11:43 A.M. of Registered Nurse (RN) #611 revealed Resident #45 had declined, she used to walk and use a rollator then she went to the wheelchair recently. RN #611 confirmed Resident #45 was incontinent now and that was a change for her. RN #611 stated she had not talked to FM #672 or updated her about Resident #45's changes in condition. Interview on 01/23/25 at 2:24 P.M. of NP #670 revealed she was not notified on 01/12/25 of a change in Resident #45's condition, but became aware of it on 01/13/25. NP #670 stated on 01/13/25 the on call Nurse Practitioner was notified early in the morning and she became aware later in the day. NP #670 stated she did not know if Resident #45 had a urinalysis completed. NP #670 indicated she was not told by the staff that Resident #45 was incontinent and she did not order a dip stick to check for a urine infection or a urinalysis or a urine culture and sensitivity. NP #670 stated there was nothing in her notes about Resident #45 having urinary incontinence and she was unaware of it. NP #670 stated she could not be in the facility 24/7. Interview on 01/23/25 at 3:32 P.M. of SSD #617 revealed FM #672 called her on 01/13/25 and asked about lab results for Resident #45's urinalysis and other lab results that were drawn and she reported this in a meeting on 01/16/24. SSD 3617 stated she told CD #506 to let FM #672 know about Resident #45's lab results and CD #506 stated she would follow up. Interview on 01/23/25 at 3:45 P.M. of CD #506 revealed she was notified FM #672 was asking about Resident #45's labs and urinalysis, but she got busy and forgot to call FM #672. CD #506 stated she checked a book she kept which had her to do list in it and confirmed she did not call FM #672. CD #506 stated she felt really badly she did not call FM #672 and confirmed FM #672 was not contacted regarding Resident #45's change in condition on 01/12/25 at 12:51 P.M. or 01/13/25 at 12:04 A.M. CD #506 confirmed neither Resident #45's physician or Nurse Practitioner were contacted on 01/12/25 regarding Resident #45's change of condition and they should have been notified. CD #506 indicated she did not contact NP #670 and report Resident #45 was incontinent and she was not aware if other nurses had contacted NP #670 about her incontinence. Review of the facility policy titled Notification of Significant Change in Resident Condition undated included the policy was established to ensure family members or designated [NAME] of Attorney (POA) were promptly notified in the event of a significant change in the condition of a resident within the Skilled Nursing Facility (SNF). Timely communication with family members or POA was essential for maintaining transparency, facilitating decision-making and ensuring the well-being of residents. The policy applied to all staff members responsible for the care and monitoring of residents within the SNF, including nursing staff, physicians and administrative personnel. A significant change in resident condition included but was not limited to changes in medical status, such as new diagnoses, exacerbation of existing conditions, or unexpected deterioration; changes in mental or cognitive status, such as confusion, agitation, or a significant decline in memory or functioning; any other change that might impact the resident's health, safety, or quality of life. In the event of a significant change in resident condition, the primary nurse or attending physician was responsible for promptly notifying the resident's family member or designated POA. Notification should occur within a reasonable timeframe, typically within 24 hours of the change being identified or as soon as practically possible. All notification to family members or POA regarding significant changes in resident condition must be documented in the resident's medical record. Following the initial notification, staff members should provide regular updates to the resident's family member or POA as appropriate, keeping them informed of any changes in the resident's condition or care plan. Staff should be available to answer questions, address concerns, and provide support to the family member or POA throughout the process. This deficiency represents noncompliance identified during investigation of Complaint Number OH00161689.

Based on observation, interview, record review and review of bowel and bladder assessments the facility failed to ensure Resident #45 was provided toileting assistance to maintain a level of ability with toileting activity of daily living. This affected one resident (Resident #45) out of three residents reviewed for Activity of Daily Living's. The facility census was 92. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and diagnoses included Alzheimer's disease, white matter disease (damage to the brain's white matter caused by reduced blood flow to the tissues), anxiety disorder, chronic ischemic heart disease and type two diabetes without complications. Review of Resident #45's Bowel and Bladder Continence Evaluation dated 09/16/24 revealed Resident #45 had high restorative potential (retraining). Review of Resident #45's Annual Minimum Data Set assessment dated [DATE] included Resident #45 had severe cognitive impairment. Resident #45 required supervision or touching assistance for toileting hygiene and setup or clean-up assistance with personal hygiene. Resident #45 was independent for eating, upper and lower body dressing, bed mobility and walking ten feet. Resident #45 required supervision or touching assistance for transfer from bed to chair or wheelchair, and toilet transfer. Resident #45 was always continent of urine and bowel. Review of Resident #45's care plan dated 11/07/23 and revised on 11/19/24 included neurological deficiencies related to white matter signal abnormalities which were likely the sequela of chronic small vessel disease, Alzheimer's dementia. Resident #45 would have ADL (Activity of Daily Living) needs met with staff assistance. Resident #45 would maintain the ability to participate in all ADL's and activities of choice as condition permitted. Interventions included to obtain labs and diagnostic tests as ordered and notify the physician of results; to obtain vital signs as clinically needed; to report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness and slurred speech. Review of Resident #45's Bowel and Bladder Continence Evaluation dated 12/16/24 revealed Resident #45 had moderate restorative potential (habit/prompted). Resident #45 was continent of bowel and usually continent of urine with occasional incontinence but not daily. Review of Resident #45's medical record including progress notes and evaluations did not reveal evidence Resident #45 had a trial of a toileting program attempted (scheduled toileting, prompted voiding, bladder training). Review of Resident #45's care plan dated 11/07/23 and revised on 12/16/24 included Resident #45 had an ADL self care deficit related to cognitive loss in dementia, generalized muscle weakness, unsteady gait, ischemic heart disease, type two diabetes and moderate malnutrition. Resident #45 would be clean, dressed and well groomed daily to promote dignity and psychosocial well-being. Interventions included toileting required supervision and verbal cues; Resident #45 was independent for bed mobility and ambulation required supervision and verbal cues. Review of Resident #45's care plan dated 11/07/23 and revised on 12/16/24 did not reveal a care plan to assist with bowel and bladder continence. Review of Resident #45's progress notes dated 12/16/24 through 01/12/25 did not reveal documentation Resident #45 was incontinent, had a trial toileting program or a toileting program was currently being used to manage Resident #45's bladder incontinence. Review of Resident #45's progress notes dated 01/12/25 at 12:51 P.M. included Resident #45 needed increased assistance with ADL's. Extensive assistance was needed with all transfers, Resident #45 was incontinent of bladder and incontinence care was provided as needed. Observation on 01/23/25 at 8:56 A.M. of Resident #45 sitting at a table in the common area, her head was down and resting on her arms which were placed on the table in front of her. Resident #45's hair was clean and tied back into a ponytail and her face could not be seen. Interview on 01/23/25 at 9:35 A.M. of Family Member (FM) #672 revealed she was Resident #45's Power of Attorney (POA). FM #672 stated Resident #45 was in diapers now. FM #672 stated she did not know if the aides attempted to take Resident #45 to the bathroom on a schedule to help keep her continent, but when Resident #45 stopped being able to go to the bathroom she noticed she started wearing diapers. FM #672 stated she was not told by facility staff Resident #45 was wearing incontinence briefs and she had no idea she was wearing them until an aide told her she needed to change Resident #45's incontinence brief. Interview on 01/23/25 at 11:43 A.M. of Registered Nurse (RN) #611 revealed Resident #45 had declined and was now incontinent. RN #611 stated she did not know if Resident #45 had a trial toileting program initiated and completed. RN #611 confirmed she did not talk to FM #672 regarding Resident #45's bladder incontinence. Interview on 01/23/25 at 2:04 P.M. of Clinical Director (CD) #506 revealed she completed Resident #45's Bowel and Bladder Evaluation on 09/16/24 and 12/16/24 and acknowledged she had a change from high restorative potential (retraining) to moderate restorative potential (habit/prompted). CD #506 indicated the aides and nurses on the unit assisted Resident #45 to the bathroom but there was no scheduled toileting program. CD #506 stated interventions to assist with continence could be placed in Resident #45's electronic record by either herself or another nurse, and she did not have a good answer for why it was not done. CD #506 stated she completed Resident #45's Bowel and Bladder Evaluations but did not do anything further once the evaluations were finished. CD #506 confirmed Resident #45 had a decline in her continence in a short period of time and had no idea why and thought maybe her disease process is catching up to her. Interview on 01/23/25 at 4:02 P.M. of the Director of Nursing confirmed no scheduled toileting program for Resident #45 was implemented and Resident #45 went from a high to a moderate restorative potential for bladder and bowel continence and it would have been a good idea to put a plan in place, but it did not happen. The DON stated the aides took Resident #45 to the bathroom but not on a schedule. Interview on 01/23/25 at 4:16 P.M. of Occupational Therapist (OT) #671 revealed she worked with Resident #45 due to shoulder pain limiting her function. OT #671 stated Resident #45 declined about halfway through therapy, became weak and could not safely walk any longer and was started on wheelchair management. OT #671 stated incontinence was not brought to her attention as an issue and she did not work with Resident #45 for incontinence. This deficiency represents noncompliance identified during investigation of Complaint Number OH00161689.

Based on observation, interview and review of facility policy the facility did not ensure a safe, functional, sanitary, and comfortable environment for all residents. This had the potential to affect all 92 residents living in the facility. Findings include: Observations were conducted on 01/21/25 from 9:30 A.M. to 10:30 A.M. and the following physical environment concerns were identified: On the 300 hallway by the telephone there were 12 holes in the drywall. The lower elevator entrance located near the activities room had excessive amount of scuff marks on the elevators interior, particularly around the kick plate. Additionally, the kick plate itself had chipped paint, and there was dark debris accumulated in each corner of the elevator. The same elevator entrance on the 300-hall had excessive scuff marks and the entrance kick plate had chipped paint. The 200 hall and 300 hall flooring had noticeable dark scuff marks and a build-up of a black, dirt-like substance along the baseboards. The 300 hall unsecured unit had a PVC pipe protruding from the wall , and the 300 hall secured unit had a PVC pipe and metal brackets extending from the wall at shoulder height. The bottom of room [ROOM NUMBER]'s door frame was detached from the wall causing the door frame to protrude. The elevator near the rehab entrance had a build-up of dark colored dirt-like substance in the corners of the flooring. The 200 hall had a missing corner piece on the hand railing exposing a sharp edge. Interviews conducted on 01/21/25 from 9:35 A.M. to 9:55 A.M. with Resident # 5, #69, #32 and #6 revealed they would like the environment to be updated. On 01/21/25 at 1:46 P.M. interview with the Housekeeping Supervisor #636 and Maintenance Director #637 verified the observations. Review of facility policy titled Quality of Life Homelike Environment dated May 2017, revealed residents would be provided a safe, clean, comfortable and homelike environment . This deficiency represents non-compliance investigated under Complaint Number OH00160967, OH00160981 and OH00159424.

Based on observation, interview and policy review the facility failed to ensure food was stored and served in a manner to prevent contamination and food born illness. This had the potential to affect all 92 residents residing in the facility. There were no residents identified as having a nothing by mouth diet. The facility census was 92. Findings include: On 09/09/24 at 10:02 A.M. a tour of the kitchen revealed in the small upright refrigerator a two-quart plastic container of chicken noodle soup that was half full and not dated as to when it was stored. There were slices of bologna wrapped in plastic with no date. There was sliced ham 48 oz open and undated. The refrigerator also contained eight hard- boiled eggs wrapped in plastic and undated. A two- pound package of cake mix was open and wrapped in plastic with no date as to when it was opened. An interview at the time of the observation with Director of Kitchen Operations (DKO) #149 verified the aforementioned findings. DKO #149 stated the items should have been dated. On 09/09/24 at 12:00 P.M. an observation of tray service in the kitchen revealed Dietary Aide (DA) #142 and DA #145 without hair nets. An interview at the time of the observation with DKO #149 verified the findings. DKO #149 stated DA #142 and DA #145 should be wearing hair nets. A review of the policy titled; Food Receiving and Storage dated December 2008 revealed, All foods stored in the refrigerator or freezer will be covered, labeled and dated. A review of the policy titled; Dress Code that was undated revealed in subpoint five: depending on duty assignment or work area. an employee with long hair may be required to wear a hair net.

Based on observation, interview and policy review, the facility failed to provide a clean and homelike environment. This affected five residents (#42, #52, #62, #65) and had the potential to affect 16 residents living on Hall 2A (#79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93 and #94)) and 25 residents living on Hall 3B (#52, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #77 and #78). The facility census was 92. Findings include: On 09/09/24 at 10:25 A.M. a tour of the building revealed the shower room in Hall 2A had an overflowing sharps container with used razors. Razors were also noted sitting on top of the sharps container. The findings were verified at the time of the observation by Registered Nurse (RN) #201. At 10:50 A.M. on observation of Resident #42's room revealed built up dirt in corners of the bathroom. Resident #42 was laying in bed and appeared sleeping. On the right side of the bed on the floor was dried spit. On the wall was dried spit. On top of register there was dried spit. The aforementioned findings were verified by State tested Nurse Aide (STNA) #136 and STNA #126 at the time of the observation. On 09/09/24 at 10:50 A.M. an observation of hall 3B revealed a built-up black substance along the baseboards. Resident #72's room had a loaf of bread and pickles on the floor. There was also clothing on hangers on the floor. Built up dirt was noted at the door thresh hold. The room of Residents #52, #62 and #65 had dried spilled coffee on the floor by a fall mat. Upon lifting the fall mat and there was a puddle of wet coffee underneath. A garbage can had garbage in it and no bag. There was resident clothing on the floor against the left-hand wall when facing the windows from the doorway. The aforementioned findings were verified by Licensed Practical Nurse (LPN) #161 at the time of the observation. LPN #161 stated floors were not done on the weekends. On 09/09/24 at 11:45 A.M. an interview with Director of Environmental Services #159 revealed resident rooms were to be cleaned daily. A review of the document titled, Park Center Daily Housekeeping Room Checklist that was undated revealed resident rooms were to have floors swept and mopped daily. A review of the document titled, Room Cleaning Policy that was undated revealed the policy was established to ensure resident rooms within the Skilled Nursing Facility were maintained in a clean, sanitary, and safe condition to promote the health and wellbeing of residents. Under the subtitle Frequency of Cleaning it indicated resident rooms would be cleaned on a regular basis according to a predetermined schedule and high touch surfaces would be cleaned and disinfected daily. Under the subtitle Cleaning Procedures it indicated the facility would follow established cleaning procedures and protocols to ensure thorough and effective cleaning of resident rooms. A review of the policy titled, Quality of Life-Homelike Environment dated August 2009 revealed residents were provided with a safe, clean, comfortable, and homelike environment. The policy also indicated the facility staff and management should maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting This deficiency represents non-compliance investigated under Complaint Number OH00156539.

Based on observation, interview, and record review the facility did not ensure all residents were provided therapeutic activities as scheduled and in the evenings to meet their needs and preferences. This affected all 92 residents residing in the facility. The facility census was 92. Findings include: Record review of the facility activity calendar dated November 2023 revealed coffee social took place every day at 10:00 A.M., one-to-one visits every day and there were no activities scheduled after 2:30 P.M. except one day on 11/24/23 there was black Friday bingo at 3:00 P.M. There were no religious services scheduled for the month. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar dated December 2023 revealed the latest activity was scheduled at 4:00 P.M. on 12/13/23 and on the weekends the last activity, coffee social, was scheduled at 10:00 A.M. with activity packets also indicated on Saturdays. No religious services were scheduled for the entire month. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar dated January 2024 revealed one-to-one visits and coffee social would be provided daily, on Saturdays was coffee social and activity packets, Sundays was coffee social except for Sunday 01/21/24 wild uno was on the calendar but crossed off. There were no activities scheduled after 2:30 P.M. except for six days there was a 5:30 P.M. activity listed on the calendar. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar for February 2024 revealed there were no scheduled activities on the weekends except for coffee social from 10:00 A.M. to 11:00 A.M. and activity packets and one-to-one visits. Monday through Friday during this month there were no activities scheduled after 4:00 P.M. except for late bingo at 5:00 P.M. on 02/23/24. There was a trip to Walmart on 02/08/24 which was circled in ink and did not go written next to it. There was one weekend activity on Sunday 02/11/24 other than resident coffee social and one-on-one visits. There were no religious services scheduled for the month of February. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar for March 2024 revealed no activities were scheduled after 4:00 P.M. and the weekend activities consisted of only one-to-one visits with no other times listed for scheduled activities. An activity listed as Fun with [NAME] was scheduled for every Sunday., however, there was no time or description on the calendar for the activity. There were no religious services scheduled for the month of March. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar for April 2024 revealed there were no activities scheduled after 4:00 P.M., and on weekends there were no activities scheduled after 1:00 P.M. There was a shopping trip scheduled for 04/04/24 but it was canceled. Activity packets were to be handed out on Saturday 04/06/24. There were no religious services scheduled for this month. A review of the document titled Facility Assessment Tool updated on 02/21/24 revealed on page four the facility will provide opportunities for social activities/life enrichment (individual, small group, community). On page eight under the subtitle services the document stated religious, exercise, recreational music and activities would be provided. Record review of the activity packets for the residents revealed the packets consisted of adult coloring pages, sudoku and word find puzzles which would not be appropriate for all residents in the facility. Some of the word find puzzles were written in very small font and would be difficult to read if visually impaired. A record review was conducted of the facility meal delivery schedules as it related to activity times on the calendar. This review revealed the 4:00 P.M. activity schedule conflicted with the dinner meal which occurred between 4:00 P.M. and 5:00 P.M. A review of the facility Activity Attendance books for April 2024 revealed 39 (#6, #8, #10, #12, #13, #15, #17, #20, #21, #24, #25, #27, #31, #32, #34, #36, #38, #44, #46, #47, #48, #50, #51, #52, #56, #60, #61, #63, #65, #67, #69, #74, #78, #81, #82, #83, #84, #88 and #195) residents had no activity attendance documented. A review of the facility One on One attendance book for April revealed 50 ( #7,#8, #9, #10, #13, #15, #16, #17, #21, #27, #31, #32, #33, #34, #35, #36, #37, #38, #40, #44, #45, #46, #47, #48, #50, #51, #52, #56, #59, #60, #61, #63, #64, #65, #67, #69, #70, #71, #72, #74, #75, #80, #81, #82, #83, #84, #86, #87, #88 and #195) residents had no documented one-on-one room visits. A review of the personnel file for AD #492 revealed a date of hire of 10/07/22 as an activity aide. AD #492 signed the job description for the activity director position on 04/20/23. A certificate from the Activity Directors Network revealed AD #492 completed the course for certification on 03/21/24. A review of the document titled Job Description and Performance Standards, Position Title: Activity Director revealed some of the primary functions and responsibilities of the position are: (1) Plan, schedule, and implement a program of individual and group activities based on residents' schedule. (2) Document all interaction with resident and or family in the assessment, care plan and progress notes as required by federal and state requirements. (3) Plan and implement Reality Orientation programs when appropriate. (4) Plan and implement evening and weekend functions as necessary. (5) Organize and schedule community events related to residents' interests. (6) Plan, schedule and implement room visits and in-room activities for residents unable to leave their rooms. (7) Plan, schedule and implement indoor and outdoor activity programs. (8) Maintain an activity attendance record for each resident. The document also revealed the Activity Director reports to the Administrator of the facility. The document was signed by AD #492 on 04/20/23. Observations conducted throughout the survey on 04/15/24 from 10:50 A.M. to 11:25 A.M., 04/16/24 3:45 P.M. to 4:00 P.M., 04/17/24 2:30 P.M. to 3:15 P.M. and 04/18/24 10:50 A.M. to 11:25 A.M. revealed residents on the secured behavior unit (unit 3A) were observed sitting in common areas entertaining themselves with watching television and talking with other residents. Several residents were observed walking the hallways with no engagement from staff. Remaining Residents were observed in resident rooms sleeping or talking with their roommates. No activity calendar was observed to be posted on the unit. Residents were observed to be taken off this unit by staff for therapy and smoking breaks during observations. On 04/15/24 at 9:16 A.M. an interview with resident #196 revealed there were no activities held at the facility that she enjoyed. Resident #196 revealed the facility would only do things they chose to do, and the residents did not get to go on outings. Resident #196 confirmed residents were given papers to complete for activities and she would like to leave the facility on outings. On 04/15/24 at 9:19 A.M. an interview with Resident #83 revealed activities did not come to her room. Resident #83 also stated she would like to go to Bingo, but no one would take her. There was an activity calendar titled December 2023 hanging on the clothing cabinet in her room. State tested Nursing Assistant (STNA) # 416 was present and verified the activity calendar date of December 2023 at the time of the interview. On 04/15/24 at 9:27 A.M. an interview with resident #38 revealed activities are not the same. The activities department often changes or cancels the activities on the calendar or cancels them, so he does not go anymore. On 04/15/24 at 9:50 A.M. an interview with resident #26 confirmed the facility only held activities when they wanted to, the residents received papers to complete as an activity and they did not get to leave the facility to go shopping. On 04/15/24 at 10:21 A.M. an interview with Resident #35 revealed residents did not get to go anywhere or do anything. Resident #35 stated would like to go shopping at Walmart, but they must give a list of things they need to staff, and they do the shopping for them. Resident #34 said she would also enjoy karaoke, watching square dancers or other shopping outings. On 04/16/24 at 12:13 P.M. an interview with the Activities Director (AD) #492 revealed one of the activities held at the facility included a coffee social. For residents who could not or chose not to come out of their rooms, they would take coffee to them and complete a one-on-one activity such as talking with them. She confirmed she did not ask for input from any of the residents about what activities they would like to see offered, and outings have been cancelled for the past few months because there is no one available to drive the facility van. She confirmed November 2023 was the last outing the residents had attended. On 04/17/24 at 7:56 A.M. an interview with Resident #41 and #53, who resided on the secured unit, revealed they did not have an updated activity calendar and there were no activities on the weekends. Both confirmed the activity staff had not asked them what they like to do for activities. On 04/17/24 at 8:06 A.M. an interview was conducted with Resident #80, who resided on the secured unit, revealed she was not asked to attend activities nor asked to attend resident council to share her thoughts on activities that she would prefer or want to attend. On 04/17/24 at 10:10 A.M. an interview with Resident #79 revealed she had never received an activity packet. On 04/17/23 at 10:17 A.M. an interview with Resident #83 revealed she has never received an activity packet. Resident #83 stated she would like that because she likes art. On 04/17/23 at 10:30 A.M. an interview with Resident #47 revealed he had never received an activity packet. On 04/17/24 at 10:35 A.M. an interview with Resident #9 who is alert and oriented to person, place, and time, revealed she has never had a one-on-one visit. Resident #9 stated it would be nice to have a one-on-one visit as she is very limited in her mobility. Resident #9 stated she would not get a visit because, that would be the right thing to do. Resident #9 stated she has never gotten an activity packet. Resident #9 stated there had not been a shopping trip for months. She also stated afternoon activities were scheduled during mealtimes, so no one goes. On 04/17/24 from 10:04 A.M. through 10:42 A.M. a resident council meeting was held with the surveyor with Resident #1, #4, #22, #29 and #54 present for the meeting. The residents were alert and oriented to person, place, time, and situation. The meeting was scheduled during the residents' coffee hour. The residents revealed they had not been provided opportunities to give input into what activities were put on the activity calendar. They identified interests such as painting, shopping, music, and pet therapy. They reported there were no activities in the evenings or on the weekend, particularly on Sundays, so they primarily stayed in their rooms. Resident #22 revealed activities were sometimes cancelled but could not recall ever being told an activity was cancelled, or anything else being done in its place. She also revealed she had talked with AD #492 about wanting to go on outings and was told she does not have a license so she can't take the residents anywhere. There have been no activities or holidays parties as far as any of the residents could remember. Resident #54 revealed the activity department was good about three years ago under the previous Administrator. Since that time activities have been very minimal. On 4/17/24 at 4:17 P.M. an observation revealed there were no residents for the sewing activity that was scheduled for 4:00 P.M. The activity room was empty with no set up for the activity. An interview with AD #492 at the time of the observation revealed there was not an activity happening. AD #492 stated she would only get stuff out if residents came down for activity. This surveyor asked if they ever went and got residents and AD #492 stated sometimes but they know what is going on. When asked about one-on-one activities for alert and oriented residents, AD #492 stated everyone needed one on one time. This surveyor asked why Resident #83 had no documented one-on-one visits. AD #492 stated the resident refuses. This surveyor asked if that was documented anywhere. AD #492 stated no. On 04/18/24 08:33 A.M. an interview with STNA #418 and STNA #449 revealed the secured unit (3A) used to have activity calendars in every room plus the dining room, but they do not get them anymore. Both stated that many residents expressed a desire to go to activities and believe the reason they do not have any calendars is, so the residents remain unaware of activities, so they don't ask to attend. STNA #418 stated she expressed her complaints to the DON and administration multiple times about the unit having activities, but no changes have been implemented. STNA #418 stated residents do not receive any one-on-one activities either. STNA #418 also stated even with y'all (state surveyors) here, they still ain't doing nothing STNA #449 Stated that the residents are neglected as far as activities. Stated activities will come at 10:00 A.M. for coffee and take residents to smoke but does not feel those are activities. She expressed being embarrassed on Easter because there were no activities planned for when family visited and stated the entire activity department took Easter off. STNA #449 expressed her disdain that the activity department does not do any activities that involve inviting family to participate. On 04/18/24 at 8:26 AM an observation of hall 3A (locked unit: rooms 301-314) revealed no activity calendars were hanging in the hallways, nurses' station or in the dining room/common area. Observation of resident rooms for Resident #15, #41, #45, #64, #70, #80 and #89 revealed no activity calendars. On 04/18/24 at 1:12 P.M. an interview with the Administrator revealed the facility did have a van which was operational. He thought it held approximately 12 people. He confirmed any licensed driver had the ability to drive the van however, AD #492 had only driven it once and was not comfortable driving it so the residents were not going on any social outings with the activity staff. 04/22/24 at 1:30 P.M. an interview with AD #492 revealed she does not schedule one-on- one visits. AD#492 stated whatever documentation was in the one-on-one visit book is what was done. AD #492 also stated there are no special activities for the secured unit so there was no specific calendar for the residents on that unit. On 04/23/24 at 10:55 A.M. an interview with STNA #419 revealed for the 3A unit (secured unit) they think coffee and donuts was an activity. At one time they were doing bingo up there. Activities may come do an activity on the secured unit when there was a special holiday but really the only activity they got was coffee and donuts four times a week. The other day they took some of the residents out of the unit for an activity but that was very rare. There were really no activities on the secured unit. They used to do more but that has dwindled. STNA #419 stated one of the women in room [ROOM NUMBER] loves bingo, but they will only do bingo with her occasionally. On 04/23/24 at 11:46 A.M. an interview AD #492 revealed usually, a day or two before the end of the month, activities will go and hang up calendars. AD #492 said the activity staff post in rooms and post in the elevator and outside elevator doors. There was a church service last night, but it was impromptu. The person called the day before to see if she could come in. On 04/23/24 at 3:00 P.M. an interview with AD #492 revealed she did not receive any training from the Administrator when she took over the position of activity director. On 04/23/24 at 3:10 P.M. an interview with Licensed Nursing Home Administrator (LNHA) #504 who was covering the facility for the Administrator revealed AD #492 would have been trained by the Administrator of the facility and the Administrator of the facility should make sure they are trained. AD #492 would have spent time at a sister facility with their activity director. AD #492 spent time at his facility and has called the AD there for her guidance. There is no formal checklist for activity director training. An interview was conducted on 04/25/24 at 9:17 A.M. with AD #492 who verified any 4:00 P.M. activity listed on the activity calendar was scheduled at the same time as the evening meal service which started at 4:00 P.M. AD #492 stated it was trial and error to have an activity at this time. When asked how the residents were going to attend the 4:00 P.M. activity if it was mealtime, AD #492 said usually after they get done eating, they will come down after that, but only a couple people participate at that time. AD #492 explained there was one activity aide in the facility from 9:00 A.M. to 6:00 P.M. on Saturdays and Sundays yet the expectation was that each resident would be provided a one-to-one activity and there was no time to document if it was completed with each resident. AD #492 said the one-to-one activity was passive and was not being done with all the residents like she wanted because the activity staff have their favorites and for those residents who do not participate in group activities the one-to-one would be very important for them. AD #492 stated that for every residents care plan, she had selected that they receive one-to-one activities. AD #492 also stated that every other week there was one activity aide Monday through Friday from 10:00 A.M. to 1:00 P.M. and that person was a runner who would go out to shop for the residents in addition to covering smoke break and coffee social at 10:00 A.M. AD #492 verified the staff does the shopping for the residents instead of the residents going shopping. A review of the policy titled Programming for Residents with Cognitive Impairments and other special needs, dated August 2006, revealed activity programs are provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive and emotional health. The facility will offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques. A review of the policy titled Preparation for Activities dated August 2006 revealed residents requiring assistance to and from scheduled activities will be assisted by the Activity Department, Nursing Services, and facility volunteers. It also revealed the Activity Director is responsible for the scheduling of all activity functions. A list of activities scheduled for the month is posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board. Also, within the policy it was stated activities should start on time as stated on the Activities Calendar. If an outside provider delays or cancels a program, an alternate, similar type of program is provided at the same time and place of the canceled event.

Based on observation, interview and facility policy review, the facility failed to store Tuberculin Purified Protein (serum used for intradermal injection to test for tuberculosis) and Lispro Insulin in a manner to ensure efficacy of the medication. This affected one resident (#18) whom the Lispro Insulin was prescribed for and had the potential to affect all residents residing in the facility. The facility census was 92. Findings include: On 04/17/24 at 8:54 A.M. an observation of the medication storage room with Registered Nurse (RN) #440 on 2A hall revealed an open container of Tuberculin Purified Protein one milliliter in the refrigerator. There was approximately one-half milliliter of serum in the vial. The container was undated as to when it was opened. There was also an open vial of Lispro Insulin for Resident #18. The vial was undated as to when it was opened. Interview with RN #440 on 04/17/24 at the time of the observation verified both vials of medication were undated as to when they were opened. A review of the package insert for the Tuberculin Purified Protein revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. A review of the package insert for Lispro at www.accessdata.fda.gov revealed Lispro insulin should be used within 28 days of opening or discarded. A review of the facility policy titled Administering Medications, dated December 2009, revealed when opening a multi-dose container, the date shall be recorded on the container.

Based on interview and record review, the facility failed to ensure they had a qualified food service director. This had the potential to affect 92 residents who received food from the kitchen. The facility identified all residents in the facility received food from the kitchen. The facility census was 92. Findings include: Interviews conducted on 04/15/24 between 8:09 A.M. and 04/18/24 at 2:35 P.M. with Food Service Director (FSD) #499 revealed the dietitian was at the facility weekly and wasn't involved in the kitchen so had not been providing regular consultations to FSD #499. FSD #499 stated she had not been a food service director until she had moved into the position of food service director, had no formal dietary education, but had a food protection manager certificate. Interview on 04/15/24 at 10:49 A.M. with resident #52 revealed the food was horrible. She revealed the person running the kitchen used to work in laundry and she did not believe she was qualified to run the kitchen. Interview on 04/18/24 at 9:45 A.M. with Registered Dietitian #503 revealed it depended on the cooks if recipes are followed and the recipes were not always followed. She stated the main issue at the facility was the quality of food. Interview on 04/18/24 at 2:20 P.M. with Human Resources #472 revealed FSD #499 had been the housekeeping director from 03/08/21 until 11/15/22, and then she moved into her new position as food service director on 11/16/22. Review of the personnel file for Food Service Director (FSD) #499 revealed she was not a certified dietary manager, did not have a similar national certification for food service managment and safety from a national certifying body, did not have at least an associate degree in food service management or hospitality, did not have two or more years in a position of director of food and nutrition services in a nursing facility prior to moving into the food service director position but had successfully completed the standard set forth for the Food Protection Manager on 11/02/23, which was valid through 11/02/28. Review of website www.always foodsafe.com, where FSD #499 had received her certificate as a food protection manager, revealed the Food Protection Manager program was the same level as the ServSafe program. Review of the facility's Job Description and Performance Standards for Food Service Director revealed the purpose of this position is to implement and maintain effective, efficient systems to operate the dietary department and provide food service to residents in a cost-effective, efficient manner to safely meet residents' needs in compliance with federal, state, and local requirements. Authority is delegated to the individual in this position to implement dietary and food service policies to meet residents' needs; supervise preparation of menus to meet residents' dietary needs; assess residents' dietary needs and develop appropriate dietary plans; and supervise the entire operation of the dietary department.

Based on observation, interviews, and review of facility policy, the facility failed to ensure the facility menu was well balanced in regards to calcium sources for all residents. This had the potential to affect all 92 residents receiving meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: Interview on 04/16/24 at 8:56 A.M. with the Ombudsman #507 revealed her biggest concern at the facility was the food. She stated she had gone back and forth with the Administrator about almost no residents getting milk on their lunch and dinner trays. She stated she had advocated for all residents to be asked what they want. Observation of tray line on 04/16/24 from 12:00 P.M. to 12:33 P.M. revealed there were three residents (#15, #53, and #84) meal trays with milk placed on them out of the 92 resident meals being served at the meal. Interview on 04/16/24 at 12:01 P.M. with Dietary Cook #498 revealed the beverage carts were stocked with Kool aid and coffee. Milk and supplements were placed on the resident's individual meal trays. Observation of lunch and dinner meals being passed on the Three B unit on 04/16/24 between 12:33 P.M. and 4:44 P.M. revealed there was a beverage cart which consisted of a carafe of coffee and a plastic square dispenser of Kool aid. There was no observation of any milk items on the beverage cart. Interview on 04/17/24 at 7:57 A.M. with Resident #27 revealed he didn't want milk for lunch and dinner, but he didn't know he could have cottage cheese or yogurt as a calcium replacement. Interview on 04/18/24 at 9:45 A.M. with Dietitian #503 confirmed there was no documentation on the tray card or in the medical chart indicating a resident did not want milk at lunch or dinner or if they were offered a calcium alternate. Dietitian #503 confirmed dietary preferences weren't being consistently obtained from the residents. Interview on 04/18/24 at 11:43 A.M. with the Administrator revealed the facility had found that generally residents were not drinking milk at lunch and dinner. The facility had sent all the residents a letter that as a standard residents would only receive milk at breakfast, and residents could receive milk at lunch and dinner upon request. The Administrator indicated the letter was sent last year and again two months ago. The Administrator was unsure how new residents who were admitted after the letter was sent would know milk was only served at breakfast unless requested by the resident. The Administrator thought the information was in the admission packet. The Administrator confirmed the residents hadn't been offered other calcium options at lunch and dinner, such as yogurt or cottage cheese. Interviews were conducted on 04/17/24 from 10:04 A.M. through 10:42 A.M. with Residents #1, #4, #22, #29 and #54 at the resident council meeting. The residents were alert and oriented to person, place, time, and situation. They were not offered milk at each meal, only at breakfast. If the residents wanted cottage cheese, they would have to order it in place of their meal since it was never offered in addition to the meal. Observation of the 04/18/24 menus posted at the two elevators on each floor revealed a choice of milk would be provided for breakfast, lunch, and dinner. There was no observation of any posting stating milk would only be provided at breakfast, unless requested by the resident for lunch and dinner. Review of the facility admission packet revealed there was nothing in the admission packet regarding when milk would be served. Interview on 04/23/24 at 9:53 A.M. with Assistant Director of Nursing (ADON) revealed during the admission process, nursing didn't go over any dietary areas, which included when a resident wanted milk. Review of facility policy Menus, revised December 2008, the Resident Council would be included in menu planning. Menus would provide a variety of foods from the basic daily food groups and will indicate standard portion at each meal. if a food group was missing from a resident's daily diet (e.g. dairy products) the resident would be provided an alternate means of meeting the resident's nutritional needs (e.g. calcium supplement or fortified non dairy alternatives).

Based on observation, interviews, record reviews and review of facility policy, the facility failed to ensure resident food preferences were honored and appropriate substitutions were made per resident preferences. This had the potential to affect all 92 residents who received meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: Interview on 04/16/24 at 8:56 A.M. with the Ombudsman #507 revealed her biggest concern at the facility was the food. She stated she had advocated for all residents to be asked what they want to eat. Observation of tray line on 04/16/24 at 12:00 P.M. revealed on the steam table was ham, mechanical soft ham, carrots, roast red skin potatoes, and fish patties. (There was no alternate vegetable prepared). Interview on 04/16/24 at 12:33 P.M. with Food Service Director (FSD) #499 stated the residents don't like the recipes. She stated the number of meal item dislikes that could be listed on a resident's tray card was limited, which left the staff to memorize what the residents disliked if they had multiple dislikes. FSD #499 confirmed the facility did not offer a select menu to any of the residents, so the residents were served whatever the kitchen prepared for the day which may or may not be what was listed on the menu. Interview on 04/17/24 at 7:57 AM with Resident #27 revealed he didn't want milk for lunch and dinner and didn't know he could have cottage cheese or yogurt as a milk replacement. Interviews were conducted on 04/17/24 from 10:04 A.M. through 10:42 A.M. with Residents #1, #4, #22, #29 and #54 at the resident council meeting. The residents were alert and oriented to person, place, time, and situation. They were not offered milk at each meal, only at breakfast. If the residents wanted cottage cheese they would have to order it in place of their meal, it was never offered in addition to the meal. They revealed if they did not want what was posted on the menu, they needed to request it an hour before meal service otherwise, you might not get the alternate. If you were served the scheduled daily meal and then decided you did not want it, you could tell your nurse, but you most likely did not get anything else. When asked about preferences, the residents stated they could identify items they did not like, but substitutions were not offered in their place. For example, if you did not like peas and peas were on the menu, you did not get an alternate vegetable. Residents revealed there had been issues with the food at the facility for as long as they could remember. They reported talking about it every month at the Resident Council meeting but nothing ever changed. Interview on 04/17/24 at 10:45 A.M. with Dietary Supervisor #500 confirmed for lunch on 04/16/24 she hadn't made an alternate vegetable. She stated she knew Resident #38 disliked carrots but had not given him an alternate vegetable for that meal. When asked what she would offer if the resident did not want ham or fish, she stated she would offer a cold sandwich even if they requested a grilled cheese she would refuse to make it if the kitchen was short staffed that day. Review of the tray card for lunch 04/16/24 revealed Resident #38 disliked carrots. Interview on 04/17/24 at 10:48 A.M. with Food Service Director #499 confirmed there were times when a request for a grilled cheese sandwich from a resident was not made. Interview on 04/17/24 at 1:55 P.M. with Registered Nurse (RN) #440 revealed everybody complained about the food. The kitchen refused to make alternates at times which was sad. Interview on 04/18/24 at 9:45 A.M. with Dietitian #503 confirmed food preferences from the residents are not being routinely done, and if a resident doesn't like a particular food item, an alternate should be given instead of the food item being eliminated. She confirmed there was no documentation on the tray card or in the medical chart indicating a resident did not want milk at lunch or dinner or if they were offered a calcium alternate. Dietitian #503 stated the quality of food was the main issue at the facility. She stated she was able to alter the menu. Dietitian #503 stated the new Spring menu was starting next week, but she hadn't had a chance to look at the new menu and had no idea what was on the menu. Interview on 04/18/24 at 11:35 A.M. with Resident #82 revealed she didn't like any of her breakfast and had never been asked about her food preferences. Interview on 04/18/24 at 11:43 A.M. with the Administrator revealed the facility had found that generally residents were not drinking milk at lunch and dinner. The facility had sent all the residents a letter that as a standard residents would only receive milk at breakfast and residents could receive milk at lunch and dinner upon request. The Administrator indicated the letter was sent last year and again two months ago. The Administrator was unsure how new residents who were admitted after the letter was sent would know that milk was only served at breakfast unless requested by the resident. The Administrator thought the information was in the admission packet. The Administrator confirmed the residents hadn't been offered other calcium options at lunch and dinner, such as yogurt or cottage cheese. Observation of the 04/18/24 menus posted at the two elevators on each floor revealed a choice of milk would be provided for breakfast, lunch, and dinner. Observation of the admission packet revealed there nothing in the admission packet regarding when milk would be served. Interview on 04/23/24 at 9:53 A.M. with Assistant Director of Nursing (ADON) revealed during the admission process, nursing didn't go over any dietary areas, which included when a resident wanted milk. Interview on 04/23/24 at 2:59 P.M. with Administrator #504, who is senior administrator over the building and the administrator of a sister facility, and the Director of Nursing revealed the residents were not happy with the menu and were asking for more food activities since they don't like the menu. Administrator #504 stated his facility shared the same ombudsman who had shared her concerns with him regarding dietary. Review of facility policy Menus, revised December 2008, the Resident Council would be included in menu planning. Menus would provide a variety of foods from the basic daily food groups and will indicate standard portion at each meal. if a food group was missing from a resident's daily diet (e.g. dairy products) the resident would be provided an alternate means of meeting the resident's nutritional needs (e.g. calcium supplement or fortified non dairy alternatives). Review of facility policy Resident Rights, revised August 2009, revealed our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and review of facility policy, the facility failed to ensure proper sanitation was followed in the kitchen and during meal tray delivery. This had the potential to affect all 92 residents in the facility. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: 1. Observation of the tray line process on 04/16/24 from 12:00 P.M. to 12:33 P.M. revealed at 12:14 P.M. Dietary Cook #498 and Dietary Aide #506 took a food cart out of the kitchen for delivery. Upon return to the kitchen at 12:16 P.M. Dietary Cook #498 and Dietary Aide #506 did not wash their hands. At 12:19 P.M. Dietary Cook #498 and Dietary Aide #506 took another food cart out of the kitchen for delivery. Upon return to the kitchen at 12:22 P.M., they did not wash their hands. At 12:24 P.M. Dietary Cook #498 and Dietary Aide #506 took another food cart out of the kitchen for delivery. Upon return to the kitchen at 12:31 P.M., they did not wash their hands. Interview on 04/16/24 at 12:33 P.M. with Food Service Director #499 confirmed Dietary Cook #498 and Dietary Aide #506 had not washed their hands upon entering the kitchen after delivering the meal trays and stated kitchen staff should be washing their hands upon entering the kitchen. Review of facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary, revised December 2008, revealed employees must wash their hands whenever entering or re-entering the kitchen. 2. Observation of tray line process on 04/16/24 from 12:00 P.M. to 12:33 P.M. revealed Dietary Cook #498 was observed with artificial nails approximately one inch to one and a half inches from the end of the finger with three-dimensional art observed on the nails. Interview on 04/16/24 at 12:33 P.M. with Food Service Director (FSD) #499 confirmed Dietary Cook #498 was wearing artificial nails with three-dimensional art. FSD #499 revealed she didn't know the facility's policy on false nails in the kitchen. Review of facility policy Park Center Health Care and Rehabilitation Employee Dress Code, effective date 01/15/16, revealed for dietary employee's nails must be kept short (no more than 1/4 from top of finger). Fingernail polish and acrylic nails were not permitted. 3. Observation of items being pureed on 04/17/24 10:50 A.M. revealed Dietary Supervisor (DS) #500 took two servings of cake and placed them into a commercial blender and processed the items until it achieved the appropriate puree consistency with the addition of milk. DS #500 took a spatula and evenly divided the pureed cake into two small bowls. DS #500 then took the bowl and lid of the commercial blender and the spatula and washed them in a bucket of soapy water and rinsed them with running water in the three-compartment sink. There was no observation of the items being sanitized. DS #500 returned from the three compartment sink with the commercial blender bowl, lid and spatula. DS #500 placed the bowl and lid on the base of the commercial blender and proceeded to puree one hotdog and bun. DS #500 used the spatula to spoon the pureed hotdog into a small bowl. Interview on 04/17/24 at 10:55 A.M. with DS #500 confirmed she washed the items in soapy water and rinsed with running water and the items were not sanitized. Review of facility policy Sanitation, revised December 2008, revealed manual washing and sanitizing will employ a three step process for washing, rinsing and sanitizing. 4. Observation on 04/16/24 from 12:33 P.M. to 12:55 P.M. of two unidentified state nursing assistants walking meal trays up the Three B hallway with coffee and Kool Aids uncovered. Interview on 04/16/24 at 12:35 P.M. with Food Service Director #499 confirmed the coffee and Kool Aid were uncovered as state tested nursing assistants passed meal trays down the hallway. FSD #499 stated the staff should take the beverage carts as they deliver the meal trays, or the beverages should be covered. Observation on 04/16/24 from 4:41 P.M. to 4:55 P.M. revealed State tested Nursing Assistant (STNA) #416 poured coffee into empty coffee cups in the resident lounge located at the end of the Three B hallway and placed the uncovered filled coffee cups on a tray on the meal cart and proceeded to walk the food cart down the hallway to deliver meal trays. STNA #415 was observed pouring Kool Aid in eight-ounce plastic cups (uncovered) in the same resident lounge and placed them on the second tier of a three tier cart. She then proceeded to push the three-tier cart down the hallway and stopped at resident rooms to see if a resident wanted Kool Aid to drink. Interview on 04/16/24 at 4:55 P.M. with FSD #499 confirmed the beverages were served uncovered and the beverage cart should be taken to the room instead of walking the beverages down the hall uncovered.

Based on observation, interview, and review of the facility policy, the facility did not maintain garbage and refuse properly in a closed dumpster free of surrounding litter. This had the potential to affect all residents residing in the facility. The census was 92. Findings include: Observation of the dumpster area during the initial kitchen tour on 04/15/24 from 8:09 A.M. to 8:29 A.M. with Food Service Director (FSD) #499 revealed the left lid was open and the right lid was closed. There was a buildup of debris around the base of the dumpster, which included approximately 20 blue medical examination gloves, numerous plastic white spoons, numerous cigarette butts, one broken blue storage bin observed to be approximately six inches by six inches, one small unidentifiable white plastic bottle with a lid, and numerous dried up white papers, which appeared to be paper towels or napkins. This lack of sanitation predisposed the faciity to the risk of pests such as rodents and insects although no pests were seen at the time of the observation. Interview on 04/15/24 at 8:20 A.M. with FSD #499 confirmed the area around the dumpster was full of debris, and the lid to the dumpster was open. FSD #499 stated the lids to the dumpster should be closed when not in use, and the area around the dumpster should be kept clean. Review of facility policy Food-Related Garbage and Rubbish Disposal, revised December 2008, revealed outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on medical record review, review of a self-reported incident (SRI), review of the local police report, review of the facility investigation, policy review, and resident and staff interviews, the facility failed to ensure residents were free from physical abuse by a staff member. This resulted in Immediate Jeopardy and serious psychosocial harm for Resident #72, when Licensed Practical Nurse (LPN) #315 pushed Resident #72's head into a wall and physically restrained Resident #72 with her hands around Resident #72's throat in response to aggressive behaviors exhibited by Resident #72 with resultant gasping for air, trying to say she could not breath, fear for her safety in the facility and subsequent sleep disturbance requiring the prescription of a hypnotic sleep medication and psychological counseling. This affected one resident (#72) of eight residents reviewed for abuse. The facility census was 90. On 10/03/23 at 12:20 P.M. the Licensed Nursing Home Administrator (LNHA) #900 and Director of Nursing were notified Immediate Jeopardy began on 09/27/23 at approximately 9:00 P.M. when LPN #315 was witnessed by State tested Nursing Assistant (STNA) #330 and Resident #92 using aggressive force against Resident # 72. LPN #315 was observed grabbing Resident #72 around the throat, pushed her head into the wall and began choking her with her hands, as a result of Resident #72 being aggressive towards the LPN. Resident #72 struggled to say she could not breath and her face was turning red. STNA #330 broke up the altercation, the police were called, and Resident #72 was taken to the hospital where she was found to have erythema (redness) present on her neck and complained of pain. The Immediate Jeopardy was removed on 10/03/23 at 11:59 P.M. when the facility implemented the following corrective actions: On 09/27/23 at approximately 9:00 P.M. State tested Nurse Aide (STNA) #330, immediately separated Resident #72 and Licensed Practical Nurse (LPN) #315 to ensure resident safety. STNA #330 remained with Resident #72 until law enforcement arrived. On 09/27/23 Resident #72 was sent to the emergency room for evaluation/assessment following the report given to law enforcement. On 09/27/23 LPN #315 was immediately placed on suspension pending investigation and removed from facility after police took her statement on 9/27/2023. On 09/27/23 at approximately 10:00 P.M. Resident #72's guardian and the medical director were notified by LPN #306 of the incident and Resident #72's transfer to the emergency room . On 09/27/23 at approximately 10:00 P.M. the Director of Nursing (DON) started full investigation of the incident. On 09/28/23 at 12:30 A.M. the DON filed a self-reported incident with the Ohio Department of Health. On 09/28/23 at approximately 9:30 A.M. the DON initiated interviews with alert and oriented residents with Brief Interview for Mental Status (BIMS) greater than or equal to 12 to ensure they had no concerns and initiated education on abuse and behavioral residents with staff. On 09/28/23 Resident #72 returned to facility from the hospital emergency room with no new orders. On 09/28/23 Resident #72 was seen by Psychiatrist # 403 to follow for any psychological effects. A new order for sleep aid was obtained for Resident #72. On 10/03/23 from 1:00 P.M. to 4:00 P.M., RN #320, LPN/Unit Manager (UM) #301 and LPN/UM #300 completed full body assessments on 90 of 90 residents with no negative findings on the skin assessments. On 10/03/23 at approximately 1:00 P.M. LNHA #900 began education on Abuse/Neglect/Misappropriation Policy as well as the Unmanageable Resident Policy on how to manage residents with behaviors with the management team including SSD #354, Staffing Coordinator (SC) #355, Human Resources (HR)#352, Physical Therapist (PT)#371, Housekeeping Supervisor (HS) #380 and Dietary Supervisor (DS) #389. The management team then went on to educate all staff working in the facility in each department. The DON also assisted with the education beginning at 1:50 P.M. with facility staff present in the facility and by phone. Education would be completed on 102 of 102 staff members by 10/03/23 at 11:59 P.M. On 10/03/23 at approximately 1:15 P.M. LNHA #900 and Activity Director (AD) #396 initiated QIS Abuse Questionnaires to ensure 90 of 90 residents felt safe in the facility. The questionnaires to be completed by 4:00 P.M. on 10/03/23. On 10/03/2023 at approximately 1:50pm facility staffing agencies were notified by LNHA #900 of necessary education required prior to next shift. Education will be available to all agency staff to be educated prior to shift. On 10/03/23 at 4:00 P.M. HR #352 and the DON terminated LPN #315's employment by phone. On 10/03/23 a Quality Assurance Performance Improvement (QAPI) meeting (with LNHA #900, the DON, AD #396, LPN/UM #301 and #300, RN #320, HS #380, SC #355, HR #352 and SSD #354 in attendance) was held, and subsequent meetings scheduled for 10/10/23, 10/17/23, 10/24/23 and 10/31/23. On 10/04/23 at 7:00 A.M. the DON will begin education audits on the Abuse and Unmanageable Resident policy. Audits will be completed on eight staff members weekly for four weeks, then twice monthly for two months and randomly thereafter. The Ohio Board of Nursing to be contacted 10/4/2023 by end of business (5:00pm) by the DON. Beginning the week of 10/08/23, the Administrator or Designee will conduct 10 resident interviews weekly for four weeks using the QIS abuse questionnaire then monthly times three, then randomly thereafter to ensure resident safety. Residents will be randomly selected from the entire population to ensure all residents are feeling safe in their home. All Audits and Facility Processes will be reported to and reviewed by the QAPI team weekly times 4 weeks. Although the Immediate Jeopardy was removed on 10/03/23, the deficiency remained at Severity level two (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of medical record for Resident #72 revealed an admitted [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, anxiety disorder unspecified, cervical disc disorder unspecified cervical region, major depressive disorder, suicidal ideations, anoxic brain damage, need for assistance with personal care and schizoaffective disorder bipolar type. Review of Resident #72's Minimum Data Set (MDS) 3.0 assessment, dated 09/29/23, revealed Resident #72 was assessed as severe cognitive impairment with a Brief Interview for Mental Status (BIMS) of 04 out of 15, and was assessed as having physical and verbal behavioral symptoms directed towards others. Review of the comprehensive care plan, start date 07/13/23, documented Resident #72 was at risk for verbal and physical agitation aggression related to cognitive impairment. Resident #72 was verbally and physically abusive toward staff and will yell and scream when she does not get her way. Further review documented a goal Resident #72 will not harm self or others, will not verbally abuse others , will not strike others. Interventions included administration of medication per physician orders, allow patient time to respond to directions or requests, gain patient's attention before speaking or touching, give patient clear and concise explanation of anything about to occur, if behavioral intervention strategies are not working then leave if safe to do so and reapproach later, and psych consult as needed. Review of a nursing note dated 09/27/23 written by Licensed Practical Nurse ( LPN) #315 revealed Resident #72 was given night medication. Resident #72 became verbally abusive toward this nurse. Nurse #315 attempted to redirect unsuccessfully. Resident #72 continued verbal assaults, threatened to physically harm this nurse then actually punched this nurse. LPN #315 documented she tried to restrain Resident #72 who continued to punch her and knocked her glasses off. LPN #315 documented Resident #72 was held where she could no longer do harm to this nurse. STNA came to assist and spent 20 minutes with the resident. Review of the facility SRI investigation, dated 09/27/23, revealed Resident #72 had a verbal exchange with LPN #315. Resident #72 began to yell at LPN #315 then Resident #72 hit LPN #315 knocking her glasses off. STNA #330 witnessed LPN #315 grab Resident #72 by the neck/throat and shoved the resident up against the wall and choked the resident until STNA #330 intervened and separated them. STNA #330 took Resident #72 to her room. STNA #330 then located the supervisor to report the incident. Education was given to staff about Abuse policy and Handling Difficult Residents. Review of STNA #330's witness statement, dated 09/27/23 revealed Resident #72 swung at Nurse #315 and nurse #315 pushed Resident #72 into a door and grabbed the resident by her neck and was choking the resident to the point Resident #72 stated she could not breath. STNA #330 brought Resident #72 to her room to calm the resident down. Resident #72 neck was bright red and resident was crying. Review of STNA #341 witness statement, dated ( not date on the statement) revealed Resident #72 punched LPN #315. LPN #315 restrained Resident #72 until STNA #330 broke them up. Review of Resident #92's witness statement, dated 09/27/23 revealed LPN #315 pushed Resident #72 head against a metal door then pushed Resident #72 into a corner and choked the resident. Resident #72 mumbled she could not breath and her face was red. Resident #92 stated she was afraid Resident #72 was going to die. Review of Resident #68 witness statement dated 09/27/23 revealed Resident #72 hit LPN #315 and LPN #315 held her forearm against Resident #72 to stop the resident. Review of LPN #315 witness statement, ( no date on report) revealed Resident #72 hit her and she restrained the resident until the STNA came. Review of the local police department report for Incident #23B016570, dated 09/28/23, revealed officers were sent to Park Center for an assault/patient abuse report following an altercation in the hallway between patient and nurse that occurred on 09/27/23 at about 9:00 P.M. Resident #92 was the reportee and witnessed the altercation. Resident #92 stated Resident #72 swung at Nurse #315 first because she did not want to take her medication and stated Resident #72 was choked. Resident #92 states she observed LPN #315 aggressively push Resident #72's head up against the metal door frame very hard, then LPN #315 grabbed Resident #72 by her throat and pushed her up against the wall with her hands choking the resident. Resident #92 stated she heard Resident #72 say I can't breathe and her face turned red. Resident #92 returned to her room because she was upset and called the police. Another State tested nurse aid ( STNA) #330 stated she saw Resident #72 swing at LPN #315 then observed LPN #315 push Resident #72 into the door frame and grabbed her by the neck and had resident up against the door. STNA #330 stated he separated the resident and nurse. STNA #330 stated he witnessed LPN #315 intentionally slam Resident #72's head against the door and choke her to the point her face was red and heard Resident #72 gasping for air and said she could not breath. LPN #315 stated she restrained Resident #72 against the wall by using her forearm. Another resident ( Resident #68) stated he was in the hallway and witnessed LPN #315 restrain Resident #72 up against the wall using her forearm to resident's chest to keep her there until another employee arrived. STNA #341 stated she observed Resident #72 hit LPN #315. LPN #315 then restrained Resident #72 up against the wall until STNA #330 arrived and broke them up. Police Report further stated Resident #72 had several fresh red marks and slight swelling around her neck area and Resident #72 complained of difficulty swallowing. Resident #72 was transported to the hospital. Review of the hospital emergency room (ER) documentation dated 09/27/23 at 11:32 P.M. revealed Resident #72 was sent to the ER after strangulation type injury. Admission physical exam revealed vague erythema (superficial reddening of the skin, usually as a result of injury or irritation causing dilatation of the blood capillaries) noted to the anterior bilateral neck. There was some concern for arterial injury, esophageal injury, and soft tissue injury therefore a Computed Axial Tomography ( CAT ) scan was ordered. Radiology preliminary results of the CAT scan showed no evidence of soft tissue injury or soft tissue hematoma in neck and was released to be discharged back to the Park Center on 09/28/23 at 5:38 A.M. with a diagnosis of reported assault and anterior neck pain in stable condition. Review of LPN #315's employee file revealed a date of hire of 01/25/23. There was a verbal warning dated 02/28/23 for not completing learning assignments by assigned dates which consisted of Ethics in Health care Part 3: Boundaries and Boundary violation, Abuse and Neglect in Healthcare. Interview on 09/29/23 at 8:33 A.M. with the Director of Nursing (DON) revealed there was conflicting evidence of what happened the night of 09/27/23 so the police did not arrest LPN #315 the night of the incident. The DON suspended LPN #315 pending results of the incident investigation and local police department detective investigation. Staff education had been started and Resident #72 was seen by a psychiatrist and was willing to attend counseling services. Interview on 09/29/23 at 9:42 A.M. with Resident #92 by phone revealed she witnessed Resident #72 hit LPN #315 and stated LPN #315 took the resident by her throat and hit her head against the wall and proceeded to choke Resident #72 . STNA #330 was in the hallway. She stated the police came around 9:30 P.M. Interview on 09/29/23 at 10:19 A.M. with STNA #341 on 09/29/23 verified Resident #72 was restrained up against the wall and STNA #330 broke up the fight. Interview on 09/29/23 at 11:24 A.M. with LNHA #901 via telephone revealed the abuse allegation was still under investigation. LNHA #901 stated LPN #315 was with the facility for a while. The facility has reeducated staff on the abuse policy and dealing with difficult residents. He stated the Human Resources department ran an entire audit on all staff in the abuse registry. A quality assurance performance plan was started on abuse with a root cause analysis. Interview on 09/29/23 at 11:20 A.M. with Resident #68 revealed he witnessed LPN #315 had one arm against Resident #72 trying to stop Resident #72 from hitting her. Resident #68 verified Resident #72 hit her head on the wall. Interview on 09/29/23 at 2:30 P.M. with Specified Resident ( SR) #72 revealed she was choked by LPN #315 . Resident #72 stated she choked me hard and verified by name LPN #315 put her hands around her neck. Resident #72 stated LPN #315 wanted to give her medication and she did not want it. Resident #72 stated she punched LPN #315 because she made her mad. After she punched LPN #315 the nurse choked her. She stated she was still a little scared and needed a sleeping pill to sleep at night. Interview on 09/29/23 at 10:04 P.M. by phone , revealed STNA #330 verified he was sitting in the lounge on the night of 09/27/23 and heard yelling escalating in the hallway of 3B. When STNA #330 went to the hallway he observed Resident #72 swing her right arm and hit LPN #315 causing her glasses to fall off her face. LPN #315 grabbed Resident #72 by the neck and choked the resident. STNA #330 broke up the fight and took Resident #72 to her room for safety. STNA #330 stated Resident #72 neck was very red, and her face was red. STNA #330 felt he had to save Resident #72. Interview on 10/02/23 at 9:30 A.M. with Nurse Practitioner (NP) #402 revealed she did evaluate Resident #72 the next day and the resident did have some bruising to her neck and neck pain. NP #402 stated Resident #72 stated she swung at LPN #315 because the nurse was not listening to her. Interview was conducted on 10/03/23 at approximately 9:20 A.M. with the DON who described Resident #72 as having good mentation and able to give a reliable recollection regarding what LPN #315 did to her the evening on 09/27/23. The DON stated she believed physical abuse occurred towards Resident #72 from LPN #315. Interview on 10/02/23 at 10:00 AM. with Psychiatrist #403 verified Resident #72 was fearful the incident would happen again and did not sleep well at night. Psychiatrist #403 stated the resident clearly stated a nurse hit her and tried to strangle her and had clear memories for the incident. Interview on 10/02/23 at 12:34 P.M. with LPN #315 verified she was passing night medication when Resident #72 started screaming at her. LPN #315 stated she told Resident #72 to go back in her room. LPN #315 continued to pass medication when Resident #72 punched her in the face and knocked her glasses off. LPN #315 stated she moved Resident #72 to the wall and held the resident's arm with one hand and her forearm across the chest with her other hand. Finally, somebody came and assisted LPN #315 and placed Resident #72 back in her room. LPN #315 stated she knows Resident #72 could have behavior problems but did not know any care plan intervention for Resident #72's aggression. LPN #315 stated she did not assault Resident #72 , but she was the one assaulted and moved Resident #72's body to the wall. Review of the facility policy titled Abuse, Neglect, and Exploitation of Residents dated 2003, documented the definition of physical abuse as the inappropriate physical contact with a resident which harms or is likely to harm the resident. It is the policy of the facility that acts of physical, verbal, mental and financial abuse directed against a resident are absolutely prohibited. Based on medical record review, review of a facility self-reported incident (SRI) and investigation, review of a police report, review of the facility Abuse policy and resident and staff interviews, the facility failed to ensure Resident #72 was free from physical and emotional/psychosocial abuse. This resulted in Immediate Jeopardy and actual physical harm with serious psychosocial harm on 09/27/23 at approximately 9:30 P.M. when Licensed Practical Nurse (LPN) #315 abused Resident #72 by pushing the resident's head into a wall and physically restraining the resident with her hands around Resident #72's throat/neck. Resident #72 was observed by witnesses gasping for air and attempting to verbalize she could not breath. The resident was assessed to have erythema (redness) and bruising to her neck, voiced fear for her safety in the facility and suffered subsequent sleep disturbance requiring the prescription of a hypnotic sleep medication and psychological counseling because of the incident. This affected one resident (#72) of eight residents reviewed for abuse. The facility census was 90. On 10/03/23 at 12:20 P.M. Licensed Nursing Home Administrator (LNHA) #900 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/27/23 at approximately 9:30 P.M. when State tested Nursing Assistant (STNA) #330 and Resident #92 witnessed LPN #315 using aggressive force against Resident # 72. LPN #315 was observed grabbing Resident #72 around the throat, pushed the resident's head into the wall and began choking her with her hands. Resident #72 struggled to say she could not breath and her face was turning red. STNA #330 broke up the altercation, the police were called, and Resident #72 was taken to the hospital where she was found to have erythema (redness) present on her neck and complained of pain. The Immediate Jeopardy was removed on 10/03/23 when the facility implemented the following corrective actions: On 09/27/23 at approximately 9:00 P.M. STNA #330, immediately separated Resident #72 and LPN #315 to ensure resident safety. STNA #330 remained with Resident #72 until law enforcement arrived. On 09/27/23 Resident #72 was sent to the emergency room for evaluation/assessment following the report given to law enforcement. On 09/27/23 LPN #315 was immediately placed on suspension pending investigation and removed from facility after police took her statement on 9/27/2023. On 09/27/23 at approximately 10:00 P.M. Resident #72's guardian and the medical director were notified by LPN #306 of the incident and Resident #72's transfer to the emergency room . On 09/27/23 at approximately 10:00 P.M. the DON started a full investigation of the incident. On 09/28/23 at 12:30 A.M. the DON filed a self-reported incident with the Ohio Department of Health. On 09/28/23 at approximately 9:30 A.M. the DON initiated interviews with alert and oriented residents with Brief Interview for Mental Status (BIMS) greater than or equal to 12 to ensure they had no concerns and initiated education on abuse and behavioral residents with staff. On 09/28/23 Resident #72 returned to facility from the hospital emergency room . On 09/28/23 Resident #72 was seen by Psychiatrist #403 to follow for any psychological effects. A new order for sleep aid was obtained for Resident #72. On 10/03/23 from 1:00 P.M. to 4:00 P.M., RN #320, LPN/Unit Manager (UM) #301 and LPN/UM #300 completed full body assessments on 90 of 90 residents with no negative findings on the skin assessments. On 10/03/23 at approximately 1:00 P.M. LNHA #900 began education on the facility Abuse/Neglect/Misappropriation Policy as well as the Unmanageable Resident Policy on how to manage residents with behaviors with the management team including Social Service Director (SSD) #354, Staffing Coordinator (SC) #355, Human Resources (HR)#352, Physical Therapist (PT)#371, Housekeeping Supervisor (HS) #380 and Dietary Supervisor (DS) #389. The management team then proceeded to educate all staff working in the facility in each department. The DON also assisted with the education beginning at 1:50 P.M. with facility staff present in the facility and by phone. A plan for education to be completed for all 102 of 102 staff members by 10/03/23 at 11:59 P.M. was implemented. On 10/03/23 at approximately 1:15 P.M. LNHA #900 and Activity Director (AD) #396 initiated Quality Indicator Survey (QIS) Abuse Questionnaires to ensure 90 of 90 residents felt safe in the facility. The questionnaires were completed by 4:00 P.M. on 10/03/23. On 10/03/2023 at approximately 1:50 P.M. facility staffing agencies were notified by LNHA #900 of necessary education required prior to next shift. Education would be available to all agency staff to be educated prior to shift. On 10/03/23 at 4:00 P.M. HR #352 and the DON terminated LPN #315's employment by phone. On 10/03/23 a Quality Assurance Performance Improvement (QAPI) meeting (with LNHA #900, the DON, AD #396, LPN/UM #301 and #300, RN #320, HS #380, SC #355, HR #352 and SSD #354 in attendance) was held to discuss the issue with subsequent meetings scheduled for 10/10/23, 10/17/23, 10/24/23 and 10/31/23. On 10/04/23 at 7:00 A.M. the DON began education audits on the Abuse and Unmanageable Resident policy. Audits would be completed on eight staff members weekly for four weeks, then twice monthly for two months and randomly thereafter. The facility indicated the Ohio Board of Nursing would be notified of the incident involving LPN #315 on 10/4/2023 by end of business (5:00 P.M.) by the DON. Beginning the week of 10/08/23, the Administrator or Designee would conduct 10 resident interviews weekly for four weeks using the QIS abuse questionnaire then monthly times three, then randomly thereafter to ensure resident safety. Residents would be randomly selected from the entire population to ensure all residents felt safe in their home. The facility implemented a plan for all audits and facility processes to be reported to and reviewed by the QAPI team weekly for four weeks. Although the Immediate Jeopardy was removed on 10/03/23, the deficiency remained at Severity level two (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of medical record for Resident #72 revealed an admitted [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, anxiety disorder unspecified, cervical disc disorder unspecified cervical region, major depressive disorder, suicidal ideations, anoxic brain damage, need for assistance with personal care and schizoaffective disorder bipolar type. Review of the comprehensive care plan, with a start date of 07/13/23 revealed Resident #72 was at risk for verbal and physical agitation/aggression related to cognitive impairment. Resident #72 was verbally and physically abusive toward staff and would yell and scream when she does not get her way. Further review documented a goal for Resident #72 to not harm self or others, not verbally abuse others and not strike others. Interventions included administration of medication per physician orders, allow patient time to respond to directions or requests, gain patient's attention before speaking or touching, give patient clear and concise explanation of anything about to occur, if behavioral intervention strategies are not working then leave if safe to do so and reapproach later, and psych consult as needed. Review of a nursing note dated 09/27/23 written by Licensed Practical Nurse (LPN) #315 revealed Resident #72 was given night medication. Resident #72 became verbally abusive toward this nurse. Nurse #315 attempted to redirect unsuccessfully. Resident #72 continued verbal assaults, threatened to physically harm this nurse then actually punched this nurse. LPN #315 documented she tried to restrain Resident #72 who continued to punch her and knocked her glasses off. LPN #315 documented Resident #72 was held where she could no longer do harm to this nurse. STNA came to assist and spent 20 minutes with the resident. Review of a facility SRI investigation, dated 09/27/23, revealed Resident #72 had a verbal exchange with LPN #315. Resident #72 began to yell at LPN #315 then Resident #72 hit LPN #315 knocking her glasses off. STNA #330 witnessed LPN #315 grab Resident #72 by the neck/throat and shoved the resident up against the wall and choked the resident until STNA #330 intervened and separated them. STNA #330 took Resident #72 to her room. STNA #330 then located the supervisor to report the incident. Resident #72 complained of neck/throat pain and difficulty swallowing. Resident #72 was very upset and difficult to calm down. Resident #72 had redness with some swelling around her neck with no other apparent injuries. The local police department was notified of the incident at 10:00 P.M. Review of STNA #330's witness statement, dated 09/27/23, revealed Resident #72 swung at LPN #315 and LPN #315 pushed Resident #72 into a door and grabbed the resident by her neck and was choking the resident to the point Resident #72 stated she could not breath. STNA #330 brought Resident #72 to her room to calm the resident down. Resident #72's neck was bright red, and the resident was crying. Review of STNA #341 undated witness statement revealed Resident #72 punched LPN #315. LPN #315 restrained Resident #72 until STNA #330 broke them up. Review of Resident #92's witness statement, dated 09/27/23, revealed LPN #315 pushed Resident #72's head against a metal door then pushed Resident #72 into a corner and choked the resident. Resident #72 mumbled she could not breathe, and her face was red. Resident #92 stated she was afraid Resident #72 was going to die. Review of Resident #68's witness statement, dated 09/27/23, revealed Resident #72 hit LPN #315 and LPN #315 held her forearm against Resident #72 to stop the resident from hitting her. Review of LPN #315 undated witness statement, revealed Resident #72 hit her and she restrained the resident until the STNA came to assist. Review of the local police department report for Incident #23B016570, dated 09/28/23, revealed officers were sent to Park Center for an assault/patient abuse report following an altercation in the hallway between patient and nurse that occurred on 09/27/23 at about 9:00 P.M. Resident #92 was the reportee and witnessed the altercation. Resident #92 stated Resident #72 swung at LPN #315 first because she did not want to take her medication and stated Resident #72 was choked. Resident #92 stated she observed LPN #315 aggressively push Resident #72's head up against the metal door frame very hard, then LPN #315 grabbed Resident #72 by her throat and pushed her up against the wall with her hands choking the resident. Resident #92 stated she heard Resident #72 say I can't breathe and her face turned red. Resident #92 returned to her room because she was upset and called the police. STNA #330 stated he saw Resident #72 swing at LPN #315 then observed LPN #315 push Resident #72 into the door frame and grabbed her by the neck and had resident up against the door. STNA #330 stated he separated the resident and nurse. STNA #330 stated he witnessed LPN #315 intentionally slam Resident #72's head against the door and choke her to the point her face was red and heard Resident #72 gasping for air and said she could not breath. LPN #315 stated she restrained Resident #72 against the wall by using her forearm. Another resident ( Resident #68) stated he was in the hallway and witnessed LPN #315 restrain Resident #72 up against the wall using her forearm to resident's chest to keep her there until another employee arrived. STNA #341 stated she observed Resident #72 hit LPN #315. LPN #315 then restrained Resident #72 up against the wall until STNA #330 arrived and broke them up. The police report further stated Resident #72 had several fresh red marks and slight swelling around her neck area and Resident #72 complained of difficulty swallowing. Resident #72 was transported to the hospital. Review of the hospital emergency room (ER) documentation dated 09/27/23 at 11:32 P.M. revealed Resident #72 was sent to the ER after strangulation type injury. The admission physical exam revealed vague erythema noted to the anterior bilateral neck. There was some concern for arterial injury, esophageal injury, and soft tissue injury therefore a Computed Axial Tomography ( CAT ) scan was ordered. Radiology preliminary results of the CAT scan showed no evidence of soft tissue injury or soft tissue hematoma in neck and was released to be discharged back to the Park Center on 09/28/23 at 5:38 A.M. with a diagnosis of reported assault and anterior neck pain in stable condition. Review of Resident #72's Minimum Data Set (MDS) 3.0 assessment, dated 09/29/23, revealed Resident #72 was assessed to have severe cognitive impairment with a Brief Interview for Mental Status (BIMS) of 04 out of 15. The assessment noted the resident had physical and verbal behavioral symptoms directed towards others. Interview on 09/29/23 at 8:33 A.M. with the Director of Nursing (DON) revealed there was conflicting evidence of what happened the night of 09/27/23 so the police did not arrest LPN #315 the night of the incident. The DON suspended LPN #315 pending results of the incident investigation and local police department detective investigation. Staff education had been started and Resident #72 was seen by a psychiatrist and was willing to attend counseling services. Interview on 09/29/23 at 9:42 A.M. with Resident #92 revealed on 09/27/23 she witnessed Resident #72 hit LPN #315 and stated LPN #315 took the resident by her throat and hit her head against the wall and proceeded to choke Res [TRUNCATED]

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, review of CMS Memo QSO 20-38 revised 09/10/21, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility COVID-19 timeline and staff statement, review of the county community COVID-19 transmission rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 laboratory results and rapid point of care (POC) test results, review of facility audits, review of resident and staff vaccination logs, staff interviews, interview with the local health department (LHD #400), review of the facility COVID-19 procedure policy and interview with facility staff, the facility failed to implement effective and recommended infection control practices including adequate monitoring, testing, contact tracing and prevention of the transmission of COVID-19 in the facility. The facility failed to ensure employees did not report to work when in contact with family members who were symptomatic and subsequently positive for COVID-19, failed to ensure all staff were properly screened for COVID-19 upon entrance into the facility and had access to and utilized appropriate PPE during a COVID-19 outbreak to help reduce the potential spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 09/08/21 when Registered Nurse (RN) #221 left the facility after her symptomatic family member had tested positive for COVID-19. RN #221, who was unvaccinated, subsequently became symptomatic and tested positive for COVID-19 on 09/12/21. A second staff member (SM), SM #191, who was unvaccinated, demonstrated respiratory symptoms (cough) on 09/13/21 and worked in the facility on 09/13/21 and 09/15/21 only wearing a surgical mask. SM #191 tested positive for COVID-19 on 09/16/21 via a rapid test and 09/17/21 with a molecular polymerase chain reaction (PCR) test. A third SM, State tested Nursing Assistant (STNA) #122 tested positive for COVID-19 on 09/20/21 during facility outbreak testing. The facility failed to conduct an investigation/contact tracing to determine those residents or staff the three positive staff members had contact with for exposure to COVID-19, quarantine exposed resident, monitor residents for signs and symptoms of COVID-19, adequately test residents and staff during an outbreak, adequately screen staff for signs and symptoms of COVID-19, follow infection control protocols for quarantine, educate residents on exposure precautions, and ensure adequate supplies of personal protective equipment (PPE) were available and properly used by all staff. On 09/28/21 at 3:11 P.M. the Administrator was notified Immediate Jeopardy began on 09/08/21 when RN #221, who had contact with a family member who was symptomatic and positive for COVID-19 had not quarantined but rather continued to work in the facility. RN #221 tested positive for COVID-19 on 09/12/21. SM #191, who had contact with RN #221 worked in the facility on 09/13/21 and 09/15/21 with respiratory symptoms (cough) without using proper PPE (N95 mask). STNA #122 also tested positive for COVID-19 following facility testing done on 09/20/21, which resulted in the potential exposure to all residents on 300B unit when the STNA worked on 09/20/21 and 09/21/21. The facility failed to conduct proper contact tracing, implement quarantine procedures and/or conduct COVID-19 testing to promptly identify any new cases of COVID-19 in the facility. All residents on the 300B unit were not adequately monitored for signs and symptoms of COVID-19. Continued observations during the onsite investigation revealed the facility was not following infection control practices to prevent the spread of COVID-19 or testing residents and staff per Centers for Medicare and Medicaid (CMS) and Centers for Disease Control (CDC) guidance. This risk for hospitalization , serious harm and/or death are likely related to a COVID-19 outbreak in the nursing home resident population. This had the potential to affect all 85 residents residing in the facility. The Immediate Jeopardy was removed on 09/29/21 when the facility implemented the following corrective actions: · On 09/27/21 ADON #109/designee completed COVID-19 PCR testing for 80 of 84 facility residents who were in the facility at that time. Four residents refused to be tested at that time. · On 09/27/21 and 09/28/21 ADON #109 obtained PCR COVID-19 tests for 53 facility employees. The facility indicated any staff not tested on these dates would be tested prior to their next scheduled workday. · On 09/28/21 Activities Director #106, Admissions Director #108, Rehab Director #403, and Regional Director of Rehabilitation #404 conducted point of care (POC) COVID testing for 85 of 85 residents residing in the facility. The facility identified no new positive COVID-19 cases from this testing. · On 09/28/21 the facility placed eight unvaccinated residents (Resident #8, #4, #11, #17, #23, #30, #31 and #43) with potential exposure to COVID-19 positive staff on the 300B unit in quarantine. · On 09/28/21 Central Supply Designee #152 completed an inventory of 13 rooms for residents in quarantine precautions to ensure all required PPE was available. · On 09/28/21 the Administrator notified two staff members (SM#128 and SM #158 who worked on unit 300B unit with the COVID positive staff member (STNA #122) on 09/20/21 and 09/21/21 of potential COVID exposure. · On 09/29/21 Regional Director of Operations #402 provided education to the Administrator and the Director of Nursing related to CMS QSO-20-38-NH (requirements for testing, PPE, quarantining). · On 09/29/21 the Administrator and/or DON provided education to 41 of 80 facility staff related to PPE requirements. A plan for any staff not educated to be educated prior to the start of their next shift by the Administrator/DON/ADON/Designee was implemented. · On 09/29/21 one of two facility receptionists (#183) was educated by the DON regarding the provision of PPE. A plan for the other receptionist (#182) to be educated before the start of her next scheduled shift was implemented. · On 09/28/21 and 09/29/21 Regional Director of Rehabilitation #404, Assistant Director of Nursing #109, and Assistant Director of Nursing #110 completed staff competencies for 30 of the 80 facility staff members (with return demonstration) for donning/doffing PPE and handwashing. A plan for any staff who did not complete the competency to do so prior to their next scheduled shift was implemented. · On 09/29/21 Regional Director of Operations #402 developed a facility Contact Tracing policy following CMS and CDC guidance. · On 09/29/21 the Administrator provided education to the DON and two facility ADONs (#109 and #110) related to the facility Contact Tracing policy. · On 09/29/21 Admissions Director #108 and Activities Director #106 provided education to 53 residents who had a Brief Interview for Mental Status (BIMS) score of 9 or greater and to the responsible parties of 29 residents with a BIMS score of 9 or lower on potential COVID exposure, COVID testing and quarantine guidelines. · On 09/29/21 the Administrator/DON provided education to 41 of 80 facility staff related to COVID testing requirements. A plan for any remaining staff to be educated prior to the start of their next scheduled shift by the Administrator/DON/ADON/Designee was implemented. · On 09/29/21 the Administrator developed a COVID testing log for residents and staff. The DON/designee would be responsible for ongoing compliance with the log. · On 09/29/21 the Administrator provided education to the DON, ADON #109 and ADON #110 related to maintaining a COVID testing log for residents and staff. · On 09/29/21 the DON/designee provided education to Receptionist #183 regarding screening procedures. A plan to educate Receptionist #182 prior to the start of her next shift was implemented. · On 09/29/21 the Administrator/DON provided education to 41 of the facility 80 staff related to proper screening for COVID-19 upon entrance to the facility. A plan for any remaining staff to be educated prior to the start of their next shift was implemented. · On 9/29/2021 the Administrator provided education to four of four contracted staffing agencies related to the facility PPE requirements, COVID testing requirements and proper screening for COVID upon entrance to the facility. · On 9/29/2021 Regional Director of Operations #402 met with Medical Director #405 related to requirements for PPE, testing, and screening for COVID for staff and residents, quarantine requirements for residents, and approval of newly developed Contact Tracing policy. · On 9/29/2021, an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Administrator, Assistant Director of Nursing #109, Assistant Director of Nursing #110, MDS Coordinator #168, Social Services designee #186, Activities Director #106, Admissions Director #108, Central Supply designee #152, Maintenance Director #167, and Rehab Director #403. The facility Immediate Jeopardy (IJ) Abatement plan was discussed and approved. The QAPI committee would review the facility plan daily for one week, then weekly for four weeks, and as needed thereafter. Although the Immediate Jeopardy was removed on 09/29/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Finding include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 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. On 09/26/21 at 1:12 P.M. and 3:04 P.M. interview with the Administrator revealed the facility currently had a COVID-19 outbreak. The Administrator revealed, RN #221, who was unvaccinated, first tested positive for COVID-19 on 09/12/21. Further information revealed RN #221's spouse had been symptomatic and tested positive for COVID-19 on 09/08/21. However, RN #221, who lived with her spouse and had contact with the spouse did not quarantine and continued to work. On 09/08/21 RN #221 was notified her spouse tested positive and she left the facility at that time. RN #221 reported to the facility on [DATE] she had tested positive for COVID-19 and was having nausea and vomiting symptoms. Per the Administrator, the facility initiated COVID-19 testing for residents on 09/13/21 and for staff on 09/13/21 and 09/14/21. On 09/16/21 SM #191, who was the facility scheduler tested positive for COVID-19. SM #191 was unvaccinated for COVID-19. On 09/15/21 SM #191's daughter (who lived in the same household as her) was ill (with COVID-19 symptoms). On 09/16/21 SM #191 had a rapid test done at the facility that was positive. A PCR test completed on 09/17/21 was also positive for COVID-19. The Administrator revealed SM #191 had been in the building on 09/15/21 for an hour or so because she had been at a sister facility much of the day providing orientation for three new staff members. The Administrator revealed SM #191 was not having symptoms, however her daughter had a fever. As part of outbreak testing being done, a third staff member (STNA #122) tested positive for COVID-19 on 09/20/21. At the time the STNA tested positive she was asymptomatic and had been vaccinated for COVID-19. The STNA worked on the 300B unit on 09/20/21 and 09/21/21 and was identified to have been in direct contact with Residents #4, #8, #11, #17, #18, #19, #23, #28, #31, #32, #34, #46, #52, #54, #58, #59, #63, #64, #65, #66, #76, #77, #85, #86, #89, and #90 who resided on the unit. Residents on the unit were noted to be both vaccinated and unvaccinated. During the interview with the Administrator, the Administrator revealed all staff should be wearing an N95 mask and eye protection as part of the procedure during the COVID-19 outbreak. On 09/26/21 at 3:04 P.M. interview with the Administrator revealed no residents had been tested for COVID-19 since 09/20/21. No residents were tested immediately, but not sooner then two days after they had direct contact with STNA #122. The Administrator revealed testing was not completed because the facility did not have laboratory service available to pick up specimens. The DON, who was also present for the interview, revealed the facility could have done rapid testing but indicated the testing would only be done if a resident showed signs or symptoms of COVID-19. The Administrator also revealed non-vaccinated residents (Residents #4, #8, #11, #17, #23, #30, #31, and #43) who resided on the 300B unit were not placed in quarantine following their exposure to STNA #122. The Administrator revealed the facility encouraged all residents to wear masks and staff were supposed to monitor all residents for signs and symptoms of COVID-19. The Administrator also indicated the local health department had been notified of the positive staff member and instructed the facility to follow facility policies. However, the Administrator reported she had no documented evidence she contacted the local health department. The Administrator then provided a written statement, dated 09/27/21 which documented she had notified the local health department on 09/13/21 of RN #221's positive results, on 09/20/21 of SM #191's positive test results and on 09/23/21 of STNA #122's positive test results. The statement did not include who from the health department the Administrator had spoken to. On 09/29/21 at 10:23 A.M. interview with local health department staff (LHD #400) confirmed she had received an email on this date (09/29/21) the facility had two COVID-19 positive staff members on 09/16/21 and 09/20/21. The email the LHD received included the Administrator reported she had called and left voice mails and just wanted to follow up. LHD #400 could not recall receiving any messages, however stated the Administrator could have called. LHD #400 reported she usually talked to another facility staff member who represented several facilities for the corporation weekly with reports of positive cases for multiple facilities, but she was unaware of talking to this person about this facility. LHD #400 revealed she did not instruct the facility to follow their policies because she was unaware the facility had any positive cases. 2. The facility provided a timeline, dated 09/27/21 (after the survey began) that included the following information: a. RN #221 tested positive and had not been in the building 48 hours prior to testing positive. The timeline did not indicate the last day the employee worked or the date the RN tested positive. b. SM #191 had a negative polymerase chain reaction (PCR) on 09/13/21 and tested positive from a rapid test on 09/16/21 with no symptoms. On 09/15/21 SM #191 had presented orientation at a sister facility. SM #191 returned to work on 09/16/21 and was in the office with the Administrator and Human Resource (HR) #109. c. STNA #122 had a positive PCR test on 09/20/21. She was off 09/18/21 and 09/19/21 and worked on 09/20/21 and 09/21/21. She worked with Licensed Practical Nurse (LPN) #158 and STNA #128. Weekly testing began on 09/13/21 for all residents and vaccinated staff and twice weekly for unvaccinated staff. N95 and face shields were initiated. Per the timeline provided by the facility the county community transmission level turned yellow as well. There was no evidence the facility initiated contract tracing following the identification of the positive staff members to determine other staff/residents with possible exposure or to implement quarantine measures. Review of the county community transmission level per the CMS website, dated 09/13/21 to 09/27/21 revealed the county level was red (greater than 10% positivity rate). 3. Review of RN #221, SM #191, and STNA #122's time sheets, screening forms, testing results, and interviews revealed the following: a. Review of RN #221's time sheets from 09/01/21 to 09/27/21 revealed RN #221 worked 09/07/21 from 9:27 A.M. to 4:17 P.M. and 09/08/21 from 9:11 A.M. to 4:13 P.M. She did not return to work after 09/08/21. Review of RN #221's COVID-19 screening questionnaire forms dated 09/07/21 and 09/08/21 revealed the RN responded she had no COVID-19 signs or symptoms in the past 48 hours, had not been in close contact with anyone confirmed with a COVID-19 test, nor traveled outside the United States in the last 30 days. Review of the laboratory results for RN #221's PCR testing, dated 08/26/21 to 09/28/21 revealed the RN had tested negative for COVID-19 on 08/26/21, 08/31/21 and 09/07/21. On 09/28/21 at 10:52 A.M. interview with RN #221 revealed her husband was having body aches and a low grade temperature so he went to get tested for COVID-19 on 09/08/21. The RN did not indicate when these symptoms had started but indicated he was having symptoms on the day he tested , which was a day she was at the facility working. The results came back positive for COVID-19. The RN did not self-quarantine upon identification of her husband's symptoms and worked on 09/08/21 until she was notified of her husband's positive test results. RN #221 revealed she began showing symptoms of COVID-19 on 09/12/21 and she tested positive as well on 09/12/21. b. Review of SM #191's time sheets, dated 09/01/21 to 09/27/21 revealed SM #191 worked 09/13/21 from 7:52 A.M. to 4:30 P.M., called off on 09/14/21 and worked 7:22 A.M. to 3:58 P.M. on 09/15/21. The facility was not able to locate any COVID-19 screening questionnaires for SM #191 for 09/13/21 or 09/15/21. This was verified during an interview with the DON on 09/27/21 at 2:13 P.M. Review of laboratory results for SM #191's COVID-19 PCR tests, dated 08/31/21 to 09/28/21 revealed the SM tested negative on 08/31/21, 09/02/21, 09/07/21, 09/09/21 and 09/13/21. A rapid screen form dated 09/16/21 revealed SM #191 had [MEDICATION(S)] symptoms. A COVID-19 rapid test was positive at that time. On 09/28/21 at 9:11 A.M. interview with SM #191 revealed on 09/13/21 she reported to work with a cough. SM #191 revealed she thought she had filled out a COVID-19 screening questionnaire, however she could not recall if she marked the form to note she had a cough since she thought she just had a cold. SM #191 revealed she was not vaccinated and shared an office with a vaccinated staff member. SM #191 revealed while working she wore only a surgical mask and had contact with other staff member, residents, vendor, and delivery personnel. SM #191 reported people were coming in and out of her office daily like a revolving door. On 09/14/21 SM #191 revealed she called off due to her daughter having a fever. On 09/15/21 she did an orientation at a sister facility and returned to the facility and worked in the facility for two hours. Later that day she went to the doctor's office to be tested for COVID-19. On the 09/16/21 SM #191 had a rapid test at the facility that was positive and confirmed on 09/17/21 with a PCR test. SM #191 revealed she had been exposed to RN #221 on 09/08/21 but had not quarantined or self-isolated following this exposure. c. Review of STNA's #122 time sheets dated 09/01/21 to 09/27/21 revealed the STNA had worked day shift on 09/08/21, 09/11/21, 09/12/21, 09/16/21, 09/17/21, 09/20/21 and 09/21/21. Her last day of work was 09/21/21. Review of STNA #122's COVID-19 screening questionnaires, dated 09/16/21, 09/17/21, 09/20/21 and 09/21/21 revealed the STNA noted she did not have any signs or symptoms (of COVID-19) in the last 48 hours, had no close contact with anyone confirmed with COVID-19 or traveled outside the United States in the last 30 days. Review of laboratory results for STNA #122's COVID-19 PCR test, dated 08/31/21 to 09/28/21 revealed the STNA had only been tested twice in this time. On 09/02/21 the results were negative and on 09/20/21 she tested positive. Review of the facility staff testing audit sheet, dated 09/28/21 revealed from 09/13/21 to 09/20/21 STNA #122 had not had a PCR or rapid COVID-19 test performed. The staff member was vaccinated and was only required to be tested on ce weekly, however the last documented test results prior to 09/20/21 were from 09/02/21. On 09/27/21 at 2:13 P.M. interview with the DON revealed she had just started working at the facility on 09/20/21. As of this time, the DON was unable to find any evidence that contact tracing was completed following the identification of the above three employees testing positive for COVID-19. The DON revealed she created a timeline on 09/27/21 of just information she had collected from the facility because she was not employed by the facility at that time. The DON reported she could not confirm what personal protective equipment staff were wearing during that time and/or if they were wearing it correctly. 4. On 09/26/21 from 10:44 A.M. to 11:03 A.M. an initial tour of the facility and subsequent observations with LPN #110 on 09/26/21 from 11:59 A.M. to 12:02 P.M. revealed STNA #114 and STNA #115 were not properly wearing N95 masks. Neither STNA had a bottom strap on the N95 to properly secure the mask. In addition, STNA #115 was not wearing any type of eye protection. LPN #207 also was not wearing any type of eye protection and the bottom strap of her N95 was missing. These findings were verified by LPN #110 at the time of the observations. Review of the undated resident vaccination log for residents residing on the 300 B unit revealed Resident #4, #11, #17, #23, #30, and #31 were not vaccinated and Resident #8 and #43 were partially vaccinated (only had one step of two). On 09/26/21 at 10:56 A.M. and 11:59 A.M. observation of the 300B unit with LPN #110 revealed no evidence any the above residents were in quarantine as result of exposure to STNA #122 on 09/20/21 and 09/21/21. In addition, Resident #17 was observed to be independently mobile and was observed on all three facility units without wearing any type of mask/facial covering or social distancing. On 09/27/21 at 3:50 P.M. a follow up observation of the 300B unit with the DON verified none of the residents on the 300B unit had been placed in quarantine. The DON confirmed the eight unvaccinated residents as noted above should have been placed in quarantine on 09/23/21 when STNA #122's COVID-19 test completed on 09/20/21 came back with positive results. Further observation of 300B unit with the DON revealed an unidentified therapy staff member was observed assisting a resident back to her room. The therapist was wearing an N95 mask, however, the straps of the mask were improperly tied to a crochet band that stretched across the top of her head. Review of the medical records, including medication and treatment administration records and orders from 09/01/21 to 09/27/21 for all 28 residents residing on the 300B unit revealed Resident #13, #30, #58, #64 and #76 were not monitored at least daily for signs/symptoms of COVID-19 including respiratory signs and symptoms, temperatures, and pulse oxygenation. In addition, Resident #31 was not monitored daily for respiratory signs and symptoms. Further review revealed Resident #43 who was partially vaccinated and Resident #30 who was unvaccinated were moved to a shared room on 09/25/21 after STNA #122 tested positive and potentially exposed every resident on the 300B unit on 09/20/21 and 09/21/21. On 09/26/21 at 3:04 P.M. interview and record review with the Administrator revealed no evidence Resident #17 and #23, who resided on the 300B unit or their representatives had been notified of the staff member testing positive on 09/20/21. On 09/27/21 at 8:02 A.M. interview with the Administrator verified all residents on 300B unit had been in contact with STNA #122 who tested positive on 09/20/21. The Administrator reported non-vaccinated residents were not placed in quarantine because the STNA should have been wearing an N95 and eye protection. However, the Administrator could not confirm this. In addition, the Administrator again confirmed residents were not tested immediately after the exposure and indicated this was because the laboratory was not available to pick up the specimens. The Administrator revealed no residents had been tested between 09/20/21 and 09/26/21. On 09/27/21 at 2:13 P.M. interview with the DON revealed there was no documented evidence Resident #17 was notified of the positive staff member or provided education on COVID-19 precautions. The DON also confirmed Resident #13, #30, #31, #58, #64 and #76 were not adequately monitored daily for signs and symptoms of COVID-19. The DON reported she completed an audit last night (09/26/21) and fixed resident orders to ensure all residents were monitored daily for temperatures, pulse oxygenation and respiratory signs and symptoms (related to COVID-19). The DON confirmed Resident #30 and #43 should have not been moved to the 300B unit due to all the residents having been exposed to STNA #122 who was positive for COVID-19 and who worked on 09/20/21 and 09/21/21 because they were not completely vaccinated. 5. On 09/26/21 at 10:44 A.M. observation revealed the facility 200A unit was the quarantine unit. There were 12 residents residing on the unit at that time. However, there were no PPE carts/supplies or biohazard trash bins available for use in room [ROOM NUMBER], 208, 209, 210, 211, 213, or 214 on the unit. Each of these rooms did have a sign to see nurse before entering on the center of the room door. There were three red biohazard cans noted in the hallway near room [ROOM NUMBER], 202, 203 and between 204 and 205. A yellow gown was observed hanging out of the can near room [ROOM NUMBER]. The doors that separated units 200A from 200B were open allowing residents to enter the quarantine unit. On 09/26/21 at 11:57 A.M. observation with LPN #110 revealed LPN #160 was observed in room [ROOM NUMBER] administering medication to the resident in the room without any gown or gloves on. There was a red sign noted on a PPE cart indicating the resident was in contact isolation. LPN #110 confirmed the resident was in quarantine. In addition, the LPN confirmed staff working on the unit had to leave the quarantine room, come out into the hallway and then remove any PPE they were wearing. The LPN also verified the red biohazard bin outside room [ROOM NUMBER] had a yellow gown partially hanging out of it. During the observation/interview LPN #110 revealed Resident #2 was in isolation for [CONDITION(S)] difficle (C Diff) and not for COVID-19 precautions. The LPN verified there was no PPE available or biohazard bins outside the rooms of Resident #12, #16, and #39 who were in quarantine. The LPN revealed Resident #35 was on the quarantine unit because the resident had requested a private room. On 09/27/21 at 3:33 P.M. observation and record review for the residents on the quarantine unit with the DON revealed the following: Resident #68 was admitted on [DATE] and was ordered contact and droplet precautions for COVID-19 from 09/24/21 to 10/04/21 because she was a new admission that was not vaccinated. Resident #61 was admitted on [DATE] and was ordered contact and droplet precautions for COVID-19 from 09/24/21 to 10/07/21 because she was a new admission and unvaccinated. Resident #2 was ordered isolation precautions on 09/01/21 due to C Diff. The DON reported she was not sure why the resident was placed on the COVID-19 quarantine unit for this. Resident #9 and Resident #67 were new admissions to the facility awaiting verification of their COVID-19 vaccine status. However, both residents were vaccinated and did not need to be quarantined. Resident #81's isolation had discontinued on the 09/25/21. However, the resident continued to have orders for contact and droplet precautions. Resident #47 was placed on the quarantine unit due to compassionate care visits. The DON reported the resident was placed in quarantine due to outside visitors visiting and the resident being unvaccinated. The DON confirmed there was no order for quarantine and stated she would write one for contact and droplet precautions. Resident #12 was placed on the quarantine unit because he was on a leave of absence greater than 48 hours and was unvaccinated. The DON confirmed there was no orders, however, stated orders should have been written for contact and droplet precautions. Resident #16 was ordered contact and droplet precautions from 09/23/21 to 10/07/21 because he was a new admission and was unvaccinated. Resident #50 should have been ordered contact and droplet isolation because she was a new admission on 09/16/21 and was unvaccinated. The DON confirmed the resident did not have any order for isolation. Resident #39 was ordered contact and droplet precautions because she was a new admission on 09/21/21 and was unvaccinated. Resident #35 was on the quarantine unit and identified to be reverse isolation because she was receiving [CONDITION(S)]. There was no order for reverse isolation, however the facility had thought she would have been safer on the quarantine unit. Further observation of the quarantine unit with the DON on 09/27/21 revealed two therapy staff (Physical Therapy Assistant #179 and Occupational Therapy Assistant #170) were observed in Resident #68's room without wearing any type of gowns or surgical mask over their N95 to allow for continued N95 use. The DON confirmed the finding during observation. There was a sign on the door to see the nurse, a red laminated sign for contact isolation and a PPE cart at the room. Interview with the therapy staff at the time of the observation revealed they had just forgot to apply the correct PPE. There was a large barrel in the hallway near room [ROOM NUMBER] with PPE hanging out the side. room [ROOM NUMBER] did not have a PPE cart or sign of what type of isolation, rooms [ROOM NUMBER] did not have signs as well for the type of isolation. Agency STNA #194 was observed leaving Resident #39's room without cleaning her mask or replacing her N95 since it was not covered with a surgical mask. The STNA left the room with dirty linen, not placed in a bag, and walked down the hallway with it. There was no cleaner observed in any of the PPE bins for staff to disinfect their e [TRUNCATED]

Based on observation, interview, review of the facility policy and procedure for skin management, and record review the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent and identify pressure ulcers in a timely manner for Resident #9. Actual Harm occurred on 06/02/20 when Resident #9, who required extensive assist of one person with bed mobility and extensive assist of two persons with transfers was found to have a Stage three (full thickness tissue loss, with subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) pressure ulcer to her right heel. In addition, the facility failed to timely complete a wound assessment upon discovery of a new wound for Resident #56. This affected two residents (Resident #9 and #56) of two residents reviewed for pressure ulcers. The facility identified two facility acquired pressure ulcers (Resident #9 and #56). The facility census was 68. Finding included: 1. Review of medical record for Resident #9 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 02/16/18 revealed Resident #9 had a risk for alteration in skin integrity related to impaired mobility and incontinence. Interventions included encourage and assist Resident #9 with repositioning and use assistive devices as needed, observe for changes in skin condition and report abnormalities, pressure redistributing device to bed and chair and provide preventative skin care after each incontinent episode and as needed. Review of a care plan dated 03/23/18 revealed Resident #9 had a functional status deficit and the inability to perform activities of daily living tasks independently related to [CONDITION(S)]. Interventions included extensive assist of one person with bed mobility. Review of the facility form titled, Guar- Braden Scale for Predicting Pressure Sore Risk dated 04/27/20 revealed Resident #9 was at risk for skin breakdown because she was constantly moist, chairfast, and had a potential problem with friction and shear. Review of quarterly Minimum Data Set (MDS) 3.0 dated 05/02/20 revealed Resident #9 had intact cognition with no behaviors. The resident required extensive assist of one person with bed mobility and extensive assist of two person with transfers. She was at risk for pressure ulcers and had no unhealed pressure ulcers. Review of nursing notes dated 05/01/20 to 06/02/20 revealed there was no documentation of Resident #9's right heel pressure ulcer being identified prior in the nursing notes other than the documentation per Wound Care Physician #501 per his wound care progress note that identified her pressure ulcer to her right heel on 06/02/20. Review of a wound care progress note labeled, Wound Assessment and Plan authored by Wound Care Physician #501 and dated 06/02/20 revealed Resident #9 had a Stage three pressure ulcer to her right heel that measured 7.0 centimeters (cm) in length, 1.0 cm in width, and 0.2 cm in depth. The wound was described as 80 percent granulation, and 20 percent slough with minimal exudate. Interventions included to offload pressure on her right lateral heel. Review of facility wound assessment labeled, Guar- Wound Evaluation (1 wound 12 weeks) - V1 authored per Former Assistant Director of Nursing (ADON) #800 and dated 06/09/20 at 5:16 P.M. revealed Resident #9 had a Stage 3 pressure ulcer (Full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscles is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) that was inhouse acquired to her right heel that was identified on 06/02/20. The pressure ulcer measured a length of 0.2 cm, width of 0.8 cm and a depth of 0.1 cm. Interventions included heel boots. There was no previous wound assessment documented in the medical record prior to 06/09/20 per the facility regarding Resident #9's pressure ulcer to her right heel other than Wound Care Physician #501's progress note dated 06/02/20. Review of the care plan dated 08/26/20 for Resident #9 revealed she had actual skin breakdown related to impaired mobility, needed assistance with personal care as she had a Stage 3 pressure ulcer to her right heel. Interventions included administer treatment as ordered, encourage to turn and reposition, encourage or assist to suspend and float heels as able when in bed, pressure reducing mattress and cushion to bed and wheelchair, and use pillows and positioning devices as needed. Review of the quarterly MDS dated [DATE] revealed Resident #9 had intact cognition and continued to require extensive assist of one person with bed mobility and extensive assist of two people with transfers. She continued to be at risk for pressure ulcers and had a Stage 3 pressure ulcer that was not present on admission. Review of current physician orders for May 2021 revealed Resident #9 had a physician order dated 10/08/20 to wear Pressure Relief of the Ankle and Foot (PRAFO) boots as tolerated for pressure relief and a physician order dated 05/11/21 to cleanse her right posterior heel pressure sore with 0.125 percent Dakin's and apply wet to moist and cover with an ABD pad and gauze wrap every shift. Review of wound care progress note labeled, Wound Assessment and Plan authored by Wound Care Physician #900 and dated 05/10/21 revealed the wound to her right lateral heel had declined as it continued to be a Stage 3 and measured a length of 1.4 cm, width of 1.1cm, and a depth of 0.6 cm. The wound contained 10 percent granulation and 90 percent slough. The peri wound was described as macerated and showed signs of infection with redness, odor, and increased warmth. Wound Care Physician #900 completed a sharp debridement to Resident #9's right heel under local anesthesia and she tolerated the procedure well. Wound Care Physician #900 changed her treatment order and recommended Resident #9 to offload pressure on both lateral heels and heel protectors to both sides when available. Interview on 05/12/21 at 1:16 P.M. with the Director of Nursing (DON) revealed she was not the DON at the time Resident #9's pressure ulcer was identified but revealed she reviewed the medical record and verified Resident #9's pressure ulcer to her right heel was found at a Stage 3 on 06/02/20 as documented by Wound Care Physician #501. She also verified Resident #9's pressure ulcer had declined as the pressure ulcer was larger in size, especially the depth from when the pressure ulcer was first identified on 06/02/20 the depth was 0.2 cm and now the depth on 05/10/21 was 0.6 cm. Observation of a dressing change completed by Licensed Practical Nurse (LPN)/ Scheduler #400 on 05/12/21 at 1:55 P.M. revealed Resident #9's pressure ulcer to her right heel was measured per LPN #400 and measured a length of 2.9 cm, width of 2.2 cm and she stated she was unable to determine the depth as there was over 90 percent slough present to the wound bed. The treatment was completed as ordered and without any issues. She revealed preventative measures were to continue with pressure reducing mattress, and off load her bilateral heels. Observation on 05/16/21 at 8:38 A.M. revealed Resident #9's bilateral heels with socks in place were in direct contact with the mattress as she was not wearing PRAFO boots as ordered and her heels were not floated. Interview and observation on 05/16/21 at 8:47 A.M. with Registered Nurse (RN) #455 revealed she was not aware if Resident #9 had PRAFO boots as an order or not and she verified Resident #9's bilateral heels were in direct contact with the mattress as they were not floated and she was not wearing PRAFO boots. Resident #9 stated to RN #455 that the facility did not have enough pillows in the building to prop her heels up off the bed like they should be. RN #455 acknowledged by shaking her head yes and then walked out of room and went back to administering medications. Resident #9's bilateral heels remained in direct contact with the mattress. Observation on 05/16/21 at 9:41 A.M. revealed Resident #9 remained in the same position with her bilateral heels without any PRAFO boots in place or her heels off loaded or floated off the bed. Interview and observation on 05/16/21 at 10:09 A.M. with State tested Nursing Assistant (STNA) #305 verified Resident #9 continued to not have any PRAFO boots in place and her bilateral heels were not offloaded or floated off the mattress. After STNA #305 verified and acknowledged that Resident #9's heels should be off loaded she continued to walk and go to the secured unit. Interview and observation on 05/16/21 at 10:15 A.M. with STNA #306, who stated she was the STNA assigned to Resident #9 revealed she was not aware of Resident #9 having any PRAFO boots and she stated she was not aware her heels were to be off loaded or floated. She revealed anytime she had come in to work on her unit Resident #9's heels were just laying flat on the mattress as they currently were, and she had never seen her heels up on a pillow or offloaded. STNA #306 walked out of the room and yelled down the hallway to RN #455 that she was going on a 15-minute break. She did not reposition, or off load Resident #9's heels prior to leaving on break. Interview and observation on 05/16/21 at 10:44 A.M. with the DON verified Resident #9's bilateral heels continued to not have PRAFO boots nor were they floated or off loaded. She verified RN #455, and STNAs #305 and #306 should have off loaded or looked for Resident #9's PRAFO boots instead of leaving her heels in direct contact with the mattress. Resident #9 stated to the DON she had not had boots for her feet for months and she had been told there were not enough pillows in the facility to prop her heels up. Observation and interview on 05/16/21 at 12:42 P.M. of the laundry room with Housekeeping Laundry Central Supply (HLCS) #500 revealed there was sufficient supply of extra pillows to assist in proper positioning of Resident #9. Review of policy labeled, Pressure Ulcers/ Skin Breakdown- Clinical Protocol dated April 2013 revealed the nurse was to assess and document a full assessment of the pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue. The policy revealed the physician would help identify medical interventions related to wound management. 2. Review of Resident #56's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record including nurse's notes found evidence of a new open wound to the coccyx discovered on 02/12/21. Further review of the medical record including wound assessments found no evidence of a wound assessment completed until 02/16/21. Interview with the DON on 05/13/21 at 11:30 A.M. verified Resident #56's wound was not assessed and staged until 02/16/21, four days after discovery.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interviews with staff and residents, review of medical records, review of facility document titled Elopement Guideline, and review of a police report, the facility failed to prevent the elopement of one resident (Resident #57) who had cognitive impairment, mental and physical illness, and changes in condition placing them at risk for serious injury or death. Resident #57 had a court appointed guardian due to poor decision making and [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy on 02/05/2020 at 11:00 A.M. when Activity Director (AD) #331 and Activity Aide (AA) #306 failed to supervise Resident #57 while on an outing to a general store. Resident #57 left the store without their knowledge and was missing until 9:45 P.M. when the local police found him at a bar in the downtown district about seven miles from the facility. The roadway in front of the facility was observed as a two-lane road that was heavily traveled by trucks and other vehicles with poor lighting and no cross walks. The roadway that continued to the downtown district was also observed as heavily traveled with two or four lanes, poor lighting, multiple intersections, and no cross walks. This affected one of sixteen facility residents who were identified as being at risk for elopement. The facility census was 61 residents. On 11/02/20 at 4:33 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Corporate Nurse were notified Immediate Jeopardy began on 02/05/2020 at 11:00 A.M. when Resident #57 walked away from a general store without staff knowledge during a facility outing on a cold 30 degree day, and in a location where the roadway was a multiple lane heavily trafficked road. The Immediate Jeopardy was removed, and the deficient practice corrected on 02/11/2020 when the facility implemented the following corrective actions: · On 02/05/2020, the DON, ADON, and RN Supervisor #354 reviewed elopement assessments for all 72 residents to ensure accuracy. · On 02/05/2020, the DON reviewed all 72 resident care plans to ensure they reflected their current risk of elopement. The DON updated 12 resident elopement care plans to reflect the residents' current elopement risk and appropriate interventions. · On 02/05/2020, the DON reviewed and verified all Wanderguard orders. · On 02/05/2020, the DON reviewed and updated the elopement risk binders to reflect residents identified as elopement risk. · On 02/05/2020, the ADON, Administrator, and Director of Clinical Operations (DCO) educated AA #306 regarding the facility elopement policy. · On 02/05/2020, the Administrator suspended AD #331 pending the investigation outcome. · On 02/05/2020 and 02/06/2020, the DON, ADON, and Staff Development Coordinator (SDC) educated 80 of 96 facility staff members on the facility elopement policy and procedure. · On 02/06/2020, the Administrator provided education to the activity department staff and department heads on completion of an activity outing checklist and ensuring adequate supervision on outings to prevent any further recurrence of elopement from outings. No further occurrences during resident outings have taken place. · On 02/06/2020, the DON assured 15-minute checks were initiated for 72 hours upon Resident #57's return to the facility, as well as 1:1 supervision for any activity/outing off the secured unit, and proper Wanderguard placement and functioning. · On 02/06/2020, an Ad-hoc QAPI meeting was completed with the committee consisting of the Administrator, DON, ADON, Social Services Director #303, Dietary Manager, Registered Nurse Assessment Coordinator (RNAC), Business Office Manager, Therapy representative, Maintenance Director, MDS RN, Director of Clinical Operations, and the Medical Director to approve the activity checklist, facility interventions for activities and outings, and facility elopement response. · On 02/06/2020, resident outings were reviewed in morning meeting by IDT to determine adequate supervision and review supply checklist. IDT consists of administrator, director of nursing, assistant director of nursing, Medical Records, Housekeeping supervisor, Dietary Manager, Maintenance Director, MDS RN, Social Services, Rehabilitation Director, Activity Director, and Business Office Manager. · On 02/10/2020, the DON reviewed and updated Resident #57's elopement assessment. · On 02/07/2020, Social Service Director (SSD) #303 reviewed and updated Resident #57's Brief Interview for Mental Status assessment. · On 02/11/2020, the Maintenance Director began the completion of one elopement drill on each shift for one month to ensure staff understanding elopement drill education. These were conducted on 02/11/2020 at 1:00 P.M. with 11 staff members; on 02/26/202 at 5:00 A.M. with nine staff members; an on 02/28/2020 at 8:10 P.M. with six staff members. · No further elopements have taken place at the facility. Findings include: Review of Resident #57's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Evaluation, dated 05/02/2019, revealed he was at risk for elopement due to cognitive impairment and verbally expressing a desire to leave the facility. A Brief Interview for Mental Status (BIMS) evaluation, dated 05/03/2019, indicated the resident had moderate cognitive impairment. The Minimum Data Set 3.0 (MDS) assessment, dated 05/09/2019 revealed the resident had moderate cognitive impairment, no wandering behavior, and needed limited assistance of one person for mobility and locomotion on and off the unit. For hygiene, toileting and dressing he required the extensive assistance of one person. For transferring he needed the extensive assistance of two people. A Nursing Note written by Registered Nurse (RN) #347 on 07/24/2019 at 12:45 P.M. revealed Resident #57 left the facility without signing out or informing staff he was leaving. He was located by staff in the plaza next to the facility drinking coffee. Resident #57 was returned to the facility and stated he will be leaving again when no one is looking. A Wanderguard device (sounds an alarm if a resident gets close to an exit door) was placed on his left wrist and after calling his guardian for approval his room was moved to the secured unit in the facility. An Elopement Risk assessment dated [DATE] revealed Resident #57 left the facility without signing out or notifying staff so a Wanderguard was applied to his left wrist and his room was moved to the secured unit in the facility. Review of the resident's care plan (initiated on 05/03/2019) revealed his risk for elopement was not added to the care plan until after he eloped on 07/24/2019. On 07/24/2019, the elopement interventions were added to include admit to secured unit; accompany to meals and scheduled activities; ask family and visitors to notify staff when leaving after a visit; engage in activities to keep occupied; secure items that may trigger an attempt to leave the facility (boots, coats); Wanderguard alarming bracelet; redirect when exhibiting exit seeking behavior; and provide supervision. Review of the facility document titled Elopement Guideline (dated February 2019) revealed residents would be evaluated for wandering/elopement risk upon admission, readmission, quarterly and with a significant change by a licensed nurse. When a resident is identified at risk for elopement the interdisciplinary team would develop a plan of care to include interventions to reduce the risk of elopement and maintain resident safety. An Elopement Risk assessment dated [DATE] revealed Resident #57 remained at risk for elopement and lived on the secured unit due to cognitive impairment and a history of elopement. Review of a progress note written by Social Service Director (SSD) #303 on 11/27/2019 at 4:03 P.M. revealed Resident #57 had increased independence and was no longer receiving [MEDICAL CONDITION] treatment at the hospital. He was alert and oriented with some confusion and could become verbally aggressive when being redirected. His discharge plan was to stay on the secured unit at the facility long term due to his need for 24-hour supervision and assistance with his daily care needs. Review of a Social Services progress note written by SSD #303 on 01/15/2020 at 11:31 A.M. revealed Resident #57 came to the social services office and stated he was done with the hospital now and wanted to leave the facility. SSD #303 said his guardian would be called, and the resident stated he would call her himself. Review of Nurses Note written by RN #348 on 01/21/2020 at 3:11 P.M. revealed the Assistant Director of Nursing (ADON) told RN #348 that Resident #57's guardian had approved him to have alone time off the unit from 8:30 A.M. to 10:00 A.M. Review of the physician order [REDACTED].M. to 10:00 A.M. daily. Review of the Nurses Note written by RN #349 on 02/05/20 at 11:45 A.M. revealed the elopement protocol was initiated, the guardian was made aware of Resident #57's elopement, and police were notified. Review of the police report dated 02/05/2020 written by Community Police Officer (CPO) #350 revealed RN #347 approached CPO #350 in his vehicle for assistance at 11:40 A.M. while RN #347 was looking for missing Resident #57 who had eloped at approximately 11:00 A.M. On 02/05/2020 at 10:05 P.M. CPO #350 was notified by his police department that Resident #57 had been found at a bar in the downtown area and was being taken to the local hospital for examination. Review of a facility self-reported incident dated 02/05/2020 and the related facility investigation revealed Resident #57 had eloped from an outing at an area general store at approximately 11:00 A.M. after being left unsupervised by Activity Director (AD) #331 and Activity Aide (AA) #306 The resident was found at 9:45 P.M. at a bar located in the adjacent town, and per his request was taken to the local hospital. Review of the Nurses Note written by Director of Nursing (DON) #351 on 02/06/2020 at 9:03 A.M. revealed the hospital notified her Resident #57 was not exhibiting any symptoms for admission to the hospital and was being returned to the facility. According to the police report, on 02/05/2020 at 10:05 P.M., CPO #350 was notified by his police department that Resident #57 had been found at a bar in the downtown area and was taken to the local hospital for examination. Review of the Hospital After Visit Summary dated 02/05/2020 to 02/06/2020 revealed the reason for Resident #57's visit was for a psychiatric evaluation. He was sent back to the facility on [DATE] from the emergency department. Interview with the Administrator on 10/29/2020 at 2:32 P.M. revealed she did not work for the facility during the timeframe of Resident #57's elopements, and DON #353 and ADON/RN#300 were also new to the facility since the elopements. The Administrator was not aware of a facility SRI being submitted by the administrator at the time of Resident #57's elopement on 07/24/2019, and she only had the investigation left by the previous administrator for the 02/05/2020 elopement. The administrator also said Activity Director #331 no longer worked for the facility. Telephone interview with AA #306 on 10/29/2020 at 3:36 P.M. verified Resident #57 had eloped on 02/05/2020 at approximately 11:00 A.M. from an outing as he was left unsupervised inside the general store for approximately five minutes. AA #306 said the weather that day was below 30 degrees Fahrenheit, it was not snowing, and Resident #57 was wearing a winter coat, shoes, blue jeans, and a shirt, but no gloves or a hat. She verified he was an elopement risk and had been making statements that if his guardian did not take him out of the facility and put him into a group home he was going to leave on his own. AA #306 said the guardian gave him permission to be unsupervised in the facility off the secured unit for a few hours a day because he did not like being on the secured unit. AA#306 said Resident #57 had a history of [REDACTED]. On 10/29/2020 at 6:18 P.M. observation of the driving distance from the general store where Resident #57's was last seen on the 02/05/2020 outing with facility staff, to the bar where he was found, revealed it was approximately 7 miles from the facility. This included roads with multiple lanes, heavy car and truck traffic, and multiple intersections without crosswalks. There were areas of low visibility due to poor lighting. On 10/29/2020 at 5:43 P.M., observation and interview with Resident #57 revealed he was well groomed, appropriately dressed and pacing in his room with a steady gait. He was alert and oriented to person, place, time. Upon greeting by the surveyor, he responded appropriately but displayed an angry facial expression. He was wearing a Wanderguard bracelet on his left wrist, and he said it was there so he did not get out. Review of the facility document titled Elopement Guideline (February 2019) revealed residents would be evaluated for wandering/elopement risk upon admission, readmission, quarterly and with a significant change by a licensed nurse. When a resident is identified at risk for elopement the interdisciplinary team would develop a plan of care to include interventions to reduce the risk of elopement and maintain resident safety. This deficiency substantiates Complant Number OH 981.

Based on record review, observation, interview and the reasonable person concept, the facility failed to prevent resident to resident sexual abuse. Actual harm occurred when Resident #6 was unable to physically or verbally consent to, or refuse, Resident #9 touching her vaginal area with his hand. This affected one (Resident #6) of five residents reviewed for abuse. The facility census was 61 residents. Findings include: Review of a facility self-reported incident (SRI) dated 10/31/2020 revealed an allegation of sexual abuse involving Resident #9 who was observed by a staff member in the room of Resident #6 with his hand inside her incontinence brief. The facility determined sexual abuse did not occur because the evidence was inconclusive, and the female resident was not psychologically affected by the peer to peer interaction. Review of the medical record for Resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated Resident #6 had severely impaired cognition and was unable to complete the brief interview for metal status assessment. The MDS also indicated the resident required extensive assistance of two staff for mobility, transfer, and toileting; needed extensive physical assistance for eating; and was totally dependent for bathing. The Plan of Care with a date initiated of 01/02/2019 revealed Resident #6 had difficulty communicating related to a decline in cognitive status and dementia and was dependent on staff assistance for her activities of daily living. Review of the Psychological Progress Note dated 10/14/20 written by Psychologist #334 revealed Resident #6 had moderate to severe depression and confusion, and severe to dysfunctional lethargy. It was noted she was confused and very lethargic, pleasant but anxious, and had increased dementia. Review of the Nurses Note dated 10/31/2020 written by Licensed Practical Nurse (LPN) #341 revealed LPN #341 was notified that Resident #9 was found in Resident #6's room with his hand in her brief. Review of the Psychological Progress Note dated 11/04/2020 written by Psychologist #334 revealed Resident #6 was sexually touched by a psychotic male resident who was moved off her unit. Resident #6 did not remember the incident and had late stage dementia. Resident #6 was noted to have moderate depression, severe to dysfunctional lethargy, and confusion. Review of the medical record for Resident #9 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed he was cognitively intact and needed supervision and set up for mobility, transfers, walking, eating, and personal hygiene. The Plan of Care with a revision date of 11/16/2020 indicated Resident #9 could become sexually inappropriate Review of the Nurses Note dated 10/31/2020 written by LPN #341 revealed LPN #341 was notified by State tested Nursing Assistant (STNA) #313 that Resident #9 was found in Resident #6's room with his hands in her brief. When asked what he was doing, Resident #9 said, I had my hands in her vagina. When asked why he replied, because I like her. Review of the Progress Note dated 11/03/2020 written by Psychiatrist #335 revealed Resident #9 had peer to peer interaction where he put his hand in a female residents' pants and claims they are boyfriend and girlfriend. He openly admitted to having a girlfriend and correctly named Resident #6. He was alert and oriented to person, place, but not time. The Psychiatrist noted Resident #9 reported they had a relationship for the last 6 months and the relationship was mutual but Resident #6 clearly lacked the capacity to effectively communicate or give consent. Psychiatrist #335 documented that Resident #9 clearly lacked insight into his relationship with an [AGE] year old woman with severe dementia, and should be separated from her at all times. Review of the SRI investigation dated 10/31/2020 revealed the incident occurred at 6:30 P.M. and LPN #341 immediately notified the Director of Nursing, removed Resident #9 from the unit and notified police. A written statement by STNA #313 dated 10/31/2020 revealed she found Resident #9 with his hand inside Resident #6's brief in her room. A written statement dated 11/02/2020 by Director of Clinical Operations (DCO) #329 revealed DCO #329 spoke with Resident #9 and asked him if he knew why his room was changed. He stated, I don't want to talk about it. DCO #329 continued the interview and Resident #9 reported to her that he and Resident #6 had been friends for a long time and really liked each other. He stated she grabbed his hand and placed it in between her legs. He was willing to finger her vagina but did not and wanted to know if he was going to go to jail. The facility did not substantiate abuse due to inconclusive evidence. On 11/16/2020 at 10:03 P.M., interview with DCO #329 said she spoke to Resident #9 on the secured unit and found him to be alert and oriented to person, place, and time with poor insight. He told her he had not loved anyone like he loved Resident #6 since his wife passed away. He said he and Resident #6 were in love with each other and he had no other relationships with anyone other women. He said he was going to finger her vagina after Resident #6 pulled his hand between her legs but got startled by a staff person so did not do it. Interview on 11/16/2020 at 4:50 P.M. with STNA #313 who witnessed the incident revealed she went to do her rounds on 10/31/2020 at around 6:30 P.M. and saw Resident #9 hunched over Resident #6 who was lying in her bed. She went into the room and walked around him to see what he was doing, and his hand was inside her brief up to his wrist and he was moving his hand around. He popped up straight as if he was startled, said he loved Resident #6, and retreated out of the room. STNA #313 said her brief was not undone but it was looser on the side where he had his hand. She said Resident #6 was not coherent and definitely was not participating or engaged in the incident. Interview on 11/16/2020 at 5:29 P.M. with LPN #341 who identified herself as the nurse on duty the night of the incident revealed STNA #313 came to her on 10/31/2020 and told her she had witnessed Resident #9 with his hand in Resident #6's brief. She went to check Resident #6 and found that her brief was fastened but definitely messed with as it was much looser on one side. She had no bruising and did not seem to be in any discomfort. When she asked Resident #9 what he had been doing in her room he responded he was just playing with her vagina a little bit. LPN #341 said Resident #6 absolutely could not give consent, as she was severely cognitively impaired and could barely communicate except to say a few words now and then. Observation of Resident #6 on 11/18/2020 at 8:46 A.M. revealed she was laying in her bed and was alert with pleasant confusion. Attempted interview with the resident revealed she spoke in a very soft voice with mostly nonsensical verbal word formation, except she was able to repeat good morning after greeted by surveyor with the same words. She appeared thin, frail, and had muscle wasting apparent in her face and arms, as well as her collar bone and sternal areas. She did not move her lower body at all, and barely moved her head or arms throughout the visit. Interview was conducted on 11/18/2020 at 8:56 A.M. with Resident #9 who was living on the secured behavior unit. He was alert and oriented to person, place, and situation, laying in his bed appropriately dressed and in no distress. Resident #9 said he was moved to this unit because he was doing some sexual things with Resident #6. He said this happened one time and he was finger playing with her clitoris. He said Resident #6 moved his hand down there. He said he had visited her a few times to talk to her. Review of the facility policy titled Abuse Policy, dated 07/2017, revealed sexual abuse is non-consensual sexual contact of any type with a resident and includes touching of any kind especially of breasts or perineal area. Generally sexual contact is non-consensual if the resident either appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur. This deficiency substantiates Complaint Number OH 068.

Based on observation, interview, record review, and reasonable person concept, the facility failed to ensure Resident #47, who had a developmental disorder and was autistic and aphasic, remained free from physical and verbal abuse. Harm occurred when Resident #47 fell and was kicked and cursed at by Licensed Practical Nurse (LPN) #301 while he was on the floor. The facility also failed to ensure Resident #47 was not video recorded by LPN #301 without consent. This affected one of five residents (Residents #14, #31, #47, #67, and #83) reviewed for abuse. The facility census was 83 residents. Findings include: Review of the record of Resident #47 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was also aphasic (unable to speak) and had a developmental disorder. Review of his most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/16/17 revealed Resident #47 was severely cognitively impaired, did not exhibit adverse moods or behaviors including refusals of care and required supervision to extensive assistance of two staff members for his activities of daily living. Review of Resident #47's care plans revealed he could have physical behaviors toward others, walking close to or chest bumping staff at times, and at times becoming demanding in requests for snacks. He was generally mute, but had started using one word answers such as yes or no. Review of nursing progress notes from 09/01/17 revealed the resident had some anxiety at times, and behaviors including following nursing staff around the unit. Review of a social service note, dated 11/09/17, revealed Resident #47 was alert and oriented to self and staff, was non-verbal and used hand gestures to communicate some of his needs, which were anticipated by staff. His mood and behavior were stable, with a [DIAGNOSES REDACTED]. Nursing notes through 12/07/17 revealed Resident #47 was stable, although a note on 11/25/17 at 12:00 A.M. indicated he frequently stood near the elevator, trying to get on and could be combative at times when redirected by staff. A care conference note dated 12/07/17 revealed Resident #47 was alert and non-verbal, but able to make his needs known through hand gestures and other non-verbal communication. The note indicated he required the supervision of staff when off the unit due to cognitive impairment and risk for wandering, and although able to understand simple commands, displayed some verbal processing deficits. A nurse's note dated 12/19/17 at 5:41 P.M. revealed the state tested nursing assistant (STNA) notified the nurse Resident #47 was observed on the floor in his room on his belly swimming. The nurse entered the room with the nursing assistant and attempted to help the resident off the floor. The resident was resistant and was instructed by the STNA to roll onto his back. He rolled over, sat up, and then was assisted up off the floor. He sat on the bed briefly, and then left the room, pacing the hallway. Review of a facility Self-Reported Incident dated 12/19/17 revealed STNA #300 reported LPN #301 had been verbally and physically aggressive toward Resident #47 when he fell on [DATE]. Review of a statement by STNA #300 revealed she found Resident #47 on the floor after he fell on water in his room. She went to get the nurse (LPN #301) and when the nurse entered the room, he cursed at the resident, saying, Get up you stupid (expletive) and said I am not writing a report on this fall. LPN #301 also started kicking Resident #47 in the stomach three times with his foot, telling him to get up and calling him names. The statement indicated STNA #300 reached down to get the resident up and the nurse then helped him with his other arm to stand him up. An interview by phone with LPN #301 on 01/09/18 at 2:25 P.M. revealed he had worked at the facility as an agency nurse, and then was hired by the facility as a staff member. He denied any issues related to the fall, stating he would never curse or kick a resident. He said he went in the room to find Resident #47 on the floor and assisted him up with the help of the STNA. He said he was later attacked by the resident, who approached him in the hall and started to scratch him. He said he even used his cell phone to document the resident attacking him by video recording him so he could prove the resident was coming at him and trying to hurt him. He said he was unable to do a full assessment on the resident after he fell because he was agitated. He said he was unaware that comments he made about STNA #300 had made her uncomfortable, and thought that she had made up the story about the cursing and kicking because of that. An interview with STNA #300 on 01/09/18 at 3:07 P.M. revealed she was walking down the hall on 12/19/17 and heard a pounding and found Resident #47 on the floor in his room. She stated he must have spilled some water and was lying on the floor, making movements like he was swimming with his arms. She stated she went to get the nurse, LPN #301. STNA #300 verified her statement as to the nurse's actions upon coming into the room, and stated she could not believe what she was seeing and hearing. She said she heard LPN #301 curse at the resident, saying he was not going to write an incident report, and kick him in the side. She said the resident did not speak, but turned on his side and looked up at the nurse. She said she was shocked at first, but then, when the resident moved to his side, she took his shoulder and the resident sat up. She said the nurse took his other arm and the resident stood up and sat at the side of the bed. STNA #300 said the nurse left the room, and she helped the resident change his shirt, which was wet from the water. STNA #300 said she took the resident to the TV area. She did not want to leave him alone, but knew she needed to report the incident to someone. She said she settled the resident in the TV area and looked for a nurse, but the first nurse she saw was with LPN #301. She said she did not feel comfortable talking to the other nurse with LPN #301 there, so she waited a short time until she saw another nurse (LPN #302) and told her about the abuse. STNA #300 said that LPN #301 scared her because he made fun of her at times, but she knew she needed to report what she had seen. An interview with the charge nurse, Registered Nurse (RN) #304, on 01/09/18 at 3:20 P.M. revealed she came to work in the building for her shift between 6:15 P.M. and 6:30 P.M. on 12/19/17. She said LPN #301 was in his car in the parking lot and walked in with her. She said she thought he had been on a break, and he talked with her briefly, but did not mention Resident #47's fall, which had occurred at approximately 5:40 P.M. She said she went to her unit and began getting ready for her shift, when LPN #301 came to her and showed her scratches on his arms, stating Resident #47 had scratched him. She said she was helping him find something to wipe off the scratches, when LPN #302 came and said she needed to talk with her immediately. She said LPN #302 told her that STNA #300 had reported physical and verbal abuse toward Resident #47 by LPN #300. She said she then told LPN #300 he could not return to the floor, needed to write a statement, and would have to leave the building. She stated LPN #300 did not work with residents after the incident was reported. Interview with the administrator on 01/09/18 at 4:00 P.M. revealed their investigation of the incident could not substantiate abuse as Resident #47 was not interviewable and could not relate what had happened, and LPN #301 denied he had cursed at or kicked the resident. She stated LPN #301 was terminated from his employment at the facility due to the violation of facility policy of video recording Resident #47 without his consent. She stated she was unsure why the employee had recorded the resident, saying he had stated he wanted to show this is how he attacked me. She stated she saw the video on the phone, which she described as not showing the resident's face but said if you knew the resident, you would know it was him. She said LPN #301 denied posting the video to any social media site. The administrator said she witnessed LPN #301 delete the video from his cellular phone, but verified she could not be sure the video had not been posted or forwarded to any other party. The administrator said the local police department; Ohio Board of Nursing and the Ohio Department of Developmental Disabilities were notified of the incident as a result of the investigation. The administrator said Resident #47 exhibited increasingly aggressive behaviors after the fall and abuse, including scratching at LPN #301 and other nurses as documented in the nursing notes. She verified he was unable to express his feelings or thoughts verbally, was developmentally delayed and autistic, and that his behaviors may have been a result of the actions as described by STNA #300. A reasonable person would have been upset, frightened, embarrassed or angry if a person in authority would have cursed or kicked at them after an accidental fall resulting in them being on the floor in a submissive and dependent situation. An interview with LPN #303 on 01/09/18 at 5:15 P.M. by phone revealed she came to work on 12/19/17 at 11:00 P.M. She stated Resident #47 was usually redirectable but on that night he appeared agitated and was grabbing at her arms, requiring other staff to assist her to calm him. She stated she called the physician and received an order to send the resident to the hospital to evaluate his behaviors. She stated she was told in report that LPN #301 had also been scratched by the resident after he had allegedly kicked the resident after a fall. She said she only knew that Resident #47 was more agitated that he usually was, and she was uncomfortable with him being on the unit with the state he was in that night. A telephone interview with LPN #302 on 01/09/18 at 5:25 P.M. revealed LPN #301 came to her floor to tell her that Resident #47 had been scratching him. She said since that was unusual behavior for the resident, she went to the unit where he resided. She said she found him following staff, who were passing the snack cart, so she got a snack for the resident and took him into his room. She said he did not seem in distress or injured in any way. She stated she was sitting with the resident in his room, when STNA #300 came in and told her about the fall and that LPN #301 had kicked and cursed at the resident while he was on the floor. She stated she immediately told the charge nurse and an investigation was started. Review of the hospital records revealed a discharge summary dated 12/30/17 which indicated the resident had been increasingly combative at the facility prior to transfer and had physically attacked two nurses. The summary indicated the facility reported an investigation into possible verbal and physical assault by a nurse at the facility after the resident fell . The summary indicated his aggression then could have been retaliation to the suspected abuse. Resident #47 was observed in his room in bed on 01/09/18 at 10:15 A.M. and at 2:00 P.M. He opened his eyes when approached, but did not speak. He appeared comfortable, was appropriately dressed, and was well groomed. He did not respond in any way to questions, but did not appear to be in any distress. Review of the facility policy on abuse (undated) revealed verbal abuse included disparaging and derogator terms to a resident, regardless of their ability to comprehend or disability. Abuse included the willful (a deliberate action) infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Additionally, the policy indicated unauthorized videos in any state of dress using any type of equipment is a violation of a resident's right to privacy and confidentiality and regardless of consent or cognitive status, abuse would be presumed and investigated if the recording demeans or humiliates a resident. This deficiency substantiates Complaint Number OH 340, and is an example of continued non-compliance from the 12/04/17 complaint survey.

Based on record review and interview the facility failed to ensure enteral feedings were provided as ordered and care planned to prevent a significant weight loss of for one resident (Resident #1.) This affected one of three residents reviewed for weight loss. The facility census was 66. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. At the time of admission Resident #1 was ventilator dependent with a [MEDICAL CONDITION], received nutrition by gastrostomy tube feeding and required total to extensive assistance for all activities of daily living (ADLs.) Resident#1 was assessed as alert and oriented and able to make his own decisions and make needs known. Resident #1 was hosptalized on [DATE] and readmitted on [DATE] with the added [DIAGNOSES REDACTED]. On 07/31/2012 Resident #1 was discharged to a short term rehabilitation facility to continue therapy. Review of Resident #1's medical record revealed a nutritional assessment completed on 04/03/12 indicated Resident #1's height was recorded at 72 inches and his current body weight was 140.7 pounds which showed a loss of 5.3 pounds based on an admission weight of 146 pounds. The resident's ideal body weight was estimated at 178 pounds. The weight loss was not significant at 5.3 pounds and was attributed to the hospital admission. The resident's nutritional needs were estimated and Fibersource HN was recommended to be provided at a continuous rate of 70 milliliters (mls) per hour via the [MEDICAL CONDITION] tube. This was implemented as a measure to increase the resident's body weight. Review of the nutrition plan of care dated 03/27/12 revealed the resident was at risk for weight loss secondary to cervical and [MEDICATION NAME] fractures. The resident was ordered to have nothing by mouth, receive tube feedings by gastrostomy tube and have a neck and back brace on at all times. The goal was for the resident to tolerate the tube feed and to increase his body weight. Interventions included tube feedings orders and monitor intakes and weights. Review of dietary progress notes revealed Resident #1 had trouble tolerating the tube feeding rate of 70 mls per hour as evidenced by nausea and vomiting and residual tube feeding was noted with aspiration of stomach content. On 04/21/12 the tube feed rate was consequently reduced to 60 mls per hour with the plan to continue to monitor weights. On 05/27/12 the resident's weight was 135 pounds which was not a significant weight loss. The resident was tolerating the tube feed rate of 60 mls/hr and the plan was to continue to monitor the resident's weight. On 06/28/12 the resident's weight was 127.8 pounds which indicated a significant weight loss of 7.23 percent in one month. A re-weigh at that time indicated the resident weighed 128.4 pounds which did not trigger a significant weight loss. The dietary progress note continued to explain that Resident #1 received therapy and following therapy sessions, per the resident's request, therapy staff had been taking the resident to the dining room and his tube feed was not hooked up during that time. The therapy staff were educated on the importance of the tube feeding and environmental services were asked to provide a wheel chair that would accommodate the tube feeding pump. Review of a dietary progress note dated 07/19/12 revealed Resident #1's weight was 124 pounds and indicated a significant weight loss of 16.7 pounds and 11.9% over three months. The resident was still unable to tolerate an increased rate of 70 mls/hr. On 07/25/12 the resident lost an additional two pounds and the plan was to attempt to increase the feeding rate to 65 mls/hr. On 07/30/12 the resident's weight was 121.5 pound. The tube feed rate had been increased to 65 mls/hr for five days now and so far the resident had been tolerating it well. On 07/31/2012 Resident #1 was discharged to another rehabilitation facility. On 08/21/2012 at 12:15 P.M. interview with the Registered Licensed Dietician (RDLD) revealed she recalled Resident #1. The RDLD explained when Resident #1 had triggered for a significant weight loss she went to the nursing staff to see what was happening. That was when she found out staff were disconnecting the tube feeding for therapy sessions and therapy staff had been taking the resident to sit in the dining room following therapy sessions without the tube feeding being reconnected. Therapy staff were unavailable for interview. On 08/21/2012 at 2:15 P.M., interview with the Director of Nursing (DON) revealed when she found out staff had been disconnecting Resident #1's tube feed for therapy sessions, which were ordered for five times a week, she inserviced all nursing staff. Inservice documentation included a review of the facility policy and procedure for tube feeding. The DON verified staff should not have discontinued the tube feed for therapy sessions. The resident's tube feed should have been maintained at the continuous rate of 70 mls/hr as ordered. On 08/21/2012 at 2:50 P.M., interview with the administrator revealed he had spoken to the Director of the Therapy (DTPT.) The DTPT had verified Resident #1's tube feeding was off during therapy sessions which would have been about two hours per session and the therapy staff should have returned the resident to his room and notified nursing staff when he was back from therapy. The administrator verified the facility failed to ensure Resident #1's tube feeding was provided as ordered and the resident suffered a significant weight loss of. This citation substantiates complaint number OH 750.

Based on observation, record review and interviews, the facility failed to ensure an implanted [MEDICATION NAME] pain pump was refilled and remained functional for Resident #64, resulting in ongoing and increasing unrelieved pain. This affected one of three residents reviewed for pain, of 16 residents that received routine, schedule pain medications. Findings include: Resident #64 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #64 had severely impaired cognition. The assessment indicated Resident #64 had unclear speech, but could sometimes make her self understood, and could sometimes understand others. The assessment revealed the resident displayed non-verbal sounds such as crying, whining, gasping, moaning or groaning and made facial expressions such as grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw. The assessment indicated the indicators of pain were observed one to two days during the five day period. A care plan was initiated on 12/07/10 that indicated Resident #64 was at risk for alteration in comfort related to a [DIAGNOSES REDACTED]. The care plan indicated the Resident #64 had a [MEDICATION NAME] pain pump in place. An intervention on the plan of care indicated the [MEDICATION NAME] pain pump was for pain management and was filled every six months by the physician's office. Weekly pain assessment dated [DATE] indicated Resident #64's pain was rated at a two (mild) with zero indicating no pain and ten as severe pain. The assessment was based on Resident #64's response to the question, "Do you have pain?" The pain was described as dull and throbbing, however the location of the pain was not identified. The frequency of the pain was occasional and intermittent. The 01/18/11, 01/25/11, and 02/01/11 weekly pain assessments indicated the mild (score of two) pain continued with the location of the pain identified as legs and hips. The assessor indicated the resident would continue to be monitored for any signs of pain. Weekly pain assessment dated [DATE] revealed Resident #64 reported an increased level of pain, rated at a six (moderate). The frequency of the pain also increased to daily and the resident indicated that movement aggravated the pain. The assessor indicated the facility would continue to monitor for any signs of pain. There was no documented evidenced that Resident #64's physician or family were notified of the increased intensity and frequency of the resident's pain. There was no modification to the pain management program for Resident #64. Weekly pain assessments dated 02/15/11, 02/22/11, 03/01/11, 03/08/11, 03/15/11, 03/22/11, 03/29/11, 04/05/11, 04/12/11 and 04/19/11 all scored Resident #64's pain at six, i.e., moderate pain. Weekly pain assessments dated 04/19/11, 04/26/11 and 05/03/11 revealed Resident #64 was not able to respond to the question, "Do you have pain?" The assessor did not complete the pain assessment portion provided for residents that were non-responsive, nonverbal or in a state of altered consciousness. The weekly pain assessment dated [DATE] indicated Resident #64 was not able to answer the pain question. Resident #64 was assessed with [REDACTED]. The assessor scored Resident #64 with moderate pain at a level six. There was no documentation in the Comments section and no evidence the resident's physician or responsible party had been notified and no changes were made to her pain management program. Progress Note dated 05/12/11 revealed that during an interdisciplinary team meeting, Resident #64's daughter inquired as to when the pain pump was due to be filled. The note indicated the facility telephoned the physician's office related to filling of the pump. The physician's office indicated they would contact the home health agency for further information. The note also revealed Resident #64 had been having spasms, pulling at [MEDICAL CONDITION] picking her scalp. Progress Notes dated 05/16/11 revealed the physician's office indicated that the pain pump had not been refilled since 2009. The physician recommended placing Resident #64 on pain medications via the gastrostomy tube, rather than replacing the pump, as that may cause the resident more pain. Resident #64 sustained a fall and was admitted to the hospital on [DATE]. Hospital operative report dated 05/21/11 indicated that the [MEDICATION NAME] pain pump was removed and a new SynchroMed II 20-milliliter [MEDICATION NAME] pump was placed and anchored into the deeper subcutaneous tissue. On 06/08/11 at 8:21 A.M., Resident #64 was observed lying in bed, with her eyes closed. She was resting comfortably. On 06/08/11 at 10:05 A.M., Resident #64 made eye contact with the surveyor, however, was confused by the surveyor's questions. Resident #64 showed no non-verbal pain indicators. During a telephone interview on 06/08/11 at 9:11 A.M., Resident #64's daughter indicated that she had observed that her mother was in "so much pain" and would sometimes be "thrashing." She indicated that she questioned the facility about the pain pump numerous times, and they told her it was fine and that it had been filled. Resident #64's daughter revealed that finally, at the last care conference meeting, she brought up the subject, and the facility discovered the pump had not been filled since September 2009. During an interview on 06/08/11 at 3:38 P.M., the director of nursing (DON) verified that weekly pain assessments indicated Resident #64 experienced on-going pain, with no evidence of modifications in her pain management program. Contact with the home health agency that managed the pain pump revealed they had not filled the pump or completed any assessments since September 2009. The DON revealed the home health agency was supposed to assess the pump every month to ensure it was functional and fill the pump every six months. The DON reported that since the pump had not been assessed or filled since 2009, the physician indicated it could no longer be used. The DON verified the facility did not follow-up with the home health agency to ensure the pump was assessed, maintained and filled, since September 2009. This deficiency substantiates Complaint Number OH 970.