Every finding on record at Park View Care Center

Based on observation, staff interviews, and review of facility policies, the facility failed to ensure stocked medications were not expired. This had the potential to affect all residents in the facility. The facility census was 63.Findings include:Observation on 03/04/26 at 3:40 P.M. of the medication storage room revealed eight five milliliter (mL) flushes with an expiration date of 02/01/26, one open bottle of milk of magnesia with no opened date, one bottle of glucosamine chondroitin advanced capsules with an opened date of 01/07/25 and was past the expiration date printed on the label, 12 10 mL flushes of normal saline with an expiration date of 03/01/26, and nine bottles of 20 mL sterile water injections with an expiration date of November 2025.Interview on 03/04/26 at 3:55 P.M. with Licensed Practical Nurse #146 confirmed the observed medications were undated and expired and the medication storage room was utilized for all residents in the facility.Interview on 03/04/26 at 12:20 P.M. with [NAME] President of Clinical Resources #219 confirmed the above noted bottle of glucosamine chondroitin advanced capsules was expired and should have been disposed of as it was over a year since it had been opened and it was past the printed expiration date on the label.Interview on 03/05/26 at 2:00 P.M. with VPCR #219 confirmed the medication storage room was utilized for all residents in the facility.Review of a facility policy dated February 2023 and titled Medication Labeling and Storage revealed the facility would contact the pharmacy for instructions on disposing of expired medications. Additionally, this policy indicated the facility would label over the counter medications with an expiration date.Review of a facility policy dated 10/15/18 and titled Policy 3.16 OTC Bulk Medications revealed bulk over the counter medications would be used within one year of opening or by the manufacturer's expiration date, whichever is shorter.

Based on record review, resident interview, staff interview, and policy review, the facility failed to provide bathing per resident choice. This affected one (Resident #27) of one reviewed for activities of daily living (ADL). The facility census was 63 residents.Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, dysphagia, epilepsy, hyperlipidemia, hypothyroidism, gastric esophageal reflux disease, anxiety, and asthma.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive impairment, and the resident required substantial/maximal assistance for activities of daily living.Review of the care plan dated 02/05/25 revealed the resident required substantial maximal assistance for showers and was to be provided every Monday, Wednesday, and Friday during second shift with staff assistance.Review of the bathing flow record, dated the last 30 days, for Resident #27 revealed on 02/13/26, 02/18/26, 02/25/26, and 03/02/26 the Resident received a bed bath instead of a shower. The bathing record confirmed that Resident preferred showers. On 02/11/26 and 02/23/26 the Resident refused a bed bath.Interview on 03/02/26 10:36 A.M. with Resident #27 confirmed staff did not provide her with a shower because there are not enough staff in the building and verified her showers become bed baths. She sometimes refuses the bed bath because she wants a shower instead.Interview on 03/04/2026 3:41 P.M. with Certified Nursing Assistant (CNA) #157 verified she was unable to provide Resident #27 her shower because she did not have time. She did provide a bed bath to the Resident. CNA #157 confirmed Resident #27 was to receive her shower on second shift every Monday, Wednesday, and Friday.Interview on 03/04/2026 3:41 P.M. with Certified Nursing Assistant (CNA) #119 verified there is few instances where showers were not given due to the lack of time. She confirmed that when she cannot give a shower, she will make sure she gives the best bed bath she can give. Review of facility policy entitled, Resident Rights Policy, dated 08/01/25 revealed Self-determination; The Resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on resident interview, observation, staff interviews, and review of facility policy, the facility failed to ensure a clean and homelike environment. This affected one (Resident #56) of 20 residents residing on B hall. The facility census was 63.Findings include:Interview on 03/02/26 at 11:40 A.M. with Resident #56 revealed she was recently admitted to the facility for rehabilitation and reported black stuff on the ceiling of the shower room on B hall. Continued interview revealed it was bothersome to her and she was concerned it was mold that would aggravate her asthma.Observation on 03/02/26 at 11:45 A.M. of the shower room on B hall revealed a black substance on the ceiling of the shower room, where the wall met the ceiling, above the door and to the right of the door. Additional observation revealed a musty odor in the shower room.Interview on 03/02/26 at 11:45 A.M. with the Director of Nursing and [NAME] President of Clinical Services #219 confirmed there was a black substance on the ceiling of the shower room and there was a musty odor in the shower room on B hall.Interview on 03/02/26 at 11:50 A.M. with the Maintenance Director confirmed there was a black substance on the ceiling of the shower room.Review of a facility policy dated 08/01/25 and titled Resident Rights Policy revealed residents had the right to a clean and homelike environment.

Based on medical record review, observation, and staff interview, the facility failed to ensure care planned interventions to reduce injury from falls were implemented. This affected one (Resident #16) of three residents reviewed for accident hazards. The facility census was 63.Findings include:Review of the medical record for Resident #16 revealed he was admitted on [DATE] with diagnoses including type two diabetes mellitus, anxiety, depression, muscle weakness, unsteadiness on his feet, and acquired absence of his right leg below the knee.Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] for Resident #16 revealed he had moderate cognitive impairment and did not display any behaviors at the time of the assessment. Resident #16 utilized a manual wheelchair with supervision. He required partial assistance for bed mobility and was dependent for all transfers.Review of the fall risk assessment dated [DATE] for Resident #16 revealed he was at risk for falls.Review of the care plan for Resident #16 revealed an intervention dated 01/22/24 for a mattress to be placed on the floor by his bed when he was in bed.Observation on 03/03/26 at 9:55 A.M. of Resident #16's room revealed he was resting in bed and did not have a mattress on the floor by his bed, as indicated in his care plan, to reduce injury from falls.Interview on 03/03/26 at 10:10 A.M. with the Director of Nursing confirmed Resident #16 did not have a mattress on the floor by his bed and should have per his care planned intervention related to reducing injury from falls.Review of facility policy dated March 2018 and titled Falls and Fall Risk, Managing revealed the facility would implement a resident-centered fall prevention plan and identify fall prevention interventions related to the resident's specific risks.

Based on observation, staff interview, review of Resident Council meeting minutes, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during a COVID-19 outbreak. This had the potential to affect all residents in the facility except 10 residents (#11, #13, #21, #25, #31, #58, #65, #68, #71, and #72) who were identified with a current COVID-19 infection. The facility census was 62.Findings include:Interview on 12/23/25 at 8:42 A.M. with Infection Preventionist (IP) #301 revealed the facility was in COVID-19 outbreak and identified ten residents with COVID-19 (#11, #13, #21, #25, #31, #58, #65, #68, #71, and #72). IP #301 reported no residents on the Memory Care Unit were diagnosed with COVID-19. Observation on 12/23/25 at 12:10 P.M. revealed signage posted outside Resident #11's door indicating Resident #11 was in droplet precautions for COVID-19. Housekeeping Manager (HM) #400 was in Resident #11's bathroom cleaning her toilet. HM #400 was not wearing a disposable gown or eye protection. Interview on 12/23/25 at 12:15 P.M. with HM #400 confirmed Resident #11 was in COVID-19 isolation and staff should wear PPE, including a gown, N95 mask, eye protection, and gloves while in the room. HM #400 confirmed she went into Resident #11's room to clean her toilet bowl and only wore the N95 mask she had on. Further observation revealed HM #400 wore a distinct striped mask. There were no striped masks observed in the PPE cart outside Resident #13's room.Further observation on 12/23/25 at 12:20 P.M. revealed signage posted outside the room shared by Resident #12 and Resident #13 indicating the residents were in droplet precautions for COVID-19. HM #400 donned a gown and gloves before entering the room shared by Resident #12 and Resident #13 and did not change her N95 mask. HM #400 did not put on eye protection before she walked past both residents in the room and entered the bathroom.Interview on 12/23/25 at 11:32 A.M. with HM #400 revealed she worked on the floor as a housekeeper and had completed all room cleanings for the day, including rooms for Resident #11, Resident #13, Resident #21, Resident #25, and Resident #31, who were identified to be in COVID-19 precautions.Interview on 12/23/25 at 12:29 P.M. with HM #400 and Housekeeper #401 stated they both do not change their N95 masks throughout the day. HM #400 and Housekeeper #401 stated they were unaware they were expected to discard their N95 mask before exiting a resident's room who was in COVID-19 droplet precautions. HM #400 confirmed she cleaned all 24 rooms on her assignment, including five rooms identified to be in COVID-19 precautions without changing her N95 mask.Follow-up interview on 12/23/25 at 3:35 P.M. with IP #301 revealed all staff should be wearing gown, gloves, N95 masks, and eye protection before entering rooms in COVID-19 precautions. IP #301 confirmed N95 masks should be changed upon exiting COVID-19 rooms. Additionally, IP #301 confirmed the facility had a COVID-19 outbreak during November 2025 and explained it was 29 days between the end of the previous outbreak and the current outbreak.Review of the Resident Council meeting minutes dated 11/18/25 revealed housekeeping staff were not using PPE in COVID-19 rooms before going into other rooms.Review of the facility's undated document Special Respiratory Precautions revealed staff were expected to wear goggles or face shield, an N95 mask, a gown, and a pair of clean gloves before entering a room in COVID-19 precautions.Review of CDC guidance titled Transmission-Based Precautions dated 04/03/24 and found at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html revealed droplet precautions included everyone must make sure their eyes, nose, and mouth are fully covered before room entry and make sure to remove face protection before room exit.This was an incidental finding during the complaint survey completed 12/24/25.

Based on observations, resident and staff interviews, record review, review of cleaning procedures, and review of Resident Council meeting minutes, the facility failed to ensure resident rooms were routinely cleaned and maintained. This affected three (#29, #54, and #56) of nine residents reviewed for room cleanliness. The facility census was 62.Findings include:1. Review of the medical record for Resident #29 revealed an admission date of 07/14/23 with diagnoses including hypertension, pulmonary fibrosis, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had intact cognition, and required substantial/maximal assistance for toileting hygiene and partial/moderate assistance to toilet transfers.Observation on 12/23/25 at 9:31 A.M. of Resident #29's bathroom revealed it had what appeared to be red discolored water stains all the way around the bowl coming from under the rim of the toilet. Additionally, a grey ring was around the water line. Concurrent interview with Resident #29 revealed she felt the toilet was always dirty, but had been told the discoloration in her toilet was rust. Resident #29 said somebody came in earlier in the morning and scrubbed it. Resident #29 stated she had not gone into the bathroom to look at it. Interview on 12/23/25 at 9:48 A.M. with Certified Nursing Assistant (CNA) #101 confirmed residents, including Resident #29, complained about the cleanliness of their toilets. CNA #101 stated she had reported her concerns to housekeepers and nurses.Observation on 12/23/25 at 11:55 A.M., and concurrent interview with Housekeeping Manager (HM) #400 revealed Resident #29's toilet bowl had discolored hard water stains coming down inside the bowl from under the rim to the water line, approximately every two inches all the way around the bowl. Additionally, the stains on the right side of the bowl were more orange/red while the remaining stains were off-white/yellow. A grey ring was around the water line. HM #400 confirmed the observations. HM #400 stated she cleaned the toilet earlier using just a rag, and wasn't able to get the hard water stains out of the toilet.Subsequent interview on 12/23/25 at 12:15 P.M. with HM #400 revealed she used a pumice stone to clean the inside of Resident #29's toilet and was able to remove the stains. HM #400 stated she did not realize the stains could be removed and had not previously attempted to use the pumice stone to clean the bowl.Observation on 12/23/25 at approximately 12:55 P.M. revealed Resident #29's toilet was free of hard water build-up and no ring was around the water line.Interview on 12/23/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she heard complaints about unclean toilets. The DON stated when she reported her concerns to the housekeeping department, and the concerns were always addressed. The DON confirmed Resident #29 used their restroom.2. Review of the medical record for Resident #54 revealed an admission date of 11/18/14 with diagnoses including anxiety, hypertension, and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Observation on 12/23/25 at 9:18 A.M., and concurrent interview with Licensed Practical Nurse (LPN) #201 revealed Resident #54's bathroom had brown substance, approximately two inches in length on the exterior front of the toilet, and a darker brown speckled substance on the back wall of the interior bowl, approximately two inches in diameter. LPN #201 confirmed these observations. LPN #201 stated residents complained about the lack of cleanliness, particularly in the bathrooms.Observation on 12/23/25 at 2:44 P.M., and concurrent interview with Housekeeping Manager (HM) #400, revealed Resident #54's toilet had a brown substance on the front exterior of the bowl, and a brown speckled substance on the back of the interior bowl. HM #400 confirmed these observations. HM #400 confirmed Housekeeper #401 was assigned to clean and restock Resident #54's room, including the bathroom. Interview on 12/23/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she heard complaints about unclean toilets. The DON stated when she reported her concerns to the housekeeping department, and the concerns were always addressed. The DON confirmed Resident #54 used their restroom.3. Review of the medical record for Resident #56 revealed an admission date of 11/18/24 with diagnoses including schizoaffective disorder, depression, and auditory hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Interview on 12/23/25 at 10:05 A.M. with Certified Nursing Assistant (CNA) #102 confirmed some residents complained about bathrooms and toilets not being cleaned.Interview on 12/23/25 at 11:21 A.M. with Infection Preventionist (IP) #301 revealed staff and residents have reported concerns to her regarding cleanliness and infection control. IP #301 stated these concerns have been reported since approximately early November 2025. IP #301 stated she reported the concerns to the Administrator.Interview on 12/23/25 at 11:32 A.M. with Housekeeping Manager (HM) #400 revealed she had received no concerns regarding the cleanliness of resident rooms.Interview on 12/23/25 at 12:01 P.M. with CNA #103 revealed she had concerns regarding the lack of housekeeping in resident rooms.Interview on 12/23/25 at 12:29 P.M. with Housekeeper #401 revealed she still needed to clean the resident rooms on the memory care unit before the end of her shift at 2:00 P.M. Housekeeper #401's assignment included Resident #56's room.Interview on 12/23/25 at 2:42 P.M. with Resident #56 revealed she had no toilet paper in her bathroom.Observation on 12/23/25 at 2:43 P.M., and concurrent interview with HM #400, revealed Resident #56's bathroom had no toilet paper. HM #400 confirmed Housekeeper #401 was assigned to clean and restock Resident #56's rooms, including the bathroom. Interview on 12/23/25 at 2:54 P.M. with HM #400 confirmed Resident #56's bathroom should have had an adequate supply of toilet paper during the observation on 12/23/25 at 2:42 P.M. if her toilet paper had been restocked by Housekeeper #401.Interview on 12/23/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she heard complaints about unclean toilets. The DON stated when she reported her concerns to the housekeeping department, and the concerns were always addressed. The DON confirmed Resident #56 used their restroom.Review of the Resident Council meeting minutes dated 10/28/25 revealed old business included housekeeping cleaning floors. Current business included residents questioning what tasks housekeeping was expected to perform. Review of a response form dated 10/30/25, completed by HM #400, revealed daily tasks included cleaning the bathroom. Review of the Resident Council meeting minutes dated 11/18/25 revealed specific residents complained their floors were not getting clean.Review of the housekeeping daily checklist revealed duties included checking and refilling supplies and cleaning the commode and base. This deficiency represents non-compliance investigated under Complaint Number 2690900.

Based on observation, resident interviews, staff interviews, and facility policy, the failed to maintain an effective pest control program. This affected all 17 (#14, #17, #21, #23, #25, #27, #29, #32, #33, #36, #38, #45, #47, #53, #57, #58, and #60) residents on the Pathways locked unit. The facility census was 53. Findings include: Observation on 07/29/24 at 10:56 A.M. of the Pathways locked unit revealed flies in the resident hall. Interview on 07/29/24 at 11:06 A.M. with Housekeeping #210 and #211 verified there were flies in the hall. Observation on 07/29/24 at 11:11 A.M. of Resident #21's room revealed a fly near the window. Subsequent interview with Resident #21 revealed there are always flies in her room. Interview on 07/29/24 at 11:13 A.M. with State tested Nursing Assistant (STNA) #203 verified the fly in Resident #21's room. Interview on 07/29/24 at 11:21 A.M. with Registered Nurse (RN) #202 verified there are flies in the facility including the hallway, common area, and resident rooms. RN #202 reports she walked around with a fly swatter earlier and tried to kill them. Observation on 07/29/24 at 11:30 A.M. revealed the dining area with the resident's eating lunch. Three flies were observed in the dining room. Interview on 07/29/24 at 11:37 A.M. with Resident #25 revealed there are always a lot of flies and it bothers her. Interview on 07/29/24 at 11:40 A.M. with Resident #40 revealed there are always flies in the dining room and it really bothers her. Interview on 07/29/24 at 3:46 P.M. with STNA #205 and STNA #206 revealed there are always a lot of flies and gnats in the facility. Review of policy, Pest Control, revised May 2008 revealed the facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. This deficiency represents non-compliance investigated under Complaint Number OH00155509.

Based on medical record review, observation, staff interview, and facility policy, the facility failed to ensure a resident's bathroom was adequately maintained and in a sanitary condition. This affected one (#29) of four residents reviewed. The facility census was 53. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included unspecified dementia severe with agitation, chronic kidney disease, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required supervision assistance with toileting and was frequently incontinent of bowel and bladder. Review of the most recent care plan revealed Resident #29 had potential for bowel and bladder incontinence, frequently or almost always urinates on the floor in the bathroom, misses the toilet or does not even attempt to sit on the toilet to urinate and urine goes all over the floor. One intervention states for staff to frequently check bathroom floor for urine on the floor. Observation on 07/29/24 at 11:00 A.M. revealed a strong malodorous odor from the hallway. Upon further investigation Resident #29's resident bathroom was observed to have a substantial amount of liquid on the floor. The tile floor was stained, discolored, and warped. The area around the toilet was black in color and the wood like bathroom cabinet appeared to be warped on the bottom left side. Interview on 07/29/24 at 11:21 A.M. with Registered Nurse (RN) #202 verified Resident #29's bathroom was unclean, unsanitary, and not in a good state of repair. RN #202 reported Resident #29 often urinated on the bathroom floor. Review of policy, Quality of Life- Homelike Environment, revised May 2017, verified the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a homelike setting including a clean, sanitary, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00155509.

Based on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure residents were notified when their personal funds account balance was within $200.00 of the Medicaid resource limit. This affected three (#1, #3 and #25) of six residents reviewed for personal funds. Further, the facility failed to ensure resident funds were disbursed in a timely manner after discharge from the facility. This affected two (#161 and #162) of six residents reviewed for resident trust accounts. The facility census was 58. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] and a readmitted [DATE] with a payer source of Medicaid. Review of the Resident Statement (bank statement) dated [DATE] through [DATE] revealed Resident #1 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $4005.35 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. 2. Review of the medical record for Resident #3 revealed an admitted [DATE] with a payer of Medicaid. Review of the Resident Statement dated [DATE] through [DATE] revealed Resident #1 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $5068.80 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. 3. Review of the medical record for Resident #25 revealed a readmitted [DATE] with a payer source of Medicaid. Review of the Resident Statement dated [DATE] through [DATE] revealed Resident #25 consistently carried a balance exceeding $3000.00. The account balance on [DATE] was $4586.94 after monthly care costs were withdrawn for [DATE]. There was no evidence the resident was notified when the personal fund account balance was within $200.00 of the Medicaid resource limit. Interview on [DATE] at 2:55 P.M. with the Business Office Manager (BOM) #332 confirmed Resident #1, Resident #3, and Resident #25 all received Medicaid funding and were subject to Medicaid's resource limit of $2000.00. Further interview revealed the BOM #332 did not issue notifications to Resident #1, Resident #3, and Resident #25 regarding the excess money in their accounts. Review of the undated policy titled Resident Trust Fund Policy and Procedure Manual revealed the facility was required to notify residents when personal funds reached $200.00 less than the maximum allowed limit to qualify for Medicaid. The maximum is $2000.00 for the State of Ohio. A letter is to be issued to the resident or responsible party, notifying them that a spend-down of funds is necessary to maintain eligibility. 4. Review of the medical record for Resident #161 revealed an admitted [DATE] and expired under the care of hospice on [DATE]. Review of the payer source for Resident #161 revealed he was covered by Hospice Private Pay. Review of the Resident Fund Management Service (RFMS) Resident Statement revealed Resident #161 had an account balance of $2,746.65 on [DATE]. Further review revealed Resident #161's account accrued $21.12 in interest between [DATE] and [DATE] for a total balance of $2,767.77 on [DATE]. 5. Review of the medical record for Resident #162 revealed an admitted [DATE]. Resident #162 expired on [DATE] under the care of hospice. Review of the payer source for Resident #162 revealed she was covered by Hospice Medicaid. Review of the RFMS Resident Statement revealed Resident #162 had an account balance of $3,708.02 on [DATE]. Further review revealed Resident #162's account accrued $34.75 in interest between [DATE] and [DATE] for a total balance of $2,767.77 on [DATE]. Interview on [DATE] at 2:55 P.M. with BOM #332 confirmed the Resident Trust accounts for Resident #161 and Resident #162 were not disbursed timely and BOM #332 further confirmed she requested checks for disbursement for both accounts on [DATE]. Review of the undated policy titled Resident Trust Fund Policy and Procedure Manual provided no guidance regarding the timely disbursement of resident funds upon discharge from the facility.

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to provide timely incontinence care to one resident (Resident #10) dependent for incontinence care. The facility identified 33 residents incontinent of bladder and 19 residents incontinent of bowel. The facility census was 58. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included depressive disorder, Parkinson's disease, encephalopathy, basal cell carcinoma of skin, muscle wasting, mood disorder, insomnia, hypertension, rheumatoid arthritis, vitamin D deficiency and vitamin B deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact, required the extensive assistance of two staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and was always incontinent urine and frequently incontinent of bowel. Review of the care plan dated 03/28/18 revealed Resident #10 had episodes of bowel incontinence related to cognitive deficit and impaired mobility with an an intervention that included peri care to be provided following episode of bowel incontinence. The care plan updated on 07/08/22 revealed Resident #10 required assistance for activities of daily living (ADL) related to weakness and a diagnoses of Parkinson's disease interventions included for staff to provide assistance to complete ADL tasks, encourage the resident to call for assistance and allow time for the staff to respond, and for staff to provide assistance as needed with bed mobility, transfers, eating and toilet use and the call light was to be kept within reach of the resident. Review of the current physician orders revealed an order dated 09/09/21 for Resident #10 to be turned and repositioned every two hours. Observation on 05/01/23 at 9:03 A.M. revealed a foul odor on Hallway B. The odor became stronger the further one progressed down the hallway. Resident #10 was observed in the room moaning and yelling out. Interview on 05/01/23 at 9:05 A.M. with Resident #10 revealed the resident had been incontinent and needed staff assistance and could not find the call light. Observation at the time of interview revealed the call light was outside the reach of Resident #10 sitting on the wheelchair to the left of the bed. The foul odor noted in the hallway became more pungent upon entering Resident #10's room. Observation of incontinence care for Resident #10 on 05/01/23 at 9:28 A.M. performed by State tested Nursing Assistants (STNA) #315 and STNA #331 revealed the bedding for Resident #10 was saturated. A large dried brown area was noted on the bottom sheet and surrounded Resident #10 from the resident's shoulders to knees. Resident #10 had a dark brown substance down the legs, between the legs and in the groin and a dried dark substance on their stomach. Resident #10 was cleansed from the front to the back, rolled onto the right side, with additional skin care provided to remove brown substances. STNA #357 entered the room at 9:34 A.M. to assist with transferring the resident. During the continued observation Resident #10 was assisted to a standing position by STNA #357 and STNA #331, at which time a brown soft substance was observed dripping from Resident #10's buttocks, down the resident's legs and onto the floor. STNA #315 cleansed the skin of Resident #10 and wrapped the resident in a sheet while STNA #357 and STNA #331 assisted Resident #10 onto a wheeled shower chair. STNA #331 assisted Resident #10 into the shower. STNA #315 removed the linen from Resident #10's bed and cleansed the mattress with disposable wipes. Interview on 05/01/23 at 9:40 A.M., STNA #315 stated care had not been provided to Resident #10 since the start of the shift at 6:00 A.M. Interview on 05/01/23 at 9:40 A.M. with STNA #331 verified Resident #10 was saturated in feces and further stated no care had been provided to Resident #10 since the beginning of the shift at 6:00 A.M. Interview on 05/01/23 at 9:40 with STNA #357 verified no care had been provided to Resident #10 since the beginning of the shift at 6:00 A.M. Additional observation on 05/02/23 at 8:16 A.M. of Resident #10 laying in bed with a brown half moon shape of brown discoloration to the bottom sheet. The brown discoloration extended off side of the mattress and was visible from the hallway. A foul odor was noted. Interview with STNA #315 on 05/02/23 at 8:16 A.M. verified the brown discoloration of the sheets and the foul odor. STNA #315 stated care had not been provided since the beginning of the shift at 6:00 A.M. Review of the facility policy titled Activities of Daily Living, Supporting, dated March 2018, stated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility policy titled Perineal Care, dated February 2018, stated care is provided for cleanliness and resident comfort, to prevent infections and skin irritation, and to observe the resident's skin condition. The supervisor is to be notified if the resident refused perineal care.

Based on observation, resident interview, staff interview and review of facility policy the facility failed to ensure the call light and bed controllers were within reach for one resident (Resident #10) dependent for incontinence care. The facility census was 58. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included depressive disorder, Parkinson's disease, encephalopathy, basal cell carcinoma of skin, muscle wasting, mood disorder, insomnia, hypertension, rheumatoid arthritis, vitamin D deficiency and vitamin B deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact, required the extensive assistance of two staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and was always incontinent urine and frequently incontinent of bowel. Review of the care plan dated 07/08/22 revealed Resident required assistance for activities of daily living with an intervention to encourage the resident to call for assistance and the call light was to be kept within reach of the resident. Interview on 05/01/23 at 9:05 A.M. with Resident #10 revealed the resident had been incontinent and needed staff assistance and could not find the call light. Observation at the time of interview revealed the call light was sitting on the wheelchair which was to the left of the bed, outside the reach of Resident #10. The bed controller also noted to be on the floor under the left side of the bed. Continuous observation on 05/01/23 from 9:05 A.M. to 9:24 A.M. revealed Resident #10 was moaning and yelling out for help. State tested Nursing Assistant (STNA) #331 entered the room of Resident #10 at 9:24 A.M. to provide water and ice. Interview on 05/01/23 at 9:25 A.M. with STNA #331 verified the call light was outside the reach of Resident #10 sitting on the wheelchair to the left of the resident. STNA #331 further verified the bed controller was under the bed and out of the reach of the resident. Review of facility policy titled Answering the Call Light, dated September 2022, stated the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor to ensure timely responses to the resident's request and needs.

Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen supplies were dated when initiated. This affected one resident (#20) of two residents reviewed for oxygen therapy. The facility census was 58. Findings Include: Review of Resident #20's medical record revealed an admitted [DATE]. Diagnoses included cognitive communication deficit, personal history of COVID-19, peripheral vascular disease, heart disease, anxiety disorder, psychosis, major depressive disorder, and paranoid schizophrenia. Review of Resident #20's Minimum Data Set (MDS) 04/09/23 revealed Resident #20's cognitive skills were moderately impaired. Resident #20 was receiving oxygen therapy at the time of the review. Review of Resident #20's physician orders revealed an order dated 04/24/23 for oxygen at zero to five liters via nasal cannula related to shortness of breath and hypoxia. May titrate oxygen settings to lowest oxygen to maintain oxygen saturation greater than 90%. An order dated 04/30/23 included to change oxygen tubing every Sunday on night shift. Observation on 05/01/23 at 9:30 A.M. of Resident #20's oxygen tubing and humidifier found it undated as to when it was last changed. The tubing was noted to be long. Interview on 05/01/23 at 9:32 A.M. with Resident #20 stated she was not sure when the last time her tubing was changed. She stated she moves herself around the room and verified her tubing was long and dragged around on the floor. Interview on 05/01/23 at 9:33 A.M. with Licensed Practical Nurse (LPN) #340 verified Resident #20's oxygen tubing and humidifier were not dated. LPN #340 reported Resident #20's oxygen tubing was supposed to be changed every Sunday and the date was to be put on the tubing to show when it was changed. Observation on 05/02/23 at 3:00 P.M. found Resident #20's oxygen tubing and humidifier continued to be undated. Resident #20 was observed walking with her walker and rolling over her tubing and dragging it around on the floor. Interview on 05/02/23 at 3:02 P.M. with LPN #340 verified Resident #20's oxygen tubing and humidifier continued to be undated and Resident #20 continued to roll over it with her walker and drag it around on the floor. LPN #340 stated the tubing was most likely changed on Sunday. Observation on 05/03/23 at 8:28 A.M. of Resident #20 found her lying in bed. Her oxygen was connected and continued to not be dated or labeled. Observation on 05/04/23 at 11:01 A.M. of Resident #20 found her lying sideways in her bed. Resident #20 was dressed and her oxygen was connected. Her tubing and humidifier continued to be undated. Review of the facility policy titled Oxygen Administration, revised 04/14/20, revealed the staff were to assure the humidifier and oxygen tubing was changed every seven days.

Based on resident interview, observation, staff interview and completion of the a lunch meal test tray revealed the facility failed to ensure residents received palatable food that was properly cooked. This affected three residents (#28, #38, and #22) of four residents reviewed for food palatability. The facility census was 58. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included dysphagia, Parkinson's disease, cognitive communication deficit, type II diabetes, dementia, morbid obesity, schizoaffective disorder, mood disorder, major depressive disorder, impulse disorder, and osteoarthritis. Review of Resident #28's Minimum Data Set (MDS) assessment, dated 04/03/23, revealed Resident #28 was moderately cognitive impaired. Resident #28 received a mechanically altered diet at the time of the review. Review of Resident #28's care plan revised 02/01/23 revealed potential for nutritional risk related to therapeutic and mechanically altered diet. Review of Resident #28's physician orders revealed an order dated 01/31/23 for a controlled carbohydrate diet with ground meat texture and thin consistency. Interview on 05/01/23 at 9:52 A.M. with Resident #28 revealed he was alert and aware. Resident #28 reported about three times a week the food was not good. He reported at times the vegetables and fruits were not cooked well enough and they were too hard for him to chew. 2. Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included dysphagia, type II diabetes, and cognitive communication deficit. Review of Resident #38's MDS assessment, dated 02/20/23, revealed Resident #38 was cognitively intact. Resident #38 received a mechanically altered therapeutic diet at the time of the review. Review of Resident #38's care plan revised 03/01/23 revealed supports and interventions for nutritional risk related to mechanically altered diet texture and significant weight gain. Review of Resident #38's dietary evaluation dated 10/24/22 revealed Resident #38 was to be on a regular diet with dysphagia advanced consistency (mechanical soft) and thin liquids. Review of Resident #38's physician orders revealed an order dated 04/27/23 and discontinued 05/02/23 for consistent carbohydrate diet, mechanical soft texture and thin consistency. An order dated 05/02/23 for a consistent carbohydrate diet with regular texture and thin consistency. Observation on 05/01/23 at 11:46 A.M. found Resident #38 was seated in the main dining room and was provided his lunch meal. Resident #38 was provided the chicken pot pie with corn and carrots in it and after taking a couple bites Resident #38 was observed telling the staff in the dining room that the carrots were too hard and he was not able to chew them. The staff was observed verifying with Resident #38 the carrots were too hard for Resident #38 and they offered to get him something else. The noon meal was observed to consist of either chicken pot pie with corn or chicken pot pie without corn, both of which contained carrots. Completion of a test tray on 05/01/23 at 11:53 A.M., which included both the chicken pot pie with the corn and carrots found the carrots in the chicken pot pie were firm and slightly under done. It was noted the carrots would be hard to chew for someone on a modified texture diet. 3. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses of vitamin deficiency and type 2 diabetes mellitus. Review of the quarterly MDS assessment, dated 04/04/23, revealed Resident #22 had slightly impaired cognition and required supervision with setup help only for eating. Review of the physician's order dated 08/10/21 revealed Resident #22 was on a controlled carbohydrate diet with regular textures and thin liquids. Interview on 05/01/23 at 9:42 A.M. with Resident #22 revealed he did not like the food because it had little taste. Completion of a test tray on 05/01/23 at 11:53 A.M., which included both the chicken pot pie with the corn and the chicken pot pie without the corn, found both pot pies to be very warm but underseasoned and bland tasting.

Based on medical record review, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, history of COVID-19, bipolar disorder, morbid obesity, retention of urine, intellectual disabilities, mood disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of Resident #2's Minimum Data Set (MDS) assessment, dated 01/20/23, revealed Resident #2 was moderately cognitively impaired. Review of Resident #2's care plan revised 05/02/23 revealed supports and interventions for potential for urinary tract infections and indwelling Foley catheter related to urinary retention. Interventions for potential for urinary tract infections included administering medications as ordered, monitor for signs and symptoms of urinary tract infections, and to continue on antibiotic therapy as ordered. Review of Resident #2's physician orders revealed a current order initiated on 12/18/21 for the antibiotic trimethroprim 50 milligrams (mg) one time a day for personal history of urinary tract infection. Review of Resident #2's Medication Administration Record (MAR) for February 2023, March 2023, April 2023, and May 2023 revealed Resident #2 received the antibiotic trimethoprim 50 mg daily. Review of Resident #2's Pharmacy Recommendations revealed on 03/08/22 the pharmacist recommended the physician consider discontinuing the trimethoprim 100 mg one time daily for urinary tract infection (UTI) prophylaxis due to the urine culture dated 01/12/22 showing Staphylococcus aureus was resistant to trimethoprim. The physician responded on 03/29/22 disagreeing with the recommendation stating it would prevent other pathogens. No further reasoning for continued use was found. Review of the Infection Prevention and Antibiotic Stewardship log for February 2023, March 2023, and April 2023 revealed Resident #2 was on trimethoprim from 12/19/21 indefinitely. Review of Resident #2's 12/16/22 urinalysis results revealed Resident #2 had a urinary tract infection with the organism enterococcus faecalis that was sensitive to ampicillin, nitrofurantoin, penicillin, tetracycline, and vancomycin. Review of Resident #2's 03/15/23 urinalysis results stated mixed skin flora was found and no sensitivity was completed. Review of Resident #2's 04/26/23 urinalysis completed at the hospital revealed Resident #2 had no urinary tract infection. Review of Resident #2's Infection Screening Evaluations dated 10/20/22, 12/15/22, 02/13/23, 03/15/23 and 04/21/23 revealed Resident #2 had no infectious disease concerns. Resident #2 had no active diagnosis of infection at the time of the reviews. Resident #2 also did not have any signs or symptoms of infection and did not meet infection criteria. Interview on 05/04/23 at 1:49 P.M., Infection Preventionist (IP) #356 revealed she was not sure why Resident #2 was still receiving trimethoprim. IP #356 verified there was no reason for the continued use of trimethoprim as Resident #2 had no history of infectious disease involvement, no signs or symptoms of of infection and no current monitoring for urinary tract infections (UTI) signs and symptoms being completed. IP #356 verified all Resident #2's infection screening evaluations reflected no infections. IP #356 reported all prophylactic antibiotic used was reviewed at the Quality Assurance meetings. IP #356 reported the physician discontinued all the other prophylactic antibiotics and she was not sure why Resident #2's were not discontinued. Interview on 05/04/23 with Registered Nurse (RN) #365 revealed Resident #2 last saw the urologist in November of 2021 and was scheduled to see the urologist again 05/11/23 at 10:40 A.M. RN #365 reported she spoke with Resident #2's physician and he indicated he wanted to continue the use of the prophylactic antibiotic for Resident #2. RN #365 verified there was no written documentation supporting the continued justification of need. Review of the facility policy titled Antibiotic Stewardship, revised October 2018, revealed prescribers were to document the dose, duration, and indication for all antibiotic prescriptions. The facility was to track, monitor antibiotic prescribing, use, and resistance.

Based on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure authorizations to open a Resident Trust account were signed by the resident. This affected two (Resident #3 and Resident #25) of six residents reviewed for Resident Trust accounts. The facility census was 58. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE]. Review of the Resident Fund Management Service Authorization revealed Resident #3's authorization to open a Resident Trust account was not signed by the resident, but was signed by a previous administrator of the facility on 10/20/20. 2. Review of the medical record for Resident #25 revealed a readmitted [DATE]. Review of the Resident Fund Management Service Authorization revealed Resident #25's authorization to open a resident trust account was not signed by the resident, but was signed by a previous administrator of the facility on 10/20/20. Interview on 05/03/23 at 3:55 P.M. with Business Office Manager (BOM) #332 confirmed the Resident Trust agreements were signed by a former administrator at the facility and no resident signature was on the form. Review of the undated Resident Trust Fund Policy and Procedure Manual revealed all residents that wish to have a resident fund must sign a Resident Personal Funds Authorization to be kept on file.

Based on medical record review and staff interview, the facility failed to provide written bed hold notification at the time of hospitalization . This affected one (Former Resident #9) of three residents reviewed. The facility census was 58. Findings include: Review of the medical record revealed Former Resident #9 was admitted on [DATE] and was discharged on [DATE]. Diagnoses included pneumothorax, traumatic hemothorax, multiple fractures of pelvis with stable disruption of pelvic ring, displaced intertrochanteric fracture of right femur, fracture of sacrum, chronic pulmonary insufficiency following surgery, multiple fractures of ribs left side, methicillin resistant staphylococcus aureus , nondisplaced fracture of greater trochanter of left femur, and fracture of lumbar vertebra. Review of the Minimum Data Set (MDS) assessment, dated 01/11/23, revealed Former Resident #9 was cognitively intact. Review of physician order, dated 01/11/23, revealed an order for left ankle surgical debridement scheduled for 01/11/23 at 6:00 A.M. Review of nurse's progress note, dated 01/11/23, revealed nonemergency transfer medical services arrived to transfer the resident to an appointment. Former Resident #9 was a four-assist slide transfer to stretcher. Former Resident #9's cell phone and charger was sent with the resident. The record revealed the resident did not return to the facility following the appointment on 01/11/23. Review of the Former Resident #9's medical record was silent of bed hold notification or attempts of notification. Interview on 03/20/23 at 11:34 A.M. with Social Services #201 revealed Former Resident #9 went to the hospital for outpatient surgery and she was admitted for 20 days. Former Resident #9 had a change in condition and the facility was not able to accept her back. Interview on 03/20/23 at 12:10 P.M. with the Administrator and Social Services #201 reported initially upon leaving the facility on 01/11/23 the resident had planned to return the same day but there were complications and she was hospitalized . The Administrator and Social Services #201 verified Former Resident #9 did not receive a bed hold notice once she was admitted to the hospital. This represents non-compliance investigated under Complaint Number OH00140419.

Based on staff interview review of the Self-Reported Incidents (SRI), and review of facility policy, the facility failed to complete a thorough investigation into allegations of abuse. This affected seven (#29, #53, #55, #61, #64, #72, and #73 of nine residents reviewed in SRIs for abuse. The facility census was 58. Findings include: Review of the facility's SRI revealed incident #227710 involved alleged physical abuse between Resident #53 and Resident #72. Review of the facility's SRI revealed incident #227569 involved alleged verbal abuse by Resident #53 toward Resident #61. Review of the facility's SRI revealed incident #226377 involved alleged physical abuse between Resident #64 and Resident #72. Review of the facility's SRI revealed incident #225771 involved alleged physical abuse between Resident #53 and Resident #73. Review of the facility's SRI revealed incident #225657 involved alleged physical abuse between Resident #53, Resident #55, and Resident #73. Review of the facility's SRI revealed incident #224976 involved alleged verbal abuse between staff and Resident #29. Interview on 02/14/23 at 1:53 P.M. with the Interim Administrator revealed the facility could not provide evidence, beyond what was uploaded into the OHAL Certification and Licensure website, of a thorough investigation into six SRIs (#227710, #227569, #226377, #225771, #225657, and #224976). Review of the undated facility policy titled Freedom from Abuse and Neglect Policy revealed under the heading Investigation at Bullet Point #2 the facility will thoroughly investigate all alleged violations and take appropriate actions. Bullet Point #3 revealed investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. The investigation will include, but is not limited to the following: All material and documentation of the pertinent data to the investigation is collected, maintained, and safeguarded by the facility. This was an incidental finding during the complaint investigation completed on 02/14/23.

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place as care-planned. This affected one (Resident #13) of three residents reviewed for falls. The facility census was 58. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of violent behavior, myocardial infarction, Alzheimer's disease, and lack of coordination. Review of the Minimum Data Set (MDS) assessments, dated 12/07/23 and 12/31/22, revealed Resident #13's cognition was not assessed. Resident #13 required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene. Further review revealed Resident #13 did not fall since the previous assessment. Review of the medical record for Resident #13 revealed she fell on [DATE] when attempting to get up from the toilet. An intervention was developed, and added to the care plan, for staff to maintain direct visualization of Resident #13 while she was using the bathroom. Continued review of the medical record for Resident #13 revealed she fell on [DATE]. Resident #13 stated she fell when attempting to ambulate to the bathroom. An intervention was developed, and added to the care plan, to place a floor mat next to her bed. Review of the current care plan for Resident #13 revealed she was at risk for falls. Interventions included applying a mat on the floor beside the bed while the resident was in bed, updated 01/23/23. Observation on 02/13/23 at 11:47 A.M. revealed Resident #13 was not in her room, and no floor mat was observed in her room or bathroom. Observation on 02/13/23 at 3:13 P.M. with the Administrator revealed Resident #13 lying in bed. No floor mat was next to the bed. Interview with the Administrator at the time of the observation on 02/13/23 at 3:13 P.M. verified Resident #13 did not have a floor mat by the bed. Review of the facility policy titled Falls and Fall Risk, Managing, revised March 2018, revealed the staff will implement a resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00139929.

Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure oxygen was provided per the physician's order. This affected one (Resident #16) of three residents reviewed for oxygen use. The facility census was 58. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses of heart failure, morbid obesity, and need for assistance with personal care. Review of the comprehensive Minimum Data Set assessment, dated 01/18/23, revealed Resident #16 had intact cognition and received oxygen. Review of a physician order dated 01/12/23 revealed Resident #16 should receive oxygen at four liters via nasal cannula every shift. Review of the current care plan revealed Resident #16 had shortness of breath related to voicing, related to congestive heart failure and fluid retention. Interventions included applying oxygen as ordered. Observation on 02/13/23 at 8:40 A.M. revealed Resident #16 sitting in a wheelchair with a nasal cannula in place. Further observation revealed Resident #16's oxygen concentrator had a scale from zero to five, and Resident #16's concentrator was set above five (liters per minute). Interview at that time with Resident #16 revealed no concerns regarding respiratory care or the oxygen settings on her concentrator. Observation on 02/13/23 at 3:14 P.M. revealed Resident #16 lying in bed with a nasal cannula in place. Further observation revealed her oxygen concentrator was set at five liters. Observation and interview with the Interim Administrator on 02/13/23 at 3:14 P.M. confirmed Resident #16's oxygen concentrator was set at five liters. Interview on 02/14/23 at 9:26 A.M. with Licensed Practical Nurse #202, who cared for Resident #16 on 02/13/23, revealed she did not know why Resident #16's oxygen concentrator was set at five liters and it should not have been set at that rate. Review of facility policy titled Oxygen Administration, revised October 2010, revealed the facility should review the physician's order for oxygen administration prior to administering oxygen. This deficiency represents non-compliance investigated under Complaint Number OH00139929.

Based on observation, resident interview, observation of resident phone call logs, and staff interview, the facility failed to ensure the phone was answered in a timely manner. This affected all residents in the facility. The facility census was 58. Findings include: Observation on 02/13/23 at approximately 7:50 A.M. revealed the facility front door was locked and no staff were visible through the door. The surveyor called the facility at 7:51 A.M. The phone rang four times and then went to voicemail. The surveyor called the facility at 7:52 A.M. The phone rang four times and the surveyor left a message. Observation during that time revealed an unidentified staff walking through the front lobby, not answering the phone. The surveyor called the facility at 7:53 A.M. and the phone rang four times and the surveyor left a message. As the surveyor was leaving the message, a staff member unlocked the door and allowed entrance to the facility. The staff member responded after the third ringing of the front doorbell by the surveyor. Interview on 02/13/23 at 8:22 A.M. with the Director of Nursing (DON) revealed the surveyor attempted to enter the facility during a medication pass time, which may have accounted for the lack of response to the phone. Interview on 02/13/23 at 4:13 P.M. with Resident #43 revealed he called the front desk twice on 02/09/23 at 10:46 P.M. in an attempt to get assistance for a resident across the hall who said she fell . Concurrent observation of his recent calls on his cell phone confirmed two calls were placed to the facility at that time. He stated staff answered the phone the second time he called. Interview on 02/14/23 at 10:00 A.M. with the DON confirmed the surveyor's voicemails from 02/13/23 were transmitted to her email in real-time. The DON stated staff do not take the portable phone with them when away from the desk because residents use the portable phone to make calls. Interview on 02/14/23 at 10:27 A.M. with the husband of Resident #71 revealed he attempted to call the facility on 02/11/23 and was unable to reach staff. He stated he did not leave a message. He intended to update the facility on Resident #71's status as she was being admitted to the hospital. Interview on 02/14/23 at 10:36 A.M. with the DON revealed voicemails left on the facility phone become audible emails sent to administrative staff. The DON verified a voicemail was left on 02/11/23 at 4:31 P.M. by Resident #15's husband. This deficiency represents non-compliance investigated under Complaint Number OH00135668.

Based on observation, record review, resident and staff interview, the facility failed to provide adequate supervision when a facility staff member microwaved a food item for a resident and served the food on a heated glass plate. This resulted in actual harm when Resident #1 sustained a burn from a heated glass food plate that was placed on Resident #1's abdomen. This affected one (#1) of four residents reviewed for supervision. The census was 61. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a nursing progress note dated 10/22/15 at 2:00 A.M., revealed Resident #1 asked staff to warm up his food on a glass plate. Resident #1 was sitting up in bed and had no shirt on. Resident #1 sat the plate on his upper abdominal area and later showed staff member a 5 centimeter (cm) by 10 cm reddened circular area on his abdomen. Resident #1 stated it was from the plate. The physician was notified and ordered a treatment of [REDACTED]. Review of the facility incident report log revealed an entry dated 10/22/15 at 2:00 A.M. indicating Resident #1 sustained a burn. The description of the incident indicated Resident #1 sat his hot plate on his abdomen. Observation on 11/22/15 between 10:15 A.M. and 12:00 P.M. of Resident #1's abdomen revealed an approximately ten cm by ten cm dressing covering a portion of his upper abdomen. Resident #1 removed a portion of the dressing at 10:15 A.M. and revealed two separate burns: one burn was a crescent-shape burn approximately 10 cm long and approximately a 1.25 cm wide, and the other burn was oval-shape an approximately 7.5 cm wide and approximately 2.5 cm high. The crescent-shape burn was oriented above the oval-shape burn on Resident #1's abdomen. Each burn was observed to have a yellow slough area in the center, with the edges of the burns being reddened and raised. The skin between the burns were dark pink in color. Further observation of Resident #1 revealed he had a music playing device resting on his abdomen connected to ear phones which were not in his ears. Interview on 11/22/15 at 8:17 A.M., with Registered Nurse (RN) #20 stated Resident #1 likes to eat snacks throughout the day, and frequently asks staff to heat food items up for him. RN #20 also stated Resident #1 puts everything on his abdomen. RN #20 stated Resident #1 still has burns on his abdomen. Interview on 11/22/15 at 9:47 A.M., with State tested Nursing Aide (STNA) #32 stated Resident #1 almost always eats in his room, and has witnessed Resident #1 place items on his abdomen including food items. Interview on 11/22/15 at 10:11 A.M., with Resident #1 stated he asked a staff member to warm up food for him in the microwave. Resident #1 stated the food was on a regular glass plate and the staff member put it on his abdomen. Resident #1 stated he is paralyzed from his chest down to his feet so he could not feel the heat of the plate. Resident #1 stated after he was done eating, he removed the plate from his abdomen and saw it burned him. Interview on 11/22/15 at 2:56 P.M., with Licensed Practical Nurse (LPN) #40 stated she was working the night Resident #1 was burned. LPN #40 stated a staff member heated food up on a glass plate in the treatment room at the end of the hallway. LPN #40 stated she was having a conversation with the staff members and observed the staff member remove the plate from the microwave, place it on the counter for a few minutes, and took it to Resident #1's bedroom. LPN #40 stated she did not recall if the plate was taken to Resident #1's bedroom on a tray or how the staff member handled the food. LPN #40 stated she did not observe the staff member serve the plate to Resident #1. LPN #40 stated she created the incident report on 10/22/15 when Resident #1 showed her a burn on his abdomen he stated was from the glass plate. LPN #40 stated Resident #1 often puts food items on his abdomen because he has computer items on his bedside table. This deficiency substantiates Complaint Number OH 596.

Based on observation, medical record review, staff and resident interviews, review of facility policy, in-service records, employee files, a self-reported incident (SRI), and review of a police report, the facility staff failed to immediately report an allegation of resident to resident sexual abuse to the administrator of the facility, take action to protect the residents after an allegation of abuse was made, and immediately initiate an investigation into the incident. This resulted in immediate jeopardy for one (#15) of four residents reviewed for alleged sexual abuse and 37 additional residents (#18, #25, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63) who live on the locked unit where the alleged perpetrator resided. The facility census was 76. On 08/20/12 at 12:29 P.M., the Administrator, Director of Nursing (DON), Registered Nurse #213 (Unit Manager of Pathways), and Corporate Consulting Nurse #1 were notified that Immediate Jeopardy began on 08/13/12 at 10:00 P.M. when Resident #15 voiced an allegation that Resident #20 attempted to get oral sex from him. Resident #15's allegation of sexual abuse was reported to Licensed Practical Nurse (LPN) #183, the charge nurse on duty. LPN #183 failed to immediately report the allegation of sexual abuse to administrative staff, take action to ensure protection of the alleged victim and other residents on the secured unit, and immediately initiate an investigation into the incident. The Immediate Jeopardy was removed on 08/14/12 at 3:15 P.M., when the alleged perpetrator (Resident #20) was placed on one to one monitoring. The deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 08/16/12 at 4:00 P.M., when the facility implemented the following corrective action: ? On 08/14/12 at 1:00 P.M., the facility initiated an investigation of the alleged sexual abuse and submitted the 24 hour preliminary report to the survey agency. ? On 08/14/12 at 3:15 P.M., the facility placed the alleged perpetrator (Resident #20) on one to one monitoring. ? On 08/14/12 at 3:30 P.M., the DON began in-servicing staff on abuse reporting, protection and investigation. The charge nurse (LPN #183) was placed on suspension pending the investigation. ? On 08/14/12 at 4:12 P.M., the facility contacted the local police department to report the alleged incident of sexual abuse. ? On 08/14/12 the facility interviewed all 38 residents on the unit for any incidents of advances toward them, if the residents felt afraid while residing at the facility and knowledge of what to do if they felt afraid or uncomfortable. ? On 08/15/12 at 1:00 P.M. and 2:00 P.M., the facility held resident council meetings with the residents in the facility to explain abuse and how to report it if a resident feels abused. ? On 08/16/12, LPN #183 was terminated from the facility for violation of the facility's abuse policy and procedures. The facility reported LPN #183 to the State Board of Nursing. ? On 08/16/12 at 12:45 P.M., the alleged perpetrator was discharged from the facility. ? On 08/16/12 at 4:00 P.M., the facility concluded in-servicing all staff currently working in the facility. Staff on medical leave and vacation will not be allowed to return to work until they have been in-serviced on abuse reporting, protection and investigation. Findings include: Review of the medical record of Resident #15 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the secured unit upon admission to the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had short and long term memory problems with moderately impaired decision making skills and was totally dependent on one to two staff members for activities of daily living (ADL). The resident displayed inattention and disorganized thinking during the assessment time frame. The resident also displayed behaviors of physical and verbal aggression toward others. Review of the medical record of Resident #20 revealed an admitted to the facility on [DATE]. The resident had multiple medical diagnoses. The facility was informed upon admission, by Resident #20's brother, that Resident #20 was a registered sex offender, which the facility had confirmed through the Attorney General's Office website, OffenderWatch. Resident #20's admitting MDS assessment, dated 01/04/12, identified deficits in temporal orientation and recall ability. There were no behaviors coded. He was totally dependent requiring extensive assists for most ADLs. Resident #20's most recent quarterly MDS assessment, dated 07/05/12, indicated he had improved cognition, with a deficit in one area of recall. Resident #20 had verbal behaviors directed toward others less than daily (4-6 days of 14 days). He was also assessed to reject evaluation and care one to three days. Resident #20 needed extensive assist for his ADLs. The medical record documented Resident #20 was transferred to the facility's 'Pathways' unit on 07/05/12 due to "aggressive verbal behaviors" toward staff and "asking other residents for money". He was resistant to the transfer and the local police were called for assistance. Review of nurse's notes on 07/25/12 at 6:30 P.M., revealed Resident #20 was observed in his room inappropriately touching a female resident (#18). When Resident #20 was questioned by LPN #187, Resident #20 stated he was only rubbing Resident #18's back. The nurse informed Resident #20 to keep his hands to himself. Resident #20 became agitated and stated "I wasn't doing anything sexual." Nurse's notes dated 07/26/12 at 10:00 P.M., revealed Resident #20's room was changed to reside in the room with Resident #15. Resident #20 was not happy with the move to the new room. Resident #20 was informed that his room was changed due to his behavior the previous night and the need for closer supervision. The psychiatrist evaluated the resident on 07/28/12 and ordered [MEDICATION NAME] (female hormone replacement medication) 10 milligrams (mg) daily for "sexual obsession". Review of the nurse's notes dated 08/06/12 at 5:45 A.M. and 08/11/12 at 4:00 P.M. and 9:30 P.M. revealed Resident #20 was observed masturbating in the hallway or with the door open to the room. Review of Resident #20's nurses' notes and behavior tracking forms from 08/09/12 through 08/16/12 revealed the resident exhibited persistent self-stimulation (public masturbation). Review of Resident #20's nurse's notes dated 08/13/12 at 10:30 P.M. revealed Resident #15 stated to State tested Nurse Aides (STNAs) #151 and #129 that Resident #20 came over and put his (#15's) side rail down. LPN #183 attempted to talk to Resident #20 about it, and Resident #20 would not respond and kept his eyes closed. Review of Resident #15's nurse's notes dated 08/13/12 revealed the last entry was at 5:45 P.M. and lacked any documentation of an incident on 08/13/12. On 08/14/12 at 8:00 A.M., nurse's notes indicated Resident #15 was up in the wheelchair per staff and to the dining room for breakfast. The resident was yelling at intervals and swearing at staff. The resident was redirected with short term results. At 2:30 P.M. the resident was transferred to a different room due to allegations of inappropriate sexual abuse. Review of social service notes dated 08/14/12 at 2:30 P.M., revealed Licensed Social Worker (LSW) #2 spoke with Resident #15 regarding an incident that occurred that morning. Resident #15 reported that there was inappropriate behavior to him by his roommate. Reassurance was provided to Resident #15 and he was encouraged to report any further incidents. The social service note documented the resident was assured he did nothing wrong and was not in trouble regarding this incident. The resident was speaking freely of the incident using foul language in regards to the roommate (Resident #20). At 3:03 P.M., LSW #2 documented the resident verbalized being upset with his roommate and he is not returning to his room this afternoon, possibly because he is concerned of future incidents. Resident #15 was moved to a new room on this date. Review of the facility's investigation and witness statements revealed on 08/14/12 at 2:30 P.M., the DON interviewed STNA #159 who stated she was informed by the night shift STNA's that Resident #20 had put down Resident #15's side rail and asked Resident #15 for "oral sex." Resident #15 stated "he hated his roommate and he is sick." Further review of the facility's witness statements revealed on 08/14/12 at 4:00 P.M. and 6:00 P.M., the DON interviewed STNA #151. STNA #151 stated at 10:00 P.M. on 08/13/12, Resident #15 was heard yelling. STNA #129 went into the room and Resident #15's side rail was down. Resident #15 stated, "he makes me blow job, I'm scared, I'm not gonna fight." STNA #129 went and got LPN #183, the charge nurse, who then came to the room. LPN #183 questioned Resident #20, the roommate of Resident #15, and he would not respond. STNA #151 was questioned by the DON about the way Resident #15 looked when she entered the room. STNA #151 stated Resident #15 had his brief intact without signs of tampering. Review of the Police report dated 08/14/12 at 4:12 P.M. revealed the police were dispatched to the facility for an alleged incident of forced gross sexual imposition. Review of police statements dated 08/14/12 revealed Resident #15 stated that Resident #20 walked to his bed and pushed down his rail. Resident #15 stated he gave me "oral sex." I told him to stop and yelled for help. Resident #15 stated Resident #20 said he had a gun and I am scared of him. Review of the witness statement documented by LSW #2, dated 08/15/12, revealed Resident #15 was re-interviewed on this date. Resident #15 stated Resident #20 put his side rail down and asked him to suck his penis. Resident #15 stated he did not do that and called Resident #20 a "derogative name". Resident #15 stated Resident #20 opened his brief, touched him and gave him (oral sex) while he yelled "help, help." Nurse's notes dated 08/15/12 at 11:30 A.M. revealed Resident #15 was sitting in the dining room for lunch when another resident went by in a wheelchair. Resident #15 stated, "There is that (expletive) that wanted me to suck his penis". When Resident #15 was questioned about his comments, the resident again pointed at Resident #20 and stated, "He wanted me to suck his (penis) and wanted (oral sex). I should have killed the (profane name). I don't do those things." Resident #15 then finished eating lunch. At 12:30 P.M., Resident #15 complained about his new room and wants to move back to his old room. Resident #15 stated, "I hope they move that (profane name) out of my room." Nurse's notes dated 08/15/12 at 9:00 P.M. documented Resident #15 reported to the aide (unknown) the resident was told by Resident #20 that he had a gun and was going to kill him (Resident #15). LPN #183 interviewed Resident #15 confirming what the aide had reported to him. Resident #15 stated to LPN #183 that he was afraid to go to sleep. The nurse reassured Resident #15 that Resident #20 did not have a gun and was under constant supervision. Resident #15 stated he was feeling better. Review of facility investigation of witness statements revealed on 08/15/12 at 5:00 P.M., the DON interviewed LPN #193 (third shift charge nurse). LPN #193 stated when she came on duty at 11:00 P.M. on 08/13/12, the second shift charge nurse (LPN #183) stated Resident #15's side rail was found down and Resident #20 was observed masturbating in the hallway and in the room. LPN #183 reported that Resident #15 stated he was scared of Resident #20, and she medicated Resident #15 because he was upset. Review of the facility's investigation witness statements revealed on 08/15/12 at 8:00 P.M., the DON interviewed STNA #129. STNA #129 stated she and STNA #151 were together on 08/13/12 at 10:00 P.M. when Resident #15's side rail was found down. Resident #15 was stating, "No blow job." LPN #183 went into the room and questioned Resident #20 then left the room and never talked to Resident #15. Nurse's notes on 08/16/12, at 12:45 P.M., revealed Resident #20 was discharged from the facility. Review of the discharge papers for Resident #20 revealed he was discharged to a hotel in Fort Wayne, Indiana. The facility documented the reason for discharge as follows: The safety of individuals in the home is endangered and the health of individuals in the home would be otherwise endangered. A thirty day notice was not provided because "an emergency exists." Interview with Corporate Nurse Consultant #1 on 08/16/12 at 3:30 P.M., revealed she and the Administrator were in the Administrator's office on 08/14/12 around lunch time. Maintenance Director #3 was also in the office and as he was leaving he stated, "Did you hear about what Resident #20 did to Resident #15?" The Administrator responded, "No". Maintenance Director #3 stated he was told by STNA #159 that Resident #20 asked Resident #15 for sexual favors the previous night. The Administrator sent LSW #2 to interview Resident #15 and began the initial investigation. During an interview on 08/16/12 at 3:30 P.M., the administrator stated the investigation of Resident #15's sexual abuse allegation began when it was first reported to her by the maintenance man, a day after it was discovered by front-line staff. The facility, contacted the local police due to the nature of the allegation. The LPN (#183) was placed on suspension. Interview with Maintenance Director #3 on 08/16/12 at 3:40 P.M., revealed he was told by STNA #159 on 08/14/12 that Resident #20 was asking Resident #15 for sexual favors. He did not tell the Administrator until later on because he thought the administrator already knew. During interview with Resident #15 on 08/17/12 at 11:24 A.M., the resident stated he wanted to go to court against Resident #20 because he gave me a "blow job". Interview with Corporate Nurse Consultant #1 on 08/20/12 at 11:00 A.M. verified the abuse policy was not followed. On 08/20/12 at approximately 4:00 PM, the Administrator and Corporate Nurse Consultant #1 were interviewed together. They stated Resident #20 was alert and oriented times three (person, place, and time) and very competent. They stated he was aware of his actions. Interview on 08/21/12 at 12:45 P.M. with local Police Officer #312 revealed he was called to the facility for a complaint of sexual abuse between two residents. After interviewing staff and residents involved he stated he was unable to determine what had actually occurred between the two residents; therefore, he was unable to file criminal charges against Resident #20. The staff interviews corroborated the sexual abuse allegation occurred on 08/13/12 at approximately 10:00 P.M. The aides stated they told the nurse on duty. During an interview with STNA #151 on 08/21/12 at 1:55 P.M., she stated on 08/13/12 around 10:00 P.M., Resident #15 put his light on. STNA #129 and I walked to the room to answer the call light. Resident #15 was visibly upset and stated "he wanted (oral sex)." I told STNA #129 to get the nurse, while I stayed with the resident. STNA #129 and LPN #183 returned to the room and asked Resident #20 what his problem was. Resident #20 pretended to be asleep. LPN #183 left the room and never talked to Resident #15. STNA #151 stated Resident#15's brief was secured and he had no signs of anything happening. Resident #15 was scared and we told him we would be back to check on him throughout the night. When we checked on Resident #15 he was asleep but Resident #20 was masturbating. Interview with STNA #159 on 08/21/12 at 2:06 P.M. revealed she was working the day shift on 08/14/12. When she came on duty, the night shift STNAs (#151 and #129) reported Resident #15 said that Resident #20 asked him for sexual favors and they reported the incident to the nurse. Resident #20 was masturbating in the hallway most of the morning and had to be constantly redirected. When Maintenance Director #3 came down the hallway, I asked him to talk to Resident #20 about masturbating in the hallway. I also told him what the third shift STNA's told me they reported. During an interview with LPN #183 on 08/21/12 at 2:31 P.M., she verified she was working the night of the alleged incident but stated she was unaware of the alleged incident. In addition, she verified she was terminated from the facility on 08/16/12 because the administrative staff said she was aware and did not report the incident. Interview with LPN #193 on 08/22/12 at 10:05 A.M. revealed she worked from 11:00 P.M. to 7:00 A.M. on the night of 08/13/12. LPN #193 stated she was unaware of the alleged incidents that occurred between Resident #20 and Resident #15. LPN #183 only reported to LPN #193 that Resident #20 put down Resident #15's side rail. Review of the facility policy entitled "Abuse, Neglect and Misappropriation Policy", dated May 2011, revealed under the Investigation subtitle: The facility investigates different types of incidents. The facility identifies the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to proper authorities. The facility must ensure alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. Review of the subtitle of Protection in the abuse policy revealed: The facility protects the residents from harm during an investigation. The facility monitors the resident during this time for harm of psychosocial issues. Review of the subtitle of Reporting/Response in the abuse policy revealed: The facility must ensure that all alleged violations involving mistreatments, neglect or abuse are reported immediately to the administrator or his designated representative of the facility and to other official in accordance with the State Law through established procedures (including to the State survey and certification agency). Staff should report any abuse or suspected abuse to their supervisor immediately. This is an incidental deficiency found during the investigation of Complaint Number OH 804.

Based on medical record review, staff and family interviews, ombudsman interview, and review of facility policy, the facility failed to adequately prepare one resident for a community discharge and ensure the resident was safely discharged . This resulted in Immediate Jeopardy for one (Resident #20) of three residents reviewed for proper discharge from a total of six residents discharged in the past 60 days. Resident #20 was placed at risk for imminent danger of physical harm when the facility left him at a hotel without assisting him with arrangements for his significant ongoing medical needs. On 08/22/12 at 2:05 P.M., the Administrator, Director of Nursing (DON) and Corporate Nurse Consultant #1 were notified that Immediate Jeopardy began on 08/16/12 at 12:45 P.M. when Resident #20 was discharged and transported by facility staff to a hotel in Indiana without making any arrangements to assure the resident's medical needs were met. The resident was left at the hotel with a box that contained 33 prescription medications and was instructed to cleanse his suprapubic catheter (a tube that drains urine from the bladder) site daily as well as cleanse his [MEDICAL CONDITION] tube site, and apply a new dressing daily; all of which were done daily by nursing staff during his entire stay at the facility. Although Resident #20 was admitted to a hospital for psychiatric evaluation from the hotel (after police and family intervention), the Immediate Jeopardy remains ongoing as the facility has taken no action to ensure other residents with significant ongoing medical needs are safely discharged in the event of an emergency discharge. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. On 04/21/12, the psychiatrist added a [DIAGNOSES REDACTED]. Review of admission documentation revealed Resident #20's brother was his power of attorney and involved in the admission process. The resident had a suprapubic catheter and a [MEDICAL CONDITION] tube which he received [MEDICATION NAME] tube feeds for nutrition. Review of the most recent quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of nurse's note from 08/13/12 at 10:30 P.M. indicated Resident #20's roommate (#15) alleged Resident #20 was sexually inappropriate to him. Further review of Resident #20's nurses' notes and behavior tracking forms from 08/09/12 through 08/16/12 revealed the resident exhibited persistent self-stimulation (public masturbation). On 08/14/12 at 4:30 P.M., the nurse documented the Resident #20 was placed on 1:1 monitoring due to behavioral issues. Review of the nurse's note from 08/16/12 at 10:00 A.M., indicated the nurse discussed discharge instructions and explained medications and treatments to his [MEDICAL CONDITION] tube and catheter sites. The nurse documented the resident understood and had no questions. The resident then signed the discharge instructions and a copy was given to him. At 12:30 P.M., the nurse noted the resident's medications were reconciled, counted and sent with Resident #20. At 12:45 P.M., the resident was discharged from the facility and transported via the facility van to the out of state hotel. Resident #20 was discharged and transported from the facility to a hotel in Indiana without ensuring the resident's medical needs were met. The resident was left at the hotel with a box that contained 33 prescription medications and was instructed to cleanse his suprapubic catheter (a tube that drains urine from the bladder) site daily as well as cleanse his [MEDICAL CONDITION] tube site (feeding tube) and apply a new dressing daily, all of which were done by nursing staff prior to his discharge. Review of the discharge notice dated 08/14/12, although the resident was not discharged until 08/16/12, indicated the reasons for discharge were the safety of individuals in the home was endangered, the health of individuals in the home would be otherwise endangered, and Resident #20's health had improved sufficiently and no longer needed the services of the facility. A 30 day discharge notice was not provided because the facility documented "an emergency exists." The discharge notice indicated Resident #20 was discharged to a hotel in Indiana. Further review of the discharge notice revealed the administrator documented the name, telephone number and address of the Ombudsman which were all incorrect. In addition, the resident was provided a list of community resources which was broad and did not indicate what agencies might be helpful for Resident #20. The discharge notice contained no physician contact information for him to call if needed. The resident was given discharge instructions that included a list of 33 prescription medications, including antipsychotic, antidepressants, antianxiety, a blood thinner, heart medication, respiratory medication and [MEDICAL CONDITION] medication. The discharge instructions also indicated the resident was to clean around the [MEDICAL CONDITION] tube site and suprapubic catheter daily, which the resident has not done for himself since he was admitted to the facility on [DATE]. The resident was not instructed to flush his [MEDICAL CONDITION] tube to maintain patency. Resident #20's medication administration and treatments were all provided by nursing staff from the time the resident was admitted until he was discharged . The discharge instructions also instructed the resident to register himself as a sex offender with the county law enforcement and to call to switch to Indiana Medicaid. Review of a social service progress notes from Licensed Social Worker (LSW) #2 dated 08/16/12 at 3:07 P.M. revealed arrangements were made for Resident #20 to be discharged this date to a hotel in Indiana and that all expenses were paid by the facility's company for the remainder of this month. The resident was informed of this agreement and all medications were sent with him along with instructions on times to take them. LSW #2 noted information was given to him on registering as a sex offender and how to apply for Indiana Medicaid. A copy of his driver's license and social security card was provided and bank statements were given to him from his business file from the facility so he would have the information to apply for Medicaid. During interview on 08/20/12 at 11:10 A.M., LSW #2 verified Resident #20 was discharged to a hotel in Indiana. She also verified the resident's brother who was his power of attorney and responsible person was not involved in the discharge planning. LSW #2 stated a registered letter was sent to him after the fact. On 08/20/12 at 2:12 P.M., Resident #20's brother was interviewed by phone. He verified the facility did not notify him of the emergency discharge until after the discharge had occurred. He indicated he was notified on 08/14/12 that the resident had displayed inappropriate behavior and needed to be moved but the facility did not indicate they were going to "dump him in Fort Wayne, Indiana." He stated he received a call from the administrator of the facility on 08/16/12 that Resident #20 had been moved to a hotel in Fort Wayne, Indiana. A few hours later he received a call from the Indiana police department that Resident #20 had been seen masturbating in his window in front of a woman and her child and then in the hallway. He vehemently stated Resident #20 had not taken any medication since he had left the facility. The facility was unable to provide documented evidence that Resident #20 had been assessed prior to discharge to ensure the resident was capable of caring for himself. There was no assessment completed to determine if the resident could complete the daily treatments to his suprapubic catheter site and [MEDICAL CONDITION] tube site. In addition, there was no assessment to indicate the resident was capable of self-administering his medication. Review of the facility's discharge planning policy, dated May 2011, indicated a discharge plan is used to assist the resident in preparing for discharge and to address continuing care needs after discharge. "This deficiency substantiates Master Complaint Number OH 920 and Complaint Number OH 911."

Based on medical record review, interviews with staff, family, a police officer and the Ombudsman, and review of the facility's discharge policy, the facility neglected to provide a safe discharge for one resident (#20) who was issued an emergency discharge to the community. This resulted in Immediate Jeopardy for one (#20) of three residents reviewed for proper discharge from a total of six residents discharged in the past 60 days. Resident #20 was placed at risk for imminent danger of physical harm when the facility left him at a hotel without assisting him with arrangements for his significant ongoing medical needs. On 08/22/12 at 2:05 P.M., the administrator, Director of Nursing (DON) and Corporate Nurse Consultant #1 were notified that Immediate Jeopardy began on 08/16/12 at 12:45 P.M. when Resident #20 was discharged and transported by facility staff to a hotel in Indiana without making any arrangements to assure the resident's medical needs were met. The resident was left at the hotel with a box that contained 33 prescription medications and was instructed to cleanse his suprapubic catheter (a tube that drains urine from the bladder) site daily as well as cleanse his [MEDICAL CONDITION] tube site, and apply a new dressing daily; all of which were done daily by nursing staff during his entire stay at the facility. Although Resident #20 was admitted to a hospital for psychiatric evaluation from the hotel (after police and family intervention), the Immediate Jeopardy remains ongoing as the facility has taken no action to ensure other residents with significant ongoing medical needs are safely discharged in the event of an emergency discharge. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. On 04/21/12, the psychiatrist added a [DIAGNOSES REDACTED]. Review of admission documentation revealed Resident #20's brother was his power of attorney and involved in the admission process. Resident #20 was hospitalized prior to his 12/29/11 admission to the facility. Resident #20's medical record included a "Transcription Report" dated 12/17/11, which indicated the resident was found unresponsive at home by his home health nurse on 12/13/11 and transferred to the hospital with a blood sugar of 15 (normal is 80 to 120). During his hospitalization , a [MEDICAL CONDITION] feeding tube was inserted. His mental status was altered and he had a [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The resident utilized a wheelchair for mobility and had a suprapubic catheter. The assessment also indicated the resident had shortness of breath with exertion. He was at risk for the development of pressure ulcers and had a pressure relieving mattress to the bed. The assessment further noted Resident #20 had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) during four to six days of the assessment period. He also had a behavior of rejection of care for one to three days during the assessment period. The resident received antipsychotic, antianxiety and antidepressant medication for the last seven days of the assessment period. Under the section of discharge planning, the assessment indicated there was no active discharge planning for the resident to return to the community. An assessment dated [DATE] indicated the resident did not self-administer his own medications. Review of Resident #20's care plans, initiated on 01/16/12, revealed the resident had a care plan in place to address uncontrolled/potentially uncontrolled blood sugars related to [DIAGNOSES REDACTED]. The resident had a care plan to address his risk for altered nutrition and dehydration and he required tube feeding for nutritional support secondary to failure to thrive and [MEDICAL CONDITION], dysphagia and recent significant weight loss. There was a care plan in place to address the resident's anti-platelet medication ([MEDICATION NAME]) related to the need to promote adequate circulation. He had a care plan for falls prevention because he was at risk for falls characterized by a history of falls/injury and risk factors of confusion, deconditioning (loss of muscle tone) and pain. A care plan was in place to address the resident's potential for altered cardiovascular status related to coronary [MEDICAL CONDITION] and history of [MEDICAL CONDITION] infarction. Due to Resident #20's history of [MEDICAL CONDITION], a care plan was developed to address the resident's [DIAGNOSES REDACTED]. The resident also had a care plan in place for verbal and physical aggression related to cognitive impairment, [DIAGNOSES REDACTED]. There was a care plan for his fluctuating cognitive state/progressive cognitive deficit with short and long term memory deficit, moderate to severe impaired decision making related to dementia and history of chronic illness. Resident # 20's medical record contained documentation the resident was hospitalized for [REDACTED]. He was also hosptalized on [DATE] through 04/19/12 for [MEDICAL CONDITION] and again on 05/19/12 through 06/05/12 for [MEDICAL CONDITION]. Review of the August 2012 monthly physician orders [REDACTED]. The [MEDICAL CONDITION] tube also required flushing with 60 milliliters (ml) of water every four hours and the site was to be cleansed and covered with a "T-Sponge" every day. In addition, the physician ordered the resident's suprapubic catheter to be changed every four weeks, change catheter bag every two weeks, change the dressing around the catheter site every day and provide catheter care every shift. The resident also had an order for [REDACTED]. Nurses' notes from 07/22/12 at 2:30 P.M. revealed Resident #20's suprapubic catheter was not draining and the resident's abdomen appeared distended. The nursing staff was unable to irrigate the catheter. The physician was notified and ordered to change the catheter; however, the nurses were unable to remove the old one so the resident was sent to the hospital to have the suprapubic catheter changed. On 07/25/12, Resident #20 was observed in his room inappropriately touching a female resident. The psychiatrist evaluated the resident on 07/28/12 and ordered [MEDICATION NAME] (female hormone replacement medication) 10 milligrams (mg) daily for "sexual obsession". The resident was transferred to another hall into another resident's room (Resident #15). Review of nurse's note from 08/13/12 at 10:30 P.M. indicated Resident #20's roommate (#15) alleged Resident #20 was sexually inappropriate to him. Further review of Resident #20's nurses' notes and behavior tracking forms from 08/09/12 through 08/16/12 revealed the resident exhibited persistent self-stimulation (public masturbation). On 08/14/12 at 4:30 P.M., the nurse documented Resident #20 was placed on 1:1 monitoring due to behavioral issues. Review of the nurse's note from 08/16/12 at 10:00 A.M. indicated the nurse discussed discharge instructions and explained medications and treatments to his [MEDICAL CONDITION] tube and catheter sites. The nurse documented the resident understood and had no questions. The resident then signed the discharge instructions and a copy was given to him. At 12:30 P.M., the nurse noted the resident ' s medications were reconciled, counted and sent with Resident #20. At 12:45 P.M., the resident was discharged from the facility and transported via the facility van. Review of the discharge notice dated 08/14/12, indicated the reasons for discharge were the safety of individuals in the home was endangered, the health of individuals in the home would be otherwise endangered, and Resident #20's health had improved sufficiently and he no longer needed the services of the facility. A 30 day discharge notice was not provided because the facility documented "an emergency exists." The discharge notice indicated Resident #20 was discharged to a hotel in Indiana. Further review of the discharge notice revealed the administrator documented the name, telephone number and address of the Ombudsman which were all incorrect. In addition, the resident was provided a list of community resources which was broad and did not indicate what agencies might be helpful for Resident #20. The discharge notice contained no physician contact information for him to call if needed. The resident was given discharge instructions that included a list of 33 prescription medications, including antipsychotic, antidepressants, antianxiety, a blood thinner, heart medication, respiratory medication and [MEDICAL CONDITION] medication. The discharge instructions also indicated the resident was to clean around the [MEDICAL CONDITION] tube site and suprapubic catheter daily, which the resident has not done for himself during his stay in the facility since 12/29/11. The resident was not instructed to flush his [MEDICAL CONDITION] tube to maintain patency. Resident #20's medication administration and treatments were all provided by nursing staff from the time the resident was admitted until he was discharged . The discharge instructions also instructed the resident to register himself as a sex offender with the county law enforcement and to call to switch to Indiana Medicaid. Review of telephone physician orders [REDACTED]. The physician telephone order dated 08/16/12 instructed to discontinue the Vitamin B12 ([MEDICATION NAME]) injections and discharge to the community. Review of a social service progress notes from Licensed Social Worker (LSW) #2 dated 08/16/12 at 3:07 P.M. revealed arrangements were made for Resident #20 to be discharged this date to a hotel in Indiana and that all expenses were paid by the facility's company for the remainder of the month. The resident was informed of this agreement and all medications were sent with him along with instructions on times to take them. LSW #2 noted information was given to him on registering as a sex offender and how to apply for Indiana Medicaid. A copy of Resident #20 ' s driver's license and social security card was provided and bank statements were given to him from his business file from the facility so he would have the information to apply for Medicaid. Review of a police report dated 08/16/12 at 7:48 P.M., approximately 12 hours after discharge from the nursing facility, revealed the Indiana police department received a call at 7:44 P.M. from the hotel where Resident #20 was taken to. The report indicated an older male/white (later identified as Resident #20) was reported to be naked and masturbating in front of his hotel window and then in the hallway. This was observed by a hotel employee and her daughter. When police arrived, Resident #20 was observed in his room with the door partially opened and still without clothing. The police report noted he was an elderly, handicapped man in a wheelchair, had an "IV" in his side (later identified as his feeding tube), and his hands were shaking. The report indicated Resident #20 stated he was from a nursing home in Williams County and he was just at the hotel until he could be transferred to a nursing home in Fort Wayne, but did not know the name of the nursing home. He also told the police officers that facility staff that had brought him to the hotel. The police officer documented they were going to arrest Resident #20 for indecent exposure but unfortunately due to his medical condition, health problems and age, that was impossible. He was not allowed to remain at the hotel and police arranged a room for him at another hotel until his brother arrived the next day (08/17/12). A second police report was filed on 08/17/12 at 11:07 A.M. The police were called to the hotel by Resident #20's brother. Resident #20 told the police officer that he had not taken his medications today because "someone usually administers it for him and he did not know what to take and when." The police officer informed Resident #20 that since he had not taken his medication, he was going to take him to the hospital for evaluation. During interview on 08/20/12 at 11:10 A.M., LSW #2 verified Resident #20 was discharged to a hotel in Indiana. She also verified the resident's brother who was his power of attorney and responsible person was not involved in the discharge planning. LSW #2 stated a registered letter was sent to him after the fact. On 08/20/12 at approximately 4:00 P.M., the administrator and Corporate Nurse Consultant #1 were interviewed. They stated the resident was alert and oriented to person, place, and time and very competent. The resident voiced desire to go to Indiana and knew what he was doing. The administrator stated he made arrangements to place Resident #20 in a handicapped accessible room with a kitchenette in a hotel in Indiana. The corporate nurse consultant stated they had planned an emergency discharge but Resident #20 wanted to go so he signed the discharge notice. They further stated the rent at the hotel was paid through the end of the month of August and he was given money for food. He was also given information for the local police department to report his sex offender status. He was given the remainder of his medication and instruction for use. They also indicated Resident #20 was given a printout of community resources and financial information to aid him in applying for public assistance. During interview on 08/20/12 at approximately 4:15 P.M., Corporate Nurse Consultant #1 verified there had been no attempts prior to discharge to assess Resident #20's ability to self-medicate. She verified the resident was sent with all his medications which included 33 prescriptions. On 08/20/12 at 2:12 P.M., Resident #20's brother was interviewed by phone. He verified the facility did not notify him of the emergency discharge until after the discharge had occurred. He indicated he was notified on 08/14/12 that the resident had displayed inappropriate behavior and needed to be moved but the facility did not indicate they were going to "dump him in Fort Wayne, Indiana." He stated he received a call from the administrator of the facility on 08/16/12 that Resident #20 had been moved to a hotel in Fort Wayne, Indiana. A few hours later, he received a call from the Indiana police department that Resident #20 had been seen masturbating in his window in front of a woman and her child and then in the hallway. He stated Resident #20 had not taken any medication since he had left the facility. On 08/21/12 at 9:50 A.M., the Ombudsman was interviewed by phone. He stated he was not made aware of Resident #20's discharge until he talked with the surveyor on 08/17/12. He then talked to the facility's social worker and confirmed the discharge. During a telephone interview with Police Officer #315 on 08/22/12 at 10:45 A.M., he stated that on 08/16/12 at approximately 7:48 P.M., the hotel manager called to report a hotel guest was masturbating in a window and the hallway. When officers arrived, they found Resident #20 in his room with no clothing. He indicated the male guest was confused. He verified there were many medications in the room but the guest had stated he did not know how to take them. Police Officer #315 stated the guest's brother was contacted and informed them he (Resident #20) had been in a nursing home but because of problems there, he was dumped at that hotel. The officer indicated the brother was able to get him admitted to a psychiatric hospital on [DATE]. On 08/22/12 at 2:10 P.M., after sharing the Immediate Jeopardy recommendation, Corporate Nurse Consultant #1 stated the facility had done nothing wrong in discharging Resident #20 to the hotel Indiana. The nurse indicated the resident could read, write, and open packages, therefore he could administer his own medications. On 08/23/12 at 9:30 A.M., an additional phone interview with Resident #20's brother revealed that when he talked to the police on 08/16/12, he had informed them he could not get to Fort Wayne, Indiana until the next day. On 08/17/12, he called the police for assistance in case Resident #20 refused to go with him. The brother stated he was very concerned because he had gone without his medication for almost 24 hours. He indicated Resident #20 was assessed at the emergency room and admitted to the hospital's behavioral unit for treatment. The brother also shared that prior to his hospitalization in December, 2011, he had home health services for eight hours per day, four hours in the morning to help him get dressed and four hours in the evening to get him ready for bed. The aide also prepared occasional simple meals and assisted with dressing due to the resident's [MEDICAL CONDITION]. Review of the facility's discharge planning policy, dated May 2011, indicated a discharge plan is used to assist the resident in preparing for discharge and to address continuing care needs after discharge. Review of the facility's policy entitled "Abuse, Neglect, and Misappropriation" dated 05/11, revealed neglect was defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. It means recklessly failing to provide a resident any treatment, care, goods, or services necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident. "This deficiency substantiates Master Complaint Number OH 920 and Complaint Number OH 911."