Every finding on record at Pearlview Rehab & Wellness CTR

Based on observation, interview, and review of facility policy, the facility failed to ensure food was stored, prepared and serviced in a sanitary manner. This had the potential to affect all 39 residents who received food from the kitchen excluding Resident #2 who was identified by the facility as having orders for nothing by mouth. The facility census was 40. Findings include: On 06/15/26 at 8:34 A.M., an observation of the kitchen revealed the following: Reach-in freezer #1 had no visible interior thermometer and there was significant ice build-up within the freezer including on food products. Reach-in freezer #2 had significant ice build-up within the freezer including on food products. The walk-in cooler had a dark colored substance spilled on the floor that was sticky and there were multiple areas of a dark colored fuzzy substance throughout the cooler including by the light fixture, in the corner to the left of the door, two areas above the door, behind the fan, and a line approximately two feet in length on the wall to the right of the door. The reach-in cooler had a container of ricotta cheese that expired on 06/03/26. The dry storage room had one loaf of moldy bread, multiple food items stacked on the floor including a case of marinara sauce with cases of pasta, syrup, and honey stacked on top of the marinara sauce, one case of toasted oats, one case of applesauce with a case of pasta stacked on top of the applesauce. In addition, there were cases of non-food items stacked on the floor including a case of Styrofoam cups with a case of lids stacked on top of the cups, and two cases of Styrofoam food containers with two cases of plastic utensils stacked on top of the containers. The floor throughout the kitchen was had a heavy coating of a sticky substance across the entire surface of the walking space of the floor that made it sticky to walk on. On 06/15/26 at 9:09 A.M., an interview with Dietary Aide (DA) #224 verified the findings in the kitchen. On 06/15/26 at 9:15 A.M., an interview with Dietary Manager (DM) #223 confirmed the findings in the kitchen. DM #223 said the two reach-in freezers were constantly in a state of defrost and she thought there was something wrong with the door seals. She said the food on the floor in dry storage was just delivered that morning and verified it sat directly on the floor. DM #223 confirmed the moldy bread and expired ricotta cheese, stating she must have missed those when she went through the kitchen cleaning it over the weekend. She verified the dark fuzzy substance throughout the walk-in cooler and stated she did not know what it was. DM #223 stated the sticky floor was a constant battle because it's a kitchen and things get spilled. Review of the facility's policy titled Environment, dated 09/2017, indicated all food preparation areas, food service areas, and dining areas would be maintained in a clean and sanitary manner. The policy indicated the dietary manager would ensure the floors, walls, ceilings, lighting, and ventilation were all maintained in a clean and sanitary manner. The dietary manager would ensure a routine cleaning schedule was in place for all cooking equipment, food storage areas, and surfaces. This deficiency represents non-compliance investigated under Complaint Numbers 2631483 and 2588125.

Based on personnel file review and staff interview, the facility failed to ensure that required staff orientation and performance evaluations were completed as part of the competency assessment process. This had the potential to affect all 40 residents residing in the facility. Findings include:Review of the personnel file for Certified Nursing Assistant (CNA) #220 revealed a hire date of 09/10/25. There was no evidence of CNA #220 completing an orientation, an initial skills evaluation, a 30-day performance evaluation, or a 90-day performance evaluation. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the findings in CNA #220's personnel file. The Administrator stated there was a lapse in human resources (HR) staff at the facility until the new HR person was hired in January 2026. This deficiency represents an incidental finding identified during the investigation of Complaint Number 3037008.

Based on review of maintenance records, observation and interviews, the facility failed to maintain kitchen equipment in proper working order. This affected all 39 residents who received food from the kitchen (except Resident #2 who was identified as having orders for nothing by mouth). The facility census was 40. Findings include: Review of the maintenance work orders revealed dietary staff reported the garbage disposal was not working on 07/21/25. The work order was set to completed on 08/29/25. Review of the repair quote dated 03/11/26 revealed the garbage disposal needed replacement. On 06/15/26 at 8:34 A.M., an observation of the kitchen revealed reach-in freezer #1 had significant ice buildup including on food products, reach-in freezer #2 had significant ice buildup including on food products, and the garbage disposal had a cover over it. On 06/15/26 at 9:09 A.M., an interview with Dietary Aide #224 verified the ice buildup in the freezers and the cover on the garbage disposal. Dietary Aide #224 stated the garbage disposal had been broken for a year, and the facility did not want to pay to fix it. On 06/15/26 at 9:15 A.M., an interview with Dietary Manager #223 verified the ice buildup in the freezers. Dietary Manager #223 said the two reach-in freezers were constantly in a state of defrost, and she thought there was something wrong with the door seals. On 06/16/26 at 8:06 A.M., an interview with Maintenance Director #206 confirmed the garbage disposal needed replacement. He stated they got a quote and it was not approved until 06/15/26. Maintenance Director #206 stated things were taking a while to get approved because the facility was being sold. This deficiency represents non-compliance investigated under Complaint Number 2631483.

Based on observations, review of facility maintenance records, and interviews, the facility failed to ensure the physical environment was maintained in a safe, sanitary condition. The facility did not address ongoing water intrusion and resulting deterioration of ceiling tiles in multiple resident use and common areas. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the maintenance work orders revealed staff reported a moldy ceiling tile in room [ROOM NUMBER] on 06/30/25 and ceiling tiles were wet and black in room [ROOM NUMBER] on 08/15/25. On 06/15/26 at 11:45 A.M., an observation of the facility revealed multiple ceiling tiles with visible brown colored water damage. In addition, several ceiling tiles had black discoloration including in hallway outside the Administrator's office, in hallway outside the business office, in hallway by room [ROOM NUMBER], and in hallway by room [ROOM NUMBER]. On 06/15/26 at 11:59 A.M., an interview with the Director of Nursing (DON) verified ceiling damage, stating the pipes in the ceiling sweat and that leaks onto the tiles. On 06/15/26 at 12:00 P.M., an interview with Maintenance Director #206 verified the water damaged ceiling tiles and stated he had to replace the ceiling tiles every two to three weeks due to the water damage. He denied that the black discoloration was mold. On 06/22/26 at 10:50 A.M., an interview with the contracted repairman who was observed installing new insulation on pipes in ceiling stated there was mold throughout the ceiling and metal parts were rusted through and falling out while he was trying to install the insulation. This deficiency represents non-compliance investigated under Complaint Numbers 2631483, 2588125, and 1366180 (OH00167045).

Based on record review, review of personnel files, review of the facility's background check log, interview, and review of facility policy, the facility failed to implement their abuse policy regarding screening potential employees through background and reference checks and maintaining evidence those screenings were completed. This affected all 40 residents residing in the facility. Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #220 revealed a hire date of 09/10/25. The personal reference check page contained the name and contact information for the references, however, there was no evidence the references were ever contacted. The unsealed envelope labeled confidential contained one blank sheet of paper and there was no evidence a background check had been completed. CNA #220's employment was terminated on 06/04/26 when law enforcement arrived to the facility and arrested CNA #220 for outstanding warrants. On 06/16/26 at 12:10 P.M., an interview with the Administrator verified CNA #220 did not have a background check completed. The Administrator stated when the incident occurred on 06/04/26, he pulled her personnel file and opened the confidential envelope to review her background check results only to find a blank piece of paper inside the envelope. On 06/16/26 at 12:35 P.M., an interview with Regional Nurse #217 stated the facility discovered the background check had not been completed for CNA #220 at the time of the incident on 06/04/26. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the reference checks were not completed for CNA #220. He said there was a lapse in Human Resources staff last year, including around the time of hire for CNA #220. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed screenings would be conducted for all potential employees including background checks, reference checks, and credential checks. The policy indicated the facility would maintain documentation of proof that the screenings occurred. 2. Review of the personnel file for the Director of Nursing (DON) revealed a hire date of 09/02/25. There was no evidence of a credentials check completed until 04/28/26, approximately eight months after hire. The personal reference check page contained the name and contact information for the references, however, there was no evidence the references were ever contacted. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the reference checks were not completed for DON and there was no evidence of a license verification prior to 04/28/26. He said there was a lapse in Human Resources staff last year, including around the time of hire for DON. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed screenings would be conducted for all potential employees including background checks, reference checks, and credential checks. The policy indicated the facility would maintain documentation of proof that the screenings occurred. 3. Review of the personnel file for Licensed Practical Nurse (LPN) #233 revealed a hire date of 08/20/25. The personal reference check page contained the names of the references, however, there was no contact information listed and no evidence the references were ever contacted. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the reference checks were not completed for LPN #233. He said there was a lapse in Human Resources staff last year, including around the time of hire for LPN #233. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed screenings would be conducted for all potential employees including background checks, reference checks, and credential checks. The policy indicated the facility would maintain documentation of proof that the screenings occurred. 4. Review of the personnel file for Registered Nurse (RN) #232 revealed a hire date of 08/08/25. The personal reference check page contained the names of the references, however, there was no contact information listed and no evidence the references were ever contacted. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the reference checks were not completed for RN #232 He said there was a lapse in Human Resources staff last year, including around the time of hire for RN #232. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed screenings would be conducted for all potential employees including background checks, reference checks, and credential checks. The policy indicated the facility would maintain documentation of proof that the screenings occurred. 5. Review of the facility's background check log revealed it did not include former employees or applicants. On 06/16/26 at 4:10 P.M., an interview with the Administrator verified the background check log was incomplete because it only contained information for current employees. On 06/22/26 at 2:20 P.M., an interview with Business Office Manager (BOM) #202 stated when he started his position in January 2026, there was no background check log so he had to create one from scratch for all current employees. He further stated a couple employees had to be re-fingerprinted because they were hired in the 1980s and did not have electronic fingerprints on file. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed screenings would be conducted for all potential employees including background checks, reference checks, and credential checks. The policy indicated the facility would maintain documentation of proof that the screenings occurred. This deficiency represents non-compliance investigated under Complaint Number 3037008.

Based on review of the facility's self-reported incident (SRI), facility investigation review, review of police reports, interviews, and review of facility policy, the facility failed to conduct a thorough investigation of an allegation of misappropriation of resident social security numbers. This had the potential to affect all 40 residents residing in the facility. Findings include:Review of the police report dated 06/04/26 at 5:29 P.M. revealed local law enforcement was dispatched to the facility regarding an anonymous tip that Certified Nursing Assistant (CNA) #220 had multiple felony warrants. CNA #220 was arrested at the facility and transported to jail. Review of the facility's self-reported incident (SRI), tracking number 275348, dated 06/04/26 revealed local law enforcement arrived to the facility asking to speak to CNA #220. Police revealed CNA #220 had an outstanding warrant for her arrest, arrested her, and removed her from the grounds. Police also notified the facility of an allegation that CNA #220 was stealing residents' social security numbers. There was no evidence the facility interviewed any staff regarding anyone accessing residents' information without authorization or suspicion of someone stealing social security numbers. The only staff statements were from the two staff members who interacted with the police officers upon their arrival to the facility and they did not include any information pertinent to the allegation made regarding social security numbers. In addition, there was no evidence that all resident power of attorneys (POAs) or guardians were notified of the allegation that social security numbers could be compromised. The facility's investigation included asking residents Has anyone in the building asked or talked to you about your social security number or other personal information? and Do you have any concerns regarding your personal information or missing personal papers or documentation? There was no indication that residents interviewed were notified of the allegation that social security numbers could be compromised or that residents/POAs were informed to monitor their financial data for discrepancies. There was also no evidence the facility conducted an audit to see if staff were accessing information without authorization. On 06/16/26 at 12:35 P.M., an interview with Regional Nurse #217 stated everything related to the facility's investigation of the incident with CNA #220 was provided. On 06/17/26 at 3:21 P.M., an interview with Director of Nursing (DON) confirmed all documentation for the facility's investigation of the incident were provided. Review of the Sherriff's Office booking history report dated 06/17/26 at 3:59 P.M. revealed CNA #220 was arrested due to probation violations from previous drug abuse charges and a warrant for theft. On 06/22/26 at 9:30 A.M., an interview with the Administrator verified the facility did not audit for staff access to residents' personal information. The Administrator also confirmed that no staff were interviewed regarding the allegation and POAs were not notified of the allegation. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occur. Procedures for investigations included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred; and providing complete and thorough documentation of the investigation. Review of the facility's policy titled Identity Theft, dated 2026, revealed personal information would be protected, including names and social security numbers. Any department or individual aware of, or who may suspect, a potential breach of security or compromise of computer systems containing personal information must immediately report such incidents to their Health Insurance Portability and Accountability Act (HIPAA) security officer and Administrator. The policy indicated the facility would decide whether or not notification to individuals was warranted. This deficiency represents non-compliance investigated under Complaint Number 3037008.

Based on record review, observation, and interviews, the facility failed to conduct initial tuberculosis testing upon hire for all staff, which had the potential to affect all 40 residents residing in the facility. In addition, the facility failed to ensure staff performed appropriate hand hygiene during incontinence care, affecting Resident #39, and failed to ensure staff did not handle ready-to-eat foods with bare hands while assisting Resident #37 with eating. The facility census was 40. Findings include: 1. Review of the personnel files for former Administrator #230, Certified Nursing Assistant (CNA) #220, and Registered Nurse (RN) #232 revealed there was no documented evidence tuberculosis (TB) testing was performed prior to hire. Review of the facility's TB risk assessment, dated 2026, revealed baseline TB skin testing would be performed for healthcare workers, healthcare workers would receive TB testing annually, and TB test records would be maintained by Human Resources (HR). On 06/17/26 at 12:35 P.M., an interview with the Administrator verified there were no TB test results in the personnel files for former Administrator #230, CNA #220, and RN #232. 2. On 06/16/26 at 12:04 P.M., an observation of the lunch meal in the dining room revealed CNA #225 was handling Resident #37's hamburger bun with her bare hands while cutting the hamburger into bite size pieces. CNA #225 put her bare hand on the bun multiple times during the observation. On 06/16/26 at 12:06 P.M., an interview with CNA #225 verified she handled Resident #37's food with her bare hands while cutting it up to assist with feeding. She stated she was holding the bun in place while cutting. 3. Review of the medical record for Resident #39 revealed an admission date of 01/01/20 with diagnoses that included diabetes mellitus type two, arthritis, peripheral vascular disease, kidney disease, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 was cognitively impaired, did not reject care, was dependent on staff for toileting, and was incontinent of bowel and bladder. An observation on 06/16/26 at 10:21 A.M. of Resident #39 incontinence care with CNAs #200 and #205 revealed the following: CNAs #200 and #205 washed their hands and applied gloves; Resident #39 was positioned for care, CNA #200 cleansed Resident #39's genital area; Resident #39 was then turned to the side with CNA #205 assisting with holding Resident #39 in position; CNA #200 provided perineal care which included cleaning Resident #39 of a small bowel movement; and after incontinence care was completed with the same contaminated gloves CNA #200 then touched the bed linens, the bed control, and then the sink handles before finally removing her gloves and washing her hands. An interview on 06/16/26 at 10:32 A.M. with CNA #200 verified the above findings. Review of the facility policy titled Hand Hygiene, dated 2025, revealed all staff were to perform hand hygiene, staff were to perform hand hygiene as indicated, and hand hygiene is to be completed with accepted standards of practice. This deficiency represents non-compliance investigated under Complaint Number 1366180 (OH00167045).

Based on record review, observation, and interviews, the facility failed to serve mechanically altered foods at an appropriate texture. This affected one resident (#24) out of one reviewed for food textures and had the potential to affect six additional residents (#6, #19, #20, #25, #27, #39) identified by the facility as receiving pureed texture. The facility census was 40. Findings include: Review of the medical record for Resident #24 revealed an admission date of 07/18/24 with diagnoses including Alzheimer's disease, depression, hypertension, and chronic obstructive pulmonary disease. Review of the speech therapy Discharge summary, dated [DATE], revealed Resident #24 had dysphasia oropharyngeal phase and had recommendations for puree consistency diet. Review of the physician's orders for Resident #24 identified orders for a regular diet with dysphagia pureed texture effective 04/17/26. Review of the nutrition care plan, revised 05/14/26, revealed Resident #24 had the potential for malnutrition and altered hydration related to Alzheimer's, dementia, depression, anemia, and diet downgraded to puree. Interventions included provide and serve prescribed diet as ordered by physician effective 07/25/24 and monitor tolerance to diet and observe for episodes of coughing or choking after trying to swallow revised 08/21/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/27/26, revealed Resident #24 had severe cognitive impairment, was dependent on assistance for eating, and required a mechanically altered diet. On 06/16/26 at 11:45 A.M., an observation of the lunch meal tray line revealed Resident #24's meal plated with visible lumps in the pureed meat entree. On 06/16/26 at 12:05 P.M., an observation of the dining room revealed Certified Nursing Assistant (CNA) #227 delivered Resident #24's plate to her table. At 12:14 P.M., CNA #227 began feeding Resident #24 her lunch, including the pureed meat entree which was not a smooth consistency with small visible lumps throughout it. On 06/16/26 at 12:14 P.M., an interview at the time of observation with CNA #227 confirmed the puree meat was lumpy. CNA #227 further stated pureed foods were not always completely smooth, and the puree consistency depended on what food items were pureed. CNA #227 said sometimes pureed items were smooth and sometimes there were lumps. On 06/23/26 at 12:52 P.M., an interview with Speech Therapist (ST) #222 revealed Resident #24 required a pureed diet because of her decline so a mechanical soft or ground meat texture would not be appropriate. ST #222 stated she would not expect any pureed foods to have visible lumps or bumps, and the consistency should be smooth. Review of the International Dysphasia Diet Standardization Initiative (IDDSI) guidance, dated January 2019, indicated pureed food texture did not require chewing and had a smooth texture with no lumps. This deficiency represents non-compliance investigated under Complaint Number 2588125.

Based on review of the Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) report, review of staff schedules and interview, the facility failed to ensure accurate staffing data was reported to CMS. This had the potential to affect all 31 residents residing in the facility. Findings Included: Review of the CMS PBJ report from 01/01/25 through 03/31/25 revealed the facility triggered for excessively low weekend staffing. Interview on 06/10/25 at 9:28 A.M. with the Administrator revealed Certified Nurse Assistant (CNA)/Activities #315 worked on the floor providing direct (resident) care on 01/18/25 but believed her hours were not coded correctly on the staffing data submitted to CMS, therefore the facility staffing was not reported accurately. The Administrator revealed the facility tried to staff two nurses and two CNAs on every shift unless someone called off and this could possibly explain why the PBJ showed low weekend staffing during the above time period. The Administrator revealed on the weekend of 01/18/25 and 01/19/25 there was only one CNA on night shift with two nurses. The Administrator revealed on 01/18/25 and 01/19/25 there was only one CNA working on night shift, but the average direct care was over 2.5 and there were no concerns identified from the provider. Review of the facility staffing from 01/17/25 through 01/19/25 revealed on 01/18/25 there were two nurses and one CNA working on night shift. The daily direct care was calculated to be 2.86 hours and was lower than the weekdays average daily direct care of 3.4 hours Review of the staffing schedule from 01/17/25 through 01/19/25 revealed CNA #315 worked eight hours on these dates.

Based on record review, facility policy review and interview, the facility failed to maintain written evidence a background check was completed as required for the Interim Director of Nursing (IDON) at the time of hire. This had the potential to affect all 31 residents residing in the facility. Findings Include: Review of IDON #320's employee file revealed a hire date of 03/25/25. Review of the employee's personnel file revealed no written evidence a background check was completed at the time of hire. Interview on 06/09/25 at 11:39 A.M. with Administrator revealed IDON #320 started as the interim director of nursing on 03/25/25 and it was unknown when her background check was completed (it was to be completed on hire). The Administrator revealed there had been a transition of human resource (HR) director and they realized there was no copy of the IDON's background check. The Administrator stated she asked the IDON if she completed the background check and she stated she did and that she would get a copy of it. However, no copy was provided. The facility followed-up with the agency who completed their background checks and determined a new background check would be obtained on 06/06/25. The Administrator revealed the Nurse Aide Registry was verified for the IDON at the time of hire as well as verification the employee had an active/valid nursing license. Interview on 06/10/25 at 9:05 A.M. with Human Resource (HR) #310 revealed she had been in the HR position since March 2025 and was in training when IDON #320 was hired. She stated at the end of May 2025 she realized the facility had not received IDON #320's background check and asked IDON #320 if she had gone to get it completed. IDON #320 reported she needed to go pick it up. HR #310 stated she told IDON #320 the background checks were sent directly to facility and felt that something was wrong after the IDON reported she needed to go pick it up. HR #310 revealed she reported this concern to the Administrator. Review of the facility Abuse, Neglect and Exploitation Policy dated 2025 revealed potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility would maintain documentation of proof that the screening occurred. Review of the facility Background Investigation dated 2024 revealed job reference checks, drug screenings, licensure verifications and criminal conviction record checks were conducted on all personnel making application for employment with the company.

Based on observation, record review, facility policy review, and interview the facility failed to maintain proper infection control practices/procedures to prevent the potential spread of Covid-19. This had the potential to affect all 39 residents residing in the facility. (#1, #2, #3, #4, #5, #6, #7, #8, #9, 12, #13, #14, #16, #17, #18, #19, #20, #21,#23, #24, #25, #26, #27, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #45, #46, #245, and #246). Findings include: 1. Observation on 11/06/23 at 9:33 A.M. revealed five residents (Residents #5, #6, #14, #21, and #39) on the second floor in isolation for Covid-19. Personal Protective Equipment (PPE) was observed hanging on the doors of the rooms of the residents or in cabinets placed just outside the entrance of each room. There was no signage on or near the residents' doors indicating the type of isolation or what PPE should be donned prior to entering the rooms. Interview on 11/06/23 at 9:33 A.M. with State tested Nurse Aide (STNA) #525 and Registered Nurse (RN) #505 confirmed there were no signs on or near the doors of Residents #5, #6, #14, #21 and #39 indicating the type of isolation or what PPE was required. Interview on 11/06/23 at 11:04 A.M. with the Administrator revealed signage should be posted on the doors of all residents in isolation indicating the type of isolation and PPE to be worn. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionist (IP) #503 revealed the facility was in Covid-19 outbreak status. IP #503 verified there should be signs posted on the doors of residents who were Covid-19 positive indicating the type of isolation and PPE required. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing (DON) revealed staff entering a room of a Covid-19 positive resident were to wear a N95 masks, eye protection, gown, and gloves. Staff were to doff the N95 mask, gown, eye protection, and gloves upon exiting the room and apply a new N95 mask. The DON also verified there should be signage on the door indicating the type of isolation precautions and PPE to be used. Review of facility policy, Coronavirus (COVID-19) Prevention and Management (An Addendum to the infection Control Manual), revised 01/03/23, revealed instructional signage was to be posted. 2. Review of the medical record for Resident #6 revealed an admitted [DATE]. Resident #6 was diagnosed with Covid-19 on 11/02/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition and required supervision to touch assistance with bed mobility, dressing, toileting, and personal hygiene. Review of physician orders dated 11/02/23 revealed Resident #6 was to be placed in contact and droplet isolation (Transmission Based Precautions) related to Covid-19 for ten days. Observation on 11/06/23 at 9:52 A.M. revealed State tested Nurse Aide (STNA) #525 donning PPE to enter Resident #6's room including gown, N95, and gloves. STNA #525 did not don eye protection. STNA #525 entered Resident #6's room and closed the door. A few minutes later, STNA #525 opened the door and yelled out for another STNA to assist. As STNA #530 was approaching, STNA #525 was asked why she was not wearing eye protection. STNA #525 responded I forgot and left at nurses' station. STNA #525 then yelled out to STNA #530 to bring her a face shield. STNA #530 brought a face shield to Resident #6's room and gave it to STNA #525. Observation on 11/06/23 at 10:17 A.M. revealed STNA #525 exiting Resident #6's room wearing a N95 mask and walking down the hallway. Interview with STNA #525, at the time of the observation, verified she did not don eye protection when she entered Resident #6 room and upon exiting the room she did not doff the N95 mask. Further observation at 10:21 A.M. revealed STNA #525 removing the N95 mask and donning a new N95 mask. STNA #525 did not secure the bottom strap of the N95 mask but left the strap hanging below her chin. At the time of the observation, STNA #525 verified incorrect N95 mask placement and said I forgot. Interview on 11/06/23 at 11:04 A.M. with the Administrator revealed staff were to wear full PPE including eye protection, N95 mask, gown, and gloves when entering a Covid-19 positive room and doff all PPE before exiting the room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionist #503 revealed the facility was in Covid-19 outbreak status and staff were to wear full PPE including N95 masks, eye protection, gown, and gloves when entering a Covid-19 positive room. Before exiting the Covid-19 positive room staff were to doff the PPE including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing verified staff were to wear N95 masks, eye protection, gown, and gloves upon entering a Covid-19 positive room. Before exiting the Covid-19 room staff were to doff the PPE including the N95 mask and upon exit get a new N95 mask. Review of facility policy, Personal Protective Equipment, dated 2023, revealed eye protection was to be worn and staff were not to reuse single-use-only respirators. 3. Observation on 11/07/23 at 7:41 A.M. revealed State tested Nurse Aide (STNA) #530 enter Resident #6's room with full PPE to answer the call light. Upon exiting the room STNA #530 removed all PPE except the N95 mask and started walking down the hall. At 7:44 A.M., STNA #530 verified she should have changed her N95 mask and got a new one before heading down the hall. STNA #530 reported I forgot. Interview on 11/06/23 at 11:04 A.M. with Administrator verified staff were to doff all PPE before exiting a Covid-19 positive room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/08/23 at 1:56 P.M. with Infection Preventionisit #503 revealed staff were to discard all PPE before exiting a Covid-19 positive room including the N95 mask. Staff were to get a new N95 upon exiting the room. Interview on 11/13/23 at 7:32 A.M. with the Director of Nursing verified before exiting a Covid-19 room staff were to doff all PPE including N95 mask and upon exiting the room get a new N95 mask. Review of facility policy, Personal Protective Equipment, dated 2023, revealed eye protection was to be worn and staff were not to reuse single-use-only respirators. 39969 4. Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included alcohol induced dementia, vascular dementia, hearing loss, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. Review of the nurses' notes dated 10/30/23 at 4:30 P.M. revealed Resident #14 tested positive for Covid-19 this afternoon. Resident #14 was immediately placed on contact/droplet precautions. Resident 14's guardian was updated on the situation. The certified nurse practitioner was notified and entered orders. Review of the physician orders for November 2023 revealed orders for contact and droplet isolation (transmission based precautions) related to Covid-19 every shift until 11/10/23. Observation on 11/07/23 at 4:56 P.M. revealed Resident #14, who independently ambulated, sitting in the dining room. Resident #14's N95 mask was not placed over her mouth and nose and she was sitting next to (less than six feet) Resident #20 who was eating. Continued observation revealed Stated tested Nurse Aide (STNA) #520 telling Resident #14 to pull her face mask up over her mouth and nose. Interview with STNA #520, at the time of the observation, revealed Resident #14 was supposed to be in isolation but would not stay in her room, and although Resident #14 was taken back to her room she returned to the dining room. STNA #520 confirmed Resident #14 was sitting at the table with Resident #20 who was negative for Covid-19. Observation of smoke break on 11/08/23 at 9:37 A.M. revealed Resident #14 outside sitting at the same table (less six feet) with Resident #33. Resident #14 was wearing a N95 face which she pulled down when talking to Resident #33. STNA #528 gave Resident #14 a cigarette and lit the cigarette. Resident #14 smoked the cigarette while seated at the same table with Resident #33. Interview on 11/08/23 at 9:39 A.M. with STNA #528 revealed other residents outside smoking during the smoke break included Resident #9, #12, and #13. STNA #528 stated she was told by the Director of Nursing that she could encourage but could not force Resident #14 to stay in her room. STNA #528 stated she was not given instructions on precautions to take when a resident who tested positive for Covid-19 was smoking, only that she could not refuse Resident #14 the right to smoke. Continued observation revealed at 9:43 A.M. Resident #33 informed STNA #528 that Resident #14 touched her cigarette and Resident #33 wanted another cigarette. STNA #528 stated she did not have any more and Resident #33 stated it was okay and went back into the facility. STNA #528 said she knew Resident #14 had to keep her hands down, not touch, and staff were to have their N95 masks on when lighting her cigarettes. Interview on 11/08/23 at 2:06 P.M. with Infection Control Preventionist (ICP) #503 revealed all staff were educated regarding Covid-19 protocols and when Covid-19 positive residents were out of their rooms staff were to ensure they were kept separated or an appropriate distance away from other residents and wore a face masks; however, they could only encourage.

Based on observations, interviews, and record review, the facility failed to maintain a clean and sanitary environment. This affected three residents (#30, #38, and #45) of three residents reviewed for physical environment. The census was 39. Findings include: Interview on 11/06/23 at 9:45 A.M. with Resident #45 revealed no one cleaned his room. Observation at the time of interview revealed the bathroom floor had dirt buildup in the four corners of floor and there was feces in the toilet bowl. There was a buildup of dirt behind the entrance door to Resident #45's room. Observation of Resident #30's room on 11/07/23 at 9:39 A.M. revealed crumbs on the floor under and behind the bed, and near the sink area. Behind the entrance door into Resident #30's room there was a buildup of dirt. In Resident #30's bathroom there was a dirty, dry towel at the base of the pipe of the toilet and on the floor at the base of the toilet there was a tan colored stain. There was also dirt buildup in the four corners of the bathroom floor. Observation on 11/07/23 at 11:54 A.M. revealed Housekeeper (HSK) #553 outside of Resident #45's room with a housekeeping cart. Interview with Resident #45, at the time of the observation, revealed it was the first time Resident #45 had seen housekeeping. Further observation revealed the floor in the bathroom and behind Resident #45's door still looked dirty, but the feces was cleaned from the toilet. Tour on 11/07/23 from 1:51 P.M. to 2:10 P.M. with HSK #553 verified the dirt buildup behind Resident #45's door and in the corners of the bathroom floor. HSK #553 stated the floor tiles were old and he had cleaned Resident #45's room about 30 minutes ago. Observation of Resident #30's room with HSK #553 verified the various crumbs and stains on floor near and under the bed, under and along the edges of the floor around sink area, as well as the dirt buildup behind the entrance door. Observation of the Resident #30's bathroom with HSK #553 verified the dirty towel on the toilet pipe, the tan colored stained at the base of the pipe on the toilet, and dirt buildup in the corners of the bathroom floor. HSK #553 stated he did not know why the towel was there and that Resident #30 did not use the bathroom. HSK #553 stated he did not work on 11/06/23 and he was not sure what the part timer did. HSK #533 verified the dirt buildup in the four corners of Resident #38's bathroom floor. HSK #553 stated it was hard to complete deep cleaning and get all the resident rooms cleaned. HSK #553 stated sometimes the floors did not look clean after they had been mopped and the mop did not hit the corners of the floor. HSK #553 stated he would have to use something different for the corners, like a brush. Review of the facility's undated Daily Cleaning Procedures for Healthcare Maintenance Program, revealed under procedure at room staff were to apply bowl cleaner to bowl swab and start in a circular motion at top rim of toilet working down to the bottom of bowl. After that, spray and wipe exterior portions of toilet fixture with germicidal detergent. Under cleaning floors the procedure indicated to check general appearance of room, using a treated duct mop, pick up all loose dirt on floor. Using germicidal solution in a mop bucket, start in the furthest corner of room and mop or spray floor, also covering bathroom floor. This deficiency represents non-compliance investigated under Complaint Number OH00146691.

Based on medical record review, staff and resident interviews and review of facility policy, the facility failed to ensure residents requiring assistance with activities of daily living received showers/bathing as scheduled. The affected two of three residents (Resident #23 and Resident #30) reviewed for showers/bathing. The facility census was 39. Findings Included: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included but were not limited to dementia, stage III chronic kidney disease and nontraumatic intracranial hemorrhage and seizures. Review of the plan of care dated 02/23/23 revealed Resident #23 had a self-care deficit related to confusion, limited mobility and limited range of motion and required total dependence of two staff for showers twice weekly. Resident #23 was noted to be resistant to care at times. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact and required total dependence of two staff for bathing. Review of the facility shower list revealed Resident #23 was to be bathed on Wednesday and Saturday. Review of Resident #23's shower sheet documentation from August 2023 to October 2023 revealed out of 26 scheduled shower days, 13 days (08/09/23, 08/16/23, 08/19/23, 08/30/23, 09/13/23, 09/16/23, 09/20/23, 10/04/23, 10/07/23, 10/14/23, 10/18/23, 10/21/23, and 10/28/23) did not indicate shower/bathing was completed. Review of nursing progress notes from August 2023 to November 8, 2023, revealed two bathing refusals 08/05/23 and 08/12/23. Interview on 11/06/23 at 10:55 A.M. with Resident #23 revealed she preferred to receive showers two times a week and it had been three weeks since she had a shower/bath. Resident #23 stated staff offered to provide bathing/showers but then did not return to provide the shower/ bath. Interview on 11/08/23 at 9:20 A.M. with the Director of Nursing (DON) confirmed 13 shower sheets for Resident #23 from August to October 2023 indicated showers were not completed as scheduled. 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included but were not limited to amputation of right lower leg below knee, type I diabetes mellitus with diabetic retinopathy, chronic heart failure, legal blindness, and Alzheimer's dementia. Review of the plan of care dated 04/06/23 revealed Resident #30 had an activities of daily living self-care performance deficit related to activity intolerance, confusion, impaired balance, and limited mobility. Interventions included extensive assist of one staff for bathing twice weekly. Review of the comprehensive MDS 3.0 quarterly assessment dated [DATE] for Resident #30 revealed Resident #30 had intact cognition and required extensive assist of one for bathing. Review of the facility shower list revealed Resident #30 was to have showers on Sundays and Thursdays. Interview on 11/06/23 at 10:21 A.M. with Resident #30 revealed it had been about four weeks since he had a bath/shower. Review of Resident #30's shower sheet documentation from August 2023 to October 2023 revealed out of 27 shower days, 12 days (08/06/23, 08/09/23, 08/13/23, 08/13/23, 08/27/23, 09/03/23, 09/07/23, 09/13/23, 09/29/23, 09/24/23 10/04/23 and 10/18/23) did not indicate showers or bed baths were completed. Review of the nursing progress notes from August 2023 through October 2023 revealed Resident #30 had refused showers on four days (08/23/23, 08/30/23, 09/06/23 and 10/08/23). Interview on 11/08/23 at 9:20 A.M. with the DON confirmed 12 shower sheets indicated showers/baths were not completed as required. Review of the 2022 revised facility policy Resident Showers revealed residents would be provided showers as per request or as per facility schedule protocols. This deficiency represents non-compliance investigated under Complaint Number OH00147716.

Based on record review and interview the facility failed to ensure the long term care ombudsman was notified of transfers to the hospital for three residents (#8, #30, and #42) of four residents (#2, #8, #30, and #42) reviewed for hospitalization s. The facility census was 39. Findings include: 1. Review of the medical record for Resident #8 revealed an initial admitted [DATE]. Diagnoses included pulmonary embolism, major depressive disorder, dementia, and Alzheimer's disease. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had an unplanned discharge to an acute hospital. Review of the nurses' notes dated 07/21/23 at 4:15 A.M. revealed Resident #8 was found by an aide attempting to get out of bed stating they needed to go to work, when discussing with the resident that she lived at the nursing home she became increasingly confused and difficult to re-direct. Normal baseline was slight confusion. Resident #8 was sent to the emergency room (ER) for evaluation. Interviews on 11/08/23 at 10:45 A.M. and 12:35 P.M. with Medical Records (MR) #584 revealed there was no transfer notice for Resident #8's transfer to the hospital on 07/21/23. MR #584 stated she was unable to locate evidence of the long term care ombudsman being notified prior to the notification the Administrator sent on 11/07/23. 45442 2. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses of right lower leg below the knee amputation, type I diabetes mellitus, retinopathy, legal blindness, and Alzheimer's dementia. Further review of the medical record revealed Resident #30 was discharged to the hospital on 10/17/23 for treatment following a fall and was readmitted to the facility on [DATE]. Review of the facility Ombudsmen notification list for October 2023 revealed Resident #30 was not on the list for his hospitalization on [DATE]. Interview on 11/08/23 at 3:00 P.M. with the Administrator confirmed Resident #30 went out to the hospital on 10/17/23 and the facility could not provide evidence of the notification to the Ombudsman. 3. Review of the medical record for Resident #42 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #42 was admitted with diagnoses of myotonic muscular dystrophy, atrioventricular block, alcoholic hepatitis, alcohol dependence, and dementia. Review of the nursing progress notes revealed on 09/29/23 Resident #42 was discharged and transported by to another facility. Interview on 11/08/23 at 3:00 P.M. with the Administrator revealed Resident #42 was discharged to another nursing home on 09/29/23. The Administrator was unable to provide evidence the Ombudsman was notified of Resident #42's discharge to another facility. Review of the 2023 facility policy Transfer and Discharge (including AMA) revealed a transfer/discharge notice was to be provided to the resident/representative and Ombudsman as indicated.

Based on record review, review of Ohio Departments Enhanced Information Dissemination Collection (EIDC) system, policy review and staff interview, the facility failed to timely report the allegation of physical abuse to the appropriate state agency. This affected one (#16) of three residents reviewed for potential abuse and neglect. The facility census was 44. Findings include: Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbance, major depressive disorder, generalized anxiety disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/23, revealed Resident #16 was rarely understood and required extensive assistance with two staff for activities of daily living (ADLs) except eating required extensive assistance with one staff. Interview on 08/23/23 at 1:30 P.M., with State tested Nursing Assistant (STNA) #350 revealed she reported on 08/15/23 to the Administrator she was told by STNA #341, that on 08/13/23, Nursing Assistant (NA) #329 slapped Resident #16 while giving care. STNA #350 was not sure if Administrator investigated the alleged physical abuse. Review of the Ohio Departments Enhanced Information Dissemination Collection (EIDC) system revealed no self-reported incident was initiated to the state agency regarding the allegation of physical abuse towards Resident #16 until 08/23/23 at 4:01 P.M. Interview on 08/23/23 at 3:00 P.M., with the Administrator revealed that an SRI was not completed because abuse was not substantiated. The administrator stated that she did investigate it and found it not to be true. Review of undated facility policy titled Abuse, Neglect, and Exploitation revealed allegations of abuse would be reported to the state agency within two hours.

Based on observation, staff interview, medical record review and review of policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy (trach) care. This affected one (#43) of two residents identified as having a trach. The facility census was 44. Findings include: Review of the medical record for the Resident #43 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included diffuse traumatic brain injury, diabetes mellitus, acute respiratory failure with hypoxia, and hydrocephalus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed the resident was in a persistent vegetative state. The resident required total dependence with two staff for activities of daily living except eating was total dependence of one staff. Review of the physician's order for August 2023 revealed Resident #43 revealed an order for trach care every shift and as needed. Observation of trach care on 08/28/23 at 5:56 A.M., with Registered Nurse (RN) #340 and Licensed Practical Nurse (LPN) #306 revealed RN #340 placed the trach kit on the table, washed his hands then donned gloves. He opened the trach care kit and took out Resident #43's reusable unclean trach tube. RN #340 then proceeded to clean the trach tube with the brush that was provided in the kit. RN #340 then took off gloves, donned the gloves that were in the kit and proceeded to put the cleaned cannula in, and placed a new split sponge around the trach. RN #340 did not need to suction Resident #43. RN #304 verified that he did not perform hand hygiene before putting on the second pair of gloves and stated that it's not a sterile procedure. Review of the undated policy titled Hand Hygiene, revealed that if a task requires gloves, perform hand hygiene prior to donning gloves. This deficiency represents non-compliance investigated under Master Complaint Number OH00145870 and Complaint Number OH00145362.

Based on medical record review, emplyee time sheet review, employee disciplinary review and staff interviews, the facility failed to ensure all resident records had accurate documentation. This affected one (#45) of six residents reviewed for accurate medical records. The census was 44. Finding include: Review of the closed medical record for Resident #45 revealed an admitted [DATE]. Diagnosis included bacterial endocarditis. Review of the physician orders revealed an order for Ampicillin-Sulbactam Sodium (antibiotic) intravenous (IV) every six hours. Keep central line dressing intact. Review of the Medication Administration Report for August 2023 revealed on 08/12/23 Ampicillin-Sulbactam Sodium doses given at 8:00 A.M., 12:00 P.M. and 4:00 P.M., were signed off by the Former Director of Nursing (DON). Review of the Ampicillin-Sulbactam Sodium administration details revealed on 08/12/23 at 8:00 A.M., Licensed Practical Nurse (LPN) #313 had signed off the medications and then it was strike out on 08/12/23 at 11:20 A.M. by LPN #313, reason declined order and then was signed out at 8:00 A.M., 12:00 P.M. and 4:00 P.M. by former DON at 5:25 P.M Interview on 08/28/23 at 8:01 A.M., with former DON stated she was on vacation on 08/12/23 and was not in the facility at all. She was notified by LPN #313 that Resident #45 needed his IV antibiotic and there was no Registered Nurse (RN) in the facility. She was told that RN #374 was notified but was not able to come in because the Administrator told her she was not allowed to. Former DON verified she got on the electronic charting remotely and signed off three doses of Resident #45's IV antibiotic even though she did not administer the medication. Interview on 08/28/23 at 10:30 A.M., with LPN #313 verified she administered Resident #45's medication Ampicillin-Sulbactam Sodium in a central line. She only remembers doing one dose. LPN #313 stated she was not sure if she could administer IV medications in a central line. So, she did look it up, thought she could under the supervision of an RN, but no RN was in the building at this time. No other LPN working was IV certified. LPN #334 instructed LPN #313 to go ahead and administer since she was IV certified. LPN #334 informed LPN #313 she had talked to RN #374, who was in charge. The former DON did not directly tell LPN #313 to administer the medications. LPN #313 stated she signed the medication off for the one time she gave it. Interview on 08/28/23 at 4:00 P.M., with LPN #334 stated she was working on 08/12/23, on the day shift. Resident #45 had an IV antibiotic that needed to be hung. There was no RN in the building and LPN #313 was IV certified, so we looked up if she was allowed to hang the IV antibiotic, so she hung the antibiotic and signed it off. LPN #334 stated she called RN #374 to see if she was coming in to give Resident #45's antibiotic, RN #374 stated she was not scheduled and did not know if she was allowed to come in. Review of the timesheet for Former DON for 08/12/23 revealed she was not clocked in on 08/12/23. She was not working. Review of the undated policy Documentation in Medical Records, revealed false documentation should not be documented. Review of former DON employee discipline form dated 08/21/23 revealed former DON was terminated for getting on the electronic charting from a remote location and signing off medication that she did not administer. This deficeincy represents non-compliance investigated under Master Complaint Number OH00145870 and Complaint Number OH00145362.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was maintained in a safe and secure manner on the second floor. This had the potential to affect all residents residing in the facility with the exception of five (#11, #20, #26, #36, and #43) residents who resided on the first floor of the facility. The facility census was 44. Findings include: Observation of the second floor of the facility on 05/24/23 at 7:47 A.M. revealed the east medication cart was observed unlocked with two drawers open in the hallway outside of a resident room. The medication cart was against the wall next to the room, with the open drawers facing the hallway. There was no licensed nursing staff was within eyesight of the cart at the time of the observation. Registered Nurse (RN) #207 was located inside the resident room, and returned to the medication cart, at 7:51 A.M., placed a blood sugar testing machine on top of the cart, and then re-entered the resident room with the medication cart remaining unlocked and two drawers open. RN #207 then returned to the medication cart at 7:59 A.M. Interview on 05/24/23 at 7:59 A.M. with RN #207 confirmed she left the medication cart unlocked and unattended. RN #207 identified she was new to the building and used to work at a hospital; however, confirmed she should not be leaving medication carts unlocked and unattended providing access to medications. Review of a medication storage policy, dated 2022, revealed it is the facility policy to ensure all medications housed on the premises will be stored to ensure security. The policy revealed during a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage cart.

Based on observation, medical record review, staff interviews, and review of facility policies, the facility failed to ensure basic life support items were immediately accessible to all staff on the emergency cart. The facility also failed to ensure all staff were trained in cardiopulmonary resuscitation (CPR). This had the potential to affect 11 (#9, #11, #16, #18, #20, #21, #24, #34, #35, #36 and #39) of 11 residents who the facility identified had orders in place for initiation of CPR in the event of cardiac or pulmonary arrest. The facility census was 44. Findings include: Interview with Registered Nurse (RN) #207 on [DATE] at 7:27 A.M. stated, in the event a resident with full code orders (full life saving measures, including CPR, for a person with cardiac or respiratory arrest) experienced cardiac or respiratory arrest she would find the emergency cart and see if the supplies needed were inside. Observation on [DATE] at 7:27 A.M., during interview with RN #207, revealed RN #207 approached the emergency cart which was located in the general sitting area on the second floor. RN #207 attempted to open the cart; however, it was secured shut with a plastic zip-tie. The tie was not breakable and RN #207 identified she would have to find scissors to get it open. Interview with RN #207 at that time verified the emergency cart was not readily accessible in an emergency situation. Further observation on [DATE] at 7:46 A.M. revealed RN #207 and Licensed Practical Nurse (LPN) #214 were able to obtain a pair of scissors and open the emergency cart. Interview with the facility Director of Nursing (DON) on [DATE] at 9:47 A.M. stated she was new to the facility and started approximately one month ago. DON stated she could not locate any emergency procedures in the facility for the facility emergency cart. DON confirmed the emergency cart was secured with a plastic zip-tie that was not the break away type, and DON confirmed staff would have to have something to cut open the cart to see what supplies are located in the emergency cart. Interview with DON on [DATE] at 10:03 A.M. stated she was sending a maintenance staff member to buy some break away plastic locks to place on the crash cart as there were none in the facility. Interview with Human Resources Manager (HRM) #254 on [DATE] at 9:55 A.M. confirmed not all direct care staff members were trained and certified related to CPR. The HRM #254 provided a listed of facility direct care staff who do not have CPR certification which included Registered Nurse (RN) #202, RN #205 and RN #208); Licensed Practical Nurse (LPN) #211, LPN #214, LPN #215, LPN #217, LPN #218, LPN #219 and LPN #220. Review of the facility emergency crash cart and automated external defibrillators (AED) policy, dated 2022, revealed the facility will ensure they maintain at least one emergency cart per nursing care floor with additional carts as deemed necessary. The purpose of the policy was to ensure that all supplies critical to basic life support are readily available on the emergency cart. The policy identified the emergency cart is checked every 24 hours and after every use. AED use is authorized from personnel certified in CPR and use of the AED. Nursing staff should be familiar with the content located on and within the emergency crash cart. The policy did not have documented evidence the cart would be locked.

Based on medical record review, observation, staff interview, review of facility policy, review of the employee handbook, and review of the facility handbook, the facility failed to ensure resident dignity was maintained while watching television. This affected three (#24, #29, and #31) of five residents reviewed for dignity. The facility census was 44. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, dysphagia, schizoaffective disorder, restlessness and agitation, kidney failure, and heart disease. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/12/23, identified the resident as having severe cognitive impairment. The resident required extensive assistance of two staff for a majority of the activities of daily living (ADLs). 2. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, depression, dysphagia, insomnia, bipolar disorder, legal blindness, and cognitive communication deficit. Review of Resident #29's annual MDS 3.0 assessment, dated 04/17/23, identified the resident as having a cognitive impairment. The resident required extensive assistance of between one and two staff for ADLs. 3. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, hypertension, chronic kidney disease, and difficulty in walking. Review of Resident #31's quarterly MDS 3.0 assessment, dated 04/01/23, identified the resident as cognitively intact. The resident required extensive assistance of two staff for a majority of ADLs. Observation on 05/24/23 at 7:22 A.M. revealed Resident #24, Resident #29, and Resident #31 were sitting in the second-floor television room in front of and facing the television. The volume of the television was not loud enough to be heard. Interview at the time of observation with State tested Nurse Aide (STNA) #231 verified the television was not loud enough to be heard by the residents who were placed in front of the television. Review of the employee handbook, revised August 2012, revealed respect toward residents was mandatory. Review of the undated facility provided handbook titled, Federal & Ohio Resident Rights & Facility Responsibilities, revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Review of the facility policy titled, Resident Rights, revised October 2017, revealed the purpose of the policy was to assure the resident's personal dignity, well-being and self-determination was maintained to assure residents were knowledgeable to their rights and responsibilities in this regard. This deficiency represents non-compliance investigated under Complaint Number OH00142721.

Based on record review, interview and observation the facility failed to notify the physician of a change of condition, failed to implement physician orders [REDACTED]. This affected one of five residents (Resident #57) reviewed for wounds and three of five residents (Resident #54, #9 and #95 reviewed for weight loss. The facility census was 51. Harm occurred when, Resident #57's wound, due to osteo[DIAGNOSES REDACTED], dehisced (split open) and the right heel wound, due to infection, became abscessed (accumulation of pus in body tissue). The noted change occurred in the wound on Sunday (05/12/16) and the physician was not notified until Monday, 05/13/16. Findings include: 1. Resident #57 was admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 05/07/16 showed the resident was cognitively intact. The MDS skin condition assessment indicated the resident had surgical wounds and applications of dressings. Review of the resident's history revealed he had an amputation of the first (aka great toe) and second toe on the right and left foot. Resident #57 was receiving dressing changes to these areas as well as receiving hyperbaric treatment to aid in the healing of these wounds. Review of the progress notes for Resident #57 revealed on 05/09/16 the surgical areas to the left amputated great toe and back of right leg remained with no odor, redness, and both areas were well approximated. There was also noted a scant amount of drainage from the left toe. On 05/12/16 the progress note stated the dressings were changed to bilateral extremities. The big toe surgical site missing stitches and copious amount of red liquid drainage was on the dressing. No odors were noted. The ankle surgical site had [MEDICAL CONDITION], redness and there was a scant amount of red liquid drainage noted on the bandage. There were no further notes stating the physician was notified or a further assessment was performed. On 05/13/16 the progress note stated that at 9:04 A.M. an as needed (PRN) dressing change was performed to the left toe surgical area. There was a large amount of red fluid on the bandages with no odor. Sutures were missing at the distal site and it was also noted to have redness and swelling at the distal site. The note stated the nurse will continue to monitor. There was no documentation indicating the physician was notified. On 05/13/16 Resident #57 went to a pre-scheduled infectious disease appointment where he was directly admitted to the hospital for wound debridement of his right Achilles tendon wound and his left toe surgical wound. The resident was also placed on intravenous antibiotics. [DIAGNOSES REDACTED]. Resident #57 returned to the facility on [DATE] Interview with Licensed Practical Nurse (LPN) #126 on 05/25/16 at 2:26 P.M. revealed that she had noticed a change in the left great toe area on the day shift of 5/08/16. She stated that a couple of the stitches were gone and she did inform the resident. LPN#126 stated she told the resident that she would pass it on to the physician. The resident stated that maybe the doctor would want to see him on Monday instead of waiting until Wednesday (05/13/16). LPN#126 stated that during end of shift report she did pass on to the nurse about the wound and to notify the physician on Monday morning. Review of the progress notes shows no documentation that this nurse had noticed a change in the residents wound on his left foot. Further interview with LPN #126 revealed that when she came back into work to her night shift on Monday (05/09/16) she was informed that the physician was notified and he ordered no further treatment to the wound and that they would see him on Wednesday, 05/13/16. There was no documentation from 05/09/16 to 05/11/16 that the wound had changed or other documentation to support the physician was notified. Interview with LPN # 166 on 05/25/16 at 3:00 P.M. revealed she did notice a change in the resident's wounds on 05/12/16. She stated that there were sutures missing and there was a large amount of drainage on the bandage of the left foot. She stated the right foot/ankle was red and slightly swollen, but not warm to touch. LPN #166 stated she did notify the physician about the changes in the wound but indicated there was nothing documented regarding any discussion with the physician. Interview with the Administrator 05/26/16 at 11:00 A.M. revealed Resident #57 was getting hyperbaric treatments to help heal the wounds from a local hospital. The Administrator stated she obtained all the treatment notes from the treatment center verifying a physician had been observing Resident #57's wounds. Review of the hyperbaric treatment forms revealed Resident #57's vital signs were monitored and pain was assessed. The forms did not list any description of the wounds. It was signed by the physician. An interview with the Physician (Physician #300) with the hyperbaric treatment center on 05/26/16 at 10:00 A.M. revealed he originally assessed Resident #57's wounds in December, 2015 and then again in March, 2016. Physician #300 stated he did have a picture of the wounds from his assessment in March. Physician #300 stated Resident #57's wounds were not assessed by him during the week of May 9th. Physician #300 stated that at the end of the week he would have changed the dressings to see how the wounds were doing but he never did this since Resident #57 was admitted to the hospital prior to the end of the week. Physician #300 also stated that the resident did not complete the hyperbaric treatment due to the admission. On 05/26/16 at 1:00 P.M. observation was made of a dressing change of Resident #57's left foot and right heel. The left toe wound measured approximately 8 centimeters (cm) long by 0.4 cm wide by 2 cm deep. The tissue was deep red in color. Wound edges were soft. There was small amount of brownish drainage coming from this wound. There was no odor or tunneling noted. The area around the wound was normal in color. The right heel wound measured approximately 10 cm long by 2.5 cm wide by 0.2 cm deep. The Achilles tendon was viewable. This wound also had a small amount of brownish drainage coming from it. There was no odor noted. The tissue surrounding the Achilles tendon was pink/red in color. Wound edges were well defined and there was no tunneling. Interview with the Administrator on 05/27/16 at 1:00 P.M. revealed she was informed that the hyperbaric treatment center did not assess or visualize Resident #57's wounds. The administrator stated she was not aware that the hyperbaric treatment center did not change the resident's dressings. 2. Resident #54 was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #54 was cognitively intact. The MDS functional assessment revealed Resident #54 needed extensive assistance for bed mobility, locomotion on and off the unit, dressing and personal hygiene. For transfers and toilet use the resident was totally dependent on staff and needed two person assistance. Resident #54 was receiving [MEDICAL TREATMENT]. [MEDICAL TREATMENT] was scheduled Monday, Wednesday and Friday. [MEDICAL TREATMENT] was to be short term since Resident #54 was transferring over to peritoneal [MEDICAL TREATMENT] and then he would be discharged home. Resident #54 was also being monitored for nutrition due to a fluctuation in his weights. He was ordered by the physician to receive weekly weights. Review of Resident #54's medical record contained no documentation from the [MEDICAL TREATMENT] center in regards to the weight taken off with [MEDICAL TREATMENT]. An interview with LPN # 177 on 05/26/16 at 9:00 A.M. revealed that they do monitor a resident's blood pressure and vital signs prior to leaving for [MEDICAL TREATMENT]. LPN #177 stated that get paperwork back from [MEDICAL TREATMENT] stating the resident's vital signs and labs drawn. An interview held with Dietician #220 on 05/26/16 at 11:00 A.M. verified that Resident #54 did have a 32 pound weight loss from 01/015/16 to 01/14/16. Dietician #220 stated she had difficulty maintaining communication with the [MEDICAL TREATMENT] center dietician. The dietician stated she has left messages for the [MEDICAL TREATMENT] center dietician. She further stated that she has called the [MEDICAL TREATMENT] center to get the copies of his treatment reports and she was waiting for them to be faxed. An interview with the Administrator on 05/26/16 at 2:00 P.M. was held regarding paperwork received from the [MEDICAL TREATMENT] center. After further review, the Administrator stated she would contact the [MEDICAL TREATMENT] center and get the paperwork with his treatment and his weights since it was not in the chart. LPN #116 obtained further paperwork from the [MEDICAL TREATMENT] center with the weights on it. An interview held with the Director of Nursing (DON) on 06/26/16 at 3:00 P.M. which revealed that the facility did not have paperwork supporting communication between the [MEDICAL TREATMENT] center and the facility in regards to weight loss, lab values or any issues encountered during [MEDICAL TREATMENT]. 3. Resident # 9 was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. This resident was receiving a diuretic, [MEDICATION NAME], to help with any fluid overload. Review of this resident's physician orders [REDACTED]. Review of the resident's weight log revealed she received three weights, on 12/22/15, 12/23/15 and 01/06/15 which was her last weight. This resident was not weighed weekly as ordered or according to the facility policy and procedure. Review of Resident # 9's weights revealed on admission she weighed 205 pounds and three weeks later her weight was 187 pounds, a weight loss of 18 pounds. Interview Dietician #220 on 05/26/16 at 4:00 P.M. revealed she did have a note stating that the resident needed to be re-weighed to double check her weight loss. Dietician #220 also verified the weekly weights were not completed per physician order. 4. Review of Resident #95's clinical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #95's comprehensive assessment dated [DATE] revealed the resident received [MEDICAL TREATMENT] but the Section Special procedures listed the resident as not receiving [MEDICAL TREATMENT]. Resident # 95 was admitted to the facility with [MEDICAL TREATMENT] on Monday, Wednesday and Fridays. Review of Resident #95 ' s plan of care (POC) dated 05/18/16 reveled the resident required [MEDICAL TREATMENT] (hemo) related to [MEDICAL CONDITION] and went to [MEDICAL TREATMENT] every Monday, Wednesday and Friday. Further review of Resident #95's clinical record revealed the clinical record contained no treatment records, assessment or orders from the [MEDICAL TREATMENT] center. The record contained no information from the [MEDICAL TREATMENT] center on treatment provided, response to the treatment or issues that may have occurred during [MEDICAL TREATMENT]. The record contained no coordination of care between the facility and the [MEDICAL TREATMENT] center. Interview with Dietitian #220 on 05/26/16 at 10:00 A.M. regarding the resident's nutritional status in regards to [MEDICAL TREATMENT] revealed she did not have any documentation from the [MEDICAL TREATMENT] center and had to call the center to have the center fax over Resident #95's [MEDICAL TREATMENT] treatment records. The dietitian called the [MEDICAL TREATMENT] center and asked for the records. On 05/26/16 at 11:17 A.M., the [MEDICAL TREATMENT] center faxed over the records from 05/11/16 to 05/23/16. Interview with the DON on 05/26/16 at 3:00 P.M. revealed she was unaware Resident #95 had no records from the [MEDICAL TREATMENT] center. The DON stated the nurses were to ensure documentation was obtained from each [MEDICAL TREATMENT] sessions from residents who go to the [MEDICAL TREATMENT] center.

Based on interview and closed record review, the facility failed to prevent verbal and physical abuse. This affected three of five residents (Residents #48, #66, #99) reviewed for allegations of abuse. The facility census was 51 residents. Actual harm occurred when Resident #66, who has a [MEDICAL CONDITION], was shaken by the shoulder and placed in her room with the door closed by Registered Nurse #200. Actual harm occurred to Resident #99 who was pushed in the back to his room by Agency Caregiver #253 causing the resident to become angry. In addition STNA #130 used profane language towards Resident #48. Findings include: 1. Review of Resident #66's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #66 had a capped [MEDICAL CONDITION] which allowed the resident to call out for help. Review of Resident #66's comprehensive assessment dated [DATE] revealed the resident was an extensive assist of two persons for bed mobility, transfers and personal hygiene. Review of Resident #66's plan of care (POC), dated 08/23/15 revealed the resident had a problem behavior of making false allegations towards staff, excessive call light use, yelling out, inappropriate language, accusing staff of not feeding her related to adjustment issues and [MEDICAL CONDITION]. The goal of the POC was to have the resident display no evidence of behavior problems, false allegations, yelling out, and not using the call light. Interventions developed on 09/10/15 included administering medication as ordered, monitor/document for side effects and effectiveness and anticipate and meet the resident's needs. Provide opportunity for positive interactions and attention with two staff members in the room while performing care. Explain all procedures to the resident before starting and allow the resident times to adjust to changes. Review of a Self- Reported Incident (SRI) dated 08/28/15 at 4:53 P.M. revealed the speech therapist (ST) came to the Director of Nursing (DON) and reported an allegation of abuse. The ST stated Resident #66 reported to her the nurse last night closed the door and shook her. According to the SRI, Resident #66 had been yelling out due to leg pain. Witness statements indicated Resident #66 reported the allegation to State tested Nurse Aide (STNA) #201 and STNA #201 reported the allegation to the alleged perpetrator, the nurse on duty, Registered Nurse (RN) #200. Neither STNA #201 nor RN #200 reported Resident #66's behavior to the physician or notified the Administrator nor the Director Nursing (DON) of the incident until approximately nine hours after the incident occurred. Review of the alleged perpetrator's, RN #200's written witness statement dated 09/01/15 revealed during third shift, the night of 08/27/15 to 08/28/15, Resident #66 was constantly complaining and screaming she did not feel comfortable and was in pain. Resident #66 was medicated with a pain medication and with as needed (PRN) anti-anxiety medication. RN #200 documented she was not able to understand Resident #66 and instructed the resident to calm down and speak more clearly. RN #200 documented it was not her intention to cause distress to Resident #66 or make her believe she was making fun of the resident's speech. RN #200 was not asked on the initial phone interview about the allegation of shaking the resident, shutting the door to allow the resident to scream or why she did not call the physician when Resident #66 did not calm down after multiple doses of the PRN [MEDICATION NAME]. Review of STNA #130's witness statement (no date) revealed she was working third shift upstairs on the east hall and Resident #66 was constantly screaming and hollering all evening. STNA #130 documented we would go in and reposition Resident #66, lotion her legs, propping her legs, change the brief and reposition her. STNA #130 documented there was no satisfying her. All I know is sometime in the evening someone closed Resident #66's door because her hollering was keeping other residents awake. Review of the facility's investigation dated 08/28/15 (no time) revealed STNA #201 documented RN #200 was visibly upset most of the shift because Resident # 66 was upset and yelling out. RN #200 had dropped Resident #66's medication while administering it though the peg tube and it was unclear how or what medication the resident actually received. STNA #201 documented Resident #66 yelled out when she saw staff walking by the room. Staff were in her room several times encouraging her to use her call light. RN #200 went into Resident #66 to tell her to stop yelling. RN #200 gave her a pencil and paper to write what she needed. RN #200 could not understand her and mocked the resident's speech. Later in the shift Resident #66 told STNA #201 that RN #200 entered her room, closed the door and shook her by the shoulders. STNA #201 reported this to RN #200 the alleged perpetrator. I told her to call the doctor and tell them about dropping the med's on the floor and the resident yelling out. RN #200 told STNA #201 she did not have the time and walked away. Review of STNA #121's witness statement, dated 08/28/15 (no time), reveled Resident #66 was yelling out all shift. The staff went into her room several times. Resident #66 did not use her call light but yelled out instead. STNA #201 reported to STNA #121 Resident #66 stated RN #200 had closed the door and shook her by the shoulders. STNA #121 documented she reported this to the first floor supervisor and was not sure what became of the discussion. Review of RN #200's telephone interview dated 08/28/15 (no time) revealed Resident #66 was yelling out and she was trying to go into her room and calm her down. RN #200 stated Resident #66 was upset about multiple things like getting repositioned and the pillow was not right. Resident #66 was upset because I could not understand what she was saying. I gave her a pen and pencil to write down what she was saying. RN #200 had STNA #201 in the room with her most of the time but there were times RN #200 was alone with Resident #66. RN #200 stated she did not think to call the doctor and at no time did she shake her. RN #200 stated she did close the door just like the STNAs did so she could calm down. RN #200 stated Resident #66 was so loud, she was disturbing the other residents. RN #200 was not asked about the dropped medication from the peg tube and the possibility of the Resident #66 not being administered her full dose of pain medication. Review of Resident #66's statement dated 08/28/15 revealed the resident was yelling out. Resident #66 described RN #200 as the nurse with red hair and glasses and was wearing a shirt with multiple colors. Resident #66 stated RN #200 was making fun of the way she talked and she shut her door. Resident #66 stated RN #200 grabbed her by the shoulders and shook her. Resident #66 stated there was nothing she could do. Resident #66 stated I am afraid. I yell out because my legs hurt. Interview with the Ombudsman on 05/24/16 at 1:30 P.M. revealed the ombudsman was unaware of an allegations of abuse made toward staff by Resident #66. The Ombudsman stated he had been involved in discharge planning and was unaware of Resident #66's calling out behavior. Interview with the Administrator on 05/25/16 at 4:10 P.M. revealed none of the staff reported Resident #66's abuse allegation. Resident #66 reported the incident to two staff and neither staff reported the allegation to the DON or to her. The administrator verified STNA #201 reported the allegation to the alleged perpetrator and the perpetrator finished the shift with the possibility of further abuse to Resident #66. The administrator stated Resident #66 had behaviors of making false allegations toward staff. The administrator was unaware the POC although documented the area of concern for making false allegations dated 08/23/15 did not have interventions in place for the concern until after the incident occurred on 08/28/15. The administrator was unaware Resident #66 may not have received all of her medication which may have been contributing factor to the yelling and calling out behavior. 2. Review of Resident #99's closed medical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Resident #99 was discharge from the facility prior to the survey. Review of Resident #99 behavioral intervention plan dated 02/27/15 revealed the resident had target behaviors of assaultive behavior defined as hitting persons or objects; throwing objects when angry and cursing at others including staff and other patients. Interventions included to clearly describe what will be done and who will do it. The behavior intervention plan did not have physical redirection as part of the behavior plan. Review of the facility SRI dated 04/02/16 at 7:00 A.M. revealed the DON received a call from the night shift nurse regarding other issues that occurred during the night. The nurse stated to the DON the resident (Resident #99) and his sitter almost got into it She said Agency Caregiver #253 was being rude and condescending to the resident as well. On 04/04/16, while conducting the investigation, the DON learned the almost altercation was in fact a physical altercation between the resident and his Agency Caregiver #253. According to the report, Resident #99 approached the nurse and asked for water. Agency Caregiver #253 then told the resident he would have to wait and stop expecting things immediately. At that point, Agency Caregiver #253 began pushing the resident from behind and the resident became angry and turned to face the Agency Caregiver #253. Both began shoving each other and the shoving continued to Resident #99's room. The incident occurred at approximately 6:00 A.M. and the shift change was happening at the same time. No further issues were observed between the resident and the Agency Caregiver #253. The report documented the evidence was inconclusive due to the fact the facility was still waiting on the final outcome of the investigation by the caregivers agency. Review of Licensed Practical Nurse (LPN) #202's late entry nurses' notes dated 04/05/16 at 7:37 A.M. revealed LPN #202 was at the water fountain on first floor and Resident #99 asked the nurse for water. LPN #202 documented she observed the night shift sitter telling Resident #99 , You can't have water, you have to wait, and the shoved Resident #99 repeatedly on the upper back down the hall until they passed the double doors after the nurse's station. LPN #202 indicated she said, It's okay, it's okay to reassure Resident #99. The resident was agitated, and Resident #99 and Agency Caregiver #253 began to push each other while facing each other until they got to Resident #99's room. LPN #202 indicated she observed the entire incident until they reached the resident's room. A head to toe assessment was completed of Resident #99 with no injuries noted. LPN #202 was told by an aide that Agency Caregiver #253 was condescending to resident in the past. Agency Care Giver #253 had also been witnessed to fall asleep during shift. Interview with the DON on 05/27/16 at 1:30 P.M. revealed she had been called by LPN #202 for other issues at the facility and was told about the incident between Resident #99 and Agency Caregiver #253. The DON stated LPN #202 originally told and Agency Caregiver #253 Resident #99 almost got into it. The DON stated as she further investigated the incident it turned out it was a physical altercation in which the care giver pushed Resident #99 back to his room. The DON verified Agency Caregiver #253 was allowed to finish his shift and Agency Caregiver #253 was not supervised. The alleged abuse happened approximately one hour before LPN #202 called the DON to report the other issues. The DON verified LPN #202 did not follow the facility's policy and procedure to notify the administrator or DON immediately and allowed the potential for further abuse toward Resident #99's. 3. Resident #48 was admitted on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #48's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and exhibited physical and verbal behavioral symptoms towards others. Review of Resident #48's care plan revealed when the resident was verbally aggressive and yelling at others, facility staff were to intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; and staff to walk calmly away, and approach later if aggressive. Review of a facility SRI revealed on 04/29/16 at 7:00 A.M. an allegation of emotional/verbal abuse occurred in Resident #48's room. The resident became combative and attempted to hit staff. Resident #48 grabbed the wrist of one of the STNAs causing her glove to rip and causing a scratch to her wrist. After this, there were separate accounts of what occurred. Per STNA #187, STNA #130 then allegedly called the resident a profane name. Resident #48 then stated God will punish you. According to STNA #187, STNA #130 then allegedly responded to the resident by stating, you are going to hell. STNA #130 admits that she muttered a profanity under her breath, but denies making any statements to the resident. Once the resident was safely transferred to her chair, two floor nurses went to the room to assist the STNAs. The resident was calmed down and taken to the activities room to wait for breakfast. After report of the allegation, STNA #130 who was alleged to have used the profane language, was immediately suspended pending an investigation. Witness statements were obtained from nurses and STNAs. Interviews were completed with nurses and STNAs. The only witnesses to the incident were the two STNAs and the resident. The resident was interviewed and had no recall of anything from 7:00 A.M. STNA #130 reported she mumbled under her breath profane language, but that the statement was not directed towards the resident. No physical injuries were observed when the resident was interviewed. After investigation, it was concluded that the allegation of verbal abuse was unable to be substantiated due to conflicting accounts of the alleged incident, and the inability of the resident to recall the incident due to her advanced dementia. One on one staff education was initiated and was ongoing on the abuse policy, and professional conduct in the facility. Review of STNA #130's witness interview statement (date and time unknown)) revealed STNA #130 and STNA #187 were getting Resident #48 dressed. The resident kept reaching out to grab up and grabbed STNA #130 arms and scratched STNA #130. Resident #48 made attempts to hit STNA #187. STNA #130 stated she was placed between the bed and heater. STNA #130 stated the aides were rolling the resident to get the hoyer pad under her and the resident grabbed STNA #130's wrist and ripped the glove and STNA #130 muttered son of a b**** under her breath because she was scratched. STNA #130 denied swearing at the resident. Both STNAs continued to provide care for the resident and two nurses joined in the assistance. STNA #130 reported notifying the nurse that the resident had ripped her glove and drew blood, but did not indicate using profane language. Review of STNA #166's interview statement revealed on 04/29/16 at 6:25 A.M. STNA #130 was upset about her assignment and threw her assignment sheet away during report. The nurse picked it out of the garbage can and gave it back to STNA #130. STNA #130 rolled it in a ball and put in it in her pocket and received report. Review of STNA #187's witness interview statement dated 04/29/16 at 7:00 A.M. revealed STNA #187 and #130 were getting Resident #48 out of bed, and the resident pinched STNA #130; STNA #130 responded you b****. Resident #48 then responded, god will punish you, and STNA #130 responded, No, you are going to hell. Review of STNA #158's witness statement revealed on 04/29/16 at 8:30 A.M. STNA #187 notified STNA #158 that while getting Resident #48 up, the resident pinched STNA #130, and #130 responded you b**** to the resident. STNA #187 noted STNA #158 was scared to report it. STNA #158 reported the allegation to Licensed Practice Nurse (LPN) #150 at 9:15 A.M. Review of Resident #48's late entry nursing note on 04/29/16 revealed LPN #150 reported to administration that she was told by STNA #158 that another STNA #130 made inappropriate comments to a resident during care delivery. There was no evidence of the time LPN #150 became aware of the incident or notifying administration. Review of LPN #171's interview statement revealed on 04/29/16 at approximate 7:30 A.M. to 7:45 A.M. the LPN assisted STNA #130, STNA #187, and LPN #150 in assisting Resident #48 while the resident had a hold of the hoyer lift. The resident was yelling and the statement does not include any verbal abuse towards the resident from staff. Review of LPN Unit Manager #117 email on 05/01/16 revealed on 04/29/16 between 2:30 P.M. and 4 P.M. LPN #150 notified the Unit Manager of the alleged verbal abuse on Resident #48 by STNA #130. This notification of alleged abuse was at least seven hours after the incident occurred. Interview on 05/25/16 at 9:40 A.M. with Administrator revealed STNA #130 continued to work with the resident until about 7:45 A.M. when two nurses came in to assist in her care. The STNA was then suspended for four days pending the investigation. Administrator revealed STNA #130 frustrations that morning were witnessed at the nurses station and LPN #150 talked to STNA #130. Interview on 05/26/16 at 1:36 P.M. with LPN #150 revealed STNA #187 told her about the alleged abuse incident in the early afternoon, and LPN #150 told the unit manager a half hour after she received the report. LPN #150 felt STNA #130 had calmed down after her frustration about her assignment on 04/29/16 and was allowed to continue to work. Review of the facility's policy and procedure for Abuse Prohibition dated 2015 revealed the facility prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of resident's property and or funds. The health care center's management will conduct prompt investigations of any allegation received of suspected abuse, neglect or misappropriate of property and/or funds. The health care center maintains that all allegations of abuse, neglect misappropriation of property are immediately reported, thoroughly investigated and appropriate actions are taken. Guidelines for an investigation: Immediately assess the resident at the time of discovery of the alleged abuse. Document the assessment in the medical record. Maintain resident's protection during the investigation. Notify attending physician and residents legal responsibly party, the administrator, director of nursing and social worker regardless of the time of day. All alleged violations concerning abuse, neglect, misappropriation or property and injuries of unknown origin are reported immediately to the administrator/designee and other enforcement agencies, according to state law including the state survey and certification agency, nurse aide registry and licensing authorities.