Every finding on record at Pickerington Care and Rehabilitation

Based on record review, interview and facility policy review the facility failed to ensure resident #22's skin was monitored for skin impairment and Resident #22 had pressure ulcer preventive measures implemented. This affected two residents (Resident #10 and Resident #22) of three residents reviewed for pressure ulcers. The census was 73.Findings include:1. Review of Resident #10's medical record revealed an admission date of 07/17/26. Medical diagnoses include respiratory failure unspecified with hypoxia, encounter attention for tracheostomy, anoxic brain injury and dependence on respirator (ventilator) status, encounter for attention to gastrostomy and pressure ulcer of sacral region, Stage III.Review of Resident #10's care plan revised on 07/24/26 confirmed Resident #10 had an area of skin impairment related to admission with pressure ulcers to sacrum, right foot and right hip, goals include healing of current impairment, and prevention of further skin breakdown and wound will remain free of infection until healed. Interventions include encourage to turn and reposition every two hours as tolerated and encourage float heels as tolerated. Further review of Resident #10's Activity of Daily Living (ADL) care plan confirmed Resident #10 was totally dependent and does not participate in any aspect of the tasks for transfers, toileting, bed mobility, bathing, dressing and personal hygiene.Review of Resident #10's skin assessments dated 07/30/26 revealed Resident #10 has a unstageable pressure ulcer to their right hip, and stage three pressure ulcer to their sacrum with interventions noted as wound care, pressure relieving interventions as indicated, serial wound assessments and monitor wound healing progression.Review of Resident #10 turn and reposition task revealed there was no evidence repositioning was completed on 07/25/26, 07/26/26, 07/27/26, 07/28/26, 07/30/26, 07/31/26 and 08/16/26.Interview on 08/18/26 at 2:46 P.M. with the Director of Nursing confirmed there was no documentation completed on the above dates for Resident #10's turn and reposition task.Review of facility's policy titled, Pressure Injury Prevention and Management dated 01/08/25 confirmed the facility is committed to the prevention avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Further review of the policy confirms the facility treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.2. Review of Resident #22's medical record revealed admission date of 10/12/24. Medical diagnoses include cerebral infarction due to unspecified occlusion or stenosis of right middle artery, type II diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, gastrostomy status, and unspecified dementia.Review of Resident #22's Minimum Data Set (MDS) 3.0 dated 06/22/26 Brief Interview for Mental Status revealed a score of 99 noting resident #22 was unable to complete the interview.Review of Resident #22's care plan revised on 01/02/26 revealed Resident #22 needs assistance with ADL's, goal includes resident will continue to participate in ADLs as able and no decline in ADL's through next review, with interventions noting Resident #10 was totally dependent and does not participate in any aspect of the task for toileting, dressing, transfers, bathing, bed mobility and locomotion. Additional interventions include staff will assist as needed with daily hygiene and will assist with showering residents as per facility policy.Review of Resident #22's Skin Monitoring STNA Comprehensive Shower Review confirms STNA's should perform a visual view of the resident's skin when giving a shower. Please report any abnormal looking skin to the charge nurse immediately. Use this form to show the exact location and description of the abnormality. Further review of Resident #22's Skin Monitoring STNA Comprehensive Shower Review sheets confirmed the skin assessment for Resident #22 was not completed on 07/01/26, 07/04/26, 07/08/26, 07/11/26, 07/15/26, 07/18/26, 07/22/26, 07/25/26, and 07/29/26.Interview on 08/18/26 at 2:46 P.M. with the Director of Nursing confirmed there was no skin observation documentation completed on the above dates for Resident #22.Review of facility's policy titled, Pressure Injury Prevention and Management dated 01/08/25 confirmed nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task.This deficiency represents non-compliance investigated under Complaint Number 3137159.

Based on closed record review, discharge notice review, hospital record review, discharge hearing document review, interview and policy review the facility failed to ensure residents were provided timely and appropriate discharge planning after the administration of a discharge notice and failed to ensure residents were permitted to return to the facility following a hospitalization. This affected one resident (#72) of two reviewed for discharge with a 30-day notice. The facility census was 68.Findings include: Review of Resident #72's closed medical record revealed an admission date of 10/14/25 with diagnoses including fusion of the spine- cervical region, Ehler's-Danlos syndrome (a group of 13 inherited genetic conditions that affect collagen that results in weakened connective tissues), secondary malignant neoplasm of unspecified lung, depression, anxiety disorder, and neoplasm related pain. Review of the resident's discharge planning plan of care dated 10/14/25 revealed the resident desired to be discharged with goals of getting an apartment with cancer support. Interventions included nursing, social services, and rehab to discuss program and discharge planning weekly or as needed. Talk to resident and allow her to express feelings regarding discharge. Review of Resident #72's 10/21/25 admission Minimum Data Set (MDS) revealed a brief interview for mental status score of 15 indicating the resident had intact cognition. Further review of the MDS revealed the resident required supervision or touching assistance with activities of daily living.Review of Resident #72's progress notes dated 11/10/25 at 11:00 A.M. and authored by Social Service Designee (SSD) #358 revealed the resident was cut from insurance on this date (11/10/25) with the last covered day, 11/08/25. Reviewed with resident, discussed appeal options, provided a copy (the note did not indicate what the copy was). Discussed a peer-to-peer initiation, discussed upcoming changes to treatment plan for cancer. The resident stated she would begin radiation treatments at the end of the month. Discussed that the resident needs assistance with dressing, help with setting up food tray, opening items. Discussed when she is incontinent, she needs assistance with cleaning up. Discussed she cannot return to previous residence. Discussed with upcoming radiation the doctor told her she may lose the use of her right arm. Resident tearful about the same. Review of Resident #72's progress notes dated 12/03/25 at 9:23 A.M. and authored by SSD #358 revealed the resident's appeal results were received and were unsuccessful. Reviewed with resident. Discussed her family is still looking into other medical plans that have a long-term care benefit. However, there was a death in the family last week and that had paused the process. Discussed last covered day 11/08/25 and need to have payor or she may receive a 30-day discharge notice. The resident stated she felt like she was at home here and hoped to stay. She stated she would reach out to her family related to the search for an alternate Medicaid plan. (Please note, there is no documentation to support staff offered to assist the resident in the application process or change in plan process for Medicaid).Review of Resident #72's progress notes revealed a note written by the Social Services Director (SSD) on 12/23/25 at 1:13 P.M. stating the Administrator and the SSD delivered a 30-day notice (of discharge) due to failure to pay.Review of Resident #72's 30-day discharge notice dated 12/23/25 revealed it was issued to the resident due to the resident had failed, after reasonable and appropriate notice to pay, or to have the Medicare or Medicaid program to pay on his or her behalf for the care provided by the facility. Further review revealed the date the discharge was to take place was 01/22/26.There were no additional social service progress notes contained in Resident #72's medical record.Review of Resident #72's progress notes dated 01/04/26 and written by Licensed Practical Nurse (LPN) #292 revealed the resident was being sent out to (named hospital) due to non-stop diarrhea.Further review of the medical record revealed the resident was discharged from the facility on 01/04/26. No further documentation was noted after the resident was transferred to the hospital.Review of Social Services Hospital documentation dated 01/09/26 at 3:58 P.M. and authored by LSW #400 revealed he had called the facility (Pickerington) and left several messages. The Social Worker received a message back that the patient owed $28,000.00 and they had given her a notice to leave before she came to the hospital. They were unable to take the patient back. Review of the Appeal decision dated 01/20/26 revealed the hearing officer found the facility had not met its burden to prove its case by a preponderance of evidence and the facility's request to discharge the resident was denied. The hearing officer had concerns that the facility had filed the discharge notice only ten weeks after the resident was admitted to the facility. The decision also highlighted the family did not receive requested information from the facility such as an itemized bill with the break down of the $28,000.00 bill.In an interview on 01/27/26 at 2:15 P.M. with Resident #72's daughter revealed a 30-day discharge notice was issued to her mother on 12/23/25. The resident and family chose to appeal, and the appeal was in process when her mom was sent to the hospital on [DATE] (the hearing was on 01/15/26). The facility was aware that she could not return to her previous living arrangements and the facility did not help with finding another facility or assisted living facility other than offering the family one option that did not take Medicaid. The case manager with passport was more help than the facility with trying to get the Medicaid changed to traditional. A follow-up interview with the Resident's daughter on 01/28/26 at 12:15 P.M. revealed the family received no documentation from the facility that they would not take the resident back upon hospital discharge but the hospital told them the facility said they would not accept her back. The resident's daughter stated her mother was happy at the facility and wanted to return. She did not want to go to another facility. Lastly, the daughter stated she did email the facility this week (week of 01/28/26) to inform them her mother had gone to another facility as a courtesy to the facility.In an interview on 01/29/26 at 10:25 A.M. with Licensed Social Worker (LSW) #400 (from the hospital the resident was transferred to on 01/04/26) verified the facility told him that the resident could not return because of nonpayment and to find her alternate placement.In an interview on 1/30/26 at 1:10 P.M. Social Services Director (SSD) #358 stated the resident was offered help with changing to traditional Medicaid but the resident declined (there is no documentation to support additional offers to assist). When the resident didn't change her Medicaid or pay her bill, a 30-day discharge notice was issued. The resident and family requested to appeal the discharge notice but the resident was in the hospital at the time of the appeal and the resident didn't return to the facility.In an interview on 01/30/26 at 2:11 P.M. the Administrator verified there was no documentation contained in the resident's medical record regarding the family or the resident not wanting to return to the facility. The Administrator verified an email was received from the resident's daughter on 01/26/26, indicating she was at another facility. Review of an email sent to the surveyor from the Administrator dated 03/02/26 at 5:13 P.M. confirmed the facility didn't have documented communication between the hospital and the facility on discharge planning for Resident #72. Review of an email from facility administrator to the surveyor dated 03/02/26 at 5:54 P.M. verified the facility was unaware of the resident's location until 01/26/26 when they received an email from the resident's family indicating the resident resided in a different facility.In an interview on 03/02/26 at 4:30 P.M. with Resident #72's daughter confirmed the resident remained in the hospital during the appeal hearing on 01/15/26. The daughter stated she never heard from Embassy of Pickerington about her mother being able to return due to the hearing results but after the facility told the hospital social worker they wouldn't take her back, they found her alternate placement, even though she really wanted to return to Embassy. The daughter also confirmed she had requested an itemized bill when the facility said her mother owed $28,000.00 but the facility didn't provide her with the bill and she was her mother's financial power of attorney. She also verified the facility did not assist her mother when trying to find an alternative Medicaid provider to become her payor so she could remain in the facility. Review of the policy titled Transfer and Discharge Policy revised 02/05/25 revealed that if the resident chooses to appeal the discharge, the facility will allow the resident to return to the facility from the hospital during the appeal process.This deficiency represents noncompliance investigated under Complaint Number 2715422.

Based on observation, interview and record review the facility failed to provide hair care to a dependent resident. This affected one resident (#67) of four residents reviewed for assistance with activities of daily living. The facility census was 68.Findings include:Review of Resident #67's medical record revealed an admission date of 01/21/26 and diagnoses including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of muscle right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. Review of Resident #67's 01/27/26 admission Minimum Data Set (MDS) revealed the MDS was in progress and not yet completed. Review of assessments completed on 01/26/26 for Resident #67, in preparation for completing the MDS, revealed a brief interview for mental status score of zero indicating the resident was severely cognitively impaired and the resident was dependent on staff for all activities of daily living except eating, which the resident required setup assistance for. Review of Resident #67's shower sheets for 01/22/26, 01/23/26, 0126/26 and 01/27/26 revealed the resident had refused to have her hair washed on those days.Review of Resident #67's medical record revealed no documentation the resident refused hair care on days other than her shower days.An observation of Resident #67's hair on 01/27/26 at 11:55 AM revealed it to be matted to the back of her head.An observation of Resident #67's hair on 01/27/26 at 1:49 PM revealed it to be matted to the back of her head.In an interview on 01/27/26 at 1:49 P.M. Certified Nursing Assistant (CNA) #228 confirmed Resident #67's hair was matted to the back of her head and her hair needed to be combed.This deficiency represents non-compliance investigated under Complaint Numbers 2727003, and 2678134.

Based on observation, interview, record review and policy review the facility failed to provide a clean, comfortable environment. This affected one resident (#67) of four residents reviewedt. The facility census was 68. Findings include: Review of Resident #67's medical record revealed an admission date of 01/21/26 and diagnoses including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of muscle right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. Review of Resident #67's 01/27/26 admission Minimum Data Set (MDS) revealed the MDS was in progress and not yet completed. Review of assessments completed on 01/26/26 for Resident #67, in preparation for completing the MDS, revealed a brief interview for mental status score of zero indicating the resident was severely cognitively impaired and the resident was dependent on staff for all activities of daily living except eating, which the resident required setup assistance for. An observation of Resident #67's room on 01/27/26 at 11:55 AM revealed a brown stain on the floor under the resident's small two drawer bedside dresser, and a dry, crumbly brown substance adhered to the lower front and corner of the small two drawer bedside dresser.An observation of Resident #67's room on 01/27/26 at 1:49 PM revealed a brown stain on the floor under the resident's small two drawer bedside dresser, and a dry, crumbly brown substance adhered to the lower front and corner of the small two drawer bedside dresser.In an interview on 01/27/26 at 1:49 P.M. Certified Nursing Assistant (CNA) #228 confirmed the brown stain on the floor, in Resident #76's room, under the resident's small two drawer bedside dresser, and the dry, crumbly brown substance adhered to the lower front and corner of the small two drawer bedside dresser.Review of the Policy titled Routine Cleaning and Disinfection, undated, revealed it is the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. Further review of the policy revealed that routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces.This deficiency represents non-compliance investigated under Complaint Numbers 2727003, 2685197 and 2678134.

Based on observations, resident and staff interviews and policy review, facility failed to ensure the survey results binder was easily accessible to all residents. This had the potential to affect all facility residents. Facility census was 71. Findings include Observation on 09/25/25 at 11:34 A.M. revealed the survey book was located in the front hallway between the administration offices and the staff and visitor bathrooms. It was sitting in a folder shelf and the binder was bolted to the wall. The shelf sat about chest high on the wall and was pointed upward requiring a person to lift the binder up and out of the shelf which would be difficult for a resident sitting lower to the ground in a wheelchair. The chain was about 18-24 inches long and would not allow a resident to review the binder without standing in the hallway up against the wall. Interview on 09/25/25 at 2:00 P.M. with Director of Nursing revealed she did not know why the binder was chained to the wall and stated likely so residents would walk away with it or take it to their rooms. The Director of Nursing acknowledged it would be difficult for residents to get the binder and have to stand and read it in the hall. Interview on 09/25/25 at 2:15 P.M. with Regional Nurse #300 revealed she was unsure why the binder would be chained up in the front hallway. Review of facility policy titled Resident Rights dated 06/01/24, revealed the resident had the right to examine the results of the recent state survey and any plans of correction with respect of the facility.

Based on observations, staff interviews, and record review, the facility failed to maintain flooring for two residents (#53 and #67) out of 25 residents observed for environment. Additionally, the facility failed to ensure carpeting throughout facility was maintained in clean and sanitary manner. This had the potential to affect all 71 facility residents.Findings include 1. Observation on 09/22/25 at 2:08 P.M. of Resident #53 and #67's room revealed flooring under and around the room air conditioner was peeling up about an inch off the floor and about eight tiles were affected. Observation and interview on 09/23/25 at 12:10 P.M. with Maintenance Director (MD) #190 confirmed Resident #53 and #67's flooring was peeling up and stated he was aware of issues with flooring and was trying to get the broken flooring replaced in order of severity. He stated the facility had been working on replacing flooring and he had a list they were working through. He reported the facility had been working on the flooring for several months and had only completed five rooms.2. Observations from 09/22/25 from 8:00 A.M. to 4:45 P.M. and 09/23/25 from 8:20 A.M. to 12:00 P.M. found facility carpeting in hallways to be dirty with grime and dark staining showing tracks and old moisture stains outside each resident room and down the middle of the hallway and around the offices and nursing stations. Observation and interview on 09/23/25 at 12:10 P.M. with Maintenance Director (MD) #190 confirmed the carpet was dirty and stated they tried to clean it, but it did not work. He revealed the facility was trying to get it replaced and revealed the corporate office was reviewing options for replacement. MD #190 was unable to provide any evidence that facility had taken any steps for replacement including quotes or order confirmations. He revealed they had a carpet cleaner that was used once monthly to maintain the carpets but confirmed they did not maintain it in a sanitized and clean manner. Review of facility policy titled Resident Environmental Quality dated 11/29/22, revealed the facility shall maintain and provide a safe, functional, sanitary and comfortable environment for residents, maintain all essential patient care equipment in safe operating condition, and all facility personnel were responsible for reporting broken, defective equipment and furnishings upon identification. It stated preventative maintenance schedules should be in place to maintain the building and equipment to maintain a safe environment.This deficiency represents non-compliance investigated under Complaint Number 2575168 and Complaint Number 1260918.

Based on medical record review, observation, staff interview and facility policy and procedure, the facility failed to ensure splints ordered and care planned for residents with decreased range of motion were applied. This affected five (Resident #5, Resident #20, Resident #76, Resident #81 and Resident #87) of seven residents reviewed for mobility and position. The facility census was 71. 1. Review of Resident #87's medical record revealed he was admitted on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was not intact (Rarely/Never understood). Resident #87 was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #87 had an indwelling urinary catheter and is always incontinent of bowel. Review of the physicians orders revealed an order dated 08/11/25 for staff to don bilateral resting hand splints up to six hours daily as tolerated. Check skin integrity and circulation every shift. Review of the treatment records revealed staff documented the splints had been applied on 09/22, 09/23 and 09/24/25. Observations made on 09/23/2025 at 9:16 A.M. and 2:07 P.M. and 09/24/25 at 7:23 A.M., 10:23 A.M., 2:36 P.M., and 3:21 P.M. revealed no splints observed in place. Interview with Licensed Practical Nurse (LPN) #129 on 09/24/25 at 3:21 P.M. confirmed Resident # 87 did not have splints in place on this shift and splints had been signed off in the electronic record as being utilized. 2. Review of Resident #81's medical record revealed he was readmitted to the facility on [DATE]. Diagnoses included acute respiratory failure, protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, depression, old myocardial infarction, contractures and anoxic brain damage. Review of the quarterly Minimum data set assessment dated [DATE] revealed Resident #81's cognition was not intact, and he was rarely/never understood. Resident #81 was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #81 had an indwelling urinary catheter and was always incontinent of bowel. Further review of the plan of care dated 04/10/25 revealed the resident had loss of muscle function/range of motion (ROM) due to contractures of bilateral upper and bilateral lower extremities. Staff to don bilateral elbow orthotics, right rolling hand splint and left resting hand splint up to six hours daily each shift with frequent skin checks. Observations made on 09/23/2025 at 2:22 P.M., on 09/24/25 at 7:15 A.M., 9:21 A.M., 11:24 A.M., 3:00 P.M. and 5:50 P.M. and on 09/25/25 at 7:30 A.M., at 10:00 A.M. and 2:25 P.M. revealed no splints observed in place. On 09/25/25 at 2:25 P.M. observation and interview with Licensed Practical Nurse (LPN) #247 confirmed his splints were not in place. 3. Review of Resident #76's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, nontraumatic intracerebral hemorrhage, cerebral infarction, chronic obstructive pulmonary disease, peripheral vascular disease, contracture of right hand, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] revealed his cognition is not intact. Resident #76 was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning, had a urinary catheter and was frequently incontinent of bowel. Resident #76 had a functional limitation in range of motion impairment on both sides of the upper and lower extremities. Review of the physician's orders dated 06/27/25 revealed staff to don bilateral elbow orthotics and bilateral resting hand splints up to six hours per shift as tolerated and check skin integrity and circulation. Observations of Resident #76 made on 09/22/25 at 9:10 A.M., 09/23/25 at 2:03 P.M. and 4:00 P.M. and 09/24/25 at 7:22 A.M., 9:58 A.M., 11:20 A.M., 2:34 P.M. and 3:18 P.M. revealed no splints were observed in place. On 09/24/25 at 3:18 P.M. LPN #129 was interviewed during the observation and it was verified the splints were not in place and the splints were located in the Resident's closet. 4. Review of Resident #5's medical record revealed an admission date of 03/03/23 with diagnoses including but not limited to congestive heart failure (CHF), anoxic brain damage, respiratory failure, ventilator dependent, high blood pressure, contractures, and anxiety. Review of Resident #5's physician orders revealed an order dated 06/17/25 for staff to don bilateral resting hand splints up to six hours daily as tolerated. Check skin integrity and circulation every shift. Review of Resident #5's Treatment Administration Record (TAR) dated 09/01/25 to 09/24/25 revealed the order for staff to don bilateral resting hand splints up to six hours daily as tolerated. Check skin integrity and circulation every shift, had been marked as being completed as ordered. An observation on 09/22/25 at 10:15 A.M. revealed Resident #5 lying in bed with the television on. There were no bilateral hand splints in place for Resident #5 and there were no hand splints visible in the room. An observation on 09/24/25 at 8:37 A.M. revealed Resident #5 lying in bed with staff performing personal hygiene tasks. Resident #5 did not have any hand splints in place and there were no hand splints visible in the room. An interview on 09/24/25 at 9:05 A.M. with Unit Manager (UM) #197 confirmed Resident #5 did not have bilateral hand splints in place. UM #197 stated Resident #5's hand splints should be somewhere in his room. An observation on 09/24/25 at 9:12 A.M. revealed UM #197 located Resident #5's bilateral hand splints in the bottom drawer of the three-drawer dresser in Resident #5's room. 5. Review of the medical record for Resident #20 revealed an admission date 11/14/22 with diagnoses including but not limited to high blood pressure, depression, dementia and contracture of left hand. Review of Resident #20's quarterly minimum data set (MDS) dated [DATE] revealed Resident #20 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of a 9 out of a possible score of 15 and Resident a#20 was dependent on staff for completion of cares. Review of Resident #20's physician orders revealed an order dated 09/09/25 for resident to wear right palm protector to right hand up to four hours daily as tolerated, check skin integrity and circulation every shift. Review of Resident #20's Activities of Daily Living (ADL) care plan dated 12/20/19 revealed encourage resident to wear left hand roll splint to right hand and fingers to wear four hours a day as tolerated, and contracture care plan dated 06/07/24 revealed Resident has contractures of bilateral knees, elbows, hips, and right hand and wrist. Review of Resident #20's TAR dated 09/01/25 to 09/24/25 revealed right hand palm protector order being documented as completed per order. An observation on 09/24/25 at 8:38 A.M. revealed a hand splint located in the broken second drawer of Resident #20's three-drawer dresser in her room. An observation on 09/24/25 at 3:10 P.M. revealed Resident #20's hand splint continued to be located in the broken drawer in her room. An interview on 09/24/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #152 confirmed Resident #20's right palm protector was located in the broken drawer of the three-drawer dresser. LPN #152 stated Resident #20 should have the right palm protector in place every day. Reviewed the facility's policy titled Promoting Range of Motion dated 10/01/22 revealed residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.

Based on observation, staff interview, and facility policy review the facility failed to store and label frozen food in a sanitary manner. This deficient practice had potential to affect 49 residents receiving prepared food from the facility's kitchen. The facility's census was 71.Findings Include:An observation on 09/22/25 at 8:45 A.M. during the initial kitchen tour revealed in the walk-in freezer a crate with an opened cardboard box of approximately 30 beef patties in a clear unsealed bag exposed to the open air, a cardboard box of frozen diced carrots in an unsealed opened blue plastic bag exposed to the open air, an opened cardboard box of frozen peas in an unsealed blue plastic bag located under the box of frozen diced carrots the bag of frozen peas were exposed to the bottom of the cardboard box of frozen carrots, and there was an opened cardboard box of frozen green bears in an opened unsealed blue plastic bag which was opened to the air. There were no open dates on any of the four cardboard boxes of frozen food.An interview on 09/22/25 at 9:00 A.M. with the Dietary Manager (DM) #206 confirmed the opened and undated boxes of frozen beef patties and frozen vegetables. DM #206 stated the bags inside the cardboard boxes should be sealed with a clip once opened, the boxes should be closed and there should be dates placed on the boxes once opened.Review of the facility's policy titled Food Handling and Storage policy dated 12/10/24 revealed all opened frozen food will be dated, labeled and wrapped or sealed. This deficiency represents non-compliance investigated under Complaint Number 1260918.

Based on observation, interview, manufacturers guidelines, and policy and procedure review the facility failed to maintain infection control practices during finger stick blood glucose monitoring. This affected one (Resident #15 ) of one reviewed for Fingerstick blood glucose monitoring. It had the potential to affected three additional residents (Resident #51, #57 and #80) on 100 hall who receive a finger stick blood sugar. The facility also failed to perform hand hygiene during meal service. This affect three residents (Residents #20, #26, and #69) out of nine residents observed eating the lunch meal in the main dining room. The census was 71.Findings include:1. Observation completed on 09/24/2025 at 7:35 A.M. of a fingerstick blood sugar for Resident #15 revealed Licensed Practical Nurse (LPN) #196 placed the glucometer on the resident's overbed table without a barrier under the glucometer. LPN #196 put on gloves, and obtained the blood sample then placed the glucometer on a tissue. LPN #196 removed her gloves and put on new gloves without performing hand hygiene. LPN #196 then placed the glucometer on the medication cart without a barrier, picked it up and then placed it on a tissue. LPN #196 then removed her gloves and used hand sanitizer. LPN #196 put on new gloves and cleaned the glucometer with a germicidal wipe for five seconds and placed the glucometer back on the same tissue, removed her gloves and put on new gloves without performing hand hygiene. LPN # 196 was then observed to prepared MiraLAX (laxative) then remove her gloves and use hand sanitizer. The actions listed were above verified during interview with LPN #196 on 09/24/25 at 7:53 A.M. Review of the policy and procedure Hand Hygiene dated 02/2019 revealed hands should be washed with soap and water or an antiseptic agent used after removing gloves. Review of the manufacturers guidelines for disinfectant wipes revealed it is registered to kill many dangerous viruses, bacteria and fungi in two minutes. 2. Review of Resident #20's medical record revealed an admission date of 11/14/22 with diagnoses including high blood pressure, dysphagia, and dementia. Further review revealed physician order dated 12/17/24 for regular diet pureed texture, regular/thin consistency. Review of Resident #26's medical record revealed admission date of 05/22/23 with diagnoses including respiratory failure, epilepsy, anxiety, and schizoaffective disorder. Review of Resident #69's medical record revealed an admission date of 09/09/25 with diagnoses high blood pressure, depression dysphagia, anxiety and heart failure. Further review revealed a physician order dated 09/10/25 for a regular diet, regular texture, regular/thin consistency. An observation on 09/22/25 from 12:14 P.M. to 12:30 P.M. during lunch meal service in the main dining room revealed Certified Nursing Assistant (CNA) #138 began serving lunch trays, prior to serving Resident #69's meal tray CNA #138 did not perform hand hygiene. CNA #138 set up Resident #69's lunch meal and went to get another meal tray without performing hand hygiene. CNA #138 served Resident #26's lunch tray and assisted in setting up Resident #26's meal and went to get another meal tray without performing hand hygiene. CNA #138 served Resident #20's lunch tray and assisted setting up Resident #20's meal without performing hand hygiene. Interview on 09/22/25 at 12:35 P.M. with CNA #138 confirmed there was no hand hygiene completed prior to and during lunch meal service for Residents #20, #26, and #69. CNA #138 verified hands are to be washed prior to and during meal service for residents. Review of the facility's policy titled Handwashing/Hand Hygiene undated revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. This deficiency represents non-compliance investigated under Complaint Number 2575168.

Based on medical record review, observation, staff interview, and review of facility policy and procedure, the facility failed to ensure residents were treated in a dignified manner by providing privacy during care and treatment. This affected three (Resident #52, #73 and #87) of 22 residents in the survey sample. The census was 71. Findings include: 1. Review of Resident #73's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, tracheostomy, gastrostomy, esophageal obstruction. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #73's cognition was severely impaired. He required supervision and/or touching supervision for oral hygiene, dependent for toileting, shower/bathing and setup/clean up assistance for personal hygiene. On 09/24/25 at 8:25 A.M. an observation of Resident #73, revealed after preparing the medication's for the resident, Registered Nurse (RN) #194 checked the gastrostomy tube for residual and by auscultation (listening with a stethoscope). She then administered the medications one at a time and flushed with 30 cubic centimeters (cc) of water prior to administration and 15 cc of water in between the medications. Resident #73's bed was by the door. At no time did RN #194 close the door or pull the privacy curtain. On 09/24/25 at 8:48 A.M. RN #194 verified she had not provided privacy during Resident #73's procedure. 2. Review of Resident #87's medical record revealed he was admitted on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was not intact (Rarely/Never understood). He was dependent on staff for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Had an indwelling urinary catheter and was always incontinent of bowel. On 09/24/25 at 10:23 A.M. observation of tracheostomy (trach) care by Respiratory Therapist (RT) #240 revealed she suctioned Resident #87's trach and mouth and changed trach ties. RT #240 left the door and the blinds open while providing care and did not pull the privacy curtain. On 09/24/25 at 10:31 A.M. an interview with RT #240 revealed he should have provided privacy while completing the care.3. Review of the medical record for Resident #52 revealed an admission date of 10/11/24. Diagnoses included cellulitis, contracture of right and left knee, muscle wasting, cerebral palsy and paraplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition and dependence with toileting. Resident #52 was frequently incontinent of bowel and bladder. Observation on 09/22/25 at 11:18 A.M. revealed Resident #52 was receiving incontinence care with the curtain partially closed and the door wide opened. The curtain hung about a foot off the ground. A soiled brief was observed from the hallway being tossed onto the floor by Certified Nursing Aide (CNA) #183. Upon entrance to the room, the resident could be seen receiving care and was exposed with no brief on. Interview on 09/22/25 at 11:19 A.M. with Certified Nurse Aide (CNA) #183 stated she should have closed to door to provide privacy but stated she did not because the door was stuck. At that time, STNA #183 tapped the door which was held with the fire release holder and the door easily swung and closed. The CNA confirmed Resident #52 should have received privacy during care. Review of facility policy titled Resident Rights dated 06/01/24, revealed the resident had the right to privacy and confidentiality during medical treatment and personal care.This deficiency represents non-compliance investigated under Complaint Number 1260918.

Based on medical record review, observation, staff interview, and facility policy and procedure, the facility failed to maintain a clean and sanitary environment. This affected two residents (#25 and #26) of 25 residents rooms observed. The census was 71. Findings Include: 1. Review of Resident #26's medical record revealed an admission date of 05/22/23 with the diagnoses including, but not limited to, respiratory failure, epilepsy, anxiety, and schizoaffective disorder. Review of Resident #26's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 10 out of 15, he was dependent on staff for completion of bathing and personal hygiene tasks, was independent with eating and used a wheelchair for mobility. Review of the facility's weekly cleaning schedule revealed on Saturday wheelchairs for residents in odd numbered rooms would be cleaned, and on Sunday wheelchairs for residents in even numbered rooms would be cleaned. An observation on 09/22/25 at 2:15 P.M. revealed Resident #26 sitting in his wheelchair watching television in his room. Resident #26's wheelchair cushion was stained, and food particles were present in the seams of the cushion. The rails and footrest pegs were noted to be covered in a white colored substance and dried food was noted to the top of the rails. An interview on 09/25/25 1:25 P.M. with Certified Nursing Assistant (CNA) #224 confirmed Resident #26's wheelchair cushion, footrest pegs, and the rails were dirty with dried food and a white substance. CNA #224 stated night shift usually cleaned the wheelchairs, but if he saw a dirty wheelchair then he would clean the wheelchair. 2. Review of the medical record for Resident #25 revealed an admission date of 06/10/20. Diagnoses included parkinsonism, kidney disease, schizophrenia, type two diabetes, lumbago with sciatica, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 indicating impaired cognition, stating the resident was rarely, if ever, understood and required substantial/maximum assistance to roll in bed and was dependent on personal hygiene. Observations on 09/22/25 at 10:40 A.M. revealed Resident #25 had a navy-blue padding bolted to the wall next to the resident's bed with a dried brownish material caked and smeared on it. Additional observations at 1:19 P.M. and 1:51 P.M. confirmed the brown smeared material remained without being cleaned up. Several staff had been observed going in and out of the Resident #25's room to provide care to Resident #25 and her roommate from 10:40 A.M. to 1:51 P.M. Interview on 09/22/25 at 1:53 P.M. with Certified Nurse Aide (CNA) #111 confirmed a dried brown substance was smeared on the wall padding against Resident #25's bed. CNA #111 could not confirm what the substance was but confirmed it was dirty. CNA stated Resident #25 was not on their assignment. Observations on 09/22/25 from 1:55 to 2:10 P.M. revealed after the interview with CNA #111, CNA #111 did not obtain supplies to clean the dirty mat on the wall and was not seen alerting other staff to clean the area. Observation on 09/22/25 at 2:30 P.M. revealed Resident #25's wall mat remained soiled with the dried brown substance. Observations on 09/23/25 at 8:35 A.M. and 9:10 A.M. revealed Resident #25's wall mat remained soiled with the dried brown substance. Observation on 09/23/25 at 9:55 A.M. revealed Resident #25's wall mat was being cleaned by housekeeping staff. Review of facility policy titled Resident Environmental Quality dated 11/29/22, revealed the facility shall maintain and provide a safe, functional, sanitary and comfortable environment for residents, maintain all essential patient care equipment in safe operating condition, and all facility personnel were responsible for reporting broken, defective equipment and furnishings upon identification. This deficiency represents non-compliance investigated under Complaint Number 1260942.

Based on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive care plan addressing the use of hand splints for a resident with contractures. This deficient practice affected one resident (Resident #5) out of three residents reviewed for care planning. The facility census was 71.Findings Include: Review of Resident #5's medical record revealed admission date 03/03/23 with diagnoses including but not limited to congestive heart failure (CHF), anoxic brain damage, respiratory failure, ventilator dependent, high blood pressure and anxiety. Review of Resident #5's quarterly [NAME] Data Set (MDS) dated [DATE] revealed Resident #5 had severe impaired cognition and was dependent on staff for all care. Review of Resident #5's physician orders revealed an order dated 06/17/25 for staff to don bilateral resting hand splints up to 6 hours daily as tolerated and to check skin integrity and circulation every shift. Review of Resident #5's Treatment Administration Record (TAR) dated 09/01/25 to 09/24/25 revealed the order for staff to don bilateral resting hand splints up to 6 hours daily as tolerated and to check skin integrity and circulation every shift were marked as being completed every shift. Review of Resident #5's comprehensive care plan revealed as of 09/23/25 there was not a care plan implemented for the use of Resident #5's bilateral resting hand splints. An interview on 09/24/25 at 3:45 P.M. with the Director of Nursing (DON) confirmed Resident #5 did not have a care plan for the use of bilateral resting hand splints implemented at the time of Resident #5's record review. The DON confirmed the care plan for Resident #5's use of bilateral resting hand splints had been written and implemented on 09/24/25. Review of facility policy titled Comprehensive Care Plans dated 08/22/22 revealed facility shall develop and implement a comprehensive care plan for each resident. Factors identified by the interdisciplinary team in accordance with residents needs and preferences. The care plan shall describe services to be furnished, services that should be provided but were not due to resident expressing their right to refuse, specialized services resulting from the PASARR assessment, discharge goals and information, resident specific preferences and interventions related to trauma. The care plan shall be reviewed and revised after each comprehensive and quarterly assessment.

Based on observations, resident and staff interviews and record review, facility failed to revise a dental care plan for two Residents (#32 and #60) and a vision care plan for one Resident (#82). This affected three residents (#32, #60 and #82) out of 25 residents in the survey sample. Facility census was 71. Findings include 1. Review of the medical record for Resident #32 revealed an admission date of 02/03/25. Diagnoses included cardiac arrest, open wound to the buttock, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, retention urine. Review of the plan of care dated 02/06/25 revealed the resident had an impaired dental status as evidenced by dentures. It noted the resident lost some/all natural teeth with interventions to arrange for dental consults and follow up visits by dentistry as needed. Review of dental visit note dated 03/28/25 revealed the resident wore dentures. Review of progress note dated 07/15/25 revealed the resident returned from a hospital stay back to the facility and the resident's dentures had gone missing while he was at the hospital. Review of speech therapy notes dated 07/16/25 revealed Resident #32's dentures were lost during a hospital stay and stated the resident was requesting a diet downgrade to mechanical soft. Speech therapy was consulted to evaluate. There was no documented evidence of an update to the care plan regarding Resident #32's missing dentures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition. Interview and observation on 09/22/25 at 10:39 A.M. with Resident #32 revealed he was missing his dentures. He revealed they were lost when he was at the hospital and was wondering if the facility was getting his dentures back. Resident #32 stated he had been asking to see the social services staff, but she had not spoken with him. Interview on 09/24/25 at 8:35 A.M. with Regional Administrator #350 confirmed the facility had no documentation that staff followed up with Resident #32 related to dental services after his dentures were lost. He revealed the facility requested an emergency request for a dental visit to address the concerns or resident getting new dentures. Interview on 09/24/25 at 11:06 A.M. with Social Services #139 revealed the facility was informed of the missing dentures when he returned from the hospital on [DATE], but she thought the resident would not want his dentures replaced and confirmed she did not speak with him about the replacement of his dentures. Interview on 09/24/25 at 4:35 P.M. with Minimum Data Set (MDS) Nurse #208 confirmed Resident #32's care plan and was not updated after the resident's dentures went missing at the hospital. 2. Review of the medical record for Resident #60 revealed an admission date of 11/11/22. Diagnoses included schizophrenia, Parkinson's dementia, diabetes, dysphagia and encephalopathy. Review of the plan of care dated 10/29/24 revealed the resident was at risk for dental or chewing problems related to impaired cognition and poor dentition with notes dated 07/16/24 that the resident refused to brush her teeth and a tooth was extracted. Interventions included arrange for periodic dental consults, assist with oral hygiene, review nutritional status at least quarterly, and follow-up with dentistry. The care plan did not include mention of broken teeth, mouth infections, and needing or declining full mouth extractions. Review of the dental notes dated 11/01/24 revealed the resident had broken teeth causing some discomfort and was requesting to have all teeth pulled and to get dentures. They informed her she would need to see an oral surgeon for the procedure and recommended her to follow up for extractions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of dental notes dated 08/04/25 revealed the resident informed the dentist she had spoken with a doctor at the hospital and was informed she would need to be under (anesthesia) for extractions and so she decided against the procedure. Interview on 09/23/25 at 8:50 A.M. with Resident #60 revealed she was supposed to get her teeth pulled and had mouth pain. Interview on 09/24/25 at 4:35 P.M. with Minimum Data Set (MDS) Nurse #208 confirmed Resident #60's care plan was not updated with changes in dental needs including needing full mouth extractions and having pain and mouth infections. 3. Review of the medical record for Resident #82 revealed an admission date of 08/24/20. Diagnoses included acute cystitis, sepsis, diabetes type two, cognitive communication deficit, dysphagia, and muscle weakness. Review of the plan of care dated 04/21/22 revealed the resident was at risk for visual decline and wore glasses. Interventions included encourage the resident to wear glasses, keep call light in reach, and keep glasses in a safe space. The care plan did not include any mention of changes in vision, increased blurring of vision or recommendations for cataract surgery. Review of the eye exam dated 04/17/25 revealed cataract surgery was recommended for Resident #82 with a follow up in four to five months. It stated to continue wearing glasses and glasses would need updated after the cataract surgery. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of the progress notes dated 08/15/25 revealed the resident was requesting to see the eye doctor and stated the cataracts were getting worse. Social Services made an appointment for 11/10/25. Interview on 09/23/25 at 8:45 A.M. with Resident #82 revealed he saw an eye doctor about 4 months ago and was wondering about the follow up. He stated he was supposed to get new glasses as well. Interview on 09/24/25 at 11:06 A.M. with Social Services #139 revealed the progress note dated 08/15/25 related to Resident #82 ' s eye appointments. She confirmed the facility had no evidence of a timely follow up or any attempts to make appointments prior to from 04/2025 until 08/2025. Interview on 09/24/25 at 4:35 P.M. with Minimum Data Set (MDS) Nurse #208 confirmed Resident #82's care plan was not updated with changes in vision and the recommendation for cataract surgery.

Based on record review, observations, staff interviews, and facility policy review, the facility failed to ensure nail care was provided for dependent care residents. This deficient practice affected three residents (Residents #26, #77, and #80) out of seven residents reviewed for activities of daily living (ADL) care for dependent residents. The facility's census was 71.Findings Include: 1. Review of Resident #26's medical record revealed an admission date of 05/22/23 with the diagnoses including, but not limited to, respiratory failure, epilepsy, anxiety, and schizoaffective disorder. Review of Resident #26's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 10 out of possible 15 and was dependent on staff for completion of bathing and personal hygiene tasks. Review of Resident #26's ADL care plan dated 06/07/23 revealed Resident #26 required staff assistance with personal hygiene tasks. Review of Resident #26's shower sheets dated 08/02/25 to 09/20/25 revealed nail care was not completed for 13 showers; there were no refusals documented. An observation on 09/22/25 at 10:04 A.M. revealed Resident #26 sitting in his wheelchair in his room. Resident #26's fingernails were noted to be long, with a dark colored substance under the nails. An interview on 09/23/25 at 2:32 P.M. with Certified Nursing Assistant (CNA) #161 confirmed Resident #26's fingernails were long and appeared to be dirty under the nails. CNA #161 stated nail care was completed following bathing or showering for the residents and refusals were reported to the nurse. 2. Review of the medical record for Resident #80 revealed an admission date 10/12/24 with diagnoses including, but not limited to, respiratory failure, hemiplegia to left side, dysphagia, dementia, and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #80 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 08 out of possible 15 and it noted the resident was dependent on staff for showering and personal hygiene task completion. Review of Resident #80's ADL care plan dated 10/25/24 revealed staff assistance was required for personal hygiene tasks. Review of Resident #80's shower sheets dated 08/02/25 to 09/20/25 revealed nail care was not completed during eight showers; there were three refusals of care documented during those dates. An observation on 09/22/25 at 10:45 A.M. revealed Resident #80 was lying in bed watching television. Resident #80's fingernails were observed to be long and Resident #80's fingernails on his left hand appeared to have a dark substance underneath the fingernails. An interview on 09/23/25 at 2:29 P.M. with Certified Nursing Assistant (CNA) #161 confirmed Resident #80's long fingernails and the left-hand fingernails with a dark substance under the fingernails. CNA #161 stated if long, dirty fingernails were observed, she would clean and cut the fingernails. 3. Review of Resident #77's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, tracheostomy, diabetes, psoriasis, obstructive hydrocephalus, high blood pressure and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed the resident was rarely/never understood. He was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, and turning and repositioning. It further noted he was always incontinent of bowel and bladder. Observations on 09/22/25 at 2:41 P.M. revealed Resident #77 fingernails and toenails were long and jagged. On 09/23/25 at 1:58 P.M. Resident #77 remained in bed with fingernails and toenails observed as long, thick and jagged. On 09/23/25 at 3:30 P.M. observation of Resident #77's fingernails and toenails revealed they were thick, long and jagged. This was verified during an interview with Registered Nurse (RN) #194 at the time of the observation. Reviewed the facility policy titled Activities of Daily Living (ADLs) dated 01/01/25 revealed care and services will be provided for the following activities of daily living including bathing, dressing, grooming and oral care.

Based on medical record review, observation and staff interview, the facility failed to ensure ongoing resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences. This affected one (Resident #87) of four residents observed for activities. The census was 71.Findings include: Review of Resident #87's medical record revealed he was admitted on [DATE]. Diagnoses included non traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed he was cognitively impaired, he was dependent upon staff for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. He also had an indwelling urinary catheter and was always incontinent of bowel. Review of the activity assessment dated [DATE] revealed he enjoyed listening to music, staff would offer one to one visits for stimulation and staff would offer bedside stimulation for cognitive difficulties two times per week. Review of the plan of care dated 09/24/25 revealed the resident needed escorted/assisted to participate in activities of interest, he was dependent on staff for activities, cognitive stimulation, social interaction due to needing bedside stimulation for sensory and tactile therapy. It noted the resident wound maintain involvement in cognitive stimulation and social activities as desired through the next review with one to one bedside/in room visits and activities if the resident was unable to attend out of room activities. Resident #87 was of Haitian decent and enjoyed cultural music therapy, staff would offer music on echo in his room as desired by the resident and family. Review of the Activity in Room Visits for 07/2025 revealed in room activities were documented on 07/01, 07/06, 07/12, 07/21 and 07/27. For 08/2025 in room activities were documented on 08/02 and 08/09, sleeping was documented as an activity, on 08/11, 08/16, 08/25 and 08/31. For 09/2025 in room activities were documented on 09/03 as up in chair and music therapy on 09/05, 09/06, 09/09, 09/16, and 09/18. On 09/20 and 09/21 family visits were documented as an activity. Observation on 09/22/25 at 9:43 A.M. revealed no television/radio activity being performed. Observation on 09/23/25 at 9:10 A.M. revealed no television/radio activities were observed being performed. At 2:18 P.M. Resident #87 remained in bed, but now with his television on. Observation on 09/24/25 at 7:30 A.M. the resident was in bed on his back with no television or radio observed on. At 2:36 P.M. and 3:31 P.M. the television was on ESPN (In English). Interview on 09/24/25 at 4:55 P.M. with Activity Director (AD) #120 confirmed Resident #87 did not speak English so they usually had his echo play Haitian music. Sensory activities were to be completed twice a week and one of her assistants who worked weekends read to him in his language. AD #120 acknowledged no music was heard playing in the last three days and that the TV had been on but it was in English.

Based on record review, staff interviews, and facility policy review, the facility failed to prevent a delay in treatment for a resident requiring antibiotic use (Resident #1). This affected one resident (Residents #1) out of four residents reviewed for quality of care. The facility census was 71.Findings Include: Review of Resident #1's medical record revealed admission date of 08/14/25 with diagnoses including but not limited to pleural effusion, chronic obstructive pulmonary disease (COPD), pneumonia, depression, high blood pressure, and anxiety. Review of Resident #1's progress notes revealed on 09/10/25 at 9:33 P.M. Resident #1 showed the nurse a medication cup with brown/tan colored sputum in it. Notification was made to MedOne and an order was received for a chest X-ray and to complete a SARS-CoV-2 (COVID-19) test, with the COVID-19 test results being negative at 10:17 P.M. Review of the chest X-ray results dated 09/11/25 at 10:30 A.M. revealed Resident #1 had bilateral lower lobe atelectasis (complete or partial collapse of a lung or a section of lung) with possible right lower pneumonia. Review of Resident #1's progress notes revealed on 09/11/25 at 8:54 P.M. the Nurse Practitioner (NP) was notified of the chest X-ray results, there was no response from the NP noted. Further review of Resident #1's progress notes revealed on 09/12/25 at 9:49 P.M. and again on 09/15/25 at 9:03 P.M., Resident #1's chest X-ray results were communicated to MedOne with no response documented. Review of Resident #1's progress note dated 09/17/25 at 6:32 P.M. revealed an order received for Levaquin (antibiotic) tablet 250 milligrams (mg) with instructions to give two tablets by mouth one time a day for pneumonia for 7 days from 09/18/24 to date 09/24/25. Review of Resident #1's physician orders revealed an order dated 09/18/25 for Levaquin (antibiotic) tablet 250 milligrams (mg) with instructions to give two tablets by mouth one time a day for pneumonia for 7 days from 09/18/24 to 09/24/25. Review of Resident #1's Medication Administration Record (MAR) dated 09/18/25 to 09/24/25 revealed the order for Levaquin was administered as ordered. An interview on 09/25/25 at 2:01 P.M. with the Director of Nursing (DON) agreed there was a 6-day delay in receiving antibiotic treatment for Resident #1. The DON stated in some cases the facility nurse practitioner would monitor the resident and may order other medications, treatments, or labs prior to ordering an antibiotic for treatment of an acute condition which required medication use. Reviewed the facility's policy titled Notification of Changes dated 01/01/25 revealed the facility must consult with the resident's physician when there is a change requiring notification including commence a new form of treatment to deal with a problem.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure timely follow up for ophthalmology services for one Resident (#82) of one reviewed for ophthalmology services. Facility census was 71. Findings include:Review of the medical record for Resident #82 revealed an admission date of 08/24/20. Diagnoses included acute cystitis, sepsis, diabetes type two, cognitive communication deficit, dysphagia, and muscle weakness. Review of the plan of care dated 04/21/22 revealed the resident was at risk for visual decline and wore glasses. Interventions included encourage the resident to wear glasses, keep call light in reach, and keep glasses in a safe space. The care plan did not include any mention of changes in vision, increased blurring of vision or recommendations for cataract surgery. Review of the eye exam dated 04/17/25 revealed cataract surgery was recommended for Resident #82 with a follow up in four to five months. It stated to continue wearing glasses and glasses would need updated after the cataract surgery. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of the progress notes dated 08/15/25 revealed the resident was requesting to see the eye doctor and stated the cataracts were getting worse. Social Services made an appointment for 11/10/25. Interview on 09/23/25 at 8:45 A.M. with Resident #82 revealed he saw an eye doctor about 4 months ago and was wondering about the follow up. He stated he was supposed to get new glasses as well. Interview on 09/24/25 at 11:06 A.M. with Social Services #139 revealed the progress note dated 08/15/25 related to Resident #82's eye appointments. She confirmed the facility had no evidence of a timely follow up or any attempts to make appointments prior to from 04/2025 until 08/2025. Review of facility policy titled Ancillary Services dated 01/01/25 revealed facility shall assist residents in obtaining routine and emergency ancillary services as needed including vision services.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure appropriate care and services for Resident #32 who utilized a Foley catheter. This affected one resident (#32) of one reviewed for catheters. Facility census was 71. Findings include Review of the medical record for Resident #32 revealed an admission date of 02/03/25. Diagnoses included cardiac arrest, open wound to the buttock, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, retention urine. Review of the plan of care dated 02/06/25 revealed the resident had potential for complications related to use of the Foley (indwelling) catheter. The catheter was indicated due to obstructive uropathy. Interventions included change Foley catheter as needed for plugging or displacement, notify the physician if there was a change in urine color consistency or output, obtain output each shift and total for 24-hour period, and provide Foley care per facility policy. Review of the physician order dated 07/16/25 to 07/17/25 revealed an order to place a Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition. The MDS assessment stated the resident had a catheter. Review of the progress note from Nurse practitioner dated 08/04/25 revealed the Foley was in place and draining without issues. Review of the progress note from Nurse practitioner dated 08/25/25 revealed the Foley was in place and draining without issues. Review of the medical record from 07/16/25 to 09/22/25 revealed no evidence of catheter care being provided and no evidence of urine output being measured documented and monitored.Review of the physician orders dated 09/22/25 from 10:42 A.M. to 6:00 P.M. revealed orders for a urinary catheter drainage bag as needed, 16 French (F) catheter with 30 milliliters (ml) of water every day shift every 30 days, change catheter anchor every 30 days and as needed, urinary catheter care every shift, Foley catheter 16 F with 30 ml balloon to straight drain due to retention, irrigate foley catheter as needed for leakage or blockage, and to change indwelling Foley as needed. There was no documented evidence of catheter orders prior to this date. Review of the progress note dated 09/22/25 revealed the nurse inserted the Foley catheter without issues. The catheter was flowing with light yellow urine draining into the catheter bag. The resident tolerated well with no complaints of pain or discomfort. Review of the medical record from 09/20/25 to 09/22/25 revealed no documentation that Resident #32's catheter came out, no documentation of what nursing staff did and no evidence of physician notification that the catheter had come out. Interview on 09/22/25 at 10:47 A.M. with Resident #32 revealed he had a catheter and it accidentally came out overnight shift (09/21/25). He revealed he was waiting for the nurse to come and replace it. Interview on 09/22/25 at 11:40 A.M. with Licensed Practical Nurse (LPN) #104 revealed she was working 6:00 A.M. to 6:00 P.M. this date (09/22/25) and during handoff, the night nurse informed her that Resident #32's catheter had come out. LPN #104 revealed she contacted the physician to clarify orders as Resident #32 did not have any orders related to his catheter. She revealed the night nurse, to her knowledge, did not attempt to replace the catheter and did not contact the physician to notify them or get orders. Interview on 09/24/25 at 2:12 P.M. with the Director of Nursing (DON) revealed the facility caught that the resident did not have orders for his catheter and reported no negative findings. The DON confirmed it was an oversite and confirmed facility had no evidence of catheter care being provided in 07/2025, 08/2025, or 09/2025. Interview on 09/24/25 at 6:45 P.M. with Registered Nurse (RN) #222 revealed she was informed by the aide that Resident #32's catheter had come out. She revealed she reviewed the chart and found the resident had no orders in place for a catheter. She revealed this happened 09/21/25 around 8:00 P.M. and she did not attempt to replace the catheter due to having no orders and also she did not contact the physician about getting orders for replacement. The RN revealed since Resident #32 did not have orders, he did not need the catheter but was unable to state why it was put in place. Review of the record further revealed no mention or evidence related to how much urine was obtained after Resident #32 was without a Foley catheter from 09/21/25 around 8:00 P.M. to 09/22/25 around 12:00 P.M., for a total of 16 hours.Interview on 09/25/25 at 1:45 P.M. with the Administrator confirmed the facility did not have any evidence the residents Foley catheter output was measured from 07/2025, 08/2025, or 09/2025. Review of facility policy titled Notification of Changes dated 01/01/25 revealed facility shall promptly inform resident's physician when there was a change requiring notification. These circumstances included accidents, significant changes, and circumstances that require a need to alter treatment.Review of facility policy titled Catheter Care dated 06/01/24 revealed facility shall ensure residents with catheters receive appropriate care. Catheter care shall be preformed each shift and as needed.Review of facility policy titled Comprehensive Care Plans dated 08/22/22 revealed facility shall develop and implement a comprehensive care plan for each resident. Factors identified by the interdisciplinary team in accordance with residents needs and preferences. The care plan shall describe services to be furnished, services that should be provided but were not due to resident expressing their right to refuse, specialized services resulting from the PASARR assessment, discharge goals and information, resident specific preferences and interventions related to trauma. The care plan shall be reviewed and revised after each comprehensive and quarterly assessment.This deficiency represents non-compliance investigated under Complaint Number 1260943.

Based on record review, observation, staff interview and review of facility policy the facility failed to ensure dietary adaptive equipment was provided for a dependent resident. This deficient practice affected one resident (Resident #20) out of two residents reviewed for adaptive equipment use. The facility census was 71.Findings Include:Review of Resident #20's medical record revealed admission date 11/14/22 with diagnoses including but not limited to high blood pressure, depression, dementia, contractures, and dysphagia.Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #20 had impaired cognition with a brief Interview of mental status (BIMS) score of 9 out of a possible score of 15. Resident #20 required assistance with meal set and was dependent for cares.Review of Resident #20 physician orders revealed an order dated 09/03/25 for resident to utilize scoop plate and two handled cup with lid for all meals to increase functional independence.Review of Resident #20's nutritional care plan dated 09/03/25 revealed Resident #20 required adaptive equipment at meals.Review of Resident #20's dietary progress note dated 09/03/25 at 6:18 P.M. revealed Resident #20 used a scoop plate and two handled cup with lids at meals to facilitate self-feeding per therapy.Observation on 09/24/25 at 8:38 A.M. revealed Resident #20 sitting up in bed with the bedside table over the bed with breakfast tray on the table. On the breakfast tray was a two-handled cup with juice, a carton of chocolate milk with a straw in it and Resident #20 was holding a single handled brown mug of coffee with no lid in place.An interview on 09/24/25 at 9:25 A.M. with Certified Nursing Assistant (CNA) #164 confirmed Resident #20's liquids were not in a two-handled cup with a lid. CNA #164 stated all of Resident #20's liquids should be adaptive cups.Reviewed the facility's policy titled Meal Supervision and Assistance undated revealed ensure that the necessary non-food items are on the tray; especially assistive and adaptive devices. Report or replace missing items.

Based on medical record review, observation, staff interview and facility policy and procedure review, the facility failed to ensure enteral feedings were labeled and dated when the feeding was initiated and hung for administration. This affected three (Resident #10, #39 and #81) of six residents with enteral feedings. The census was 71. Findings include:1. Review of Resident #10's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, depression, anxiety, atrial fib, tracheostomy and gastrostomy. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact (BIMS 15). Requires partial/moderate assistance for oral hygiene, dependent on toileting, shower/bathing, dressing, personal hygiene and substantial maximal assistance for turning and repositioning. Resident was frequently incontinent of bowel and bladder. Review of the physicians orders on 08/26/25 Enteral Nutrition of Isosource 1.5 (high-calorie, high-protein, high-fiber tube-feeding formula) at a rate of 65 milliliters (ml) per hour via pump per gastrostomy (tube through the abdominal wall into the stomach) tube to infuse 1560 ml/24 hrs. Observation on 09/22/25 at 9:00 A.M. observed the enteral feeding of Isosource 1.5 at 65 ml per hour per pump and it was not label with Resident #10's name or the date. Also a syringe was hanging undated and without the residents name. Interview on 09/22/25 at 11:35 A.M. with Registered Nurse (RN) #228 it was verified the tube feeding was not labeled with the resident name and it was undated. 2. Review of Resident #81's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, depression, old myocardial infarction, contractures and anoxic brain damage. Review of the quarterly Minimum data set assessment dated [DATE] revealed the resident's cognition was not intact, and he was rarely/never understood. Resident #81 was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Had an indwelling urinary catheter and was always incontinent of bowel. Review of the physicians orders for 07/08/25 Enteral Nutrition via pump Isosource 1.5 at rate of 60 ml per hour via pump per nasogastric (tube through the nose down into the stomach) tube to infuse 1140ml/24 hrs. Observation on 09/22/2025 9:10 A.M. revealed Isosource 1.5 and the syringe was not labeled or dated. Interview on 09/22/25 at 11:25 A.M. with RN #228 it was verified the Isosource 1.5 and syringe were not labeled or dated for Resident #81. 3. Review of Resident #39's medical record revealed admission date 09/15/25 with diagnoses including but not limited to history of stroke, high blood pressure, depression and anxiety. Review of Resident #39's physician orders revealed an order dated 09/16/25 for enteral nutrition via pump – Diabetisource at 50 milliliters (ml) per hour for 10 hours via percutaneous endoscopic gastrostomy (PEG) tube, start feeding at 8:00 P.M. and continue until 6:00 A.M. until 500 ml is infused and an order dated 09/15/25 for feeding tube hydration bag and set-up change daily (label with patient identifier and date) one time a day. Review of Resident #39's alteration in nutrition care plan dated 09/23/25 revealed Resident #39 received tube feeding and altered diet. An observation on 09/22/25 at 11:32 A.M. revealed in Resident #39's room a feeding tube pump attached to a pole with a bag of Diabetisource formula without a date or time when hung for administration, and a clear bag of water with no date of when hung for administration. Resident #39 was not receiving either water flushes of formula at the time of the observation. An interview on 09/22/25 at 11:40 A.M. with Licensed Practical Nurse (LPN) #104 confirmed Resident #39's Diabetisource formula bag and the water flush bag was not dated at the time of administration. A review of the facility's policy titled Enteral Tube Feeding via Continuous Pump dated 03/01/15 revealed on the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.

Based on staff interview and record review the facility failed to ensure physician's orders for insulin were followed and given as ordered for Resident #50. Actual harm occurred when Resident #50 received insulin at the incorrect time, without the required blood sugar test, causing a low blood sugar level with the resident becoming unresponsive to both verbal and physical stimuli. Resident #50 continued to be unresponsive and was sent out to the hospital. This affected one of four residents (Resident #50), reviewed for medication administration. The facility census was 68. Findings Include: Review of the medical record for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident cognition was intact. A review of the plan of care dated 06/22/21 revealed Resident #50 was at risk for Hyper/Hypoglycemic (high or low blood sugars) due to diabetes. Interventions included to administer medications as ordered, be alert for signs and symptoms of high and low blood sugars and obtain blood sugar levels as ordered. A review of the discharge orders from the hospital dated 06/09/21 revealed Resident #50 was ordered regular insulin concentrated 500 unit/ml vial, 100 units under the skin three times daily before meals. A review of the hospital history and physical note, dated 06/13/21, revealed Resident #50 was on U500 insulin (concentrated insulin with fast acting and slow acting factors) 50 units three times a day plus [MEDICATION(S)] (insulin) per sliding scale. The note indicated the U500 insulin had been increased to 100 units three times a day due the resident's [MEDICATION(S)] being increased. A review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders for June 2021 revealed Resident #50 was ordered Insulin Regular Human solution (U500) 100 units subcutaneously before meals There was no order for the [MEDICATION(S)] found in the electronic physician orders. Review of the Medication Administration Records (MAR) for June 2021 revealed Resident #50's insulin Regular Human Insulin solution 100 units was scheduled for 4:00 A.M., 7:00 A.M. and 11:00 A.M. There was no documentation that the insulin was at mealtimes. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. injection due to being too early to give. Resident #50 refused insulin the other scheduled times. On 06/23/21 the Regular Human Insulin solution 100 units was held at 4:00 A.M. due to being too early and the insulin was given at 7:00 A.M. and 11:00 A.M., according to the MAR. On 06/24/21 the Regular Human solution Insulin 100 units was held at 4:00 A.M. due to being too early to give and it was given at 7:00 A.M. and 11:00 A.M. according to the MAR. On 06/25/21, the Regular Human Insulin solution 100 units was given at 5:53 A.M.; there was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 7:08 A.M. Resident #50's blood sugar was 24 milligram per deciliter (mg/dL). There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated 06/25/21 at 8:02 A.M., revealed at 7:08 A.M. Resident #50 was found in bed unresponsive to verbal and physical stimuli. Resident #50's blood sugar level was taken at this time and read LOW. It was taken a second time with a reading 24 mg/dL. The resident was given two emergency [MEDICATION(S)] kits. The blood sugar level was rechecked and found at 39 mg/dL. Two additional emergency kits were given, and resident's blood sugar was at 49 mg/dL. The blood sugars were tested again after waiting five minutes with blood sugars dropping to 47 mg/dL. Emergency Medical Service (EMS) was called and Resident #50 was transported to the emergency room . The resident's blood sugar was 96 mg/dL when EMS arrived, but the resident was still unresponsive. Resident #50 was taken to the hospital for evaluation. Interview on 07/06/21 at 10:35 A.M. with Hospice Nurse Registered Nurse (RN) #300 revealed Resident #50 was to receive 100 units of insulin before all three meals. Interview on 07/06/21 at 2:38 P.M. with Hospice Supervisor RN #304 verified Resident #50 was on Human regular 100 units three times a day, before meals. RN #304 stated a pulmonary critical care note dated 06/07/2, indicated Resident #50 was to have regular Insulin U500 (long and short acting insulin) 100 units three times a day with meals and was on [MEDICATION(S)] 5 mg three tablets daily. RN #304 stated there was no stop date on the [MEDICATION(S)] due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 07/07/21 at 11:17 A.M. with LPN #310 revealed she was the admitting nurse for Resident #50 on 06/21/21. LPN #310 stated she put all the orders in the electronic charting. LPN #310 verified she did not realize there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #310 stated when the insulin popped up to give at 4:00 A.M. she held it due to being too early. LPN #310 stated she was going to change the order but forgot to. Interview on 07/07/21 at 11:22 A.M. with LPN #311, who stated he was the nurse working on 06/24/21 from 6:00 P.M. to 6:00 A.M., revealed on 06/24/21 at around 8:00 P.M., Resident #50's blood sugar was 114 mg/dL. He stated at 4:00 A.M. Resident #50's insulin popped up as ready for administration, but he did not give it to her because he was unsure about the amount of insulin she was to receive. LPN #311 verified at 5:53 A.M., just before end of shift report, he went ahead and gave Resident #50 her Insulin, the Regular Human solution of 100 units. LPN #311 stated Resident #50 was awake at that time and took her 5:00 A.M. medications. LPN #311 verified he did not check Resident #50's blood sugar because it did not come up on the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/07/21 at 11:38 A.M. with LPN #312 stated she was working dayshift on 06/25/21 and was the nurse that sent Resident #50 out to the ER. LPN #312 stated during report, that LPN #311 told her, he gave Resident #50 her insulin, 100 units at 5:53 A.M. LPN #312 stated she checked Resident #50's blood sugar at 7:08 A.M. and it was 24 mg/dL. She indicated Resident #50 was unresponsive to verbal and physical stimuli. LPN #312 stated Resident #50's blood sugar was still low after giving her [MEDICATION(S)] to bring up her blood sugar level, so she called EMS. She confirmed that Resident #50 was sent out at that time. Interview on 07/07/21 at 1:12 P.M. with Director of Nursing (DON) revealed orders were usually transcribed by the floor nurse. The DON indicted that nursing staff should be checking all orders. The DON verified the regular insulin concentrate,100 units was to be given before meals. The DON verified the times on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also verified Resident #50 should have had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified that [MEDICATION(S)] could cause your blood sugars to be high and without the insulin the [MEDICATION(S)] may have needed adjusted. This deficiency substantiates Complaint Number OH 775.

Based on observation, medical record review, resident interview, staff interview and review of the facility's policy and procedure on Abuse and Neglect Prevention, the facility failed to ensure Resident #57 was free from sexual abuse by State tested Nursing Aide (STNA) #76. This resulted in Immediate Jeopardy and actual harm for one resident (#57), who reported physical pain (harm) and fear of the STNA following perineal care provided during incontinence. This affected one of one resident reviewed for sexual abuse. The facility census was 75. On 03/23/17 at 10:08 A.M., the Administrator, Administrator-in-Training #3, Regional Nurse #4, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/20/17 at 9:15 A.M. when Resident #57 reported to STNA #81 that she did not like that aide referring to STNA #76. The resident reported STNA #76 put her finger in her vagina twice (on unidentified dates) which had caused pain and she was now fearful of the STNA. At 9:30 A.M., STNA #81 reported the resident's allegation to the DON including communication the resident was fearful of STNA #76. The DON allowed STNA #76 to continue working on the nursing unit until approximately 10:30 A.M. when the DON asked STNA #76 to come to her office to be interviewed. After being interviewed, STNA #76 resumed working her assignment which included care of Resident #57. On 03/20/17 at 11:00 A.M. the DON instructed STNA #76 to have another staff member present with her to provide care to Resident #57. However, STNA #76 continued to provide care to Resident #57's roommate without supervision. STNA #76 was also assigned to provide care to Resident #57 on 03/21/17 from 6:51 A.M. to 7:04 P.M. The Immediate Jeopardy was removed on 03/24/17 when the facility initiated the following corrective actions: On 03/23/17 at 10:55 A.M., STNA #76's employment was terminated by the facility. On 03/23/17 at 11:00 A.M., the Administrator initiated an investigation related to Resident #57's allegation of sexual abuse utilizing a form titled, Alleged abuse, neglect and Exploitation Investigation Worksheet. The investigation was completed on 03/23/17 at 2:00 P.M. The facility reported the allegation of sexual abuse to the State agency on 03/23/17 at 11:00 A.M. On 03/23/17 at 11:27 A.M., Regional Nurse #4 initiated a resident abuse questionnaire which included an interview of all current interviewable residents. The questionnaire was given to all family members of residents identified to be non-interviewable. On 03/23/17 at 12:58 P.M., all residents and family interviews were completed by the following staff members: Scheduler #5, Licensed Social Worker (LSW) #6, Medical Records #7, Registered Nurse (RN) #8, Administrator-in-Training #4, Licensed Practical Nurse (LPN) #80 and Assistant Director of Nursing (ADON) #10. On 03/23/17 at 11:27 A.M., the facility implemented the form titled, Alleged abuse, neglect, Exploitation Investigation Worksheet to be used for any allegations of abuse. All staff were educated by the DON and Regional Nurse #4 to use this form in the event of an allegation of abuse. On 03/23/17 the DON began in-servicing all facility staff on the current policy and procedure regarding abuse and neglect prevention. A plan for all staff to be in-serviced by the end of the day on 03/23/17 was provided. Any staff not educated by 03/23/17 would be unable to return to work until the in-service was completed. As of 03/24/17 at 10:31 A.M. 80 of 88 employees had been in-serviced. A plan was provided to ensure the remaining eight employees were in-serviced. On 03/23/17 at 4:00 P.M. the DON and Administrator received disciplinary action in the form of a written warning by Regional Nurse #4 related to failure to properly report abuse and failure to complete an investigation as per the facility's policy and procedure on abuse and neglect. The DON and administrator were provided a performance improvement plan and education on the procedure for investigations of allegations of abuse, abuse and neglect policy by Regional Nurse #4. On 03/23/17 the facility initiated a system that all new admissions beginning on 03/23/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. On 03/23/17 a plan for the Administrator/designee to monitor compliance via the Resident Abuse Questionnaire audit, Resident Abuse audit tool five times per week for three months with results reviewed at the monthly performance meeting to determine continued focus. On 03/23/17 a plan for the DON/designee to utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. On 03/23/17 a plan for the Administrator to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. On 03/23/17 a plan for the Administrator to submit initial and final reports to Regional Nurse #4 through a self-reported incident log upon notification of allegations of abuse. Regional Nurse #4 would monitor for compliance of reporting through the Self-Reported Incident Log three to five times per week for three months, with results reviewed with monthly performance improvement to continue focus for quality improvement measures. On 03/24/17 from 7:19 A.M. to 7:30 A.M. interview with Unit Clerk #101, Housekeeper #105 and STNA #95 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 03/24/17 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. was intact, she had no identified behaviors and required extensive assistance with one person physical assistance for toilet use. The assessment revealed the resident was frequently incontinent of bowel and bladder. Review of a plan of care, initiated 01/19/16 and last revised on 11/07/16 revealed the resident had an activity of daily living (ADL) self-care performance deficit related to impaired balance and limited mobility. Interventions reflected the resident was bedfast most of the time and required two staff to assist with toileting. The care plan was updated on 03/20/17 to reflect the resident required two staff with all ADL care. A plan of care, initiated on 01/19/16 and last revised on 11/07/16 revealed the resident had bowel incontinence related to immobility and medications. The goal developed was for the resident to be clean, dry and free of odor as well as maintain current status and have a bowel movement every three days. Interventions included to assess for signs/symptoms of constipation, monitor bowel movement status, frequency, amount and consistency, provide medication as ordered and provide pericare after each incontinent episode. On 03/22/17 at 8:10 A.M. interview with STNA #81 revealed Resident #57 had reported to her on 03/20/17 during breakfast time that she did not like that girl and pointed to STNA #76 who was present in the room at the time of the conversation. STNA #81 stated she asked STNA #76 to leave the room and then continued talking to the resident. Resident #57 then stated the other day STNA #76 put her finger in her vagina twice. The resident told her, I might be (sp) but I know where my vagina is and I know when something is in there that I don't want in there. The resident stated she told STNA #76 that she did not like her doing that. STNA #81 stated she shared the resident's concerns with STNAs #95 and #93 and Activity Staff #94 and then immediately notified the DON who was in the facility at the time of the allegation. During an interview with Resident #57 on 03/22/17 at 10:26 A.M. the resident was asked if she had any concerns with any staff providing care to her. The resident responded yes, she was mean. She put her finger in my vagina and it was uncomfortable and I was hurting. The resident continued by stating she was afraid of this STNA and had seen her since the incident. Further interview revealed the resident was unable to provide the name of the STNA or the date this incident occurred. When the resident was asked directly if she felt she had been abused, the resident replied, yes, sexually. The resident denied any concerns with any other staff except this one particular STNA. Review of Resident #57's medical record revealed there was no assessment of the resident or notation in the resident's progress notes on 03/20/17 following this allegation/incident. This was confirmed by the DON on 03/22/17 at 10:54 A.M. On 03/22/17 at 9:00 A.M. review of the facility's Self-Reported Incidents revealed there had been no investigations of sexual abuse reported to the State agency from 03/01/17 to 03/22/17. Review of the facility's information regarding the above incident involving Resident #57 revealed a one page typed time line, dated with an incorrect date of 02/20/17 which was not signed by the person who completed it. The time line did not include any staff, resident or witness statements but rather summary statements. Interview with the DON on 03/23/17 at 9:57 A.M. revealed she had completed the time line and confirmed the time lines sheet dates were incorrect as it should have been 03/20/17 and not 02/20/17. The facility's timeline revealed the following: 1. On 03/20/17 at 10:30 A.M., STNA #81 came to the DON and stated Resident #57 pointed to STNA #76 and stated I don't like her. She stuck her finger in my vagina two times last week. Review of the time line investigation revealed here was no written statement from STNA #81 obtained at that time. However, interview with STNA #81 on 03/23/17 at 8:50 A.M. revealed she notified the DON of the incident between 9:00 and 9:30 A.M. on 03/20/17 and reported to her Resident #57 alleged STNA #76 put her finger in her vagina twice while changing her and the resident was now fearful of the aide. STNA #81 stated the DON did not immediately remove STNA #76 from the resident's assignment. STNA #81 stated STNA #76 provided care to the resident unsupervised from 9:30 A.M. until 10:30 A.M. when the DON pulled STNA #76 into her office. STNA #81 stated the DON told her, following the incident, STNA #76 must have another staff member present when providing care to Resident #57. 2. On 03/20/17 at 10:33 A.M. STNA #76 was asked to sit in the DON's office. Interview with STNA #76 on 03/23/17 at 10:03 A.M. revealed she was not removed from her assignment until after the DON spoke to Resident #57. 3. On 03/20/17 at 10:45 A.M., the DON spoke to STNA #76 and asked STNA #76 if Resident #57 had complained to her during any pericare. The STNA stated last week the resident yelled out when she was being cleaned after a bowel movement. STNA #76 stated the resident had a loose bowel movement and stool was high in her peri area and vagina so she had to clean up higher in her peri area. The STNA stated she explained this to the resident, that there was stool in there and she needed to clean it well so that she would not get an infection. The employee was educated the resident would now be a two-person assist with all care and to always explain to the resident what was going to happen with care before performing the care. Employee expressed understanding. 4. On 03/20/17 the interviewable residents who were assigned to receive care from STNA #76 were interviewed by unidentifiable staff with no concerns identified. However, interview with the DON on 03/22/17 at 10:54 A.M. confirmed there were no names or times of the above resident interviews completed or who they were completed by. The DON revealed she did not have any documented evidence of the content of these interviews. On 03/22/17 at 9:25 A.M. interview with the Administrator revealed there had been no investigations of abuse in the facility since January, 2017. During a follow up interview with the Administrator and DON on 03/22/17 at 11:33 A.M. the administrative staff revealed they did not feel Resident #57's allegation was considered abuse. The DON denied any staff stating the resident was hurt or scared. The Administrator stated STNA #81 did the right thing by reporting it to the DON immediately. The DON confirmed she did not obtain any witness statements as of the time of this interview. When the DON and Administrator were asked to clarify the documentation on the above time line stating on 03/20/17 at 10:30 A.M. I don't like her. She stuck her finger in my vagina two times last week. the Administrator stated that would be an allegation of abuse. The Administrator stated, they looked at it so fast that they didn't think to report it. The Administrator stated it was his opinion that the story was just getting bigger because the resident was getting attention for it. An additional interview with STNA #81 on 03/23/17 at 8:50 A.M. revealed Resident #57 was usually very pleasant and did not typically complain about care or staff. STNA #81 stated she thought when the resident initially made the allegation against STNA #76 it seemed out of character for the resident (as she never really complained about things). STNA #81 stated to her knowledge the resident had never complained about how she or any other staff (with the exception of STNA #76) provided pericare. She stated at times she would moan but never told her to stop, that it was hurting nor that she was pressing too hard. STNA #81 stated the resident did have intellectual disabilities but when the resident stated I might be (sp) but I know where my vagina is and I know when something is in there that I don't want in there she felt the resident had a significant and valid concern. Additionally, when Resident #57 was able to report that she told STNA #76 to stop and that she didn't like what she was doing and the STNA did not stop, it was a concern. STNA #81 stated she took the resident's concerns seriously and reported to the DON immediately. STNA #81 stated the resident deserved at least an investigation to see if the allegation was true. Interview with STNA #76 on 03/22/17 at 10:03 A.M. revealed Resident #57 had previously told her stop doing pericare but she told the resident she couldn't just stop because she could not leave her that way. The STNA stated the resident would tell her no a lot of the time. The STNA acknowledged there had been an incident where the resident told her she was pushing too hard while providing pericare. The STNA revealed she had never been asked to do any type of skills assessment with nursing staff to evaluate her competency to provide pericare. The STNA confirmed she was aware of the allegation made against her on 03/20/17 involving Resident #57 and continued to work on the resident's assignment on 03/20/17 and 03/21/17. STNA #76 stated following the incident, she was told she had to provide pericare to the resident with another staff assisting. STNA#76 confirmed she was able to provide care to Resident #57's roommate without supervision. On 03/22/17 at 9:22 A.M. interview with STNA #93 and #95 at 9:56 A.M. revealed they had been alerted by STNA #81 on 03/20/17 that Resident #57 was alleging STNA #76 stuck her fingers into the resident's vagina. STNA #93 and #95 stated neither staff reported the incident to the DON because STNA #81 told them that she had already reported it to DON. They stated they were told by the DON that they were to assist STNA #76 when she had to provide care to Resident #57. STNA #93 and #95 stated they would be permitted to provide care to Resident #57 unassisted. Interview with Activity Staff #94 on 03/22/17 at 9:35 A.M. revealed she was alerted by STNA #81 on 03/20/17 around 9:00 A.M. that Resident #57 alleged an STNA stuck her fingers into her vagina. Activity Staff #94 confirmed STNA #81 stated she reported the incident to the DON. The Activity Staff confirmed this occurred on 03/20/17 at approximately 9:00 A.M. when she heard about the alleged incident. Interviews conducted with STNA #81, STNA #93, STNA #94 and STNA #96 on 03/22/17 between 3:50 P.M. and 4:10 P.M. and on 03/23/17 between 8:26 A.M. and 8:50 A.M. revealed they denied Resident #57 having any complaints with the care, including pericare they provided to her. The staff interviewed denied Resident #57 had ever told them to stop, that they were hurting her or that the resident had ever yelled at them. On 03/23/17 at 2:11 P.M. interview with Resident #57's two visiting family members revealed they believed this situation might have occurred as they had witnessed STNA #76, on at least three separate occasions while one family member was sitting in the room say how much she hated that she had to provide so much pericare to Resident #57. The family member stated STNA #76 did not have the patience to take care of Resident #57 and did not understand her disability. The family stated she may have done it because she was mad at the resident and did it out of spite. During the interview, Resident #57 was observed to be tearful and stated to both the family and surveyor that she was not lying about this and that this STNA had done this to her. On 03/23/17 at 2:00 P.M. the facility initially submitted the allegation of sexual abuse involving Resident #57 to the State Agency. The allegation of sexual abuse was substantiated by the facility. A corresponding statement, provided to the facility from STNA #81 dated 03/23/17 revealed at breakfast time on 03/20/17 she had entered Resident #57's room to set up the resident roommate's breakfast tray. STNA #81 called out to STNA #76 to ask if she had brought the meal tray in yet. STNA #76, who was in the room stated it hadn't come yet and then walked away. After leaving, Resident #57 stated she didn't like that girl. When asked why, the resident stated she had stuck her finger in her vagina twice. When asked to clarify and asked if possibly the STNA was just cleaning her a little too rough, the resident stated, no, that I might be (sp), but I know when something is in there that I don't want in there. The resident stated she told STNA #76 that she didn't like it and it hurt her and STNA #76 said, you don't know what your talking about. The resident stated she didn't want STNA #76 in her room and she was afraid of her. STNA #81 reassured Resident #57 that she would report the incident to the nurse. Continued review of STNA #81's statement revealed about an hour after she reported the incident to the DON, STNA #76 approached her and said she had just changed Resident #57 and she was good. STNA #81 stated she asked STNA #76 why she went in the resident's room after the resident said she didn't want her in there and no information was provided. STNA #81 stated she then went to follow up with the DON who indicated she had not had a chance to speak with STNA #76 as of that time. Later in the day she was informed two staff were needed when providing care to Resident #57. Review of the facility's policy on abuse and neglect prevention dated 01/2016 and revised on 02/2017 revealed the purpose of the policy was to establish guidelines that prevent, identifies and reports resident abuse and neglect. The policy stated all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Sexual abuse was defined as non-consensual contact of any type with a resident. All allegations of resident abuse should be reported immediately to the charge nurse. The charge nurse was responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. All allegations of abuse shall be reported to the State survey agency, no later than two hours after the allegation was made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Should an incident or suspected incident of resident abuse be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. If there was any indication that injury had or might have occurred, any physical assessment must be completed by the Director of Nursing or charge nurse immediately. Documentation of any physical assessment conducted would be made in the resident's chart and a copy of this documentation would be included in the abuse investigation file. Interview with person(s) reporting the incident and the alleged perpetrator and document witness statements. Interview all witnesses to the incident and document all witness statements. Interview staff members (on all shifts) who have had contact with the Resident during the period of the alleged incident. Interview the resident's roommate, family members and visitors if appropriate. In circumstances where the allegation involved an employee, interview other residents to who the accused employee provided care or services to. Witness reports will be reduced to writing. Witnesses will be requested to sign and date such reports. A copy of such reports would be maintained with the investigation file. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation was in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee; and/or 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. This deficiency substantiates Complaint Number OH 284.

Based on medical record review, resident interview, staff interview and review of the facility's policy and procedure on Abuse and Neglect Prevention, the facility failed to ensure an allegation of sexual abuse involving Resident #57 was thoroughly investigated and reported to the State Agency as required. This resulted in Immediate Jeopardy and actual harm for one resident (#57), who reported physical pain (harm) and fear of the STNA following perineal care provided during incontinence. The facility also failed to ensure an allegation of abuse, involving Resident #5 was immediately reported to administrative staff and the State agency as required. This affected two residents (#57 and #5) of two residents reviewed for abuse. The facility census was 75. On 03/23/17 at 10:08 A.M., the Administrator, Administrator-in-Training #3, Regional Nurse #4, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/20/17 at 9:15 A.M. when Resident #57 reported to STNA #81 that she did not like that aide referring to STNA #76. The resident reported STNA #76 put her finger in her vagina twice (on unidentified dates) which had caused pain and she was now fearful of the STNA. At 9:30 A.M., STNA #81 reported the resident's allegation to the DON including communication the resident was fearful of STNA #76. The DON allowed STNA #76 to continue working on the nursing unit until approximately 10:30 A.M. when the DON asked STNA #76 to come to her office to be interviewed. After being interviewed, STNA #76 resumed working her assignment which included care of Resident #57. On 03/20/17 at 11:00 A.M. the DON instructed STNA #76 to have another staff member present with her to provide care to Resident #57. However, STNA #76 continued to provide care to Resident #57's roommate without supervision. STNA #76 was also assigned to provide care to Resident #57 on 03/21/17 from 6:51 A.M. to 7:04 P.M. The Immediate Jeopardy was removed on 03/24/17 when the facility initiated the following corrective actions: On 03/23/17 at 10:55 A.M., STNA #76's employment was terminated by the facility. On 03/23/17 at 11:00 A.M., the Administrator initiated an investigation related to Resident #57's allegation of sexual abuse utilizing a form titled, Alleged abuse, neglect and Exploitation Investigation Worksheet. The investigation was completed on 03/23/17 at 2:00 P.M. The facility reported the allegation of sexual abuse to the State agency on 03/23/17 at 11:00 A.M. On 03/23/17 at 11:27 A.M., Regional Nurse #4 initiated a resident abuse questionnaire which included an interview of all current interviewable residents. The questionnaire was given to all family members of residents identified to be non-interviewable. On 03/23/17 at 12:58 P.M., all residents and family interviews were completed by the following staff members: Scheduler #5, Licensed Social Worker (LSW) #6, Medical Records #7, Registered Nurse (RN) #8, Administrator-in-Training #4, Licensed Practical Nurse (LPN) #80 and Assistant Director of Nursing (ADON) #10. On 03/23/17 at 11:27 A.M., the facility implemented the form titled, Alleged abuse, neglect, Exploitation Investigation Worksheet to be used for any allegations of abuse. All staff were educated by the DON and Regional Nurse #4 to use this form in the event of an allegation of abuse. On 03/23/17 the DON began in-servicing all facility staff on the current policy and procedure regarding abuse and neglect prevention. A plan for all staff to be in-serviced by the end of the day on 03/23/17 was provided. Any staff not educated by 03/23/17 would be unable to return to work until the in-service was completed. As of 03/24/17 at 10:31 A.M. 80 of 88 employees had been in-serviced. A plan was provided to ensure the remaining eight employees were in-serviced. On 03/23/17 at 4:00 P.M. the DON and Administrator received disciplinary action in the form of a written warning by Regional Nurse #4 related to failure to properly report abuse and failure to complete an investigation as per the facility's policy and procedure on abuse and neglect. The DON and administrator were provided a performance improvement plan and education on the procedure for investigations of allegations of abuse, abuse and neglect policy by Regional Nurse #4. On 03/23/17 the facility initiated a system that all new admissions beginning on 03/23/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. On 03/23/17 a plan for the Administrator/designee to monitor compliance via the Resident Abuse Questionnaire audit, Resident Abuse audit tool five times per week for three months with results reviewed at the monthly performance meeting to determine continued focus. On 03/23/17 a plan for the DON/designee to utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. On 03/23/17 a plan for the Administrator to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. On 03/23/17 a plan for the Administrator to submit initial and final reports to Regional Nurse #4 through a self-reported incident log upon notification of allegations of abuse. Regional Nurse #4 would monitor for compliance of reporting through the Self-Reported Incident Log three to five times per week for three months, with results reviewed with monthly performance improvement to continue focus for quality improvement measures. On 03/24/17 from 7:19 A.M. to 7:30 A.M. interview with Unit Clerk #101, Housekeeper #105 and STNA #95 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 03/24/17 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to the allegation of abuse involving Resident #5 not being immediately reported to administrative staff and the State Agency and ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. was intact, she had no identified behaviors and required extensive assistance with one person physical assistance for toilet use. The assessment revealed the resident was frequently incontinent of bowel and bladder. On 03/22/17 at 8:10 A.M. interview with STNA #81 revealed Resident #57 had reported to her on 03/20/17 during breakfast time that she did not like that girl and pointed to STNA #76 who was present in the room at the time of the conversation. STNA #81 stated she asked STNA #76 to leave the room and then continued talking to the resident. Resident #57 then stated the other day STNA #76 put her finger in her vagina twice. The resident told her, I might be (sp) but I know where my vagina is and I know when something is in there that I don't want in there. The resident stated she told STNA #76 that she did not like her doing that. STNA #81 stated she shared the resident's concerns with STNAs #95 and #93 and Activity Staff #94 and then immediately notified the DON who was in the facility at the time of the allegation. During an interview with Resident #57 on 03/22/17 at 10:26 A.M. the resident was asked if she had any concerns with any staff providing care to her. The resident responded yes, she was mean. She put her finger in my vagina and it was uncomfortable and I was hurting. The resident continued by stating she was afraid of this STNA and had seen her since the incident. Further interview revealed the resident was unable to provide the name of the STNA or the date this incident occurred. When the resident was asked directly if she felt she had been abused, the resident replied, yes, sexually. The resident denied any concerns with any other staff except this one particular STNA. Review of Resident #57's medical record revealed there was no assessment of the resident or notation in the resident's progress notes on 03/20/17 following this allegation/incident. This was confirmed by the DON on 03/22/17 at 10:54 A.M. On 03/22/17 at 9:00 A.M. review of the facility's Self-Reported Incidents revealed there had been no investigations of sexual abuse reported to the State Agency from 03/01/17 to 03/22/17. Review of the facility's information regarding the above incident involving Resident #57 revealed a one page typed time line, dated with an incorrect date of 02/20/17 which was not signed by the person who completed it. The time line did not include any staff, resident or witness statements but rather summary statements. Interview with the DON on 03/23/17 at 9:57 A.M. revealed she had completed the time line and confirmed the time lines sheet dates were incorrect as it should have been 03/20/17 and not 02/20/17. The facility's timeline revealed the following: On 03/20/17 at 10:30 A.M., STNA #81 came to the DON and stated Resident #57 pointed to STNA #76 and stated I don't like her. She stuck her finger in my vagina two times last week. Review of the time line investigation revealed here was no written statement from STNA #81 obtained at that time. However, interview with STNA #81 on 03/23/17 at 8:50 A.M. revealed she notified the DON of the incident between 9:00 and 9:30 A.M. on 03/20/17 and reported to her Resident #57 alleged STNA #76 put her finger in her vagina twice while changing her and the resident was now fearful of the aide. STNA #81 stated the DON did not immediately remove STNA #76 from the resident's assignment. STNA #81 stated STNA #76 provided care to the resident unsupervised from 9:30 A.M. until 10:30 A.M. when the DON pulled STNA #76 into her office. STNA #81 stated the DON told her, following the incident, STNA #76 must have another staff member present when providing care to Resident #57. On 03/20/17 at 10:33 A.M. STNA #76 was asked to sit in the DON's office. Interview with STNA #76 on 03/23/17 at 10:03 A.M. revealed she was not removed from her assignment until after the DON spoke to Resident #57. On 03/20/17 at 10:45 A.M., the DON spoke to STNA #76 and asked STNA #76 if Resident #57 had complained to her during any pericare. The STNA stated last week the resident yelled out when she was being cleaned after a bowel movement. STNA #76 stated the resident had a loose bowel movement and stool was high in her peri area and vagina so she had to clean up higher in her peri area. The STNA stated she explained this to the resident, that there was stool in there and she needed to clean it well so that she would not get an infection. The employee was educated the resident would now be a two-person assist with all care and to always explain to the resident what was going to happen with care before performing the care. Employee expressed understanding. On 03/20/17 the interviewable residents who were assigned to receive care from STNA #76 were interviewed by unidentifiable staff with no concerns identified. However, interview with the DON on 03/22/17 at 10:54 A.M. confirmed there were no names or times of the above resident interviews completed or who they were completed by. The DON revealed she did not have any documented evidence of the content of these interviews. On 03/22/17 at 9:25 A.M. interview with the Administrator revealed there had been no investigations of abuse in the facility since January, 2017. During a follow up interview with the Administrator and DON on 03/22/17 at 11:33 A.M. the administrative staff revealed they did not feel Resident #57's allegation was considered abuse. The DON denied any staff stating the resident was hurt or scared. The Administrator stated STNA #81 did the right thing by reporting it to the DON immediately. The DON confirmed she did not obtain any witness statements as of the time of this interview. When the DON and Administrator were asked to clarify the documentation on the above time line stating on 03/20/17 at 10:30 A.M. I don't like her. She stuck her finger in my vagina two times last week. the Administrator stated that would be an allegation of abuse. The Administrator stated, they looked at it so fast that they didn't think to report it. An additional interview with STNA #81 on 03/23/17 at 8:50 A.M. revealed Resident #57 was usually very pleasant and did not typically complain about care or staff. STNA #81 stated she thought when the resident initially made the allegation against STNA #76 it seemed out of character for the resident (as she never really complained about things). STNA #81 stated to her knowledge the resident had never complained about how she or any other staff (with the exception of STNA #76) provided pericare. Additionally, when Resident #57 was able to report that she told STNA #76 to stop and that she didn't like what she was doing and the STNA did not stop, it was a concern. STNA #81 stated she took the resident's concerns seriously and reported to the DON immediately. STNA #81 stated the resident deserved at least an investigation to see if the allegation was true. Interview with STNA #76 on 03/22/17 at 10:03 A.M. revealed the STNA confirmed she was aware of the allegation made against her on 03/20/17 involving Resident #57 and continued to work on the resident's assignment on 03/20/17 and 03/21/17. STNA #76 stated following the incident, she was told she had to provide pericare to the resident with another staff assisting. STNA#76 confirmed she was able to provide care to Resident #57's roommate without supervision. On 03/22/17 at 9:22 A.M. interview with STNA #93 and #95 at 9:56 A.M. revealed they had been alerted by STNA #81 on 03/20/17 that Resident #57 was alleging STNA #76 stuck her fingers into the resident's vagina. STNA #93 and #95 stated neither staff reported the incident to the DON because STNA #81 told them that she had already reported it to DON. They stated they were told by the DON that they were to assist STNA #76 when she had to provide care to Resident #57. STNA #93 and #95 stated they would be permitted to provide care to Resident #57 unassisted. Interview with Activity Staff #94 on 03/22/17 at 9:35 A.M. revealed she was alerted by STNA #81 on 03/20/17 around 9:00 A.M. that Resident #57 alleged an STNA stuck her fingers into her vagina. Activity Staff #94 confirmed STNA #81 stated she reported the incident to the DON. The Activity Staff confirmed this occurred on 03/20/17 at approximately 9:00 A.M. when she heard about the alleged incident. On 03/23/17 at 2:00 P.M. the facility initially submitted the allegation of sexual abuse involving Resident #57 to the State Agency. The allegation of sexual abuse was substantiated by the facility. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. was intact. The resident exhibited no behaviors and required extensive assistance with one person physical assistance with bed mobility and transfers. On 03/23/17, the facility conducted interviews with all alert and oriented residents regarding abuse. As a result, on 03/23/17 at 12:30 P.M. Resident #5 verbalized she had been abused to the Assistant Director of Nursing (ADON). When asked if she had reported this to any facility staff, the resident replied, yes she had reported it to RN #115. The resident alleged STNA #117 was impatient when the resident moved slowly. The STNA told the resident that she was a burden to her family and if she didn't straighten up they would put her some place. The resident reported STNA told her she was lazy and didn't try to get better. The resident stated the STNA told her that her legs were gigantic tree stumps and refused to reposition her in bed. Interview with RN #115 on 03/24/17 at 9:49 A.M. revealed Resident #5 voiced concerns to her about STNA #117 on 03/19/17 between approximately 5:00 P.M. and 5:30 P.M. The resident expressed she didn't like STNA #117, the STNA was too fast with her care and the STNA didn't listen to the resident's concerns. RN #115 stated the resident told her STNA #117 intentionally made her walk and that was not her job. The resident also reported the STNA might have hurt her legs when she threw them in bed. RN #115 stated she encouraged the resident to talk to someone about it if she was uncomfortable. The RN stated she was going to wait until 03/23/17 when she next worked to report the incident to the DON. The RN stated in hindsight she should have reported it immediately and confirmed she should have reported it on 03/19/17, when it was reported to her. Interview with ADON #10, DON and Administrator-in-Training #3 on 03/24/17 at 10:45 A.M. revealed RN #115 received disciplinary action, dated 03/23/17 for failure to report Resident #5's abuse allegation and the RN received in-service training regarding the facility abuse policy. The administrative staff indicated the investigation of Resident #5's allegation was on-going as of this time. Review of the facility's policy on abuse and neglect prevention dated 01/2016 and revised on 02/2017 revealed the purpose of the policy was to establish guidelines that prevent, identifies and reports resident abuse and neglect. The policy stated all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Sexual abuse was defined as non-consensual contact of any type with a resident. All allegations of resident abuse should be reported immediately to the charge nurse. The charge nurse was responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. All allegations of abuse shall be reported to the State survey agency, no later than two hours after the allegation was made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Should an incident or suspected incident of resident abuse be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. If there was any indication that injury had or might have occurred, any physical assessment must be completed by the Director of Nursing or charge nurse immediately. Documentation of any physical assessment conducted would be made in the resident's chart and a copy of this documentation would be included in the abuse investigation file. Interview with person(s) reporting the incident and the alleged perpetrator and document witness statements. Interview all witnesses to the incident and document all witness statements. Interview staff members (on all shifts) who have had contact with the Resident during the period of the alleged incident. Interview the resident's roommate, family members and visitors if appropriate. In circumstances where the allegation involved an employee, interview other residents to who the accused employee provided care or services to. Witness reports will be reduced to writing. Witnesses will be requested to sign and date such reports. A copy of such reports would be maintained with the investigation file. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation was in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee; and/or 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. This deficiency substantiates Complaint Number OH 284.

Based on medical record review, resident interview, staff interview and review of the facility's policy and procedure on Abuse and Neglect Prevention, the facility failed to effectively implement their abuse policy and procedure to prevent an incident of sexual abuse involving Resident #57 and to ensure the allegation was thoroughly investigated and reported to the State Agency as required. This resulted in Immediate Jeopardy and actual harm for one resident (#57), who reported physical pain (harm) and fear of the STNA following perineal care provided during incontinence. The facility also failed to ensure an allegation of abuse, involving Resident #5 was immediately reported to administrative staff and the State Agency as required. This affected two residents (#57 and #5) of two residents reviewed for abuse. The facility census was 75. On 03/23/17 at 10:08 A.M., the Administrator, Administrator-in-Training #3, Regional Nurse #4, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/20/17 at 9:15 A.M. when Resident #57 reported to STNA #81 that she did not like that aide referring to STNA #76. The resident reported STNA #76 put her finger in her vagina twice (on unidentified dates) which had caused pain and she was now fearful of the STNA. At 9:30 A.M., STNA #81 reported the resident's allegation to the DON including communication the resident was fearful of STNA #76. The DON allowed STNA #76 to continue working on the nursing unit until approximately 10:30 A.M. when the DON asked STNA #76 to come to her office to be interviewed. After being interviewed, STNA #76 resumed working her assignment which included care of Resident #57. On 03/20/17 at 11:00 A.M. the DON instructed STNA #76 to have another staff member present with her to provide care to Resident #57. However, STNA #76 continued to provide care to Resident #57's roommate without supervision. STNA #76 was also assigned to provide care to Resident #57 on 03/21/17 from 6:51 A.M. to 7:04 P.M. The Immediate Jeopardy was removed on 03/24/17 when the facility initiated the following corrective actions: On 03/23/17 at 10:55 A.M., STNA #76's employment was terminated by the facility. On 03/23/17 at 11:00 A.M., the Administrator initiated an investigation related to Resident #57's allegation of sexual abuse utilizing a form titled, Alleged abuse, neglect and Exploitation Investigation Worksheet. The investigation was completed on 03/23/17 at 2:00 P.M. The facility reported the allegation of sexual abuse to the State agency on 03/23/17 at 11:00 A.M. On 03/23/17 at 11:27 A.M., Regional Nurse #4 initiated a resident abuse questionnaire which included an interview of all current interviewable residents. The questionnaire was given to all family members of residents identified to be non-interviewable. On 03/23/17 at 12:58 P.M., all residents and family interviews were completed by the following staff members: Scheduler #5, Licensed Social Worker (LSW) #6, Medical Records #7, Registered Nurse (RN) #8, Administrator-in-Training #4, Licensed Practical Nurse (LPN) #80 and Assistant Director of Nursing (ADON) #10. On 03/23/17 at 11:27 A.M., the facility implemented the form titled, Alleged abuse, neglect, Exploitation Investigation Worksheet to be used for any allegations of abuse. All staff were educated by the DON and Regional Nurse #4 to use this form in the event of an allegation of abuse. On 03/23/17 the DON began in-servicing all facility staff on the current policy and procedure regarding abuse and neglect prevention. A plan for all staff to be in-serviced by the end of the day on 03/23/17 was provided. Any staff not educated by 03/23/17 would be unable to return to work until the in-service was completed. As of 03/24/17 at 10:31 A.M. 80 of 88 employees had been in-serviced. A plan was provided to ensure the remaining eight employees were in-serviced. On 03/23/17 at 4:00 P.M. the DON and Administrator received disciplinary action in the form of a written warning by Regional Nurse #4 related to failure to properly report abuse and failure to complete an investigation as per the facility's policy and procedure on abuse and neglect. The DON and administrator were provided a performance improvement plan and education on the procedure for investigations of allegations of abuse, abuse and neglect policy by Regional Nurse #4. On 03/23/17 the facility initiated a system that all new admissions beginning on 03/23/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. On 03/23/17 a plan for the Administrator/designee to monitor compliance via the Resident Abuse Questionnaire audit, Resident Abuse audit tool five times per week for three months with results reviewed at the monthly performance meeting to determine continued focus. On 03/23/17 a plan for the DON/designee to utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. On 03/23/17 a plan for the Administrator to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. On 03/23/17 a plan for the Administrator to submit initial and final reports to Regional Nurse #4 through a self-reported incident log upon notification of allegations of abuse. Regional Nurse #4 would monitor for compliance of reporting through the Self-Reported Incident Log three to five times per week for three months, with results reviewed with monthly performance improvement to continue focus for quality improvement measures. On 03/24/17 from 7:19 A.M. to 7:30 A.M. interview with Unit Clerk #101, Housekeeper #105 and STNA #95 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 03/24/17 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to the allegation of abuse involving Resident #5 not being immediately reported to administrative staff and the State Agency and ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. was intact, she had no identified behaviors and required extensive assistance with one person physical assistance for toilet use. The assessment revealed the resident was frequently incontinent of bowel and bladder. Review of a plan of care, initiated 01/19/16 and last revised on 11/07/16 revealed the resident had an activity of daily living (ADL) self-care performance deficit related to impaired balance and limited mobility. Interventions reflected the resident was bedfast most of the time and required two staff to assist with toileting. The care plan was updated on 03/20/17 to reflect the resident required two staff with all ADL care. On 03/22/17 at 8:10 A.M. interview with STNA #81 revealed Resident #57 had reported to her on 03/20/17 during breakfast time that she did not like that girl and pointed to STNA #76 who was present in the room at the time of the conversation. STNA #81 stated she asked STNA #76 to leave the room and then continued talking to the resident. Resident #57 then stated the other day STNA #76 put her finger in her vagina twice. The resident told her, I might be (sp) but I know where my vagina is and I know when something is in there that I don't want in there. The resident stated she told STNA #76 that she did not like her doing that. STNA #81 stated she shared the resident's concerns with STNAs #95 and #93 and Activity Staff #94 and then immediately notified the DON who was in the facility at the time of the allegation. During an interview with Resident #57 on 03/22/17 at 10:26 A.M. the resident was asked if she had any concerns with any staff providing care to her. The resident responded yes, she was mean. She put her finger in my vagina and it was uncomfortable and I was hurting. The resident continued by stating she was afraid of this STNA and had seen her since the incident. Further interview revealed the resident was unable to provide the name of the STNA or the date this incident occurred. When the resident was asked directly if she felt she had been abused, the resident replied, yes, sexually. The resident denied any concerns with any other staff except this one particular STNA. Review of Resident #57's medical record revealed there was no assessment of the resident or notation in the resident's progress notes on 03/20/17 following this allegation/incident. This was confirmed by the DON on 03/22/17 at 10:54 A.M. On 03/22/17 at 9:00 A.M. review of the facility's Self-Reported Incidents revealed there had been no investigations of sexual abuse reported to the State Agency from 03/01/17 to 03/22/17. Review of the facility's information regarding the above incident involving Resident #57 revealed a one page typed time line, dated with an incorrect date of 02/20/17 which was not signed by the person who completed it. The time line did not include any staff, resident or witness statements but rather summary statements. Interview with the DON on 03/23/17 at 9:57 A.M. revealed she had completed the time line and confirmed the time lines sheet dates were incorrect as it should have been 03/20/17 and not 02/20/17. The facility's timeline revealed the following: On 03/20/17 at 10:30 A.M., STNA #81 came to the DON and stated Resident #57 pointed to STNA #76 and stated I don't like her. She stuck her finger in my vagina two times last week. Review of the time line investigation revealed here was no written statement from STNA #81 obtained at that time. However, interview with STNA #81 on 03/23/17 at 8:50 A.M. revealed she notified the DON of the incident between 9:00 and 9:30 A.M. on 03/20/17 and reported to her Resident #57 alleged STNA #76 put her finger in her vagina twice while changing her and the resident was now fearful of the aide. STNA #81 stated the DON did not immediately remove STNA #76 from the resident's assignment. STNA #81 stated STNA #76 provided care to the resident unsupervised from 9:30 A.M. until 10:30 A.M. when the DON pulled STNA #76 into her office. STNA #81 stated the DON told her, following the incident, STNA #76 must have another staff member present when providing care to Resident #57. On 03/20/17 at 10:33 A.M. STNA #76 was asked to sit in the DON's office. Interview with STNA #76 on 03/23/17 at 10:03 A.M. revealed she was not removed from her assignment until after the DON spoke to Resident #57. On 03/20/17 at 10:45 A.M., the DON spoke to STNA #76 and asked STNA #76 if Resident #57 had complained to her during any pericare. The STNA stated last week the resident yelled out when she was being cleaned after a bowel movement. STNA #76 stated the resident had a loose bowel movement and stool was high in her peri area and vagina so she had to clean up higher in her peri area. The STNA stated she explained this to the resident, that there was stool in there and she needed to clean it well so that she would not get an infection. The employee was educated the resident would now be a two-person assist with all care and to always explain to the resident what was going to happen with care before performing the care. Employee expressed understanding. On 03/20/17 the interviewable residents who were assigned to receive care from STNA #76 were interviewed by unidentifiable staff with no concerns identified. However, interview with the DON on 03/22/17 at 10:54 A.M. confirmed there were no names or times of the above resident interviews completed or who they were completed by. The DON revealed she did not have any documented evidence of the content of these interviews. On 03/22/17 at 9:25 A.M. interview with the Administrator revealed there had been no investigations of abuse in the facility since January, 2017. During a follow up interview with the Administrator and DON on 03/22/17 at 11:33 A.M. the administrative staff revealed they did not feel Resident #57's allegation was considered abuse. The DON denied any staff stating the resident was hurt or scared. The Administrator stated STNA #81 did the right thing by reporting it to the DON immediately. The DON confirmed she did not obtain any witness statements as of the time of this interview. When the DON and Administrator were asked to clarify the documentation on the above time line stating on 03/20/17 at 10:30 A.M. I don't like her. She stuck her finger in my vagina two times last week. the Administrator stated that would be an allegation of abuse. The Administrator stated, they looked at it so fast that they didn't think to report it. On 03/22/17 at 9:22 A.M. interview with STNA #93 and #95 at 9:56 A.M. revealed they had been alerted by STNA #81 on 03/20/17 that Resident #57 was alleging STNA #76 stuck her fingers into the resident's vagina. STNA #93 and #95 stated neither staff reported the incident to the DON because STNA #81 told them that she had already reported it to DON. They stated they were told by the DON that they were to assist STNA #76 when she had to provide care to Resident #57. STNA #93 and #95 stated they would be permitted to provide care to Resident #57 unassisted. Interview with Activity Staff #94 on 03/22/17 at 9:35 A.M. revealed she was alerted by STNA #81 on 03/20/17 around 9:00 A.M. that Resident #57 alleged an STNA stuck her fingers into her vagina. Activity Staff #94 confirmed STNA #81 stated she reported the incident to the DON. The Activity Staff confirmed this occurred on 03/20/17 at approximately 9:00 A.M. when she heard about the alleged incident. On 03/23/17 at 2:00 P.M. the facility initially submitted the allegation of sexual abuse involving Resident #57 to the State Agency. The allegation of sexual abuse was substantiated by the facility. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. was intact. The resident exhibited no behaviors and required extensive assistance with one person physical assistance with bed mobility and transfers. On 03/23/17, the facility conducted interviews with all alert and oriented residents regarding abuse. As a result, on 03/23/17 at 12:30 P.M. Resident #5 verbalized she had been abused to the Assistant Director of Nursing (ADON). When asked if she had reported this to any facility staff, the resident replied, yes she had reported it to RN #115. The resident alleged STNA #117 was impatient when the resident moved slowly. The STNA told the resident that she was a burden to her family and if she didn't straighten up they would put her some place. The resident reported STNA told her she was lazy and didn't try to get better. The resident stated the STNA told her that her legs were gigantic tree stumps and refused to reposition her in bed. Interview with RN #115 on 03/24/17 at 9:49 A.M. revealed Resident #5 voiced concerns to her about STNA #117 on 03/19/17 between approximately 5:00 P.M. and 5:30 P.M. The resident expressed she didn't like STNA #117, the STNA was too fast with her care and the STNA didn't listen to the resident's concerns. RN #115 stated the resident told her STNA #117 intentionally made her walk and that was not her job. The resident also reported the STNA might have hurt her legs when she threw them in bed. The RN stated she encouraged the resident to talk to someone about it if she was uncomfortable. The RN stated she was going to wait until 03/23/17 when she next worked to report the incident to the DON. The RN stated in hindsight she should have reported it immediately and confirmed she should have reported it on 03/19/17, when it was reported to her. Interview with ADON #10, DON and Administrator-in-Training #3 on 03/24/17 at 10:45 A.M. revealed RN #115 received disciplinary action, dated 03/23/17 for failure to report Resident #5's abuse allegation and the RN received in-service training regarding the facility abuse policy. The administrative staff indicated the investigation of Resident #5's allegation was on-going as of this time. Review of the facility's policy on abuse and neglect prevention dated 01/2016 and revised on 02/2017 revealed the purpose of the policy was to establish guidelines that prevent, identifies and reports resident abuse and neglect. The policy stated all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Sexual abuse was defined as non-consensual contact of any type with a resident. All allegations of resident abuse should be reported immediately to the charge nurse. The charge nurse was responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. All allegations of abuse shall be reported to the State survey agency, no later than two hours after the allegation was made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Should an incident or suspected incident of resident abuse be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. If there was any indication that injury had or might have occurred, any physical assessment must be completed by the Director of Nursing or charge nurse immediately. Documentation of any physical assessment conducted would be made in the resident's chart and a copy of this documentation would be included in the abuse investigation file. Interview with person(s) reporting the incident and the alleged perpetrator and document witness statements. Interview all witnesses to the incident and document all witness statements. Interview staff members (on all shifts) who have had contact with the Resident during the period of the alleged incident. Interview the resident's roommate, family members and visitors if appropriate. In circumstances where the allegation involved an employee, interview other residents to who the accused employee provided care or services to. Witness reports will be reduced to writing. Witnesses will be requested to sign and date such reports. A copy of such reports would be maintained with the investigation file. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation was in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee; and/or 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. This deficiency substantiates Complaint Number OH 284.

Based on record review and interview the facility failed to ensure fall interventions were in place to prevent falls for Resident #74 and Resident #75. The facility failed to implement interventions to prevent a fall and failed to investigate a fall for Resident #75. This resulted in harm to Resident #75 when the resident fell , with no interventions in place and fractured her tibia and fibula, which required surgical intervention. This affected two residents (Resident #75 and Resident #74) of three residents reviewed for falls. Findings include: 1. Review of the clinical record for Resident #75 revealed the resident was admitted to the facility on [DATE] for a short respite stay, with a planned discharge on 10/20/14 at 1:00 P.M. She was admitted with [DIAGNOSES REDACTED]. Review of the Patient Nursing Evaluation, dated 10/15/14 at 2:15 P.M., revealed Resident #75 was admitted for respite care with a dementia diagnosis. She was assessed as being confused, having altered safety awareness due to cognitive decline, being independently ambulatory with a walker, and at a medium risk for falls. Review of the Morse Fall Risk Scale section revealed there was no history of falling, no secondary diagnoses, and no intravenous access. Resident #75 was assessed to require a walker for ambulation, having a weak gait, although it noted the resident's gait was steady with a walker. The assessment also revealed the resident overestimated or forgets her limitations. The Morse Fall Risk Assessment listed hypertension as a secondary [DIAGNOSES REDACTED]. If accurately assessed, Resident #75 would have been a high fall risk. Review of the care plan related to falls, dated 10/15/14, revealed Resident #75 was at moderate risk for falls due to decreased awareness of safety needs, confusion, wandering, use of roll-aider walker, and independent ambulation. Interventions included providing a safe environment free of clutter with her walker and call light within reach and anticipating and meeting her needs. Interventions also included a low bed and a personal safety alarm (PSA) to the bed and wheelchair for 72 hours. Review of physician orders, dated 10/16/14, revealed a clarification that a personal alarm to the bed and a low bed were to be in place for 72 hours after admission. Review of the Wandering Evaluation, dated 10/15/14, revealed Resident #75 was at risk for wandering due to being cognitively impaired, frequently pacing or wandering, having impaired decision making skills that decreased safety awareness, and wandered around the nurse's station. Review of the nursing notes revealed on 10/19/14 at 2:26 P.M., Resident #75 was assessed as pleasantly confused and ambulating in the hallway with her walker. Review of the nursing notes revealed the next note was on 10/20/14 at 5:11 A.M. This note revealed Resident #75 was "found sleeping on the floor lying in the fetal position in her bedroom." Resident #75 complained of right ankle pain when she attempted to move. The physician was notified and an x-ray was ordered which revealed an ankle fracture. Resident #75 was sent to the hospital and the resident's daughter was notified. Review of the radiology report, dated 10/20/14 at 3:49 A.M. revealed Resident #75 had a bimalleolar fracture of the right ankle, which included a fracture of the medial malleolus and the distal fibula with moderate displacement. Fractures of that nature make the ankle unstable and almost always require surgical intervention. Review of the incident report revealed on 10/20/14 at 2:30 A.M., Resident #75 was found laying on the floor next to her bed in a fetal position with eyes closed and when aroused, complained of right ankle pain. There was no documentation as to what interventions, if any, were in place at the time of the fall. There was no documentation related to the alarm sounding or not sounding, the bed being in a low position, or the resident having her walker or call light within reach. No documentation was noted as to the last time and location the resident was seen. No injuries other than the ankle pain were noted. Review of the treatment administration record (TAR) revealed the low bed and PSA were to be in place for 72 hours. On 10/19/14 for the 10:00 P.M. to 6:00 A.M. shift (third shift), the interventions were signed off as being in place. These interventions were also signed as being in place on 10/20/14 for the first, second, and third shifts, during which time Resident #75 was not in the facility and had already been sent to the hospital. The interventions were also not signed as in place on 10/16/14 for second and third shifts and on 10/18/14 for the first shift. On 12/30/14 at 9:03 A.M., an interview with the family member of Resident #75 revealed Resident #75 had broken her ankle while at the facility. She revealed Resident #75 required surgery to fix the ankle, which included a metal plate and screws, as she was told by the emergency room physician that Resident #75 had suffered shearing fractures of the ankle with displacement. She revealed Resident #75 had not been able to ambulate independently since the fracture. The family member revealed when the nurse called her to notify her of the accident, she was told that Resident #75 had been up wandering most of the night. The family member indicated the facility had refunded her money for the resident's stay and sent her a form requesting she sign a waiver of liability for Resident #75's injury. She reported she had requested the facility investigate how and why her relative fell , and the facility refused to do so. On 12/30/14 at 9:15 A.M., an interview with the Director of Nursing (DON) revealed there was only an incident report related to Resident #75's unwitnessed fall and the facility did not complete an investigation. A follow-up interview at 11:03 A.M. revealed the facility implemented the low bed and PSA for Resident #75 for 72 hours and confirmed no interventions were in place at the time the resident sustained [REDACTED]. The DON confirmed there was no documentation as to why the two interventions were not continued or if they were effective at all. On 12/30/14 at 11:12 A.M., an interview with Unit Manager (UM) #4 revealed Resident #75 was independently ambulatory and did not need fall interventions as she was only a moderate fall risk, not a high fall risk. UM #4 confirmed that although the TAR was signed on the night of the fall that the low bed and PSA were in place, it was also signed the entire next day when Resident #75 was not in the facility. She confirmed the facility did not do a fall investigation and she could not be certain what interventions were in place at the time of the fall at 2:30 A.M. on 10/20/14. She revealed that the care sheet signed by the State tested nursing assistants (STNAs) showed Resident #75 was put into bed on 10/19/14, although she confirmed she did not know what time or that Resident #75 stayed in bed after that, as she was independently ambulatory. UM #4 confirmed there was a lack of documentation regarding what interventions were in place at the time of the fall, that she was unsure if the PSA was on or even sounding or if the resident's walker and call light were within reach, and that the resident was found curled up in the fetal position on the floor of her room sleeping when she was found. She confirmed that the facility did not know how Resident #75 fell , how long she had been on the floor prior to being found, or what interventions had been in place at that time of the fall. On 12/30/14 at 12:40 P.M., an interview with the DON confirmed the lack of evidence to show any interventions were in place at the time of Resident #75's fall, a lack of investigation into the fall, and that Resident #75 did have a secondary [DIAGNOSES REDACTED]. 2. Review of the clinical record for Resident #74 revealed the resident was admitted on [DATE] with a most recent re-admission on 01/26/13. Resident #74 had [DIAGNOSES REDACTED]. Review of the most recent comprehensive MDS 3.0 assessment, dated 07/07/14 revealed Resident #74 was severely cognitively impaired and required extensive assistance of one staff member for transfer, ambulation, toileting, dressing, and bathing. She had no falls during the assessment period. The most recent quarterly MDS 3.0 assessment, dated 10/07/14, revealed she was moderately cognitively impaired, required limited assistance of one staff member for activities of daily living, and had experienced two or more falls with no injury in the assessment period. Review of the fall care plan, dated 09/06/12 and last revised on 07/16/14, revealed Resident #74 was at high risk for falls related to a gait and balance problem, a history of falls, Parkinson's disease, [DIAGNOSES REDACTED], decreased safety awareness, use of psychotropic medications, and attempts to transfer herself without assistance. Interventions included, but were not limited to, a body pillow to the left side of the bed, dycem to the wheelchair, a low bed with a mat to the floor, a PSA to the bed, removing the recliner from the room, a thicker mat to the floor (added 12/13/13), and visual reminders to ask for assistance. On 12/29/14 at 2:45 P.M., an observation of Resident #74 revealed she was asleep in bed. The bed was low and there was a thin white mat on the floor next to the bed, approximately one quarter inch thick. Observation of multiple rooms on the other unit revealed thick red mats on the floor next to multiple beds. On 12/30/14 at 11:00 A.M., an interview with STNA #5 revealed Resident #74 had a thin mat to place on the floor while she was in bed. When asked if there was a thicker mat available, STNA #5 went into a room across the hall and revealed a thicker mat was in that room. She revealed that when the nurses tell the STNAs to get a mat for a resident, they do not usually specify what thickness. On 12/30/14 at 11:08 A.M., an interview with UM #2 revealed he was unsure why Resident #74 had the intervention for a thicker mat to bedside ordered. He confirmed there was a thinner mat being used. At 12:00 P.M. a follow-up interview revealed UM #2 brought two mats, both thin, one white and one blue, stating those were the two mats available in the facility. UM #2 then confirmed the presence of the thick red mats on the other unit and was unsure why one was not in use for Resident #74. Review of the facility "Fall Reduction Policy", dated 01/01/14 revealed the facility will identify residents at risk for falling and develop appropriate interventions to prevent or minimize fall related injuries. This deficiency is an incidental finding to Complaint Number OH 270.

Based on medical record review, observation, and staff interview the facility failed to ensure that a resident with the [DIAGNOSES REDACTED]. appropriate treatment when a resident's insulin was not administered according to orders and and failed to administer insulin medication without physician clarification. This affected two (Residents #139 and Resident #84) of seven residents reviewed with [DIAGNOSES REDACTED]. residents with [DIAGNOSES REDACTED]. Harm occurred to Resident #139 when facility staff administered the resident two different types of insulin without providing a snack or meal resulting in the resident's blood sugar dropping resulting in [DIAGNOSES REDACTED] requiring intervention at the hospital. Findings include: 1 Record review for Resident #139 revealed the resident was admitted to the facility on 08/16/11 with [DIAGNOSES REDACTED]. diabetic, diabetic ketoacidosis, hypertension, and end stage [MEDICAL CONDITION]. Review of Resident #139's current physician orders [REDACTED]. subcutaneously (injection) three times a day with meals, [MEDICATION NAME] (fast acting insulin that indicates residents receiving the medication should eat within 5-10 minutes of receiving the medication) 6 units subcutaneously with meals three times a day. [MEDICATION NAME] was also scheduled before meals and was to be given with meals based on a sliding scale depending on the blood sugar reading. For a blood sugar of 101-150= no insulin was to be administered, 151-200= 1 unit of insulin, 201-250= 2 units of insulin, 251-300= 3 units of insulin were to be administered. For a blood sugar reading above 300 the doctor was to be called. Review of Resident #139's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR for 11/30/11 revealed the resident was given the scheduled insulin Detemir 8 units, and was given the scheduled insulin [MEDICATION NAME] 6 units at 6:00 AM. No sliding scale insulin was documented as being given. Review of Resident #139's medical record and meal intake record for November 2011 revealed no documented evidence of the resident eating a meal or snack on 11/30/11 for the 6:00 AM dose of insulins. Review of the November 2011 MAR indicated [REDACTED] was scheduled three times a day was signed off as being given at 6:00 AM on a daily basis and the sliding scale insulin was noted to be given at 6:00 AM if it was indicated. Review of nurse's note dated 11/30/11 revealed Resident #139 was assessed to be presenting with [MEDICAL CONDITION] type activity, safety measures in place, and had a blood glucose of 12. Review of the nurse's note stated [MEDICATION NAME] (a medication administered for critically low blood sugars) was injected per the resident's order and 911 was called. Emergency personnel came to transport Resident #139 at 8:15 A.M. Observation was completed of Resident #139 on 11/30/11 at 8:10 AM to 8:20 AM. Resident #139 was noted to be in his room with the emergency medical technicians. Resident #139 was being assessed at the time for low blood sugar. The resident was taken out of facility to ER for assessment. Observation on 11/30/11 at 8:20 A.M. revealed food carts were on the hall and being passed by staff. Observation was again observed on 12/01/11 at 8:00 AM and revealed that carts were brought to the northeast hall at 8:10 AM. Interview with Licensed Practical Nurse (LPN) #12 on 12/01/11 at 4:15 P.M. revealed residents have their blood sugar checked at 6:00 A.M. per facility protocol. Coverage was provided by the night shift nurses if coverage was needed before they left at 7:00 A.M. LPN #12 stated that meal trays come to the northeast hall anywhere from 8:00 A.M. -8:15 A.M. LPN #12 stated that residents who ate in the dining room were fed earlier at 7:30 AM. LPN #12 revealed that Resident #139 resided in the northeast hall, and when he ate breakfast, it was normally in his room. Interview with the Director of Nursing (DON) at 4:30 PM on 12/01/11 confirmed Resident #139's ordered [MEDICATION NAME] 6 units with meals three times a day was not given with meals. The DON confirmed Resident #139 did not have anything documented about being offered breakfast or snack with the insulin that was given at 6:00 AM. The DON confirmed Resident #139 was sent out of the facility with a [MEDICAL CONDITION] type of activity and blood sugar noted to be 12. The DON confirmed the scheduled [MEDICATION NAME] was scheduled at 6:00 A.M. and the resident's sliding scale insulin was scheduled at 6:00 AM and both were ordered to be given with meals. The DON confirmed meals were provided to the northeast hall about 8:00 AM. 2. Review of the clinical record for Resident #84 revealed a physician's orders [REDACTED]. The order identified if blood sugar was above 400 call the physician. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. the resident's blood sugar was 491. The nurse documented 10 units of [MEDICATION NAME]was given. The order was to give 10 units if blood sugar was 351-400. There was no documented evidence the physician was notified of the blood sugar of 491 for further instructions on the amount of insulin to give. Review of the MAR for November 2011 revealed Resident #84 had a blood sugar of 427 on 11/27/11 at 11:00 A.M. Review of the MAR indicated [REDACTED]. The order for sliding scale insulin was for blood sugar 351-400 to give 10 units of [MEDICATION NAME] insulin, above 400 to call physician. There was no documented evidence the physician was called and the nurse gave [MEDICATION NAME]10 units which was ordered to be given for blood sugar of 351-400. Interview on 12/01/11 at 8:55 A.M. with LPN #10 confirmed there was no evidence the physician was notified of blood sugars above 400 and confirmed the nurse did give 10 units of insulin on both occasions without calling the physician for further instructions.