Every finding on record at Pleasant Ridge Healthcare Center

Based on interview, observation, record review, and policy review, the facility failed to report concerns of injuries of unknown origin to the state agency in a timely manner. This affected one (Resident #12) of seven residents sampled for abuse. The facility census was 75. Findings include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, atherosclerotic heart disease, legal blindness, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/04/25, revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #12 was dependent on staff for all ADL care. Review of progress note dated 05/29/25 at 10:45 AM revealed Resident #12 had a swollen right knee that was warm and painful to touch. Nursing staff notified the provider and received orders for a STAT X-ray of the right knee, Tylenol 1000 milligrams (mg) by mouth now, and topical Voltaren 1 percent gel as needed for pain. The nurse administered Tylenol 1000 mg for pain. Review of the Radiology Results Report dated 05/29/25 at 11:44 AM revealed Resident #12 had a three-view X-ray performed on the right knee on 05/29/25 at 11:12 AM. Results showed acute nondisplaced oblique fractures proximal tib-fib, joint effusion, moderate tricompartmental osteoarthritic change, decreased, mineralization, and scattered vascular calcifications. Review of progress note dated 05/31/25 at 3:57 P.M. revealed Resident #12 had an X-ray result showing right knee fracture and had a new order to send to the hospital. Review of facility investigation dated 05/31/25 revealed the facility interviewed staff involved with Resident #12 patient care on 0/5/29/25. Nursing assistants stated they noticed Resident #12 grimaced and moaned as if in pain during incontinence care but denied any indications that injury had occurred during care. The aides notified the nurse who assessed the patient and noted her right knee was swollen and warm to the touch. The nurse notified the on-call provider and set up a tele-health visit via video. The provider noted swelling and possible displacement of the right knee and ordered imaging. The imaging was completed within the hour; however, the results were not reported to the provider until 05/31/25 when the ADON accessed the results through the electronic record. During an interview on 07/14/25 at 1:56 P.M. Regional Clinical Director #99 stated the immediately began an investigation due to the extent of Resident #12's injuries, but it was decided not to file a self reported incident for injury of unknown origin because the provider deemed the injury to be idiopathic. Review of policy titled Ohio Abuse, Neglect, and Misappropriation dated 10/04/24 revealed an injury was classified as an injury of unknown origin when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury. Accurate and timely reporting of incidents, both alleged and substantiated, were sent to officials in accordance with the state law. This is an incidental deficiency discovered during the course of this complaint investigation.

Based on observation, record review, resident interview, staff interview and facility policy review, the facility failed to ensure a resident was provided with a comfortable environment when the air conditioning unit was not maintained in working order. This affected one (#65) of four residents reviewed for environment. The facility census was 82. Findings included: Review of the admission record for Resident #65 with admission date of 02/20/25 and diagnoses including [NAME] fascial fibromatosis and paroxysmal atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/22/25, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Interview on 05/26/25 at 11:07 A.M., with Resident #65 stated the air conditioning (AC) unit in their room did not work correctly. Resident #65 stated the room would get hot on warm days. Resident #65 stated they had informed staff, and the Director of Maintenance (DOM) had come to their room and agreed the unit was blowing warm air. Observation on 05/29/25 at 11:10 A.M., of the AC unit in Resident #65's room, revealed the AC unit did not blow cool air. The AC unit was turned on to the lowest setting. After it ran for a few seconds, the AC unit was turned to level 8 and the AC unit still did not blow cool air. Interview on 05/29/25 at 11:11 A.M., with Resident #65 stated the DOM had informed them the day prior that the AC unit would be replaced. Observation on 05/29/25 at 2:16 P.M., with the DOM tested the AC unit in Resident #65's room and confirmed the unit was not blowing cold air and that the unit needed to be replaced. The DOM stated he did not recall speaking with Resident #65 about the AC unit; however, he may have forgotten and did not come back and look at the unit. At 2:18 P.M., Resident #65 entered the room and stated they had spoken with the DOM about the AC unit a couple of weeks prior. Interview on 05/30/25 at 2:07 P.M., with the Director of Nursing (DON) stated the expectation was when equipment was broken, a work order would be initiated, and the equipment should be fixed or replaced immediately, depending on the type of equipment. The DON said they were unaware of any complaints of non-working AC units in the hall where Resident #65 resided. Interview on 05/29/25 at 3:36 P.M., with the Executive Director (ED) stated the temperatures in the facility were a high priority. The ED stated when there were complaints of AC units were not working; the facility ensured the residents were comfortable and offered a fan or room change until the AC unit could be repaired or replaced. Review of the undated policy titled, Resident Rights, indicated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. This deficiency represents noncompliance investigated under Complaint Number OH00164412.

Based on record review, staff interview, and policy review, the facility failed to identify a potential elopement and take action for finding a resident, when a resident's empty wheelchair was found on the facility curb in the rain. This affected one (#34) of one resident reviewed for potential elopement. The facility census was 82. Findings included: Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses including peripheral vascular disease, manic depression, and psychotic disorder. Review of the discharge Minimum Data Set (MDS) assessment, dated 09/09/24, revealed Resident #34 had independent cognitive skills for daily decision-making and had no short-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident utilized a manual wheelchair for mobility and independently mobilized the wheelchair 150 feet in a corridor or similar space. Review of the quarterly MDS, dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident utilized a wheelchair for mobility and required staff assistance to mobilize the wheelchair 150 feet in a corridor or similar space. Review of Resident #34's Care Plan Report included a focus area, revised on 12/12/24, that indicated the resident was known to leave the building without signing out despite provided education. Interventions directed staff to encourage the resident to maintain as much independence and control/decision making as possible and praise any indication of progress with behaviors. Review of nursing Progress Note, dated 09/30/24 at 7:05 PM, revealed Resident #34 left the facility without notifying staff or signing out at approximately 2:45 P.M. that day. Per the note, the resident's (empty) wheelchair was discovered on a facility curb while it was raining outside. The note indicated staff brought the wheelchair inside the facility and notified the Executive Director (ED) and Resident #34's guardian. Per the note, the resident returned to the facility that day at 6:25 P.M. as a passenger in another resident's vehicle. The note revealed staff notified the driving resident of the dangers of having other residents in the vehicle with them. The note indicated staff assisted Resident #34 out of the vehicle and into the facility. Per the note, Resident #34 refused an assessment of their vital signs and expressed a desire to leave the facility again to see a family member. Review of physician Progress Note, dated 09/30/24 at 7:00 P.M., revealed a physician was notified that Resident #34 left the facility without signing out or notifying anyone and returned with no apparent injuries. The Progress Note further indicated the facility ED was aware. Interview on 05/28/25 at 1:02 P.M., with Certified Nurse Aide (CNA) #10 stated they had not previously known Resident #34 to leave the facility without notification. CNA #10 stated if a resident was not in their room, they would notify the nurse and then begin looking for the resident in the facility. CNA #10 stated residents were to sign out when they left the building. Interview on 05/28/25 at 1:15 P.M., with Licensed Practical Nurse (LPN) #11 stated if they identified a resident who was missing, they would search the building grounds and call the ED and the Director of Nursing. LPN #11 stated they would also check to see if the resident had signed out. Interview on 05/28/25 at 3:42 P.M., with the ED stated she remembered calling Resident #34's guardian after the incident wherein the resident did not notify staff they were leaving the facility. The ED stated they reminded Resident #34 to sign out before and after the incident in question. The ED stated that, on the day of the incident in question, it was raining outside, and staff identified a wheelchair belonging to Resident #34 was on the curb of the property. The ED stated Resident #34 was unable to walk. The ED stated she expected a resident to sign out if leaving the facility and, if a resident was unaccounted for, she expected the elopement process to be initiated. Interview on 05/30/25 at 12:29 P.M., with the ED stated she expected residents to sign out if they were leaving the property and for the facility to have no elopements. Review of the undated policy titled Elopement Prevention and Management Overview, indicated, Elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. This deficiency represents non-compliance investigated under Complaint Number OH00164628.

Based on observation, resident interview, staff interview, record review, and policy review, the facility failed to ensure there was ongoing communication and collaboration with the dialysis center regarding dialysis care and service. This affected one (#37) of one sampled resident reviewed for dialysis. The facility census was 82. Findings included: Review of the admission record revealed Resident #37 was admitted on [DATE], with diagnosis including end stage renal disease (ESRD). Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/23/25, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Review of Resident #37's Care Plan Report, included a focus area revised 04/28/25, that indicated the resident received dialysis therapy related to ESRD by way of a port/catheter in their right upper chest wall. Interventions directed staff to communicate with the dialysis center regarding medications, vital signs, weights, any restrictions, diet orders, nutritional/fluid needs, laboratory results, and who to notify with concerns; coordinate resident's care in collaboration with dialysis center (initiated 04/01/25); evaluate resident following dialysis treatment and report abnormal findings to medical provider, nephrologist/dialysis center, and resident/resident representative (initiated 04/01/25). Interview on 05/28/25 at 9:34 A.M., with Registered Nurse (RN) #5 stated they only sent a resident's face sheet to dialysis with a resident. Per RN #5, the dialysis center called when a resident was sent to the emergency department or if they had any problems. Observation on 05/28/25 at 2:27 P.M., revealed Resident #37 returned from dialysis with no papers or forms. Observation on 05/28/25 at 2:29 P.M., revealed RN #4 provided Resident #37's medication and obtained their blood pressure. No papers or forms were provided by the resident to the staff from dialysis. Interview on 05/28/25 at 2:49 P.M., with Resident #37 stated they had not taken or returned with information, written or verbal, for communication between the facility and the dialysis center. Interview on 05/29/25 at 11:29 A.M., with the Director of Nursing (DON) stated the facility will call the dialysis center for any concerns. The DON denied having any type of formal communication with the dialysis center regarding pre and post dialysis treatment. The DON said she expected nursing staff to assess the fistula site or central venous catheter (CVC) site upon the resident's return and complete the pre- and post-dialysis assessments in the electronic medical record (EMR). Interview on 05/29/25 at 11:39 A.M., with the Executive Director stated they relied on clinical staff regarding dialysis care and services but expected that the policy be followed. Review of the undated policy titled, Hemodialysis Care and Monitoring, revealed the section titled, XI. Shared Communication, included, b. The care of the residents receiving dialysis services will include ongoing communication, coordination and collaboration between the dialysis center and the facility that may include but is not limited to i. Telephonic communication ii. Providing pre and post documentation of resident assessment to evaluate the resident response to dialysis and update care plan in collaboration with dialysis recommendations. The policy revealed, c. The facility will provide a copy of the current MAR [medication administration record], and the pre-evaluation for dialysis from the electronic medical record to the dialysis center.

Based on record review, staff interviews, and policy review, the facility failed to ensure residents were free from delay of care and treatments as ordered by physicians. This affected one (#69) resident of three reviewed for quality of care. The facility census was 77. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE]. Diagnoses included sepsis with methicillin resistant staphylococcus aureus (MRSA), chronic obstructive pulmonary disease (COPD), and hepatitis C, and Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Section O (special treatments, procedures, and programs) revealed Resident #69 had intravenous (IV) medications. Review of the Continuity of Care (COC) (hospital discharge paperwork) dated 07/22/24 revealed Resident #69 was to continue Daptomycin (antibiotic) 500 milligrams (mg) IV via peripheral inserted central catheter (PICC) every 24 hours through 08/29/24, Teflaro (Antibiotic) 600 mg IV every eight hours through 08/29/24, get weekly laboratory (labs) tests on Mondays for basal metabolic panel (BMP), complete blood count (CBC) with differential, and liver function tests (LFTs) and fax all laboratory (lab) results to the Infectious Disease (ID) specialist's office. The resident was to follow up with the ID specialist in three to four weeks and the facility was to call the ID specialist's office with any questions or concerns. Review of a physician order dated 07/22/24 revealed Resident #69 was ordered Teflaro Solution Reconstituted 600 mg IV every eight hours for seven days. Review of the physician order dated 07/23/24 revealed Resident #69 was ordered Daptomycin solution reconstituted 500 mg IV one time a day for seven days. Review of a nurse practitioner (NP) note dated 07/27/24 revealed Resident #69 was admitted to the facility with MRSA bacteremia and would order labs. Medications were reviewed, the resident had a PICC line in his right bicep and was to continue IV antibiotics as directed and follow up with ID specialist as directed. Review of the medication administration record (MAR) dated July 2024 revealed Resident #69 missed six out of the 22 physician ordered doses of Teflaro and five out of seven physician ordered doses of Daptomycin. Review of the medical record from July and August 2024 for Resident #69 with the Director of Nursing (DON) revealed no physician order to discontinue the PICC line and no documentation of when the resident's PICC line was removed and by whom. Interview with the DON on 10/03/24 at 12:45 P.M., verified the resident's PICC line was removed without a physician order and the resident missed the doses of his antibiotics. Review of a progress note from the ID specialist's office dated 08/28/24 revealed Resident #69 arrived at the appointment with no PICC line in place, and the resident was unsure when it was removed or if he had been receiving IV antibiotics. The Orders were placed for Daptomycin and Teflaro to be continued through 08/29/24. The office had not received any out-patient monitoring of labs from his nursing facility. The nursing facility was contacted and learned that Resident #69 had not received any IV antibiotics since 08/01/24 when he had an emergency room (ER) visit for a fall. The ID specialist's office was not contacted, and it was unclear why the PICC line was removed. New orders for STAT (right now or immediately) blood cultures needed drawn, PICC line placement, restart Daptomycin 500 mg IV via PICC daily for six weeks, Teflaro 600 mg every eight hours for six weeks, monitor weekly labs (BMP, CBC with diff, and LFTs) and send to the ID specialist's office, an abdominal ultrasound (US) with elastography, and follow-up in three weeks. Review of the progress note from the ID specialist's office dated 08/30/24 at 9:46 A.M. revealed an outreach was made to the facility's DON regarding the plan of care for Resident #69 with no answer. Review of the progress note from the ID specialist's office dated 08/30/24 at 2:15 P.M. revealed an outreach was made to the facility and spoke with the DON. Verbal orders were given to the DON for STAT blood cultures, PICC placement, Daptomycin 500 mg IV via PICC daily for six weeks, and Teflaro 600 mg every eight hours for six weeks. The DON verbalized understanding. Review of the progress note from the ID specialist's office dated 08/30/24 at 4:38 P.M. revealed an outreach was made to the facility, which revealed the physician's orders had not been placed for Resident #69. Review of the progress note from the ID specialist's office dated 09/05/24 at 4:47 P.M. revealed no blood cultures had been received with several outreach attempts to the facility with no answer. Review of the progress note from the ID specialist's office dated 09/06/24 at 4:00 P.M. revealed an outreach was made to the facility, which revealed blood cultures were not collected for Resident #69. Review of the progress note from ID specialist's office dated 09/09/24 at 2:39 P.M. revealed an outreach was made to the DON and she indicated blood cultures were collected but the results were not in yet. DON indicated the IV antibiotics had not been started yet related to not having the blood culture results. Review of the progress note from ID specialist's office dated 09/09/24 at 3:55 P.M. revealed an outreach was made to the DON. Verbal orders were given for PICC placement and to start dual IV antibiotics (Daptomycin and Teflaro). The DON verified and assured the specialist's office this would happen as soon as possible. Review of the progress note from ID specialist's office dated 09/10/24 at 4:53 P.M. revealed an outreach was made to the facility where they revealed Resident #69's PICC had just been placed and was awaiting an X-ray confirmation. Review of the MAR dated September 2024 revealed Resident #69 missed six doses of Teflaro and three doses of Daptomycin. Review of the MAR dated October 2024 revealed Resident #69 missed three additional doses of Daptomycin. Interview on 10/03/24 at 10:30 A.M. with Registered Nurse (RN) #35 from the ID specialist's office revealed Resident #69's antibiotics should have been continued through 08/29/24 and not have never been stopped in July. RN #35 revealed Resident #69 was seen in their office on 08/28/24, where they learned the resident had not continued his two IV antibiotics and his PICC line had been removed without a physician's order. RN #35 revealed communication between the nursing facility and their office had been a nightmare. RN #35 also stated the facility was not following orders per the physician in a timely manner. Interview on 10/03/24 at 11:29 A.M. with Regional Corporate Nurse (RCN) #36 verified there was a delay of care to Resident #69 related to orders received from his 08/28/24 ID specialist appointment because the orders were not initiated until 09/09/24. RCN #36 also verified it was the nursing staff's responsibility to follow up with outside providers within 24-48 hours if paperwork was not returned with the resident. Interview on 10/03/24 at 12:06 P.M. with the DON revealed Resident #69's IV antibiotics were not started in September because she was informed by the ID specialist's office that the blood cultures had to be drawn first. The DON reported there were issues with getting the STAT labs completed. Review of the facility policy titled, Physician Orders, dated 10/08/24 revealed the purpose of the policy was to provide orders as determined by the licensee's scope of practice. The provider may write the order in the medical record or may enter an electronic order. The nurse that received the physician order will be responsible for executing the order or providing for the safe hand-off to the next nurse. This deficiency represents non-compliance investigated under Complaint Number OH00157798.

Review of the medical record, staff interviews, observations, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (#69) of three residents reviewed for medication administration. The facility census was 77. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE]. Diagnoses included sepsis with methicillin resistant staphylococcus aureus (MRSA), chronic obstructive pulmonary disease (COPD), chronic hepatitis C, and emphysema. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of section O (special treatments, procedures, and programs) revealed Resident #69 had intravenous (IV) medications. Review of the physician order dated 07/22/24 revealed Resident #69 was ordered Teflaro (antibiotic) IV Solution Reconstituted 600 milligrams (mg), use 600 mg IV every eight hours for seven days. Review of the pharmacy delivery manifest dated 07/23/24 at 8:03 P.M. revealed Resident #69 had six doses of Teflaro delivered and four doses Daptomycin delivered. Review of the physician order dated 07/23/24 revealed Resident #69 was ordered Daptomycin IV solution reconstituted 500 mg, use 500 mg IV one time a day for seven days. Review of the pharmacy delivery manifest dated 07/24/24 at 6:59 P.M. revealed Resident #69 had six doses of Teflaro delivered. Review of the pharmacy delivery manifest dated 07/26/24 at 8:15 P.M. revealed Resident #69 had three doses of Daptomycin delivered. Review of the pharmacy delivery manifest dated 07/27/24 at 8:42 A.M. revealed Resident #69 had nine doses of Teflaro delivered. Review of the medication administration record (MAR) dated July 2024 revealed Resident #69 missed six out of 22 doses of Teflaro on 07/22/24, 07/23/24, and 07/24/24 morning and afternoon dose. Resident #69 missed five out of seven doses of Daptomycin on 07/23/24, 07/24/24, 07/25/24, 07/26/24, and 07/27/24. Review of the physician order dated 09/09/24 revealed Resident #69 was ordered Daptomycin IV solution reconstituted 500 mg, use 500 mg IV every 24 hours until 10/21/24. Review of the pharmacy delivery manifest dated 09/10/24 at 9:13 A.M. revealed Resident #69 had four doses of Daptomycin delivered Review of the pharmacy delivery manifest dated 09/14/24 at 9:08 A.M. revealed Resident #69 had three doses of Daptomycin delivered. Review of the pharmacy delivery manifest dated 09/16/24 at 8:29 P.M. revealed Resident #69 had two doses of Daptomycin delivered. Review of the pharmacy delivery manifest dated 09/19/24 at 9:20 A.M. revealed Resident #69 had three doses of Daptomycin delivered. Review of the MAR dated September 2024 revealed Resident #69 missed three doses of Daptomycin on 09/09/24, 09/10/24, and 09/30/24. Interview on 10/02/24 at 2:32 P.M. with Pharmacist #60 revealed the delivery of Resident #69's IV antibiotics for the month of July and September. Pharmacist #60 reported there was a mess up on their end regarding Daptomycin order, which caused the facility to not receive any more doses after 09/19/24. Pharmacist #60 reported the person who processed the refills on 09/19/24 accidentally put the end date as 09/21/24 instead of 10/21/24. Interview on 10/02/24 at 3:49 P.M. with Registered Nurse (RN) #30 verified Daptomycin was still an active order, but the facility did not have this medication available and had not outreached to the pharmacy to inquire where the medications were. Observation on 10/02/24 at 3:50 P.M. revealed the medication stock room had no IV Daptomycin available for Resident #69. Interview on 10/03/24 at 11:29 A.M. with Regional Corporate Nurse (RCN) #36 verified missed doses in July 2024 for IV antibiotics and verified missed doses in September. Review of the facility policy titled, Medication Administration, revealed the purpose of the policy was to provide guidelines for general medication administration to be provided by personnel recognized as legally able to administer. Staff administer medication only as prescribed by the provider. Licensed or authorized personnel may administer prescribed medication. This deficiency represents non-compliance investigated under Complaint Number OH00157798.

Based on medical record review, observation, resident interview, staff interviews, and review of the facility policy, the facility failed to ensure appropriate storage of residents' medications. This affected one (Resident #28) of 11 residents reviewed for environmental concerns. The facility census was 71 residents. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including fibromyalgia, personality disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #28 revealed the resident was mildly cognitively impaired. Observation on 04/23/24 at 10:55 A.M. revealed Resident #28 was alone in the room and there was a plastic medication cup with two pills on the residents over the bed table. Interview on 04/23/24 at 10:55 A.M. with Resident #28 confirmed the resident was unsure where the medications had come from, what they were, how long they had been there, or if they were his. Interviews on 04/23/24 at 11:00 A.M. with Licensed Practical Nurses (LPNs) #350 and LPN #570 confirmed there was a plastic cup of medication lying on the over the bed table in Resident #28's room which should not have been left unattended by staff. Review of the facility policy titled Medication Administration undated revealed medications were never to be left unattended. This deficiency represents noncompliance investigated under Complaint Number OH00152673.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure a resident's preference for showers were honored. This affected one (Resident #6) of one resident reviewed for preferences. The facility census was 76. Findings include: Medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and was dependent on staffing for bathing. Review of the bathing records for Resident #6 from 10/01/23 through 12/12/23 revealed Resident #6 received all bed baths. Resident #6 did not receive a shower during this time. Interview with Resident #6 on 12/11/23 at 11:05 A.M. revealed he has asked everyone to get a shower including State tested Nursing Aide (STNA) #145 a couple of days ago. STNA #145 told him the facility doesn't have the right equipment to give him showers. He stated he gets bed baths only. Interview with STNA #145 on 12/11/23 at 2:40 P.M. confirmed Resident #6 had asked her to give him a shower, but she gave him a bed bath instead. STNA #145 confirmed she didn't provide Resident #6 his preference of a shower for his bathing. Review of the facility's undated policy titled Resident Rights revealed to respect resident's choice and attend to needs in a timely fashion. This was an incidental finding during the complaint investigation.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure bathing and personal hygiene were provided to residents who dependent on staff for assistance with activities of daily living (ADL). This affected two (Residents #6 and #77) of three residents reviewed for ADL care. The facility census was 76. Findings include: 1. Medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. His functional status was impairment on upper and lower extremities. He was dependent on staff for bathing. Review of the bathing records for Resident #6 from 10/01/23 through 12/12/23 revealed out of 20 opportunities for bathing, he received 12 bed baths. Review of the care plan dated 12/01/23 revealed Resident #6 had an activities of daily living deficit and required assistance for bathing with up to two-person assistance. Interview and observation with Resident #6 on 12/11/23 at 11:05 A.M. revealed he received bed baths, but not on a regular basis. He said they don't wash under his bandage on his left hand, don't wash his feet, and staff hasn't trimmed or cleaned his nails. In between his fingers on both hands were dry, scaly, and dirty. His nails were long and had a dark substance under them. His toes were dry, scaly and dirty. Interview with Licensed Practical Nurse (LPN) #160 on 12/12/23 at 1:03 P.M. confirmed the nails, fingers and toes were dirty and needed some attention. LPN #160 stated the staff were supposed to be doing this during his bathing. 2. Closed medical record review for Resident #77 revealed an admission on 11/07/22. Diagnoses included obstructive uropathy, bipolar disorder, and Schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. His functional status was impairment on upper and lower extremities. Resident #77 was dependent on staff bathing. Review of the care plan dated 11/08/23 revealed Resident #77 was dependent for bathing. Review of the bathing records for Resident #77 revealed from 11/08/23 through 11/22/23, the resident received four bed baths. Resident #77 missed three baths on on 11/10/23, 11/17/23, and 11/20/23. The documentation was marked non-applicable (NA) on 11/10/23, 11/17/23, and 11/20/23. Interview with the Regional Director of Clinical Services (RDCS) #200 on 12/12/23 at 2:00 P.M. revealed she tried to call some of the staff who either didn't documented the bathing or placed a NA for non-applicable in the box for Resident #6 and #77, but was unsuccessful in reaching the staff. RDCS #200 verified if it wasn't documented, it wasn't completed for the bathing. Review of the facility's undated policy titled Routine Resident Care revealed their policy was to provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse bathing. Review of the facility's undated policy titled Nail and Hair Hygiene Services revealed it is the policy of this facility to promote resident centered care by attending to the physical emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility. This facility will provide routine care for the resident for hygienic purposes and for the routine care also includes nail hygiene services including routine trimming, cleaning and filing. Routine nail hygiene may be performed in conjunction with bathing or performed separately. This deficiency represents non-compliance investigated under Complaint Number OH00148560.

Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to follow the physician's orders for treatment of a resident's pressure ulcers. This affected one (#6) of three residents reviewed for pressure ulcers. The facility identified there were three residents with pressure ulcers residing in the facility. The facility census was 76. Findings include: Medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was dependent on staff for bed mobility and transfers. Resident #6 had four stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), and three of them were present upon admission. Resident #6 also had one stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle.) that was present upon admission and one unstageable pressure ulcer (Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) that wasn't present upon admission. Review of the care plan dated 12/01/23 revealed Resident #6 has impaired skin integrity with five pressure wounds and three skin tears due to incontinence, poor mobility, with diagnoses of quadriplegia and poor nutritional intake. Interventions included to encourage and assist the resident to turn and reposition every two hours and to provide appropriate off-loading cushion. Review of the physician orders for Resident #6 dated 12/02/23 revealed an order to turn and reposition Resident #6 every two hours as tolerated. There was also a physician order to place moon boots on Resident #6 when in and out of bed as tolerated. Interview and observation with Resident #6 on 12/11/23 at 11:05 A.M. revealed the staff don't turn him like they were supposed to, and they don't place his moon boots on him either. He stated his moon boots had not been on him since he came back from the hospital. Resident #6 was observed in bed without his moon boots on. The boots were observed up on the top shelf of the closet. Observations on 12/11/23 from 11:10 A.M. to 1:30 P.M. revealed there was staff who went into Resident #6's room, but there was no staff who turned and repositioned Resident #6 and staff did not place his moon boots on Resident #6's feet. Interview with State tested Nursing Aide (STNA) #145 on 12/11/23 at 1:36 P.M. revealed she came into work at 7:00 A.M. and didn't have time to turn Resident #6. STNA #145 stated she didn't know Resident #6 was supposed to be turned every two hours and verified Resident #6 was dependent on staff for turning and repositioning. Observation and interview with Resident #6 on 12/12/23 at 1:02 P.M. revealed the resident didn't have his moon boots on. Licensed Practical Nurse (LPN) #160 on 12/12/23 at 1:03 P.M. confirmed Resident #6 didn't have his moon boots on. Observation of dressing changes to Resident #6's pressure ulcers on 12/12/23 at 1:08 P.M. with Licensed Practical Nurse (LPN) #160 revealed she double gloved her hands, sprayed wound cleanser on the bandages of the one area of the left buttock and lower back region and removed the bandages and didn't clean with a clean gauze. LPN #160 removed her gloves and placed a set of new gloves on her hands and continued to place moistened Dakin's gauze to the left buttock and upper back region. LPN #160 changed her gloves and applied abdominal pad over the wounds. LPN #160 continued with the left hip ulcer and removed the bandage and sprayed wound cleanser on the wound and didn't clean the wound. LPN #160 applied Dakin's moistened gauze to this wound and removed her gloves and went to the bathroom to wash her hands. Interview with the LPN #160 on 12/12/23 at 2:24 P.M. stated she was told she could wash her hands at the beginning of a dressing change and at the end of it. LPN #160 verified she didn't wash her hands after hands were contaminated. LPN #160 verified she did not follow the physician orders to clean the wounds with normal saline. LPN #160 verified she should not have double gloved her hands. Interview with the Director of Nursing (DON) on 12/12/23 at 2:33 P.M. revealed the expectation of the nurse would be to cleanse the wound with the normal saline per physician order and to wash her hands from dirty to clean no matter how many times it would take. The DON verified the nurse should have not double gloved her hands. Review of the facility's undated policy titled Skin Care and Wound Management revealed to communicate risk factors and interventions to the care giving team. Review of the facility's policy titled Standard Precautions, dated 04/01/17, revealed practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Proper cleaning of hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming resistant to antibiotics. This facility will adhere to Centers for Diseace Control and Prevention (CDC) guidelines and recommendations for hand hygiene unless otherwise explicitly stated. When hands are not visibly soiled, alcohol-based hand sanitizers are the preferred method for cleaning hands in this healthcare setting. Use soap and water method for cleaning hands when hands are visibly dirty or soiled or known or suspected exposure to Clostridium difficile (C.difl) or norovirus, if the facility is experiencing an outbreak, before eating and after using a restroom (CDC, 2016). For all other times, alcohol based hand sanitizers are recommended by the Centers for Disease Control and Prevention in the healthcare setting. When hands move from a contaminated body site to a clean body site during patient care including dressing changes. This deficiency represents non-compliance investigated under Complaint Number OH00148905.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure catheter care and incontinence care was provided correctly to a resident. This affected one (#6) of three residents reviewed for catheter care and one (#6) of one resident reviewed for incontinence care. The facility identified there were four residents who required catheter care. The facility census was 76. Findings include: Medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was dependent on staff for toileting and had an indwelling catheter. Observation on 12/13/23 at 10:04 A.M. revealed State tested Nursing Aide (STNA) #79 was providing incontinence care to Resident #6. STNA #79 took a wet washcloth and wiped from under the scrotum up across the top of the scrotum. As STNA #79 was wiping upwards, there was stool on the washcloth. STNA #79 continued to fold the washcloth and wipe upwards and continued to find stool on the cloth. STNA #79 didn't wash the penis or the scrotum. She didn't rinse or dry the area. Further observation of catheter care revealed STNA #79 removed a bloody four by four bandage from around of the insertion site of the suprapubic catheter. STNA #79 didn't wipe the tubing from the insertion site pulling upward and she didn't clean around the insertion site. Interview with STNA #79 on 12/13/23 at 10:20 A.M. confirmed she didn't perform the incontinence care properly and it wasn't her practice to perform the care in this manner. STNA #79 stated she didn't know how to clean the supra/pubic catheter because it wasn't done for the residents. Review of the facility's undated policy titled Catheter Care revealed catheter care is to be performed at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place. The policy revealed to don gloves, expose the area only, observing for dignity and warmth. Obtain clean, wet washcloth with warm soap and water, securely grasp the catheter tubing nearest the opening to prevent movement or accidental dislodgement. Clean around catheter just above entrance and wipe in an upward motion to clean the tubing. This deficiency represents non-compliance investigated under Complaint Number OH00148560.

Based on observation, medical record review, staff and resident interview, the facility failed to ensure a resident's pain was managed. This affected one (#26) of one resident reviewed for pain. The facility census was 76. Findings include: Medical record review for Resident #26 revealed an admitted [DATE]. Diagnoses included cerebrovascular attack with paralysis, diabetes mellitus, and arthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician's order dated 12/22/22 revealed Buralbital-APAP-Caffeine (also known as Fioricet) oral tablet 50-325-40 milligram (mg) to give one tablet every six hours as needed for migraine headache. Review of the care plan dated 05/03/23 revealed Resident #26 has complaints of acute and chronic pain. Interventions were to observe for pain every shift, provided medication per orders, and monitor for side effects. Review of the progress notes dated 12/03/23 through 12/11/23, revealed the Fioricet had not been administered to Resident #26 and there wasn't any evidence the Fioricet was reordered either. Review of a note written on 12/12/23 at 8:22 A.M. revealed Resident #26 complained about a headache and was given 650 mg of Tylenol. A follow up note written on 12/12/23 at 9:43 A.M. revealed Resident #26 rated his pain level score at a ten, 10/10 (zero was no pain and 10 was the most severe pain) and Tylenol was ineffective. At 11:30 A.M., the physician discontinued the Fioricet and ordered Excedrin 250-250-65 mg to take two tablets every 24-hours for migraine headache. This was administered to the resident at 1:03 P.M. and at 2:29 P.M., Resident #26 said he felt like the Excedrin was working and rated his pain at a eight out of a ten. At 5:27 P.M., the physician reordered the Fioricet 50-325-40 mg to administer one tablet every six hours as needed for migraine headache to start on 12/13/23. Observation on 12/12/23 at 8:00 A.M. revealed Resident #26 was asking for his Fioricet for his migraine headache. The nurse said she put in the order on 12/11/23 for the medication and she would check to see if it was in the facility yet. She administered a 500 milligram (mg) Tylenol for his headache. Interview with Resident #26 on 12/11/23 at 8:23 A.M. revealed he has asked for his migraine medication for one to two weeks now and the facility hasn't received it yet. Resident #26 stated he has a headache when he wakes up in the morning and when he goes to bed in the evening. He rated his pain at a seven out of a 10 pain scale. Interview with Licensed Practical Nurse (LPN) #152 on 12/12/23 at 8:25 A.M. revealed she sent in a script on 12/11/23, but had not received the medication from the pharmacy yet and hopefully the medication would come in on the next delivery today. She confirmed there wasn't any evidence she re-ordered the medication on 12/11/23. This deficiency represents non-compliance investigated under Complaint Number OH00148560.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure drinks were available on the meal trays for the residents. This affected two (#6 and #15) of two residents reviewed for meals. The facility census was 76. Findings include: 1. Medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and he was dependent on staff for eating. Interview with Resident #6 on 12/11/23 at 11:05 A.M. revealed the kitchen runs out of juices and coffee at the end of his hall due to it being the last hall in the facility to get served for meals. Observation of the lunch meal service on 12/11/23 at 1:15 P.M. revealed Resident #6's hall was the last to be served. The lunch was delivered to the resident's room at 1:25 P.M. and there wasn't coffee or juice on Resident #6's meal tray. Interview with State tested Nursing Aide (STNA) #145 on 12/11/23 at 1:36 P.M. confirmed there wasn't anymore coffee or juice to give to Resident #6 so she gave Resident #6 water. STNA #145 confirmed she didn't check with the kitchen to see if there was more coffee or juice available. 2. Medical record review for Resident #15 revealed an admitted [DATE]. Diagnoses included neurological condition. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was cognitively intact and he was able to feed himself. Interview with Resident #15 on 12/11/23 at 11:05 A.M. revealed his room was at the end of the hall and the last hall served for meals. He stated there were times when the staff run out of coffee and juice to serve to them. Observation of the lunch meal service on 12/11/23 at 1:25 P.M. revealed Resident #15's hall was the last to be served. The lunch was delivered to the resident's room at 1:25 P.M. and there wasn't coffee or juice on Resident #15's meal tray. Interview with STNA #145 on 12/11/23 at 1:36 P.M. confirmed there wasn't anymore coffee or juice to give to Resident #15 so she gave Resident #15 water. STNA #145 confirmed she didn't check with the kitchen to see if there was more coffee or juice available. This was an incidental finding during the course of the complaint investigation.

Based on observation and review of a test tray, staff and resident interview, and policy review, the facility failed to ensure the coffee was served hot and was at the proper temperature. This affected two (#6 and #15) of two residents reviewed for meals and had the potential to affect other residents who drink coffee. The facility census was 76. Findings include: Interviews with Resident #6 and #15 on 12/11/23 at 11:05 A.M. revealed the coffee was cold when it was served to them. Review of the last tray from the kitchen on 12/13/23 at 9:00 A.M. after all of the trays were delivered revealed the coffee temperature was 114 degree Fahrenheit (F) and it tasted lukewarm. Interview with Dietary Manager #74 on 12/13/23 at 9:10 A.M. confirmed the coffee was at 114 degrees F. Review of the facility policy titled Food Preparation, dated 09/01/17, revealed all foods will be held at appropriate temperatures, greater than 135 F for hot holding, and less than 41 F for cold food holding. This deficiency represents non-compliance investigated under Complaint Number OH00148560.

Based on record review, observation, resident interview, and staff interview, the facility failed to monitor and identify residents with weight loss and failed to ensure appropriate nutritional interventions were recommended and implemented to prevent severe weight loss. This resulted in Actual Harm when Resident #67, with a with a diagnosis of failure to thrive (FTT) and was at nutritional risk related to a body mass index (BMI) (A measure of body fat based on height and weight) of 19.5 was not weighed from 04/08/23 through 07/04/23. There was a lack of nutritional interventions and Resident #67's weight was not monitored while Resident #67 had decreased meal intakes from 04/08/23 to 07/04/23. Subsequently on 07/05/23, Resident #67's weight was obtained at 102.3 pounds which was a severe weight loss of 29.7 pounds or 22.5 percent (%). This affected one resident (#67) of four residents reviewed for nutrition. The facility census was 86. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including FTT, congestive heart failure (CHF), metabolic encephalopathy, osteomyelitis, chronic pulmonary edema, diabetes mellitus (DM), and atherosclerotic heart disease. Review of the weight record for Resident #67 dated 04/07/23, revealed the resident weighed 132 pounds. There was no documented evidence of any weights being recorded from 04/07/23 to 07/04/23. There were no notations of Resident #67 refusing to be weighed during this time. Review of a nutrition progress note for Resident #67 dated 04/27/23, revealed the resident's current body weight was 132 pounds and the resident's intakes had been low from 25 to 50 percent. There were no new diet recommendations. Review of the nutrition progress note for Resident #67 dated 05/26/23, revealed the resident's current body weight was 132 pounds based on the weight obtained on 04/07/23. There were no recommendations to prevent weight loss. Review of the care plan for Resident #67 updated 05/26/23, revealed the resident had the potential for altered nutrition status/nutrition related problems due to significant weight loss, chewing and swallowing issues including dysphagia and FTT. Interventions included the following: family providing additional food in room to assist resident in meeting calorie needs, identify resident food/ beverage preferences, monitor meal intake, notify medical provider and resident representative of unplanned significant weight changes, nutrition related medications per order, nutritional consult on admission, quarterly, and as needed, offer substitutions if provided meal is declined, provide meals per diet order, and obtain weight per facility order. There was no refusal of care plan related to weights. Review of the nutrition progress note for Resident #67 dated 06/22/23, revealed the resident's current body weight was 132 pounds based on the weight obtained on 04/07/23. There were no recommendations to prevent weight loss. Review of the weight record for Resident #67 dated 07/05/23, revealed the resident weighed 102.3 pounds which indicated a 29.7-pound weight loss (22.5 percent) since the last recorded weight on 04/07/23. Review of the nutrition progress notes for Resident #67 dated 07/07/23 authored by Registered Dietitian (RD) #525, revealed the resident's weight on 07/05/23 was 102.3 pounds and the resident's BMI was 15.1 (underweight.) RD #525 made a recommendation for Ensure plus supplement twice daily to prevent further weight loss. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #67 dated 07/12/23, revealed the resident was cognitively impaired and required supervision and set up help with eating. The resident was assessed as being 69 inches tall, 102 pounds and coded positive for unplanned weight loss. The resident was assessed as not rejecting any care. Observation of Resident #67 on 08/07/23 at 2:29 P.M., revealed the resident was very thin in appearance and was edentulous. Interview with Resident #67 on 08/07/23 at 2:29 P.M., revealed the resident confirmed he had lost weight recently. The resident confirmed he was not able to eat everything he wanted to eat due to being edentulous and he was awaiting new dentures. Interview with the Director of Nursing (DON) on 08/09/23 at 2:39 P.M., confirmed Resident #67 was edentulous and was awaiting dentures through the facility's dentist. The DON confirmed resident's weight was 132 pounds on 04/07/23. The DON further confirmed all residents should be weighed at least monthly unless there is an order to do otherwise. The DON confirmed the facility did not obtain a monthly weight for Resident #67 in May or June of 2023 and when he was weighed on 07/05/23 his weight was 102.3 pounds which showed a 29.7-pound weight loss. The DON confirmed the facility had no documentation regarding refusals of weight for Resident #67. The DON indicated the facility did not have a policy regarding weight loss or obtaining weights. The DON indicated the facility had no policy on weights or obtaining weights and /or weight loss. Review of email correspondences from the Regional Director of Clinical Operations (RDCO) #510 dated 08/15/23 at 9:40 A.M. and 08/16/23 at 7:02 A.M., indicated the facility did not have a weight loss policy. Interview with RD #525 on 08/10/23 at 11:10 A.M. confirmed the residents should be weighed upon admission, then weekly for four weeks, then monthly thereafter unless ordered more frequently. RD #525 confirmed Resident #67 was weighed on 04/07/23 at 132 pounds and was underweight. RD #525 confirmed the facility did not obtain weights for May and June 2023 and the previous RD based the resident's nutritional assessment on the weight obtained 04/07/23. RD #525 confirmed the facility did not implement interventions to prevent a severe weight loss of 22.5 percent for Resident #67 from 04/07/23 to 07/05/23. Review of the facilities undated timeline for Resident #67, revealed Resident #67 had a diagnosis of adult failure to thrive, CHF, convulsions, and Diabetes. A weight was recorded on 04/07/23 at 132.0 pounds. On 04/27/23, the Dietitian offered supplements and the resident refused. From 05/19/23 to 05/26/23, the resident was on an antibiotic and had decreased appetite. From 06/29/23 to 07/06/23, the resident was on an antibiotic and had a decreased appetite. On 07/05/23, the resident weighed 102.3 pounds and on 08/14/23, ensure for resident was increased to four times daily. The timeline revealed no documented evidence the resident refused to be weighed from 04/07/23 and 07/05/23.

Based on observation, staff interview, and policy review, the facility failed to ensure foods were stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all 86 residents in the facility. Findings include: Observation on 08/07/23 at 9:25 A.M. of the facility's walk-in cooler revealed two unlabeled metal pans covered in foil. Culinary Director (CD) #285 present at the time of the observation and identified one pan as pureed eggs and the other as pureed sausage. CD #285 verified neither pan was labeled or dated and stated all foods should be labeled and dated. Observation on 08/07/23 at 9:27 A.M. of the facility's walk-in freezer revealed the following: a. Two boxes of shakes stored directly on the floor. b. A bag of corn open and not sealed nor dated. c. A bag of hamburger patties open and not sealed nor dated. d. A bag of cheese omelets open and not sealed nor dated. e. A plastic pitcher of unidentifiable yellow frozen substance without a label nor date. Interview at the time of the observations, CD #285 verified the two boxes of shakes stored directly on the floor and affirmed no food should ever be stored directly on the floor, the open and unlabeled bags of corn, hamburger patties, and cheese omelets, and the plastic pitcher of an unidentifiable yellow frozen substance without a label or date. CD #285 stated all opened foods should be labeled and dated and further stated she was unsure what the yellow frozen substance was. Review of the facility policy titled, Food Storage: Cold Foods, dated 04/2018, revealed all food items will be stored six inches above the floor and all foods will be stored wrapped or in covered containers, labeled, and dated.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission. This affected eight residents (#41, #243, #26, #244, #27, #89, #61, and #140) of the eleven residents reviewed for baseline care plans. The facility census was 86. Findings include: 1) Review of the medical record of Resident #26 revealed an admitted [DATE]. Diagnoses included cerebral infarction, psychotic disorder with delusions, cocaine abuse, schizophrenia, and bipolar disorder. Review of the quarterly [NAME] Data Set (MDS) assessment 3.0 dated 06/07/23 revealed the resident had moderately impaired cognition. The resident exhibited one to three days of verbal behavioral symptoms directed towards others during the assessment period. The resident required limited assistance of one staff for bed mobility, extensive assistance of two for transfers, extensive assist of one for toileting, and supervision for eating. Review of the Admission Initial Evaluation dated 01/31/23 revealed the assessment was locked on 07/13/23. Further review of the assessment revealed the 48-hour baseline care plan was not completed until 07/13/23. 2) Review of the medical record of Resident #27 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, atrial fibrillation, essential hypertension, oropharyngeal dysphagia, and depression. Review of the quarterly MDS assessment 3.0 dated 07/05/23 revealed the resident had intact cognition. The resident was not assessed as having any behaviors during the assessment period. The resident was independent with bed mobility and required supervision for transfers, eating, and toileting. Review of the Admission Initial Evaluation dated 03/23/23 and locked on 07/11/23 revealed the 48-hour baseline care plan was not completed until 07/11/23. 3) Review of the medical record of Resident #61 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of prostate, essential hypertension, benign prostatic hyperplasia, depression, anxiety, dementia with behavioral disturbance, and syncope and collapse. Review of the quarterly MDS assessment 3.0 dated 07/14/23 revealed the resident had severely impaired cognition. The resident did not refuse care during the assessment period. The resident was independent after setup with personal hygiene. Review of the Admission Initial Evaluation dated 12/22/22 revealed the assessment was incomplete and the 48-hour baseline care plan was incomplete. 4. Review of the medical record of Resident #89 revealed an admitted [DATE]. The resident passed away in the facility on 05/10/23. Diagnoses included acute respiratory failure with hypoxia, chronic systolic heart failure, cardiomyopathy, acute ischemic heart disease, chronic obstructive pulmonary disease, myocardial infarction (heart attack), and obesity. Review of the quarterly MDS assessment 3.0 dated 04/15/23 revealed the resident had severely impaired cognition. The resident was independent with all activities of daily living. Review of the Admission Initial Evaluation dated 12/31/22 revealed the 48-hour baseline care plan was not completed. 44412 5) Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included [NAME]-Barre syndrome, atrial fibrillation, type two diabetes mellitus (DM II), depression, chronic kidney disease, and hypertension. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the admission initial evaluation dated 05/21/23 revealed the 48-hour baseline care plan was not completed until 06/27/23. 6) Review of the medical record for Resident #243 revealed an admitted [DATE]. Diagnoses included quadriplegia, major depressive disorder, pressure ulcer of sacral region, and neuromuscular dysfunction of the bladder. Review of the MDS assessment dated [DATE] revealed Resident #243 had intact cognition as evidenced by a BIMS score of 15. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing and eating, and one-person total dependence with toileting and bathing. Review of the medical record for Resident #243 revealed he did not have an initial admission evaluation completed including the 48-hour baseline care plan. 7) Review of the medical record for Resident #244 revealed an admitted [DATE]. Diagnoses included acute right ankle osteomyelitis, paraplegia, third degree burn on right foot, and stage four pressure ulcer of right buttock. Review of the Admission MDS assessment dated [DATE] revealed Resident #244 had intact cognition as evidenced by a BIMS score of 15. This resident was assessed to require supervision with transfers, dressing, eating, and toileting, and independent with bathing. Review of the medical record for Resident #244 revealed the 48-hour baseline care plan was not completed. Interview on 08/10/23 at 11:03 A.M. with Regional Director of Clinical Operations (RDCO) #510, verified Resident #26, #27, #41, #61, #89, #243, and #244's baseline care plans had not completed within 48 hours. 39703 8) Review of the medical record for Resident #140 revealed an admitted [DATE] with diagnoses including hemiplegia affecting left non-dominant side, traumatic subdural hemorrhage with loss of consciousness, cerebral infarction, viral hepatitis, malignant neoplasm of ovary, human immunodeficiency virus (HIV), and psychoactive substance abuse. Review of the MDS for Resident #140 dated 07/24/23 revealed resident was cognitively intact and required extensive assistance of one to two staff with ADLs. Review of the admission evaluation/baseline care plan for Resident #140 dated 07/11/23 revealed the baseline care plan section had not been completed and/or signed by resident/resident representative and staff. Interview on 08/09/23 at 2:38 P.M. with the Director of nursing (DON) confirmed the facility had not completed a baseline care plan for Resident #140. Review of the undated facility policy titled Care Plan Overview revealed the facility would provide a copy of the baseline care plan to the resident and their representative.

Based on record review, staff interview, and review of the facility policy, the facility failed to provide care conferences to residents/resident representatives to discuss the resident's care plan. This affected four residents (#24, #41, #44, and #67) of the 20 residents sampled. The facility census was 86. Findings include: 1) Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), atherosclerotic heart disease, atrial fibrillation, anxiety disorder, polyosteoarthritis, hyperlipidemia, and hypertension (HTN.) Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #24 dated 06/04/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the medical record for Resident #24 revealed it did not include documentation of care conferences for the resident from August 2022 to August 2023. Interview with Resident #24 on 08/07/23 at 11:29 A.M. confirmed the facility did not offer regular care conferences for her to offer input and discussion of her plan of care. Interview with Regional Director of Clinical Operations (RDCO) #510 on 08/09/23 at 2:00 P.M., confirmed the facility had not held care conferences for Resident #24 from August 2022 to August 2023. 2) Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including cerebral infarction (stoke), hemiplegia, and hemiparesis, right and left above the knee amputation, and atherosclerotic heart disease. Review of the MDS assessment 3.0 for Resident #44 dated 04/26/23 revealed the resident was cognitively intact and required supervision with ADLs. Review of the medical record for Resident #44 revealed it did not include documentation of care conferences for resident from November 2022 to August 2023. Interview of Resident #44 on 08/08/23 at 8:53 A.M., confirmed he had never been invited to a care conference since his admission to the facility and he knew the facility was supposed to have regular conferences so he could discuss his care concerns. Interview with RDCO #510 on 08/09/23 at 2:00 P.M., confirmed the facility had not held care conferences for Resident #44 from November 2022 to August 2023. 3) Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, osteomyelitis, chronic pulmonary edema, DM, atherosclerotic heart disease, congestive heart failure (CHF), and adult failure to thrive (FTT.) Review of the MDS assessment 3.0 for Resident #67 dated 07/12/23 revealed resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the medical record for Resident #67 revealed it did not include documentation of care conferences for resident from August 2022 to August 2023. Interview with Resident #67 on 08/07/23 at 2:30 P.M. confirmed he did not recall having a care conference since his admission to the facility. Interview with RDCO #510 on 08/09/23 at 2:00 P.M. confirmed the facility had not held care conferences for Resident #67 from August 2022 to August 2023. RDCO #510 further confirmed care conferences should be held upon admission, quarterly, with a significant change in resident status, and upon resident/resident representative request. 44412 4) Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included [NAME]-Barre syndrome, atrial fibrillation, DM, depression, chronic kidney disease, and hypertension. Review of the Quarterly MDS assessment 3.0 dated 07/17/23 revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the medical record for Resident #41 for care conferences revealed there was no documentation of care conferences provided by the facility. Interview with RDCO #510 on 08/09/23 at 2:02 P.M. confirmed there were no care conferences or documentation to confirm Resident #41 had a care conference completed since admission.

Based on review of personnel files, staff interview, and review of job descriptions, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 42 residents (#1, #3, #5, #7, #9, #11, #13, #15, #21, #22, #23, #26, #30, #31, #32, #34, #35, #39, #40, #41, #42, #44, #47, #50 #52, #61, #62, #64, #67, #68, #71, #72, #73, #75,#80, #84,#140, #240, #241, #243, #243, #244) who the facility identified as not participating in any facility led activities. The facility census was 86. Findings include: Review of personnel record for Interim AD #145, revealed the employee changed positions from that of Activity Assistant (AA) on 05/20/23 to the AD. Review of personnel record for AD #145 revealed employee did not meet the qualifications required of an AD. Interview on 08/09/23 at 9:35 A.M. of Interim AD #145 confirmed she was asked to fill in as Interim AD when the former AD left employment in May 2023. Interim AD #145 confirmed she did not meet the qualifications required of an AD. Interview on 08/10/23 at 1:43 P.M. with the Administrator confirmed the facility had not had a qualified AD since 05/22/23 Administrator confirmed AD #145 had worked as an AA and started as the facility AD on 05/23/23. Administrator confirmed AD #145 did not meet the qualifications to be an AD. Review of the job description titled Activities Director June 2019 revealed the AD would establish and activity program of a wide variety for the residents, enhancing the resident's wellness in harmony with the overall plan of care. The AD should have a bachelor's degree in therapeutic recreation or related field or completion of a 90-hour course for activity professionals and continuing education.

Based on record review, observation, resident interview, staff interview, review of the facility policy, and review of Social Worker (SW) job description, the facility failed to provide medically related social services including provision of written notification of Medicare non-coverage to residents, notification to the Ombudsman of resident transfers to the hospital, arrangement of care conferences, and arranging for the provision of dental services. This affected two residents (#48 and #65) of three residents reviewed for notice of Medicare non-coverage (NOMNC), two (Residents #48 and #88) of two residents reviewed for Ombudsman notification of resident transfers to the hospital, four (Residents #24, #41, #44, and #67) of four residents reviewed for care conference, and two (Residents #24 and #49) of four residents reviewed for dental services. The facility census was 86. Findings include: 1) Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including paraplegia and pyogenic arthritis. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #48 dated 07/11/23 revealed resident was cognitively intact and required extensive assistance with activities of daily living (ADLS.) Review of the form completed by the facility titled Skilled Nursing Facility (SNF) Beneficiary Notice Review revealed Resident #48 had Medicare Part A service episode starting on 06/13/23 and was discharged from Medicare Part A services on 07/25/23 with Medicare days remaining. Further review of the form revealed the facility did not provide Resident #48 with CMS Form 10055 nor with CMS Form 10123, NOMNC, due to the facility did not have a social worker. Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses including chronic kidney disease (CKD) depression, osteoarthritis, and hypothyroidism. Review of the MDS assessment for Resident #65 dated 06/30/23, revealed the resident was cognitively intact and required supervision with ADLs. Review of the form completed by the facility titled SNF Beneficiary Notice Review revealed Resident #48 had Medicare Part A service episode starting on 04/13/23 and was discharged from Medicare Part A services on 06/29/23 with Medicare days remaining. Further review of the form revealed the facility did not provide Resident #65 with CMS Form 10055 nor with CMS Form 10123, NOMNC, due to the facility not having a social worker. Interview on 08/09/23 at 9:08 A.M. with Resident #65 revealed resident was discharged from therapy and her Medicare part A services were stopped in June 2023 but she did not receive anything in writing. Resident #65 confirmed she believed she could have benefited from more therapy and wished she had been given the opportunity to appeal the decision. Interview on 08/10/23 at 1:43 P.M. with the Administrator, confirmed Residents #48 and #65 did not receive required notices regarding Medicare non-coverage due to the facility not having a social worker to perform the task. 2) Review of the medical record of Resident #48 revealed an admitted [DATE]. Diagnoses included paraplegia, moderate protein-calorie malnutrition, osteomyelitis of vertebra, sacral, and sacrococcygeal region, generalized anxiety disorder, schizophrenia, major depressive d/o, post-traumatic stress disorder, psychosis, and cachexia. Review of the 5-day MDS assessment 3.0 dated 07/11/23 revealed the resident had intact cognition. The resident did not exhibit behaviors during the assessment period. The resident required extensive assistance of one for bed mobility, transfers, and toileting and was independent with eating. Review of the medical record for Resident #48 revealed the resident discharged to the hospital on 06/23/23 and readmitted to the facility on [DATE]. There was no documentation to indicate the ombudsman was notified of the resident's discharge. Interview on 08/10/23 at 9:19 A.M., Regional Director of Clinical Operations (RDCO) #510 verified the ombudsman was not notified of Resident #48's transfer to the hospital and stated the notification was not completed because the facility did not have a social worker. Review of the medical record for Resident #88 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic viral hepatitis-C, Chronic Obstructive Pulmonary Disease (COPD), panic disorder, altered mental status, and opioid dependence. Review of the MDS assessment 3.0 for Resident #88 dated 06/22/23 revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require one-person limited assistance with transfers, independent with dressing, eating, toileting, and supervision with bathing. Review of the transfer form for Resident #88 dated 06/30/23, revealed the resident went out to the hospital per a change in condition. Review of the medical record for Resident #88 revealed there was no documentation for a notification of the Ombudsmen related to the hospitalization . Interview on 08/09/23 04:02 PM with RDCO #510 verified there was no documentation regarding notification of the Ombudsman related to Resident #88's hospitalization because the facility did not have a social worker. 3) Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), atherosclerotic heart disease, atrial fibrillation, anxiety disorder, polyosteoarthritis, hyperlipidemia, and hypertension (HTN.) Review of the Minimum Data Set (MDS) for Resident #24 dated 06/04/23 revealed resident was cognitively impaired and required extensive assistance of one staff with ADLs. Review of the medical record for Resident #24 revealed it did not include documentation of care conferences for resident from August 2022 to August 2023. Interview on 08/07/23 at 11:29 A.M. of Resident #24 confirmed the facility did not offer regular care conferences for her to offer input and discussion of her plan of care. Interview on 08/09/23 at 2:00 P.M. with Registered Nurse (RN) #510 confirmed the facility had not held care conferences for Resident #24 from August 2022 to August 2023. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, right and left above the knee amputation, and atherosclerotic heart disease. Review of the MDS for Resident #44 dated 04/26/23 revealed resident was cognitively intact and required supervision with ADLs. Review of the medical record for Resident #44 revealed it did not include documentation of care conferences for resident from November 2022 to August 2023. Interview on 08/08/23 at 8:53 A.M. with Resident #44 confirmed he had never been invited to a care conference since his admission to the facility and he knew the facility was supposed to have regular conferences so he could discuss his care concerns. Interview on 08/09/23 at 2:00 P.M. with RDCO #510 confirmed the facility had not held care conferences for Resident #44 from November 2022 to August 2023. Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, osteomyelitis, chronic pulmonary edema, DM, atherosclerotic heart disease, congestive heart failure, and adult failure to thrive. Review of the MDS for Resident #67 dated 07/12/23 revealed resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the medical record for Resident #67 revealed it did not include documentation of care conferences for resident from August 2022 to August 2023. Interview on 08/07/23 at 2:30 P.M. with Resident #67 confirmed he did not recall having a care conference since his admission to the facility. Interview on 08/09/23 at 2:00 P.M. with RDCO #510 confirmed the facility had not held care conferences for Resident #67 from August 2022 to August 2023. RDCO #510 further confirmed care conferences should be held upon admission, quarterly, with a significant change in resident status, and upon resident/resident representative request. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included [NAME]-Barre syndrome, atrial fibrillation, DM, depression, chronic kidney disease, and hypertension. Review of the MDS assessment 3.0 dated 07/17/23 revealed Resident #41 had intact cognition. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the medical record for Resident #41 for care conferences revealed there was no documentation of care conferences provided by the facility. Interview on 08/09/23 at 2:02 P.M. with RDCO #510 confirmed there were no care conferences or documentation to confirm Resident #41 had a care conference completed since admission. Interview on 08/10/23 at 1:43 P.M. with the Administrator confirmed the facility had not arranged care conferences as required (upon admission, quarterly, significant change, and resident/representative request) because they did not have a social worker. 4) Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, DM, atherosclerotic heart disease, atrial fibrillation, anxiety disorder, polyosteoarthritis, hyperlipidemia, and hypertension. Review of the MDS for Resident #24 dated 06/04/23 revealed resident was cognitively impaired and required extensive assistance of one staff with ADLs. Review of physician's orders for Resident #24 revealed an order dated 05/17/19 for resident to be seen by the dentist. Review of the care plan for Resident #24 updated 11/01/22, revealed the resident was at risk for oral/dental health problems and needed assistance and set up for oral care. The resident was edentulous and wanted full upper and lower dentures because she had trouble chewing. Interventions included the following: diet as ordered, consult with dietitian and change if chewing/swallowing problems are noted, monitor for any difficulties with chewing/swallowing, monitor for proper fit and placement of dentures, use denture adhesive as needed, monitor/document/report as needed any signs and symptoms of oral/dental problems needing attention, offer and encourage fluids, set up/assist with oral/dentures care as needed due to no natural teeth. Review of dentist visit note for Resident #24 dated 11/16/22, revealed the resident was examined and was noted to be edentulous and denied mouth pain. The note did not include documentation regarding any dentures. Review of the annual MDS for Resident #24 dated 03/04/23, revealed the resident was assessed as being edentulous. Further review of the MDS 06/04/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Observation of Resident #24 on 08/07/23 at 11:29 A.M., revealed the resident was edentulous. Interview with Resident #24 on 08/07/23 at 11:29 A.M. confirmed the resident did not have teeth and had never been offered dentures. Resident #24 confirmed she did not remember being seen by the facility dentist and she would like to have dentures. Interview on 08/09/23 at 2:00 P.M. with RDCO #510 confirmed Resident #24 was edentulous and wanted to receive dentures. RDCO #510 confirmed Resident #24 was last seen by the facility dentist on 11/16/22 and the dentist's note did not include documentation regarding dentures for resident. RDCO #510 confirmed she was unsure why dentist note did not include documentation regarding dentures. Interview on 08/10/23 at 10:55 A.M. of RDCO #510 confirmed she called the dentist and asked why the dentist note for Resident #24 dated 11/16/22 did not include documentation regarding dentures. RDCO #510 confirmed the dentist said the resident never requested dentures, so he did not offer them. RDCO #510 confirmed Resident #24 was cognitively impaired and the facility social worker was responsible for coordinating care with the dentist. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including cerebral infarction, viral hepatitis, chronic obstructive pulmonary disease, DM, hypertension, and depression. Review of the care plan for Resident #49 dated 05/26/22 revealed resident had oral/dental problems related to resident was edentulous. Interventions included the following: dental consult as needed, observe for signs and symptoms of infection: abscess, swelling, fever, pain, redness, observe for weight loss secondary to dental issues. Review of the MDS for Resident #49 dated 05/26/23 revealed the resident was cognitively intact and was independent with activities of daily living ADLs. Review of the medical record for Resident #49 revealed it did not include documentation of dental visits for resident. Interview on 08/10/23 at 2:00 P.M. with the Administrator confirmed Resident #49 was edentulous and was admitted without dentures. Administrator confirmed Resident #49 was not seen by the facility dentist or any dentist during his stay at the facility. Review of the facility policy titled Dental Services undated revealed the facility would assist the resident in obtaining routine dental services and obtaining services to meet the needs of each resident. Review of the job description titled Social Services Director dated June 2019 revealed the position of Social Service Director provides planning, assessing, coordinating and implementation of services to enhance each resident's social and psychosocial well-being and assure that care standards are met, and the highest degree of quality resident care is provided at all times. The position must function as both a team member, team leader, and supervisor to ensure that work is accomplished, and quality care is delivered, supporting team members, and leading the way in celebrating team successes. While focusing on delivering quality care, the position must also manage the resources within their control and assist others in managing resources.

Based on medical record review, review of a Self-Reported Incident (SRI), review of witness statements, review of employee corrective action forms, staff interviews, and review of the facility abuse policy, the facility failed to ensure Resident #58 was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical and/or psychosocial harm on 02/05/23 at approximately 3:30 P.M., when Resident #58, who was cognitively impaired and was exhibiting signs of agitation and aggression, was physically abused by facility staff. Licensed Practical Nurse (LPN) #200 and State tested Nursing Assistant (STNA) #400 were observed and video recorded to physically pull Resident #58 by his arms on the ground. Resident #58 attempted to kick at staff and LPN #200 kicked Resident #58 in the back. The incident was witnessed by Activity Aide #600 and LPN #800. Activity Aide #600 video recorded the incident; however, neither Activity Aide #600 nor LPN #800 immediately reported the incident. On 02/07/23, Activity Aide #600 sent the video to Dietary Aide #16 who then reported the incident to management staff. This affected one resident (#58) of three residents reviewed for abuse. The facility census was 73. On 02/23/23 at 3:34 P.M., the Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #140 were notified Immediate Jeopardy began on 02/05/23 at approximately 3:30 P.M. when LPN #200 and STNA #400 were observed and video recorded to physically pull Resident #58 by his arms on the ground, and LPN #200 kicked Resident #58 in the back. The Immediate Jeopardy was removed on 02/24/23 when the facility implemented the following corrective actions: On 02/07/23, the DON and Social Services Director #28 interviewed all residents in the facility on abuse. Any resident that could not be interviewed due to cognition, had a head-to-toe skin assessment completed. These interviews and skin assessments were completed on 02/07/23 without any reports or signs of abuse. On 02/07/23, all staff were interviewed on abuse by the DON and Executive Director (ED) #190 and no staff members were aware of any incidents of abuse that had not been reported or any additional incidents involving LPN #200 and STNA #400. On 02/07/23, RDCO #140 reviewed the care plans of all behavioral residents to ensure the care plans included the resident behaviors and interventions. All of the care plans were found to be appropriate. Starting on 02/07/23, all relevant agency staff who worked between 02/07/23 and 02/23/23 as well as all facility staff were educated by the DON and ED #190 regarding the Abuse, Neglect, and Misappropriation Policy which included the immediate notification of the DON and ED #190 of all forms of abuse, known or suspected. This was completed on 02/23/23. Starting on 02/07/23, all relevant agency staff who worked between 02/07/23 and 02/23/23 as well as all facility staff were educated by the DON and ED #190 regarding the prohibition of cell phone use in resident care units, photography, and videography in the facility. This was completed on 02/23/23. Starting on 02/07/23, all licensed nurses including agency nurses, STNA's, and the therapy department staff were educated by the DON and ED #190 on the use of gait belts for resident transfers. This was completed on 02/23/23. Starting on 02/07/23, all licensed nurses and STNA's as well as agency nurses who worked between 02/07/23 and 02/23/23 were educated by the DON and ED #190 on the Kardex (plan of care) to obtain information and interventions for residents. This was completed on 02/23/23. On 02/07/23 and 02/08/23, education sessions were completed on abuse, de-escalation, and immediate reporting for all facility and agency staff working on 02/07/23 and 02/08/23. These were presented by Director of Behavioral Programming (DBP) #160. Future sessions will be presented by DBP #160 on abuse, de-escalation, and immediate reporting in order to ensure all facility staff receive the education. Binders were created by ED #190 for all new agency staff which includes the Abuse, Neglect, and Misappropriation Policy, reporting requirements, the Use of Electronics policy, Kardex information and the Gait Belt policy. These binders were placed at each nurse's station with a sign-off sheet for all new agency staff when they begin their shift. The DON/Designee will conduct abuse interviews with three residents and three staff twice a week for four weeks, two residents and two staff twice weekly for four weeks, and one resident and one staff twice weekly for four weeks. All variances will be corrected upon discovery, and additional training/follow-up will be provided as deemed necessary. The DON/Designee will bring the results of the audits to the monthly Quality Assurance and Performance Improvement (QAPI) meeting. The results of the audit will be reported, reviewed, and trended for a minimum of six months, then randomly thereafter for further recommendations. Interviews on 02/22/23 from 12:35 P.M. to 12:55 P.M. with Receptionist #120, STNA #80, and STNA #108 revealed they had all recently had training on abuse and cell phone use. STNA #80 and STNA #108 had additional training on the Kardex and use of gait belts. Observations on 02/23/23 from 10:00 A.M. to 6:00 P.M. revealed no concerns related to abuse. Staff were observed providing care in a kind and appropriate manner. No residents were observed to be treated in an abusive or undignified manner. Although the Immediate Jeopardy was removed on 02/24/23, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #58 revealed Resident #58 was admitted to the facility on [DATE]. Resident #58's diagnoses included down syndrome, post-traumatic stress disorder, dementia, and major depressive disorder. Review of Resident #58's plan of care, initiated on 06/07/22 and revised on 02/08/23, revealed Resident #58 had behaviors related to diagnoses of down syndrome and dementia evidenced by putting himself down on the floor, being physically aggressive towards staff, asking staff and residents for money to purchase soda and snacks, attempting to take change from the activity room, and wandering in the rooms of others. Interventions included approach and speak in a calm manner, behavioral health consults as needed, communicate with resident and resident representative regarding behaviors and treatment, encourage support by family/resident representatives, encourage the resident to express feelings, encourage the resident to participate in activities of choice, encourage the resident to maintain as much independence and control as possible, honor Resident #58's preferred choices, intervene as necessary to protect the rights and safety of others, minimize the potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine underlying causes, and praise any indication of progress in behaviors. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/27/23, revealed Resident #58 had severely impaired cognition. Resident #58 was assessed to require limited assistance for personal hygiene, toilet use, and dressing as well as supervision for bed mobility, transfer, and eating. Review of the facility assessment titled Weekly Skin Check, dated 02/07/23, revealed Resident #58 was assessed for injuries. Resident #58 was noted to have discoloration on both of his lower extremities. The assessment indicated Resident #58 wore high tube socks at times and had experienced episodes of edema. Resident #58's socks were noted to have made an imprint due to swelling. The skin assessment revealed no other areas were identified on Resident #58. Review of Resident #58's progress note, dated 02/07/23, revealed staff were informed of an incident involving Resident #58 and two staff members that were being unkind to resident. The note indicated ED #190 and Nurse Practitioner (NP) #180 were notified. Review of Resident #58's progress note, dated 02/07/23, revealed Resident #58 was assessed by NP #180. The note indicated Resident #58 had been grabbed by the shoulders by two facility staff (later identified as LPN #200 and STNA #400) that brought him down to the ground where he landed on his buttocks. The note also revealed Resident #58 reported pain with palpation located on his shoulders as well as his hips, but Resident #58 had no signs of bruising or lacerations to his torso or buttocks. Resident #58 had appropriate range of motion in all extremities and denied any pain associated with movement. Further review of the progress note revealed that x-rays would be ordered for the bilateral shoulders and hips, lumbar spine, coccyx, and head due to Resident #58's reported pain. Review of the SRI, dated 02/07/23, revealed the allegation of abuse involving Resident #58 and facility staff was verified by evidence and was substantiated. The SRI indicated ED #190 and the DON were notified on 02/07/23 of an incident involving Resident #58 which had occurred on 02/05/23 around 3:30 P.M. after Resident #58 became agitated. Further review of the SRI revealed LPN #200 and STNA #400 pulled Resident #58 by his arms and continued to pull him as he resisted. Resident #58 began kicking at the staff, and then LPN #200 kicked Resident #58. Resident #58 was assessed once the facility was aware of the incident with no issues noted. Resident #58 had x-rays ordered with no injuries identified. LPN #200 and STNA #400 were suspended and then terminated along with Activity Aide #600 and LPN #800, who had witnessed the incident. Review of the witness statement from LPN #200 revealed it was obtained via phone on 02/07/23 by ED #190. The statement indicated LPN #200 denied staff had pulled Resident #58 across the floor and/or kicked Resident #58. Further review of the statement revealed when LPN #200 was informed by ED #190 there was video of the incident, LPN #200 became silent and did not provide any additional information. Review of the witness statement from STNA #400 revealed it was obtained via phone on 02/07/23 by ED #190. The statement indicated Resident #58 became agitated, so staff let him be. Further review of the statement revealed when STNA #400 was informed by ED #190 there was video of the incident, STNA #400 stated staff were trying to get Resident #58 off the floor, but no staff dragged or kicked Resident #58. STNA #400 expressed staff had pulled Resident #58 to a wheelchair. Review of the written witness statement from Activity Aide #600, dated 02/07/23, revealed on 02/05/23 around 3:30 P.M., Resident #58 became aggressive. Activity Aide #600 wrote two staff members (later identified as LPN #200 and STNA #400) pulled Resident #58 by his arms and he dropped to his knees. The statement then indicated the staff (LPN #200 and STNA #400) started pulling Resident #58 on the ground when he began to kick, and the nurse (LPN #200) kicked him back. Per the statement, Resident #58 was pulled down the hall and the staff (LPN #200 and STNA #400) started acting as though they were tasering Resident #58 with a phone. According to the statement, another nurse (LPN #800) arrived, and the staff (LPN #200, STNA #400, and LPN #800) attempted to get Resident #58 into a wheelchair, which he pushed himself out of, so the staff (LPN #200, STNA #400, and LPN #800) left him alone. Review of the witness statement from LPN #800 revealed it was obtained via phone on 02/07/23 by ED #190. The statement indicated Resident #58 was agitated about not being able to get a soda, so staff (later identified as LPN #200, STNA #400, and LPN #800) attempted to get Resident #58 off the floor and into a wheelchair. Further review of the statement revealed Resident #58 slid out of the wheelchair, which prompted staff to leave him alone at that time. Review of the written witness statement from Dietary Aide #16, dated 02/08/23, revealed Dietary Aide #16 received video of the incident on 02/07/23 and informed his direct supervisor, Dietary Manager #24. Review of Resident #58's progress note, dated 02/08/23, revealed therapy informed staff that Resident #58 had complained of pain in his lower legs and was noted to have bruises and cuts on both of his lower legs. The note indicated Resident #58 was reassessed and had mild circumferential bruising noted on mid pretibial legs with a small abrasion on the right leg that measured 0.1 centimeters (cm) by three cm, which was noted to be mostly healed. Further review of the note also revealed Resident #58 wore a wander guard bracelet on the right leg, which was believed to have possibly contributed to the abrasion. The note revealed x-rays of the bilateral pretibial and feet were ordered for Resident #58. Review of Resident #58's progress note, dated 02/09/23, revealed Resident #58's x-ray results were reviewed by Nurse Practitioner (NP) #180. The note indicated Resident #58's x-ray results revealed no acute fractures or dislocations. Review of the four Employee Corrective Action Forms, dated 02/13/23, revealed LPN #200, STNA #400, Activity Aide #600, and LPN #800, were all terminated because of the incident on 02/05/23 involving Resident #58. Interview on 02/22/23 at 12:14 P.M. via phone with LPN #200 revealed she was helping an aide remove Resident #58 from the vending machine area as Resident #58 was hitting the soda machine, hitting staff, and shaking tables. LPN #200 stated staff did not drag Resident #58 but were trying to get him off the floor. LPN #200 denied that any staff hit or kicked Resident #58. Interview on 02/22/23 at 1:11 P.M. with RDCO #140 revealed an investigation was conducted once ED #190 and the DON became aware of the incident on 02/07/23. RDCO #140 stated a dietary aide (later identified as Dietary Aide #16) received video of the incident and informed his supervisor (Dietary Manager #24), and the supervisor (Dietary Manager #24) informed the DON. RDCO #140 expressed Resident #58 was assessed from head-to-toe and received x-rays with no issues noted. RDCO #140 stated all residents were interviewed and residents that were unable to be interviewed received a head-to-toe assessment. RDCO #140 indicated staff were educated and the employees involved were terminated as well as reported to the board of nursing and the nurse aide registry. Interview on 02/22/23 at 1:30 P.M. with Dietary Aide #16 revealed he received the video of the incident from Activity Aide #600 and informed his supervisor (Dietary Manager #24). Interview on 02/22/23 at 1:32 P.M. with Dietary Manager #24 revealed Dietary Aide #16 informed her of the video, which she immediately shared with the DON. Interview on 02/22/23 at 1:39 P.M. with RDCO #140 revealed LPN #200 and STNA #400 were terminated due to abusive conduct towards Resident #58. RDCO #140 expressed Activity Aide #600 was terminated due to witnessing but not reporting abuse as well as violating Resident #58's privacy by recording the incident. RDCO #140 reported LPN #800 was terminated due to witnessing but not reporting abuse. Interview on 02/22/23 at 2:20 P.M. with the DON revealed she was informed of the incident on 02/07/23 by Dietary Manager #24, and immediately notified ED #190 and Human Resources #170 of the incident. Interview on 02/22/23 at 2:54 P.M. with ED #190 revealed the video recorded by Activity Aide #600 showed two staff pulling Resident #58 by his arms on the floor. ED #190 indicated Resident #58 was kicking at the staff and LPN #200 kicked him in the back. ED #190 stated LPN #200 and STNA #400 were the two staff that were seen dragging Resident #58. LPN #800 was present during the incident but was not in the video. Interview on 02/22/23 at 4:25 P.M. via phone with Activity Aide #600 revealed Resident #58 was throwing a fit due to not being able to get a diet coke from the vending machine. Activity Aide #600 stated Resident #58 began hitting and kicking LPN #200 and STNA #400. Activity Aide #600 indicated Resident #58 was pulled down the hall by his arms and the nurse (LPN #200) kicked Resident #58 in the lower back. Activity Aide #600 confirmed she recorded the incident and shared it with Dietary Aide #16. Review of the undated facility policy titled, Abuse, Neglect & Misappropriation, revealed the policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed it was the intent of the facility to prevent abuse and guide staff on how to manage allegations of abuse. This deficiency represents non-compliance investigated under Self-Reported Incident Complaint Number OH00140359 and Complaint Number OH00140237.