Every finding on record at Rae-Ann Westlake

Based on observation, staff and resident interview, and record review the facility failed to ensure Resident #152 received timely incontinence care. This affected one (Resident #152) of two residents reviewed for incontinence care. The facility census was 110. Findings include: Review of the medical record for Resident #152 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of anterior wall of bladder, COVID-19, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/04/24 revealed Resident #152 had a self-care performance deficit related to ambulatory dysfunction and cervical myelopathy with interventions that included provide physical assistance with toileting of two persons and use bell to call for assistance. Review of the progress note dated 01/30/24 at 10:46 A.M. revealed Resident #152 required assistance with ADLs and transfers. Observation on 02/06/24 at 10:00 A.M. revealed Resident #152's call light was activated. Observation and interview on 02/06/24 at 10:09 A.M. revealed Resident #152 was sitting in her room with the call light still activated. Resident #152 revealed she activated her call light because she needed to use the bed pan but had already urinated on herself. Resident #152 revealed she had been waiting 15 minutes. Observation and interview on 02/06/24 at 10:10 A.M. revealed State tested Nursing Assistant (STNA) #817 entered Resident #152 room and stated she could not change her by herself and that she needed help and would return. STNA #817 revealed Resident #152 was unable to walk and required two staff to assist for toileting. Observation and interview on 02/06/24 at 10:38 A.M. with Resident #152 revealed her call light was still activated and she still needed incontinence care assistance. Resident #152 revealed she wanted to be cleaned up prior to her visitors arriving but no staff had returned. Observation and interview on 02/06/24 at 10:44 A.M. with the Director of Nursing (DON) confirmed Resident #152's call light was activated and Resident #152 needed assistance to the bathroom. Observation revealed Resident #152 waited approximately 45 minutes for staff assistance after activating her call light. Follow-up Interview on 02/06/24 at 11:15 A.M. with STNA #817 revealed she was aware Resident #152 needed assistance to the bathroom but she was helping another resident with a shower and Resident #152 had to wait.

Based on observation, interview, and record review the facility failed to ensure Resident #6 was receiving an adequate amount of fluids to meet her basic needs. This affected one of one resident reviewed for hydration. The facility census was 110. Findings include: Medical record review revealed Resident #6 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, and disorders of electrolyte and fluid balance. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired and required hands on assistance of two staff persons for completing activities of daily living. Observation on 02/05/24 at 11:22 A.M. revealed Resident #6 sitting in a Broda wheelchair (a wheelchair that provides supportive positioning through a combination of tilt, recline, enhancing patient safety and support) in her room, a Styrofoam cup with a lid and a straw filled with water was sitting on the bedside table placed behind Resident #6, where she was unable to reach it. Observation on 02/06/24 at 10:42 A.M. revealed two Styrofoam cups of water with lids and straws in them sitting on Resident #6 bedside table. Resident #6 was not in her room. Further observation revealed Resident #6 sitting in the dining room in a Broda wheelchair pushed up to a dining room table with no drinks or beverages present. Observation on 02/06/24 at 2:57 P.M. revealed Resident #6 sleeping in her bed with a fall mat lying next to the bed and a bedside table placed next to a wall by the bathroom. There were no beverages present in Resident #6's room. Observation on 02/06/24 at 5:21 P.M. revealed Resident #6 sitting in the dining room in a Broda wheelchair placed at a table, no beverages were present. Observation on 02/07/24 at 8:13 A.M. revealed Resident #6 's room had no beverages present. Observation on 02/07/24 at 8:14 A.M. revealed Resident #6 sitting in a Broda wheelchair in the dining room, with no beverages present. An interview on 02/02/24 at 10:44 A.M., revealed Resident #6 expressed that she was thirsty. Interview on 02/05/24 at 11:11 A.M. with Residents #6's family member revealed when the family member visited Resident #6, there was never any beverages present. The family member said each time she visited Resident #6, she had to get her a cup of water because Resident #6 told the family member she was thirsty each visit. Interview on 02/06/24 at 10:48 A.M. with Licensed Practical Nurse (LPN) #899 revealed she tried to interact with the residents and ask if they were thirsty including Resident #6. LPN #899 further stated activities was also incorporated in helping with providing beverages. Interview on 02/06/24 at 10:53 A.M. with Activities Director (AD) #946 revealed she passed water out to the residents first thing in the morning between 8:00 A.M. to 8:45 A.M. AD #946 said a lot of times the aides helped serve the residents water that needed assistance. AD #946 further stated the aides should be passing the water and she was not sure why there was no water or beverages in front of Resident #6. AD #946 further stated she just recently got her position, and really, it was the aide's job to make sure the residents had water. Review of Resident #6 fluid intake record from January 2024 to February 2024 revealed: 01/25/24 Resident #6 had a total daily intake of 960 milliliter (ml). 01/26/24 Resident #6 had a total daily intake of 720 ml. 01/27/24 Resident #6 had a total daily intake of 1200 ml. 01/28/24 Resident #6 had a total daily intake of 720 ml. 01/29/24 Resident #6 had a total daily intake of 720 ml. 01/30/24 Resident #6 had a total daily intake of 490 ml. 01/31/24 Resident #6 had a total daily intake of 720 ml. 02/01/24 Resident #6 had a total daily intake of 742 ml. 02/02/24 Resident #6 had a total daily intake of 340 ml. 02/03/24 Resident #6 had a total daily intake of 486 ml. 02/04/24 Resident #6 had a total daily intake of 406 ml. 02/05/24 Resident #6 had a total daily intake of 484 ml. 02/06/24 Resident #6 had a total daily intake of 484 ml. Interview on 02/07/24 at 8:44 A.M. with Licensed Dietician (LD)#857 revealed that minimum fluids were calculated using the current standards of practice. LD #857 explained the current standard of practice was 30 (ml) per kilogram (kg) of body weight. (LD) #857 confirmed using the current standards of practice calculations Resident #6 should be receiving approximately 1200 ml of fluid per day, and verified the contents of the fluid intake records listed above were correct.

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate assessment before applying side rails to a bed. This affected one (Resident #44) of five residents reviewed for accident hazards. The total census was 110. Findings include: Observation on 02/05/24 at 9:34 A.M. revealed Resident #44 had a raised side rail on each side of his bed. Record review of Resident #44 revealed he was admitted to the facility 11/14/23 and had diagnoses including lumbar fracture, muscle weakness, and obesity. His current care plan did not include any mention of side rails. Review of his assessments since admission revealed no evidence he was assessed for entrapment risk or appropriate use of bed rails. Interview with the Director of Nursing on 02/07/24 at 12:24 P.M. confirmed the above findings.

Based on record review, medication error/incident report review, order summary review, facility investigation time line review and staff interview the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #101) of one resident reviewed for admission medications and one (Resident #71) of five residents reviewed for unnecessary medications. Findings include: 1. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of the medication error/incident report dated 11/17/23 timed 2:00 P.M. revealed Resident #101 was admitted to the facility on the evening of 11/16/23. On the following day the facility conducted a 24 hour medication audit per its standard policy. Upon completing the audit it was revealed that Resident #101 was sent to the facility from a hospital with another resident's clinical information and medication. At the time of admission nursing staff verified the incorrect medication orders with Resident #101's attending physician. Subsequently Resident #101 received incorrect medication on the evening of 11/16/23 between 5:30 P.M. and 6:00 P.M. These medications included Lisinopril (blood pressure regulating medication) 20 milligrams (mg), Metoprolol Succinate 25 mg (blood pressure regulating medication), Hydralazine (blood pressure regulating medication) 25 mg, insulin 55 units, acetaminophen (pain reliever) 650 mg, Spironolactone (blood pressure/fluid regulating medication) 50 mg, Allopurinol (gout treatment) 300 mg, Amlodipine (blood pressure regulating medication) 25 mg, aspirin (pain reliever) 81 mg and Furosemide (fluid retention treatment) 80 mg. Upon realizing the errors Resident #101 was immediately assessed (no negative finding) and put on hourly checks which also produced no negative findings. Resident #101's attending physician and family were notified of the errors. Correct medication lists were obtained from a local hospital and re-verified with Resident #101's physician. Resident #101's family requested that Resident #101 be sent to a local emergency room for evaluation. Resident #101 left the facility without incident on 11/17/23 at approximately 5:00 P.M. Resident #101 did not return to the facility. Review of an order summary for Resident #101 dated 11/17/23 timed 2:24 P.M. revealed Resident #101's medications included acetaminophen extended release 650 mg twice a day, Allopurinol 300 mg once daily, amlodipine besylate 5 mg once daily and ammonium lactate external lotion 12 percent topically twice a day. Review of the facility investigation time line of events dated 01/17/24 revealed on 11/17/23 at 4:20 P.M. Resident #101 was alert and in dining room participating in activities, eating snack and drinking fluids. At 3:07 P.M. Resident 101's vitals included blood pressure 74/59, heart rate 98, respirations 18, and blood sugar 125. The nurse practitioner was notified and ordered Miderine (anti-hypotensive agent). The family declined administration of Miderine and wanted resident sent to emergency room . At 3:20 P.M. emergency services arrived and conducted an assessment of Resident #101. Blood pressure was 118/84. Family talked with paramedics debating on sending to the hospital or continuing to monitor at facility. It was decided to send to hospital. The Director of Nursing (DON) called the daughter on 11/18/23 to check on resident and was told Resident #101 was monitored overnight and given intravenous fluids. Interview with the DON on 02/07/24 at 3:00 P.M. verified that incorrect medications were given to Resident #101 upon her admission to the facility. Review of the policy entitled Administering Medications dated 04/01/19 revealed Medications are administered in accordance with prescriber orders, including any required time frame. 37095 2. Record review of Resident #71 revealed she was admitted [DATE] and had diagnoses including anxiety disorder, dementia, major depressive disorder, and bipolar schizoaffective disorder. Review of a physician order dated 01/31/24 indicated the resident was to receive Paxil (an antidepressant) 10 milligrams for seven days until 02/06/24. Review of the medication administration record revealed the dose was only administered on 01/31/24. Review of Resident #71's progress notes and orders revealed no cancellation or other explanation why the medication was not given the remaining six days. Interview with the Director of Nursing (DON) on 02/07/24 at 12:24 P.M. confirmed the above findings. Follow-up interview with the DON on 02/07/24 at 1:59 P.M. revealed the facility investigation found the order was entered incorrectly into their computer documentation system.

Based on record review and staff interview the facility failed to ensure a complete and accurate medical record for Resident #101. This affected one of thirty sampled residents. The facility census was 110. Findings include: Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of census records for Resident #101 revealed Resident #101 was discharged to an acute care hospital on 11/17/23 and did not return to the facility. Review of the electronic and hard chart revealed no information related to the reason Resident #101 was discharged to hospital or condition at the time Resident #101 left the facility to go to the hospital. Interview with the Director of Nursing on 02/07/24 at 3:11 P.M. verified Resident #101's medical record lacked any information related to what lead up to the resident being transferred to the hospital or condition at time of discharge.

Based on observation, record review, staff and resident interview, and policy review, the facility failed to ensure smoking assessments and care plans were completed in a timely manner. This affected two residents (#58 and #152) of two reviewed for smoking. The facility identified twelve residents (#2, #22, #24, #42, #58, #59, #68, #92, #102, #103, #104, #152) who smoked. The facility census was 110. Findings include: 1. Review of the medical record for Resident #152 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of anterior wall of bladder, COVID-19, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/04/24 revealed Resident #152 had no care plan in place for smoking. Review of the progress note dated 01/03/24 at 5:58 P.M. revealed Resident #152 was a smoker. Interview on 02/06/24 at 2:11 P.M. with Registered Nurse (RN) #923 revealed Resident #152 was a smoker upon admission and utilized the designated smoking area daily. RN #923 confirmed there was not a smoking assessment or care plan for Resident #152 in paper chart or electronic medical record. Interview on 02/06/24 at 2:19 P.M. with the Director of Nursing (DON) and the Administrator revealed the Activities Director (AD) #832 was responsible for completing the smoking assessments and was behind in completing them. Follow-up review of the medical record revealed an updated care plan dated 02/06/24 that reflected Resident #152 was a smoker and was safe to smoke with group supervision. Review of the facility document titled Screen for Smoking revealed Resident #152 was screened and assessed for smoking, approximately 29 days after admitting to the facility. Review of the facility document titled Resident Smoking revised 01/30/24, revealed the facility had a policy in place to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Review of the policy revealed residents who smoked would be assessed during the admission process, quarterly and during comprehensive MDS assessments and documented in the resident's care plan. Review of the document revealed the facility did not implement the policy. 49040 2. Review of the medical record for Resident #58 revealed the resident was admitted into the facility on [DATE] with diagnoses including muscle weakness and multiple sclerosis. Review of the annual quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was cognitively intact, and required maximal/substantial assist for activities of daily living. Further review of the medical record revealed Resident #58 used tobacco products and was assessed to be an independent smoker upon admission on 09/20/21. No other smoking assessments were noted in the medical record. Interview on 02/07/24 at 11:30 A.M. with the Executive Director (ED) confirmed Resident #58 had a smoking assessment completed on 09/20/21 when she was admitted to the facility and no other smoking assessments were completed until 02/01/24. Review of the Smoking Policy dated 1/30/24 revealed All residents will be asked about tobacco use during the admission process and during each quarterly or comprehensive MDS assessment process. In addition, Residents who smoke will be further assessed using the Screen for Smoking assessment to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all.

Based on observation, staff interview, record review, and policy review, the facility failed to maintain infection control practices to prevent the potential spread of COVID-19. This had the potential to affect 16 (#89, #24, #51, #68, #41, #96, #99, #5, #57, #9, #93, #74, #66, #73, #75, and #30) of 16 residents residing on the affected hall. The facility census was 101. Findings include: Review of the medical record for Resident #89 revealed an admitted [DATE], with a current diagnosis of COVID-19. Review of the Annual Minimum Data Set (MDS) for Resident #89 dated 09/06/23, revealed Resident #89 was cognitively intact. Resident #89 required assistants, was not steady, and used a wheelchair for mobility. Review of the Care Plan for Resident #89 dated 11/07/23 revealed Resident #89 had an active COVID-19 diagnosis. Interventions included to maintain infection control per Centers of Disease Control (CDC) Prevention guidelines latest recommendations. Review of the physician orders for Resident #89 dated 11/07/23 revealed droplet precautions due to COVID-19 infection. Interview on 11/13/23 at 3:25 P.M., with Housekeeper #297 revealed Resident #89 was on isolation for COVID-19. Observation and interview beginning on 11/13/23 at 3:26 P.M., revealed Resident #89 had a sign on his door which revealed droplet precautions. Resident #89 had an isolation cart sitting next to the entrance of his doorway. Observation revealed Housekeeper #297 donned Personal Protective Equipment (PPE) to enter and clean Resident #89's room. Housekeeper #297 donned gloves, a gown, and an N95 mask. Housekeeper #297 did not put on goggles or a face shield. Housekeeper #297 entered Resident #89's room with cleaning supplies. Housekeeper #297 began wiping items down in Resident #89's room. Housekeeper #297 then exited the room with her same gown, gloves, and mask, went into the hall where the cleaning cart was located, (in the middle of the hall, outside of Resident #89's room), grabbed additional supplies off the housekeeping cleaning cart, (touching multiple items on the cart) then reentered Resident #89's room to continue cleaning. Within a few minutes, Housekeeper #297 again exited Resident #89's room with her same PPE on, went back to the housekeeping cart and gathered more supplies (after touching several items on the cart) then re-entered Resident #89's room with new supplies. Again, after a few minutes of cleaning in Resident #89's room, Housekeeper #297 again exited Resident #89's room, with the same PPE on (did not remove PPE or wash her hands), went back to the housekeeping cart and grabbed the broom and mop then reentered Resident #89's room. The Administrator walked by and witnessed and verified Housekeeper #297 exited Resident #89's room without removing the PPE and reentering Resident #89's room with the cleaning supplies and no face shield or goggles. The Administrator verified there were no face shields or goggles on Resident #89's isolation cart located at the entrance of his room. The Administrator obtained a face shield and instructed Housekeeper #297 on the appropriate PPE to be donned before entering a room with COVID-19 and instructed her she should not be exiting the room without removing the PPE and washing her hands. Housekeeper #297 donned the face shield and completed cleaning Resident #89's room. Housekeeper #297 then removed the PPE, exited Resident #89's room, the put the used, uncleaned face shield back into the isolation cart. The Administrator was present during the observation. Interview at this time, with Housekeeper #297 and the Administrator verified the face shield was not cleaned prior to placing it in the isolation cart with other clean PPE supplies. Observation and interview on 11/13/23 at 3:50 P.M., with Housekeeper #297 who revealed Resident #89's room was the last room to be cleaned. Housekeeper #297 placed the used rags and the unused rags in a separate bag to be sent to laundry. Emptied the mop water in the housekeeping soiled utility room, emptied trash from the housekeeping cart, took the trash to the dumpster outside the facility and returned to the housekeeping cart. Housekeeper #297 then placed the housekeeping cart in the utility room to be stored with five other housekeeping carts. Housekeeper verified she used a clean mop head for each room and used the same broom and dustpan for each room. Housekeeper #297 then left the storage area and revealed she was done cleaning. Housekeeper #297 confirmed she did not clean the cart, broom, dustpan, or mop handles after she touched each of them while cleaning Resident #89's room. Housekeeper #297 revealed the housekeeping carts were cleaned every other day. Housekeeper #297 confirmed she did not use hand sanitizer or wash her hands after emptying the mop water, taking the trash out and removing the soiled rags from the housekeeping cart. Interview on 11/13/23 at 5:00 P.M., with Administrator revealed housekeeping carts were assigned to specific units. Administrator revealed Housekeeper #297's cart was used for cleaning 15 resident rooms, Resident #24, #51, #68, #41, #96, #99, #5, #57, #9, #93, #74, #66, #73, #75, and #30 that were not diagnosed with COVID-19, daily. Review of the policy titled PPE-Contingency and Crises Use of Eye Protection (COVID-19 Outbreak), revised September 2021, revealed to prevent transmission of infectious agents through the use of PPE included eye protection, gloves, masks, and gowns. Ensure appropriate cleaning and disinfection between users if goggles or reusable face shields are used. This deficiency represents non-compliance investigated under Complaint Number OH00148191 and the Focused Infection Control Survey.

Based on observation, record review and interview the facility failed to consistently ensure Resident #66's wound treatment was maintained and Resident #75's dressing to prevent skin breakdown was maintained. This affected two of three residents reviewed for pressure ulcers. The facility census was 97. Findings include: 1. Medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage, cerebral infarction (stroke), chronic respiratory failure, neuromuscular dysfunction of bladder, hydrocephalus epilepsy and anemia. Resident #75's physician order dated 05/11/23 indicated to cleanse Resident #75's sacral wound with normal saline, pat dry, apply 50/50 mix triad and calmoseptine and then cover the wound with a foam dressing once a day for wound care. Resident #75's Treatment Administration Record (TAR) dated 07/01/23 to 07/31/23 indicated Resident #75's wound treatment was applied to the sacral area during the night shift hours from 11:00 P.M. to 7:00 A.M. on 07/24/23. Resident #75's plan of care dated 04/25/23 indicated Resident #75 had actual/potential impairment of skin integrity related to lack of mobility, respiratory failure and muscle weakness. Interventions on the plan of care included to follow facility protocols for treatment of skin injury. An observation of Resident #75's sacral wound on 07/25/23 at 4:50 P.M. revealed there was no wound treatment in place on Resident #75's sacral wound. State tested Nursing Assistant (STNA) # 102 and Licensed Practical Nurse (LPN) #103 entered Resident #75's room to provide incontinence care for Resident #75. When Resident #75's bed linens were removed Resident #75's incontinence brief was soaked with urine and leaked on the under pad on Resident #75's bed. When STNA #102 and LPN #103 removed Resident #75's incontinence brief there was no wound treatment present on Resident #75's sacral area. Resident #75's sacral area had a white colored scarred area with a small reddened center approximately the size of a 50 cent piece coin. At the time of the observation on 07/25/23 at 4:50 P.M. both STNA #102 and LPN #103 verified there was no wound treatment present on Resident #75's sacral/coccyx area. 2. Resident #66 was admitted on [DATE] with diagnoses including osteomyelitis of lumbar vertebra, discitis, escherichia coli infection, severe protein calorie malnutrition, diabetes mellitus, alcoholic cirrhosis of the liver with ascites, spinal stenosis, chronic viral hepatitis C, retroperitoneal abscess, neuromuscular dysfunction of the bladder, high blood pressure, need for assistance with personal care, limitation of activities due to disability and reduced mobility. Resident #66's wound assessment dated [DATE] indicated a stage four pressure ulcer was located on the coccyx measuring 4.2 centimeters (cm) long by 3.4 cm wide by 1.6 cm deep with undermining at the 10 o'clock and 12 o'clock position with yellow slough (dead tissue). The coccyx wound was noted to have an odor. The assessment indicated the area had worsened due to Resident #66's recent hospitalization . The treatment on the assessment indicated to cleanse the wound with Vashe wash, pack wound with calcium alginate rope and cover with a foam dressing once a day and as needed. The assessment indicated Resident #66 should only be out of bed and up to a chair for two hour increments. Resident #66's plan of care dated 04/21/23 indicated Resident #66 had skin impairment noted on admission to the facility. Interventions on the plan of care indicated to apply wound treatment and maintain wound treatment as ordered by the physician. An observation of Resident #66's wound treatment on 07/25/23 at 4:00 P.M. revealed there was no wound treatment present on Resident #66's sacral/coccyx area covering the stage four pressure ulcer. LPN #104 and STNA #105 assisted Resident #66 to a standing position and removed his incontinence brief. There was no wound treatment present on Resident #66's sacral wound. Resident #66's sacral wound had a large dinner plate sized red area with a quarter sized open area on the coccyx with yellow slough present with exposed bone. An interview with STNA #105 following the wound treatment on 07/25/23 at 4:05 P.M. verified there was no wound treatment present on Resident #66's sacral area when Resident #66's incontinence brief was removed. An interview with STNA #106 on 07/25/23 at 5:04 P.M. revealed Resident #66 had a large bowel movement before lunch at approximately 12:00 P.M. and she had provided incontinence care. STNA #106 stated Resident #66's wound treatment had become soiled and was removed during the incontinence care and STNA #106 had informed the Assistant Director of Nursing (ADON) of the need to have the wound treatment reapplied. An interview with the ADON on 07/26/23 at 1:24 P.M. revealed STNA #106 had informed her on 07/25/23 at approximately 2:00 P.M. to 2:30 P.M. that Resident #66's wound treatment had become soiled and was removed during incontinence care and needed reapplied. The ADON stated she informed LPN #107 of the need to apply the wound treatment and the decision was made to reapply the wound treatment at on 07/25/23 at 4:00 P.M. with the oncoming nurse (LPN #104). The ADON stated she was unaware STNA #106 had provided Resident #66 incontinence care before lunch at approximately 12:00 P.M. The ADON agreed Resident #66's wound treatment was not in place from approximately 12:00 P.M. to 4:00 P.M. on 07/25/23 and should have been immediately reapplied due to Resident #66's stage four pressure ulcer with osteomyelitis (bone infection). Review of the facility policy and procedure titled Prevention of Pressure Injuries revealed teh policy included skin care for prevention of pressure ulcers. The interventions included in the skin prevention included: 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. 3. Use a barrier product to protect skin from moisture. 4. Use incontinence products with high absorbency. 5. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 6. Use facility-approved protective dressings for at risk individuals. This deficiency represents non-compliance investigated under Master Complaint Number OH00144047 and OH00143949.

Based on observation and interview the facility failed to maintain infection control standards to prevent potential cross contamination of germs during Resident #72's and Resident #26's medication administration. This affected two out of five residents observed for medication administration. The facility census was 97. Findings include: 1. Medical record review revealed Resident #72 was admitted on [DATE] with diagnoses including cerebral vascular disease, hemiplegia, hemiparesis, vascular dementia, pulmonary and heart disease with heart arrhythmia and anemia. Resident #72's physician order dated 06/08/21 indicated to administer acetaminophen 650 milligrams (mg) orally every six hours as needed for pain. Resident #72's Medication Administration Record (MAR) dated 07/01/23 to 07/31/23 revealed on 07/25/23 at 11:18 A.M. Resident #72 had a pain level of 6 out of 10 on a scale of 1 to 10 with 10 indicating extreme pain. An observation on 07/25/23 at 11:15 A.M. of Licensed Practical Nurse (LPN) #100 administer Resident #72 acetaminophen 650 mg orally for a complaint of a headache revealed a failure of LPN #100 to wash or sanitize her hands before dispensing the medication and after completion of the task. LPN #100 approached the medication cart and proceeded to remove the acetaminophen medication without washing or sanitizing her hands before starting the task. LPN #100 preceded to dispense Resident #72's acetaminophen in a medication cup and then walked to Resident #72's room and handed the medication cup to Resident #72. After Resident #72 consumed the medication LPN #100 discarded the empty medication cup in the trash receptacle and exited the room without washing or sanitizing her hands. An interview with LPN #100 immediately following the observation on 07/25/23 at 11:20 A.M. verified she should have washed or sanitized her hands prior to starting the medication administration task and before exiting Resident #72's room. A review of the facility policy and procedure titled Handwashing/Hand Hygiene dated 08/2019 indicated the policy interpretation and implementation steps including the following guidance: 1. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents; b. Before preparing or handling medications; c. Before performing any non-surgical invasive procedures; d. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); e. Before donning sterile gloves; f. Before handling clean or soiled dressings, gauze pads, etc.; g. Before moving from a contaminated body site to a clean body site during resident care; h. After contact with a resident's intact skin; i. After contact with blood or bodily fluids; j. After handling used dressings, contaminated equipment, etc.; k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; l. After removing gloves; m. Before and after entering isolation precaution settings; n. Before and after assisting a resident with meals; and o. After personal use of the toilet or conducting your personal hygiene. 2. Medical record review revealed Resident #26 was admitted on [DATE] with diagnoses including diabetes mellitus, pulmonary and heart disease with heart failure, peripheral vascular disease, chronic pain and depression. Resident #26's physician order dated 12/27/22 indicated to administer percocet (medication for pain) 5 mg/325 mg tablet orally every six hours as needed for severe pain. A review of Resident #26's MAR dated 07/01/23 to 07/31/23 indicated Resident #26 had a pain level of 3 out of 10 on a scale of 1 to 10 with 10 indicating extreme pain on 07/26/23 at 7:57 A.M. An observation on LPN #101 administer Resident #26's medications on 07/26/23 at 7:52 A.M. revealed LPN #101 was dispensing Resident #26's percocet medication and punched the percocet tablet out of the medication card on to the medication cart surface. LPN #101 proceeded to use a glove to pick up the medication off the medication cart and placed the medication in the medication cup and proceeded to enter Resident #26's room and administered the percocet medication to Resident #26. Immediately following the observation on 07/26/23 at 8:00 A.M. LPN #101 verified the above findings and agreed he should have discarded the percocet medication and should not have administered the potentially contaminated percocet to Resident #26.

Based on record review, observation, and interview, the facility failed to ensure safety devices were implemented to prevent falls. This affected one (Resident #79) of three residents reviewed for falls. The census was 97. Findings Include: Review of medical record for Resident #79 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, morbid obesity, anxiety disorder and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/06/22, revealed Resident #79 had intact cognition. Resident #79 required extensive assistance for bed mobility, transfers, locomotion, and toilet use. Review of the plan of care dated 12/15/21 revealed Resident #79 was at risk for falls due to psychoactive drug use, history of falling, impaired balance, weakness, and Parkinson's disease. Interventions included to ensure call light was in reach and apply a sensor pad to the bed and wheelchair dated 01/26/23. Review of fall assessments dated 02/01/23 and 05/16/23 revealed Resident #79 was at high risk for falls. Review of the incident log revealed Resident #79 had falls on 01/26/23, 04/14/23 and 05/29/23. Review of the progress note dated 01/26/23 timed 7:20 P.M. revealed Resident #79 was found lying on the floor in pain. Resident #79 stated he was going to the bathroom when he fell . Resident #79 was taken to the hospital for evaluation. A new fall intervention to help prevent further falls included a flat sensor alarm to bed and recliner. Review of the progress note dated 04/14/23 at 7:46 A.M. revealed Resident #79 was observed sitting on the floor, no injuries were noted. Staff educated Resident #79 on calling for assistance before getting up. Review of progress note dated 05/29/23 at 1:23 P.M. revealed Resident #79 was observed lying on the floor on his right side. Resident #79 was unable to verbalize what happened. Resident #79 sustained an abrasion to the right elbow. Interview on 05/31/23 at 3:22 P.M. with the wife of Resident #79 revealed Resident #79 had some falls this year. The wife stated staff were to apply sensor pads to Resident #79's bed and wheelchair but they were lying on the floor and she didn't understand why. Observations on 05/31/23 at 4:07 P.M. revealed Resident #79 was sitting in his wheelchair. Further observation revealed the sensor pad alarm for the wheelchair was under Resident #79's bed frame at the top of the bed. The sensor pad alarm for the bed was on the floor at the opposite side of the bed unplugged. The Administrator observed and confirmed the findings. Review of facility policy titled Falls and Fall Risks, Managing, dated 2018 revealed staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors for those at risk of falls or with a history of falls. Position-change alarms were not be used as the primary or sole intervention to prevent falls, but rather were to be used to assist the staff in identifying patterns and routines of the resident. This deficiency represents noncompliance investigated under Master Complaint Number OH00142865 and Complaint Number OH00142662.

Based on record review and interview, the facility failed to document treatments were completed in the treatment administration record (TAR). This affected two (Residents #41 and #65) of six residents reviewed. Findings include: 1. Review of medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, anxiety disorder and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/04/23, revealed Resident #41 had intact cognition and required extensive assistance for bed mobility, transfers, and toilet use. Review of May 2023 TAR for Resident #41 revealed an order dated 01/26/23 for Interdry moisture wicking fabric to abdominal fold one time a day for wound care. There was no documentation the Interdry moisture wicking fabric was applied to the abdominal fold 16 of 31 days. Further review of the TAR revealed an order to apply house stock antifungal cream to bilateral breasts two times a day dated 02/15/23. There was no documentation the antifungal cream was applied 25 of 31 days. An order to cleanse right thigh with normal saline, pat dry, apply collagen powder, followed by silver alginate, and cover dated 04/26/23 was not documented as completed eight of 31 days. Interview on 06/01/23 at 12:45 P.M. with the Director of Nursing (DON) verified the missing documentation. The DON stated it was a challenge working and monitoring agency staff. 2. Review of medical record for Resident #65 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, dysphagia, functional urinary incontinence, and other symbolic dysfunctions. Review of the quarterly MDS assessment, dated 04/10/23, revealed Resident #65 had intact cognition, was independent for eating, and required extensive assist for transfers, locomotion, and toilet use. Review of the [NAME] 2023 TAR for Resident #65 revealed an order dated 05/08/23 to 05/15/23 to cleanse coccyx with normal saline, pat dry, apply Triad cream and cover with foam dressing daily. The treatment was not documented as completed four of six days. The same order was re-written on 05/15/23 and was not documented as completed five of the remaining 16 days of the month. An order to apply house barrier cream to bilateral buttocks every shift dated 02/01/23 was not documented as completed 12 of 31 days. Interview on 06/01/23 at 12:45 P.M. with the DON verified the missing documentation. The DON stated it had been a challenge working and monitoring agency staff. This deficiency represents noncompliance investigated under Master Complaint Number OH00142865 and Complaint Number OH00142662.

Based on record review, interview, and review of the facility policy the facility failed to ensure mood and behavior monitoring for Resident #12 related to the use of Depakote, a mood stabilizer. This affected one resident (#12) out of three residents reviewed for unnecessary medications. The facility census was 93. Findings include: Review of the medical record for the Resident #12 revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbance, diabetes mellitus, mood affective disorder, mild intellectual disabilities, and Down's syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had moderately impaired cognition. No behaviors were identified on the MDS. Resident #12 required limited assistance of one-staff for dressing, toilet use, and personal hygiene. Further review of the MDS assessment revealed Resident #12 received antidepressants daily during the seven-day look back period. Review of the family/resident communication note dated 02/08/23 at 8:07 A.M. revealed Resident #12's sister was made aware and in agreement with increase in Depakote from 250 milligrams (mg) twice a day to 375 mg twice a day. Review of the progress notes dated from 01/06/23 to 04/05/23 revealed no progress notes related to Resident #12 having behaviors. Interviews on 04/07/23 from 7:15 A.M. through 2:00 P.M. with Licensed Practical Nurse (LPN) #201, Registered Nurse (RN) #203, and LPN #204 stated behaviors must be documented in the resident's medical record. Interview on 04/08/23 at 12:44 P.M. with Director of Nursing (DON) #205 and Corporate Administrative Nurse (CAN) #208 revealed behaviors for residents were documented in the progress notes and verified there was no documented evidence of behaviors for Resident #12 to justify the increase in Depakote. Review of the facility policy titled Dementia - Clinical Protocol, dated 11/2018, revealed the interdisciplinary team (IDT) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise and the physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00141350.

Based on observation, interview, record review and policy review, the facility failed to assure that respiratory supplies included an extra trach tube and that the tube was available at the bedside for three residents, Residents #10, #69 and #7, out of 10 residents, Residents #94 #40, #62, #5, #86, #29, and #49, reviewed for` tracheostomy supplies. The facility also failed to assure one resident's ventilator was connected timely to provide oxygen and assure that trach suctioning and physician's orders were followed for one resident, Resident #7, out of three residents, Residents #5, #7, and #62, reviewed for suctioning and physician's orders. The facility census was 96 Findings include: 1. Record review for Resident #10 revealed an admitted [DATE]. Diagnosis included acute respiratory failure, muscle weakness, cerebral infarction due to thrombosis of right middle cerebral artery, and tracheostomy. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was rarely or never understood. Resident #10 required limited assistants for bed mobility, extensive assist for transfers and total dependence for eating and locomotion with use of a wheelchair. Resident #10 had a tracheostomy, received oxygen and suctioning. Record review of the care plan for Resident #10 dated 01/23/23 revealed the resident had a tracheostomy related to acute respiratory failure. Interventions included to keep an extra trach tube and obturator at the bedside. If the tube is coughed out, open stoma with hemostat. If the tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. Record review of the physician orders for March 2023 for Resident #10 included to change #six shiley flex trach every 60 days and as needed. Observation on 03/15/23 at 4:53 P.M. with Assistant Director of Nursing (ADON) Registered Nurse (RN) #302 revealed a crash cart near the nurses station. The crash cart was fully supplied and had an ambu bag on top of the crash cart. ADON RN #302 revealed an ambu bag was also located in each residents room who had a trach or ventilator. Observation of Resident #10's room revealed Resident #10 did not have an extra trach tube at the bedside or in Resident #10's room. ADON RN #302 confirmed Resident #10 should have had an extra trach tube next to Resident #10's bed and was not. 2. Record review for Resident #69 revealed an admitted [DATE]. Diagnosis included stenosis of larynx, muscle weakness, acute respiratory failure, and tracheostomy. Record review of the admission MDS dated [DATE] for Resident #69 included Resident #69 was cognitively intact. Resident #69 was independent with activities of daily living with exception of bathing, Resident #69 required supervision. Resident #69 had a tracheostomy, received oxygen and suctioning. Record review of the care plan for Resident #69 dated 03/13/23 revealed the resident had a tracheostomy related to stenosis of the larynx and respiratory failure. Interventions included to keep an extra trach tube and obturator at the bedside. If the tube is coughed out, open stoma with hemostat. If the tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. Record review of the physician orders for March 2023 for Resident #69 included to change #four shiley flex trach every 60 days and as needed. Observation on 03/15/23 at 4:59 P.M. with ADON RN #302 revealed Resident #69 did not have an extra trach tube at the bedside or in Resident #69's room. ADON RN #302 confirmed Resident #69 should have had an extra trach tube next to Resident #69's bed. 3. Record review for Resident #7 revealed an admitted [DATE]. Diagnosis included acute and chronic respiratory failure with hypoxia, muscle weakness, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, volume depletion, paroxysmal atrial fibrillation, old myocardial infarction, tracheostomy, and atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm. Record review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview of Cognitive Status (BIMS) score of 15 out of 15 (cognitively intact). Resident #7 required limited assistants of one for bed mobility, transfers, personal hygiene and toilet use. Resident #7 required extensive assistants of one for locomotion with use of walker or wheelchair. Resident #7 had a debility, cardiorespiratory condition, respiratory failure, and anxiety disorder. Resident #7 required oxygen, suctioning, tracheostomy, and an invasive mechanical ventilator. Record review of the care plan for Resident #7 dated 02/28/23 revealed Resident #7 had a tracheostomy related to chronic respiratory failure with hypoxia and hypercapnia and tracheal stenosis. Interventions included Interventions included to keep an extra trach tube and obturator at the bedside. If the tube is coughed out, open stoma with hemostat. If the tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. Interventions also included to give humidified oxygen as prescribed, Resident #7 was able to communicate with staff instructions on how to connect ventilator, monitor and document respiratory rate, depth and quality, check every shift as ordered, provide means of communication and procedural information. Reassure help is available immediately, and ventilator assist as ordered by the physician. Review of the Treatment Administration Records (TAR) for Resident #7 for March 2023, revealed the physician order was to suction every shift and as needed. The TAR revealed day shift and PRN was the only shift scheduled to suction Resident #7. There were no other shifts on the TAR scheduled to suction Resident #7 per the physician orders which were to be completed every shift. Observation on 03/15/23 at 5:12 P.M. with ADON RN #302 revealed Resident #7 did not have an extra trach tube at the bedside. Resident #7 revealed she had one in the hospital bag on the shelf located across the room. ADON RN #302 located the extra trach tube on the shelf in a small bag with multiple items sitting on top the bag. ADON RN #302 confirmed Resident #7 should have had an extra trach tube next to Resident #7's bed and was not. Interview on 03/16/23 at 10:06 A.M. with Respiratory Therapist (RT) #312 revealed Resident #7 was on vent at night only and the cuff would be inflated while on the vent. Resident #7 wore a trach collar during the day and the cuff would be deflated. RT #312 revealed Resident #7 could tell you what needs done. Interview with RT #312 on 03/16/23 at 1:47 P.M. regarding Resident #7's vent history, revealed on 03/14/23 at 10:27 P.M. Resident #7's vent unit was turned on. The vent history read low minute ventilation. RT #312 explained that Resident #7 was not getting the adequate amount of oxygen. The vent unit also showed low respiratory rate and the low pressure was alarming. RT #312 explained that was due to the trach cuff not being inflated. RT #312 indicated that Resident #7 did not receive adequate ventilation on 03/14/23 from 10:27 P.M. through 03/14/23 at 10:34 P.M. (seven minutes). RT #312 also explained that the alarming was sounding at high rate due to not enough ventilation and she was breathing very fast until 11:15 P.M. due to the cuff not being inflated. RT #312 revealed Resident #7 required eight liters of oxygen at all times to keep the oxygen saturation at 94%. RT #312 confirmed the physician orders read four L oxygen bleed-in. RT confirmed that should have been changed several weeks ago, RT #312 revealed he was unable to print Resident #7's vent history on the vent unit. Interview on 03/16/23 at 2:00 P.M. with Agency Nurse LPN #309 confirmed she was working the vent unit on this day and was Resident #7's primary caregiver. LPN #309 revealed she was unsure how much oxygen Resident #7 was to receive. LPN #309 reviewed Resident #7's physician orders and revealed Resident #7 was to receive four liters of oxygen during the day and at night while on the ventilator. Observation on 03/16/23 at 2:03 P.M. with Agency Nurse LPN #309 of Resident #7 revealed Resident #7 was receiving eight liters of oxygen while on the collar. LPN #309 confirmed the order should reflect what Resident #7 was receiving. Interview on 03/16/23 at 2:14 P.M. with the DON and ADON #302 revealed residents with trachs were to have an extra trach tube located next to the residents bed for emergency situations. The DON confirmed orders should reflect what residents receive. Record review with the DON of the physician orders and TAR for March 2023 confirmed Resident #7's physician orders to vent check every six hours pressure control ventilation pressure support 10 peep 10- and four-liters oxygen bleed in order date 02/20/23. The DON confirmed the nurses documented Resident #7 had been receiving four liters of oxygen for March 2023 and Resident #7 had been receiving eight liters. The orders included to suction every shift and as needed. The DON confirmed the order was scheduled for day shift and PRN only. DON confirmed Resident #7 was not suctioned every shift as ordered. The orders stated also to wear four-liter trach collar daytime as tolerated. The DON confirmed Resident #7 had been receiving eight liters for several weeks. Interview on 03/16/23 at 2:19 P.M. with DON and ADON #302 confirmed ADON #302 investigated the incident on 03/14/23 regarding Resident #7 and LPN #310 hooking up the ventilator. ADON #302 revealed she did not document the investigation. The DON confirmed there was no nursing assessment completed on 03/14/23 after Resident #7 went without her oxygen for seven minutes. Interview on 02/21/23 at 11:18 A.M. with Primary Physician #316 for Resident #7 revealed he told the facility DON in the past if the resident becomes hypoxic or if they have trouble with the vent or are unsure about it, to call 911. Primary Physician #316 revealed he would have expected the facility staff to call 911 for Resident #7 on 03/14/23 when the nurse was unable to connect the oxygen to the vent. Primary Physician #316 also revealed a nursing assessment should also have been completed on Resident #7 at that time. This deficiency represents non-compliance investigated under Complaint Number OH00140400.

Based on observation, interview, record review, review of the local police report, witness statements, National Weather Forecast, and facility policy on elopement, the facility failed to provide adequate supervision to prevent one resident (Resident #30) with severe cognitive impairment from eloping from a secured memory care unit. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 09/04/22 at approximately 7:21 A.M. Resident #30 exited from a secured memory care unit through an exit door requiring a security code into rainy weather. The exit door was within close proximity to a busy two- lane road. The audible alarm on the exit door was activated at 7:21 A.M. and turned off at 7:27 A.M. Upon hearing the alarm, State tested Nurse Aide (STNA) #200 looked at the area directly outside of the door and returned to her duties without completing a resident head count to ensure all residents were present. Resident #30 was not identified as missing until approximately 9:00 A.M. to 9:15 A.M. Resident #30 was found by police at a local drug store 0.8 miles away wearing a long-sleeved tee-shirt, sweatpants, and slippers and returned to the facility at 10:13 A.M. This affected one of 11 residents who resided in the memory care unit and were identified as an elopement risk (Residents #20, #23, #25, #26, #27, #28, #29, #30, #32, #33, and #35). Facility census was 77. On 09/12/22 at 3:55 P.M., the Administrator was notified Immediate Jeopardy began on 09/04/22 at approximately 7:21 A.M., when Resident #30, a severely cognitively impaired resident, eloped from the secured memory care unit. Resident #30 exited via a malfunctioning door. The door alarmed and the alarm was turned off at 7:27 A.M. by STNA #200. The STNA looked out the door, did not see anyone and returned to her duties as she was the only staff present in the memory care unit in which 16 cognitively impaired residents resided. STNA #200 did not complete a head count to ensure all residents were present. Resident #30 was not reported as missing until sometime between 9:00 A.M. and 9:15 A.M. Police were called at 9:25 A.M. and subsequently located Resident #30 approximately 0.8 miles away from the facility at a drug store. The immediate Jeopardy was removed on 09/12/22 when the facility implemented the following corrective actions: On 09/04/22 beginning at 9:45 A.M. all doors in the facility were tested by Director of Maintenance (DM) #202 to ensure the magnetic locks were functioning as intended. The Wanderguard system (a system which includes a bracelet worn by a resident which triggers a protected door to lock when the resident is within a certain parameter of the protected door) was tested on all applicable doors. No issues were found at the time of testing. Initial testing was completed at 10:05 A.M. Testing continued daily since 09/04/22 and will continue daily for four weeks ending on 10/02/22. On 09/04/22 at 12:30 P.M. a contracted service technician repaired the wiring to the magnetic lock to the door Resident #30 exited. The wiring track which was previously located in the attic was secured between the ceiling and the ceiling tiles to prevent animals from tampering with the wires. On 09/04/22 beginning at 10:30 A.M. education on the elopement policy was completed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for all staff including 23 nursing assistants, 14 nurses, four housekeepers, two laundry aides, four maintenance staff, four administrative staff, two social services staff, two activities staff, fourteen therapy staff, six dietary staff, the dietitian, the clinical liaison, the memory care aide, the admissions director, the medical records employee, and three receptionist staff. All staff were educated either in-person or via phone. This education was completed on 09/06/22. The education included door alarms responses, annunciator panels located behind the nurses ' stations, and missing resident procedures and initiating a head count. On 09/04/22 elopement drills were completed for all shifts starting on 09/04/22 by DM #202. DM #202 will conduct elopement drills three times a week for four weeks ending on 10/02/22. On 09/04/22 STNA #200 was counseled by the DON and education was provided on proper alarm response and elopement procedure. Review of STNA #200 ' s personnel file on 09/13/22 at 3:32 P.M. confirmed a written disciplinary action regarding the elopement incident of Resident #30 on 09/04/22. On 09/12/22 elopement screening was completed on the 11 high-risk residents in the memory care unit by the DON and ADON. Quality Assurance meetings will be held monthly starting in September 2022 and continue through December 2022 and will discuss elopement risk assessments/care plans, elopement drills, policies and procedures related to Wanderguards, and any attempted elopements. Although the Immediate Jeopardy was removed on 09/12/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #30's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, disorientation, and [CONDITION(S)]. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of seven indicating severe cognitive impairment. The assessment indicated Resident #30 ambulated independently. Review of the Quarterly Dementia Unit Functional Assessment and Review dated 08/02/22 revealed Resident #30 had a history of wandering, delusions and attempted to push on doors to try and get out. Continued placement on the memory care unit was recommended. Review of Resident #30's care plan dated 08/04/22 revealed Resident #30 was at risk for elopement and had exit seeking behaviors due to poor safety awareness and cognitive deficits. Resident #30 had a history of wandering and frequently asked how to get out because she wanted to go home. Interventions included frequent monitoring, redirection, reorientation and a Wanderguard ankle bracelet. The care plan also indicated Resident #30 was at risk for falls related to history of wandering and a diagnosis of dementia and poor safety awareness. Interventions included frequent safety checks. The care plan indicated Resident #30 had behaviors including wandering and exit seeking and was known to cut or tear off her secure band (Wanderguard bracelet) and was placed on the secure unit for safety related to wandering. Review of the police report dated 09/04/22 revealed a call was received on 09/04/22 at 9:25 A.M. of a missing person. The report indicated police arrived at the facility (no time documented) and the Administrator informed them Resident #30 had walked out of the facility, staff searched the facility and were not able to locate her, and some staff were driving around the area in an attempt to locate her. As police were still on scene at the facility an officer received a call (no time documented) indicating Resident #30 was located at a local drug store. The report indicated Resident #30 complained her arm was hurting from a fall and the officer called for a paramedic to assist with assessing the resident for injuries. Resident #30 was assessed with no injuries and was released to MD #202 at 10:13 A.M. who was present on scene. Review of the facility investigation initiated on 09/04/22 revealed STNA #200's written statement did not include times of the events. STNA #200 wrote she heard the door alarm going off near the dining room and she looked outside and did not see anyone. STNA #200 wrote she searched the residents ' rooms and was not able to locate Resident #30 and informed the nurse (no time provided). Further review of the investigation revealed a handwritten statement by the DON and the ADON dated 09/04/22 (untimed) indicating upon arrival back to the facility Resident #30 had a full body assessment with a small abrasion noted to her left pinkie. The statement did not include any information related to physician or family notification. Observation on 09/08/22 at 10:51 A.M. revealed Resident #30 laying in her bed in her room with an ankle monitoring device (Wanderguard/secure band) on her left ankle. Resident #30 was unable to state her name or answer any questions. Interview on 09/08/22 at 12:19 P.M. with MD #202 revealed he was present on 09/04/22. MD #202 was made aware Resident #30 was missing by Receptionist #203 sometime between 9:15 A.M. and 9:30 A.M. MD #202 proceeded to look for Resident #30 in his car at nearby businesses because it was raining heavily, and he thought Resident #30 may have gone inside a business for shelter. MD #202 stated he saw police and fire at a local drug store and entered the store and identified Resident #30 was inside. MD #202 returned Resident #30 to the facility at approximately 10:30 A.M. After returning Resident #30, MD #202 checked the doors on the memory care unit and determined the magnetic strip above the door was not functioning, however the alarm was working. Interview on 09/08/22 at 12:49 P.M. with Receptionist #203 revealed she was present at the facility on 09/04/22. Receptionist #203 was notified via a walkie talkie sometime between 9:00 A.M. and 9:15 A.M. Resident #30 was missing. Receptionist #203 immediately called the Administrator, DON, and the local police department. Receptionist #203 stated Resident #30 was returned to the facility by MD #202 between 10:30 A.M. and 10:45 A.M. Interview on 09/08/22 at 1:22 P.M. with the Administrator revealed he received a call from Receptionist #203 on 09/04/22 at approximately 9:00 A.M. and was informed Resident #30 was missing. The Administrator advised Receptionist #203 to contact the police. The Administrator stated the staff searched the facility and had gotten in their cars to drive around to locate Resident #30. Resident #30 was located at a local drug store, returned to the facility between 9:30 A.M and 9:45 A.M., and was assessed by the DON with no injuries. The Administrator stated they contacted a company to fix the door the same day The door was fixed, and all other doors were audited to ensure they functioned appropriately. Interview on 09/08/22 at 3:00 P.M. with STNA #200 revealed she was the only staff member present on the memory care unit on 09/04/22 at the time Resident #30 exited the facility. STNA #200 stated Licensed Practical Nurse (LPN) #201 was assigned to the memory care unit but also was assigned residents that were outside of the memory care unit. STNA #200 stated she saw Resident #30 in the dining room at approximately 8:00 A.M. as she was assisting other residents with breakfast. STNA #200 stated during the time she was assisting other residents she heard the alarm to the door sounding; however, she denied turning off the alarm and stated she was unsure who had turned off the alarm as she was the only staff member present. STNA #200 stated when she heard the alarm, she looked outside the door and did not see anyone. STNA #200 noticed Resident #30 was no longer present in the dining room and began to look in other resident rooms and bathrooms. After searching the rooms and not locating Resident #30 STNA #200 informed the nurse who came to the memory care unit to assist in the search for Resident #30. STNA #200 stated some of the staff got in their cars to drive around and help locate Resident #30 and the receptionist called the police. STNA#200 could not provide an accurate timeframe of notification. STNA #200 stated after the police arrived, she provided a statement as well as a description of Resident #30. STNA #200 stated Resident #30 was returned to the facility and STNA #200 did not observe any injuries. STNA #200 stated she was in-serviced after the incident on the elopement procedures. Interview on 09/12/22 at 9:11 A.M. with LPN #201 revealed she was the assigned nurse on the memory care unit and in addition she was assigned residents outside of the memory care unit. LPN #201 stated STNA #200 asked for her assistance with Resident #32's [CONDITION(S)] at approximately 9:00 A.M. After LPN #201 completed the care for Resident #32, STNA #200 informed her Resident #30 was missing. LPN #201 was unable to recall the exact time STNA #200 informed her Resident #30 was missing but stated it had taken her approximately 15-20 minutes to complete the [CONDITION(S)] care. LPN #201 stated immediately after STNA #200 informed her she began looking in the resident rooms and some staff proceeded to look outside. LPN #201 stated the police arrived at the facility (unable to recall an approximate time) and she provided a statement, however, was not able to provide specific information because she was not present on the memory care unit when the elopement occurred. LPN #201 was informed Resident #30 had been located at a local drug store at approximately 10:00 A.M. and the DON and ADON performed a full body assessment on Resident #30 with no injuries noted. Review of Weather.com revealed the weather conditions on 09/04/22 were 73 degrees Fahrenheit with scatter rain showers. Review of the facility policy titled Wandering and Elopements revised 03/19 revealed if a resident is at risk for elopement a care plan will include strategies and interventions to maintain the resident ' s safety. If a resident was missing staff were to initiate the elopement emergency procedures that included a search of the building and premises, if resident was not located notify the Administrator, DON, law enforcement, legal representative, and physician. Once the resident was located and returned to the facility conduct an examination for injuries, contact the physician and report findings, notify the legal representative, and notify the search team the resident had been located. This deficiency substantiates Complaint Number OH 660.

Based on observation, interview and record review, the facility failed to ensure accurate documentation in resident medical records. This affected two residents (#20 and #76) of six residents reviewed for documentation. The facility census was 77. Findings include: Review of Resident #76's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 had intact cognition, and required extensive assistance with transfer, toileting and personal hygiene. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/12/22 at 8:35 A.M. with Resident #76 revealed she did not use her inhaler and had not used it in over a year. Resident #76 stated she did not have an inhaler at the bedside and she did not self administer it. Interview with Licensed Practical Nurse (LPN) #310 at the time of the interview, which was during medication administration, revealed he was not aware Resident #76 did not use her inhaler and stated it was been reported by the nursing staff that Resident #76 self administered the inhaler. Interview on 09/12/22 at 2:18 P.M. with the Director of Nursing (DON) confirmed Resident #76's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #20's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 07/25/22 revealed Resident #20 was at risk for elopement related to dementia diagnosis. Interventions included the use of a Wanderguard (monitoring device worn by a resident that when a resident is within close proximity of a secured/armed door the door will not open). Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had impaired cognition, required extensive assistance with toileting, limited assistance with personal hygiene and supervision with ambulation. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for September 2022 revealed the Wanderguard had been checked on 09/10/22 at 12:10 A.M., 09/11/22 at 7:17 A.M., no documentation for the evening shift and also checked on 09/12/22 at 10:50 A.M. Observation on 09/12/22 at 12:17 P.M. revealed Resident #20 was seated in a common dining area and was not interviewable. Further observation revealed no visible Wanderguard on Resident #20. Interview with State tested Nursing Assistant (STNA) #200 at time of observation confirmed Resident #20 was not wearing a Wanderguard. STNA #200 stated Resident #20 had returned from the hospital on 09/09/22 and was not aware why Resident #20 did not have a Wanderguard placed when he returned. Interview on 09/12/22 at 2:18 P.M. with the Director of Nursing (DON) confirmed the TAR contained documentation the Wanderguard had been checked for placement each day since the resident returned from the hospital and further stated Resident #20 was not wearing a Wanderguard when she observed the resident. The DON stated she had informed the unit manager at the time she observed Resident #20 and a Wanderguard was placed on the resident.

Based on observation, interview and record review the facility failed to ensure adequate staffing to ensure resident safety and timely incontinence care. This affected one resident (#30) of three reviewed for elopement and one resident (#32) of three observed observed for incontinence care. The facility identified 11 residents at risk for elopement and 34 for incontinence. The facility census was 77. Findings include: 1. Review of Resident #30's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) of seven that indicated severe cognitive impairment. Resident #30 was able to ambulate independently. Review of Quarterly Dementia Unit Functional Assessment and Review dated 08/02/22 revealed Resident #30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued placement on the memory care unit was recommended at time of assessment. Review of the care plan dated 08/04/22 revealed Resident #30 was at risk for elopement and had exit seeking behaviors due to poor safety awareness and cognitive deficits. Resident #30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included frequent monitoring, redirection and reorientation and a Wanderguard ankle bracelet (monitoring device worn by a resident that when a resident is within close proximity of a secured/armed door the door will not open). Resident #30 was at risk for falls related to history of wandering and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 had behaviors that included wandering and exit seeking as well as being known to cut or tear off her Wanderguard and was placed on the secure unit for safety related to wandering. Review of police report dated 09/04/22 revealed a call was received on 09/04/22 at 9:25 A.M. of a missing person. Police arrived at the facility (no time documented) and the Administrator informed them Resident #30 had walked out of the facility. Staff searched the facility and were not able to locate the resident. Some staff were driving around the area in an attempt to locate Resident #30. As police were still on scene at the facility an officer received a call (no time documented) indicating Resident #30 had been located at a local drug store. Interview on 09/08/22 at 12:19 P.M. with Maintenance Director (MD) #202 revealed he was present on 09/04/22. MD #202 was made aware Resident #30 was missing by Receptionist #203 sometime between 9:15 A.M. and 9:30 A.M. MD #202 proceeded to look for Resident #30 in his car at nearby businesses. MD #202 stated he saw police and fire at a local drug store and entered the store and identified Resident #30 was inside. MD #202 returned Resident #30 to the facility at approximately 10:30 A.M. After returning Resident #30, MD #202 checked the doors on the memory care unit and determined the magnetic strip above the door was not functioning, however the alarm was working. MD #202 indicated he reviewed the door alarm log and the audible alarm on the exit door which Resident #30 exited was activated at 7:21 A.M. and turned off at 7:27 A.M. Interview on 09/08/22 at 3:00 P.M. with State tested Nurse Aide (STNA) #200 revealed she was the only staff member present on the memory care unit on 09/04/22 at the time Resident #30 exited the facility. STNA #200 stated Licensed Practical Nurse (LPN) #201 was assigned to the memory care unit but also was assigned residents that were outside of the memory care unit. STNA #200 stated she saw Resident #30 in the dining room at approximately 8:00 A.M. as she was assisting other residents with breakfast. STNA #200 stated during the time she was assisting other residents she heard the alarm to the door sounding. STNA #200 stated when she heard the alarm, she looked outside the door and did not see anyone. STNA #200 noticed Resident #30 was no longer present in the dining room and began to look in other resident rooms and bathrooms. After searching the rooms and not locating Resident #30 STNA #200 informed the nurse who came to the memory care unit to assist in the search for Resident #30. STNA#200 could not provide an accurate timeframe of notification. Interview on 09/12/22 at 9:11 A.M. with Licensed Practical Nurse (LPN) #201 revealed she was the assigned nurse on the memory care unit and in addition she was assigned residents outside of the memory care unit. LPN #201 stated STNA #200 asked for her assistance with Resident #32's [CONDITION(S)] at approximately 9:00 A.M. After LPN #201 completed the care for Resident #32, STNA #200 informed her Resident #30 was missing. LPN #201 was unable to recall the exact time STNA #200 informed her Resident #30 was missing but stated it had taken her approximately 15-20 minutes to complete the [CONDITION(S)] care. LPN #201 stated immediately after STNA #200 informed her she began looking in the resident rooms and some staff proceeded to look outside. LPN #201 was informed Resident #30 had been located at a local drug store at approximately 10:00 A.M. and the Director of Nursing and Assistant Director of Nursing performed a full body assessment on Resident #30 with no injuries noted. Review of the memory care census provided by the facility revealed a census of 16 residents on 09/04/22. 2. Review of Resident #32's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 32 had impaired cognition, required extensive assistance with toileting, was incontinent of urine, and had a [CONDITION(S)] for bowel. Review of the care plan dated 09/07/22 revealed Resident #32 had self care deficits and required assistance with incontinence and [CONDITION(S)] care as needed . Interview on 09/08/22 at 10:51 A.M. with State tested Nursing Assistant (STNA) #305 revealed she was the only staff member present on the memory care unit where 16 residents resided. STNA #305 stated there was a nurse assigned to the unit, however the nurse also had residents outside of the unit that she was caring for. STNA #305 stated the memory care unit often only had one STNA assigned and she further stated she had observed residents who appeared to have been incontinent from the previous evenings when she had started her shift at 7:00 A.M. on occasions, however she could not recall exact dates. Observation on 09/08/22 at 11:57 A.M. revealed Resident #26's bed alarm was going off. At 11:59 A.M. Licensed Practical Nurse (LPN) #306 entered Resident #26's room to assist the resident back into bed. At time of observation LPN #306 stated she was the only staff present due to STNA #305 had went on a break. Observation of incontinence care on 09/12/22 at 8:19 A.M. with STNA #200 for Resident #32 revealed Resident #32 was in bed and an odor of stool was detected. STNA #200 approached Resident #32 and removed her blanket stating this is soaked and threw the blanket across the room. Further observation revealed Resident #32 had a [CONDITION(S)] and was covered in stool with some areas of stool dried on to her nightgown. STNA #200 stated she had not cared for Resident #32 yet this morning and stated she started her shift at 6:30 A.M. STNA #200 stated she was the only STNA present on the unit. Further observation revealed Resident #32's incontinence brief was heavily saturated with urine that had soaked through her sheets and onto her mattress. Resident #32 was not interviewable. Interviews on 09/12/22 between 8:35 A.M. and 8:47 A.M. with Residents #76 and #77 revealed concerns related to staffing. Resident #76 stated her medications were sometimes more than an hour late. Resident #77 stated on 09/10/22 he had several bowel movements and he had to wait between three and four hours to be cleaned up. Resident #77 further stated on occasions his morning medications had been given around lunch time. This deficiency substantiates Complaint Numbers OH 660, OH 366 and OH 662.

Based on observation, record review and interview the facility failed to ensure residents received timely incontinence care. This affected one Resident (#32) of three observed for incontinence care. The facility identified 34 incontinent resident. The facility census was 77. Findings include: Review of Resident #32's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had impaired cognition, required extensive assistance with toileting, was incontinent of urine and had a [CONDITION(S)] for bowel. Review of the care plan dated 09/07/22 revealed Resident #32 had self care deficits and required assistance with incontinence and [CONDITION(S)] care as needed . Observation of incontinence care on 09/12/22 at 8:19 A.M. with State tested Nurse Aide (STNA) #200 for Resident #32 revealed Resident #32 was in bed and an odor of stool was detected. STNA #200 approached Resident #32 and removed her blanket stating this is soaked and threw the blanket across the room. Further observation revealed Resident #32 was covered in stool with some areas of stool dried on to her nightgown. STNA #200 stated she had not cared for Resident #32 yet this morning and stated she started her shift at 6:30 A.M. STNA #200 stated she was the only STNA present on the unit. Further observation revealed Resident #32's incontinence brief was heavily saturated with urine that had soaked through her sheets and onto her mattress. Resident #32 was not interviewable. This deficiency substantiates Complaint Number OH 366.

Based on observation, record review and interview, the facility failed ensure Resident #34 recieved staff asstistance to shower. Actual Harm occurred when Resident #34 was showering unattended and fell fracturing her shoulder. This affected one (Resident #34) of three residents reviewed for falls. The facility census was 65. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses including frontal lobe executive function deficit following a cerebral infarction, [CONDITION(S)] with behavioral disturbances, difficulty walking, and history of falls. Review of the fall risk assessments dated 03/15/21, 05/04/21, and 07/29/21 revealed the resident was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/29/21, revealed the resident had impaired cognition. The resident was independent for bed mobility, transfers, and ambulation. The resident required one-staff physical assistance for bathing. Review of the plan of care dated 08/24/21 revealed the resident was at risk for falls due to gait/balance problems, poor communication and comprehension, psychoactive drug use, history of falls, and poor safety awareness. Interventions included to place the call light within reach and encourage the resident to use it, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, maintain a safe environment with even floors free from spills or clutter, and keep personal items within reach. Review of the plan of care dated 09/18/20 revealed the resident had an activities of daily living (ADL) care performance deficit related to confusion. Interventions included to provide physical assist/supervision with bathing dated 04/21/21 and 08/12/21 and a flat sensor pad to the bed and wheelchair dated 09/24/21. Review of physician orders for the past three months identified no fall prevention devices ordered. A lowboy bed and flat sensor pads were implemented on 09/24/21, two days after the fall incident. Review of the nurse's notes dated 09/22/21 at 11:45 A.M. revealed resident was found on her bathroom floor after another resident called out for help. The Director of Nursing, the nurse on duty, and the State tested Nurse Assistant (STNA) assisted with the occurrence until the paramedics arrived and transported the resident to the hospital. Review of the nurse's notes dated 09/22/21 at 12:30 P.M., revealed the resident was found in her bathroom in the prone (facedown) position with her arm under her. The resident was taking a shower and slipped. Review of the nurse's notes dated 09/22/21 at 9:08 P.M. revealed the facility was informed by the family that the resident had a minor shoulder fracture. Review of the fall investigation dated 09/22/21 revealed Resident #34 was alert to person and place. The root cause of incident was a wet floor, resident had gait imbalance, impaired memory, and weakness. The report had limited documentation related to interventions that were in place at the time of the incident. Interview on 09/27/21 at 10:27 A.M., MDS Nurse #80 stated that according to the assessments dated 05/04/21 and 07/29/21 the resident required one staff assistance for bathing which means that staff would be assisting the resident and must be physically present during the shower. Interview on 09/29/21 at 10:32 A.M., Restorative Director (RD) #79 stated that no residents were authorized to take a shower without staff regardless of the residents functioning status. Interview on 09/29/21 at 10:40 A.M., Licensed Practical Nurse (LPN) #6 stated that he was at the nurse's desk when he heard the resident call for help. LPN# 6 stated that he told STNA #2 to go to the resident's room. LPN#6 stated that he went down to the resident's room and observed the resident lying on the bathroom floor. LPN#6 stated that Resident #34 would always take showers on her own, but staff would check on her periodically. LPN #6 stated that Resident #34 was not at risk for falls at the time of the incident. Interview on 09/29/21 at 10:49 A.M., STNA #2 stated that she observed water in the hallway in front of the resident's room. STNA #2 stated that no resident called out for help, and she alerted LPN #6 to the incident. The STNA stated that the last time she observed the resident, the resident was lying in bed. STNA #2 stated when she went into the room to check on the resident, the resident was lying face down on the bathroom floor with the lower half of her body resting in the shower. STNA #2 stated that the water was out in the hallway almost reaching the resident room across the hall. Observations at the time of interview revealed that the water had traveled at least 15 feet into the hallway, the hallway had hard floors at time of the incident. STNA #2 stated that the resident's lower body was blocking the drain in the shower. STNA #2 stated that no alarms were sounding at the time of the observation as the resident could have turned off the fall alarm. Further review of the medical record after the interview revealed that the no fall alarms were ordered or implemented until 09/24/21, two days after the fall. Interview on 09/29/21 at 2:53 P.M., the Director of Nursing stated that the resident would be up ad lib (meaning at one's desire) in her room and on the unit. The DON could not state why a resident who is a high fall risk would be able to rise and walk the room or unit without staff assistance. The DON also stated that the resident would be very upset if the facility implemented the sensory pads. This deficiency substantiates Complaint Number OH 985.

Based on record review, observation, interviews and policy review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all 65 residents who received food from the kitchen. The census was 65. Findings include: 1. Initial tour of the kitchen was conducted on 09/27/21 5:58 A.M. to 6:25 A.M. with Registered Dietitian (RD) #44. Above a stainless-steel food preparation table holding the uncovered meat slicer and food processor was a heavily soiled ceiling and side wall of the hood fire suppression unit. The ceiling and side wall had dried on splatters of food crumbs and staining. RD #44 said she believed while processing food some had blown up to the ceiling and had not been cleaned up yet. Next to the hand washing sink were two black plastic polymer dish carts having multiple dividers to separate and stack dishes inside the carts. Both were uncovered, full of dishes and thermal dome covers leaving the clean dishes and domes open for back splashing from the hand sink. The carts presented as unwashed for an extended period, as the bottom had a heavy buildup of whitish-yellow crusting in the crevices and various crumbs and unidentifiable crumb-like particles on the top of the carts and throughout the inside. Within the walk-in cooler were multiple packages of open cheeses either undated or outdated presenting as evidence the cheese was not being rotated and discarded to prevent potential food borne illness sources. An open bag of parmesan cheese within a Ziploc baggie was dated 07/28/21. An opened and partially used block of yellow American cheese was wrapped in Saran Wrap and was undated. An open mozzarella cheese was dated 08/30/21 and open provolone cheese was dated 08/22/21. RD #44 verified the findings and threw out the items saying they usually go through the cooler on Mondays and toss out any outdated food products. When asked if it was acceptable to have open cheese still in the cooler from 07/28/21, 08/22/21 and 08/30/21 she replied the kitchen went by manufacture use by dates if the packages were unopened but once open those items should have been thrown out. The facility provided the surveyor with an undated document titled Policy: Labeling and Discarding of Commercial Food Items. The document stated leftover food should be labeled with the date it was opened and first used and foods need to be discarded within seven days after the commercial product is opened but no longer than the expiration date listed on package. The document gave no instructions for highly perishable foods or time controls for safety for various refrigerated, prepared food items demonstrating a lack of policy guidance to ensure food safety. 2. Observation of the general kitchen environment was conducted on 09/29/2021 from 9:31 A.M. to 9:49 A.M. with Dietary Supervisor (DM) #82 and RD #44. The meat slicer remained uncovered, and the dish carts remained next to the hand sink and remained uncovered. The dish carts were still dirty with crumbs and staining on the bottom and throughout the crevices in the plastic. Gnat traps were observed on the floor behind the three-basin sink with evidence of heavy buildup of black, beige staining and crumbs where the baseboard meets the floor. The uncleanliness of the perimeter of the floor where the baseboards met the floor was noted to be pervasive throughout the kitchen especially behind the cooking ranges and stainless-steel pan tables holding cooking pans. There was a silver bait box approximately eight inches long and four inches wide for catching rodents behind a stainless-steel preparation table next to the cooking ranges. There was a similar size silver bait box for catching rodents in the dry stock room below a rack of dry breadcrumbs. A heavy collection of crumbs and accumulated buildup of black dirt surrounded the bait box presenting as a concerning opportunity to attract pests to the food supply. The entire perimeter of the dry stock room where the baseboards met the floor was heavily collected with crumbs and dirt build up showing evidence it had gone a long while without proper attention. During this observation DM #82 and RD #44 verified the findings. Both said they had not seen any rodents, but gnats were an ongoing issue. DM #82 said she was in the process of hiring more staff for the kitchen and she expressed she did put out daily assignment sheets for cleaning but did not really keep cleaning lists. Record review was conducted of the facility document titled [NAME]-Ann [NAME] Dietary Cleaning Log dated 09/05/2021 to 09/30/2021. The log had zones for cleaning listed with the assigned employee position responsible for those zones. It was void for any cleaning assignments specific to the kitchen floor and ceiling. Record review was conducted of the facility document titled State of Ohio Food Inspection Report dated 09/20/2021 and authored by Sanitarian #900. Sanitarian noted the kitchen was found out of compliance for a lack of clean and sanitary food contact surfaces and carts holding plates being stored next to the hand sink.

Based on record review, observation and interviews, the facility failed to ensure the residents on the secured unit had a dignified dining experience. This affected eleven (Resident's #5, #7, #14, #27, #30, #36, #46, #47, #50, #51 and #53) eating in the dining room during the observations and had the potential to affect all 13 residents living on the unit. The facility census was 65. Findings include: Record review was conducted of the resident council minutes dated 06/23/21 and 07/21/21 and signed by the Administrator. A concern was noted on 06/23/21 residents would like to have their dining room trays come out with the person they sit with. It was noted to resolve the problem a seating chart was put in the kitchen to assist with loading up trays in an orderly fashion. On 07/21/21 minutes it was noted the residents stated their trays were coming out at a closer time with their lunch mates. 1. Observation was conducted on 09/27/21 from 8:15 A.M. to 8:53 A.M. of the breakfast meal service within the secured unit. The meal consisted of cereal, eggs, toast, juice, milk, and other beverage choices. State tested Nursing Assistant (STNA) #72 began passing trays with a second STNA at 8:37 A.M. upon receiving the tray cart from the kitchen. Resident #5 and Resident #51 were seated at a table together. Resident #5 received her tray at 8:40 A.M. At 8:46 A.M. her tablemate Resident #51 said to her where is my food? How come you get yours and I don't? I am hungry. Can I have some of your bread? Resident #5 broke off a piece of her soft bread and handed it to Resident #51 who said, oh it tastes like peanut butter and quickly ate the bread. At 8:46 A.M. Resident #51 got her meal tray. During this observation period the STNAs proceeded to serve other tables in the same fashion where only one person would get served while the other resident at the table was without food. Resident #46 was seated with Resident #36. Resident #36 had her meal and Resident #46 could be seen sitting with a frowled face, throwing her hands in the air and saying, come on and she sat for several minutes watching Resident #36 eat her meal. Upon initial observation of Resident #46 entering the dining room for the meal she had presented as calm then developed the frowling facial expression as she watched her table mate and others get served their food before her. Interview was conducted on 09/27/21 at 8:54 A.M. with STNA #72 who verified the above findings. When asked what her procedure was for passing trays in the dining room, she replied she takes one tray out at a time and however the kitchen sends them out that is how she serves them. She verified there were two residents seated at most of the tables and she did not serve each person at a table before moving onto the next. 2. Observation was conducted on 09/29/21 at 12:20 P.M. of the lunch meal service within the secured unit. The meal was cabbage rolls, mashed potato, vegetable blend, cake, and various beverages. Registered Nurse (RN) #83 was the nurse on the unit and identified all eleven residents seated in the dining room (Resident's #5, #7, #14, #27, #30, #36, #46, #47, #50, #51 and #53). Dietary Aide (DA) #41 was assisting in the dining room as the trays got delivered from the kitchen at 12:36 P.M. Resident #7 was seated with Resident #47. Resident #7 was the first tray served at 12:38 P.M. At 12:42 P.M. Resident #47 began banging his knuckles of both hands on the table and made slapping hand motions over his head as he watched Resident #7 eat and others around him eating their food. At 12:45 P.M. Resident #47 got his tray. During this observation period the staff proceeded to serve other tables before making sure both residents seated at a table had their food before moving onto the other tables. Interview was conducted on 09/29/21 at 12:50 P.M. with DA #41 who verified she was passing the trays as she pulled them out of the cart and not in order of the tables. When she was asked if she knew who sat at each table, she showed the surveyor each resident's tray card with a table number on the back. When asked why she did not serve one table at a time before moving onto the next she said she served them in the order the trays were placed into the cart.

Based on the review of the medical record, facility policies and procedures for abuse and crime reporting, interviews with staff, and interview with local law enforcement, the facility failed to report a reasonable suspicion of a crime involving an allegation of staff sexual abuse to local law enforcement. This resulted in Immediate Jeopardy and the likelihood of serious emotional harm on 09/24/19 when State tested Nursing Assistant (STNA) #200 was alleged to perform a sexual act in Resident #42's room, and the facility failed to report this suspected crime to local law enforcement. This had the potential to effect the facility population of 91 residents. On 10/01/19 at 5:00 P.M., Administrator #201, Administrator #202, and Director of Nursing (DON) were notified the Immediate Jeopardy began on 09/24/19 at 7:00 [NAME]M. when STNA #203 alleged STNA #200 was in Resident #42's room performing a sexual act. The Immediate Jeopardy was removed on 10/02/19 at 4:00 P.M. when the facility implemented the following corrective action: · On 10/01/19 from 5:31 P.M. to 10/02/19 at 12:00 P.M., all staff were in-serviced by Assistant Director of Nursing (ADON) #208, ADON #209, the Director of Nursing (DON), and Registered Nurse (RN) #105 on the facility Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy and procedures. · On 10/01/19 at 6:30 P.M. local law enforcement was notified of the allegation of abuse and was dispatched to the facility at 6:45 P.M. · On 10/02/19 at 11:00 [NAME]M., Administrator #202 was in-serviced on the facility Elder Justice Crime Reporting policy by Owner #201. · On 10/02/19 at 1:30 P.M., a quality assurance performance improvement (QAPI) meeting was held, which included a plan that all abuse allegations would be tracked and reviewed monthly. The plan for improvement included the facility staff were to follow their Abuse Prevention Policy including, but not limited to: Allegations to be reported immediately to the supervisor or Administrator. The Administrator will report to local law enforcement per the Elder Justice Crime Reporting and Abuse Prevention Policy guidelines. The Owner/Health Services Executive, will review the SRI upon its initiation and completion. These will be reviewed in this manner for six months from 10/02/19. Although the Immediate Jeopardy was removed on 10/02/19 at 4:00 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired and she required extensive assistance with one staff person for transfers, dressing, and personal hygiene, and extensive assistance with two staff for bed mobility and toileting. Review of Resident #42's medical record revealed no documented evidence of an allegation of sexual abuse or that it was reported to local law enforcement. Interview on 10/01/19 at 11:48 [NAME]M. with STNA #203 revealed on 09/24/19 between approximately 7:00 [NAME]M. and 7:30 [NAME]M. she walked into Resident #42's room to find staff to help her with a resident transfer. After opening the door, she had to close the bathroom door a little to see inside the room. The room was dark, but she said she could see STNA #200 slouched in a chair at the foot of Resident #42's bed. STNA #203 said STNA #200's stomach was exposed, his pants were pulled down, exposing parts of his legs, and he was masturbating. STNA #203 said Resident #42 was sleeping, but if awakened she could have seen STNA #200 masturbating. STNA #203 said she told STNA #200 that she needed assistance when he had time and then left the room. STNA #203 revealed she reported the incident to RN #204 and RN #205 on 09/24/19, approximately 10 minutes after her observation. Interview on 10/01/19 at 11:31 [NAME]M. with RN #204 revealed last week STNA #203 reported to her and RN #205 that STNA #200 was observed masturbating in Resident #42's room. RN #204 revealed STNA #203 reported she was looking for someone to help her with another resident and she walked in on STNA #200 performing a sexual act on himself in Resident #42's room. RN #204 indicated STNA #203 reported Resident #42 was sleeping. RN #204 said STNA #203 reported it to her about 7:30 [NAME]M. and she said she attempted to contact Administrator #202 by phone at 9:00 [NAME]M. to report the incident but did not get through. RN #204 said she reported the allegation to Administrator #202 at 10:00 [NAME]M. Interview on 10/01/19 at 12:02 P.M. with Administrator #202 revealed RN #205 came to her after morning rounds, around 9:30 [NAME]M., gave her a note which said for her to come to her office. At that time, she went to her office and she was notified that STNA #203 reported entering Resident #42's room about 7:00 [NAME]M. and observed STNA #200 masturbating. STNA #200 was in the dark, but the light was shining from the bathroom. Administrator #202 said STNA #203 demonstrated how STNA #200 was sitting back in the chair and he had just finished masturbating. STNA #203 reported she then closed the door and reported it to RN #205. After discussing the incident with STNA #203 and RN #205, Administrator #202 went to Staffing Coordinator #206, and learned STNA #200 left the facility due to a family emergency and was no longer there. Administrator #202 said the facility did not identify the incident as a potential abuse situation because Resident #42's room was dark, and she was sleeping. Administrator #202 confirmed, as of 10/01/19, the facility had not interviewed STNA #200 and did not report the allegation to local law enforcement as required. Interview on 10/02/19 at 3:49 P.M. with Patrolman #207, from local law enforcement, confirmed the facility did not report the allegation of sexual abuse involving Resident #42 until 10/01/19. He said he was dispatched to the facility at 6:46 P.M. on 10/01/19. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/10/18, revealed it is the facility policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation and mistreatment, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. In cases where a crime is suspected, the Administrator is to report to local law enforcement in accordance with the facility's Crime Reporting policy. Review of the undated facility policy titled, Elder Justice Act Crime Reporting, revealed the facility will report any reasonable suspicion of a crime against a resident, that does not result in serious bodily injury, within 24 hours to the local police department. This deficiency substantiates Complaint Number OH 406.

Based on the review of the medical record, the facility's abuse policy and procedure, facility Self-Reported Incident (SRI) history, and interviews with staff, the facility failed to timely report an allegation of sexual abuse involving Resident #42. This resulted in Immediate Jeopardy and the likelihood of serious emotional harm on 09/24/19 when State tested Nursing Assistant (STNA) #200 was alleged to perform a sexual act in Resident #42's room. The facility staff failed to immediately report the allegation to supervisory staff and the Administrator and failed to timely report the alleged criminal activity to local law enforcement. This had the potential to effect the facility population of 91 residents. On 10/01/19 at 5:00 P.M. Owner #201, Administrator #202, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/24/19 at 7:00 [NAME]M. when STNA #203 alleged STNA #200 performed a sexual act in Resident #42's room. The Immediate Jeopardy was removed on 10/02/19 at 4:00 P.M. when the facility implemented the following corrective action: · On 10/01/19 from 5:31 P.M. to 10/02/19 at 12:00 P.M., all staff were in-serviced by Assistant Director of Nursing (ADON) #208, ADON #209, the Director of Nursing (DON), and Registered Nurse (RN) #105 on the facility Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy and procedures. · On 10/01/19 at 5:50 P.M. a Self-Reported Incident (SRI) and was initiated by Administrator #202. · On 10/02/19 at 9:00 [NAME]M. the Medical Director was notified of the allegation of abuse. · On 10/02/19 at 1:30 P.M. a quality assurance performance improvement meeting was held, which includes a plan that all abuse allegations will be tracked and reviewed monthly. The plan for improvement includes the facility will follow their Abuse Prevention Policy including, but not limited to: Allegations will be reported immediately to the supervisor or Administrator; and The Administrator will report to the State survey agency immediately or within two hours when the allegations involve abuse or serious bodily injury. The Owner/Health Services Executive will review the SRI upon its initiation and completion for six months from 10/02/19. Although the Immediate Jeopardy was removed on 10/02/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #42's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed her cognition was moderately impaired and she required extensive assistance with one staff person for transfers, dressing, and personal hygiene, and extensive assistance with two staff for bed mobility and toileting. Review of the facility SRI history revealed no allegations of sexual abuse involving Resident #42 had been reported to the State Agency. Interview on 10/01/19 at 11:48 [NAME]M. with STNA #203 revealed on 09/24/19 between 7:00 [NAME]M. and 7:30 [NAME]M. she walked into Resident #42's room to find staff to help her with a resident transfer. After opening the door, she had to close the bathroom door a little to see inside the room. The room was dark, but she could see STNA #200 slouched in a chair at the foot of Resident #42's bed. STNA #203 said she could see STNA #200's stomach was exposed, his pants were pulled down, exposing parts of his legs, and he was masturbating. STNA #200 said Resident #42 was sleeping, but if awakened she could have seen STNA #203 masturbating. STNA #203 said she told STNA #200 that she needed assistance when he had time and then left the room. STNA #203 revealed she reported the incident to, RN #204 and RN #205 on 09/24/19, approximately 10 minutes after her observation. Interview on 10/01/19 at 11:31 [NAME]M. with Registered Nurse (RN) 204 revealed last week STNA #203 reported to her and RN #205 that STNA #200 was masturbating in Resident #42's room. RN #204 said STNA #203 reported she was looking for someone to help assist with a transfer and she walked in on STNA #200 performing a sexual act on himself in Resident #42's room. RN #204 indicated STNA #203 reported the resident was sleeping when it occurred. RN #204 revealed STNA #203 reported it to her about 7:30 [NAME]M. RN #204 revealed she attempted to contact Administrator #202 by phone at 9:00 [NAME]M. to report the incident but did not get through. RN #204 revealed she reported it at 10:00 [NAME]M. to Administrator #202. Interview on 10/01/19 at 12:02 P.M. with Administrator #202 revealed RN #205 came to her after morning rounds, around 9:30 [NAME]M., gave her a note which said for her to come to her office. At that time, she went to her office and she was notified that STNA #203 reported entering Resident #42's room about 7:00 [NAME]M. and observed STNA #200 masturbating. STNA #200 was in the dark, but the light was shining from the bathroom. STNA #203 reported she then closed the door and reported it to RN #205. After discussing the incident with STNA #203 and RN #205, Administrator #202 went to Staffing Coordinator #206, and learned STNA #200 left the facility due to a family emergency and was no longer in the facility. Administrator #202 then called STNA #200 twice and left a message informing him that his employment would be terminated. Administrator #202 revealed the facility did not identify the incident as a potential abuse situation because the room was dark, and the resident was sleeping. The Administrator confirmed the allegation was not reported to the State Agency. Interview on 10/01/19 at 12:15 P.M. with RN #205 revealed on 09/24/19 close to 8:00 [NAME]M., STNA #203 reported to her and RN #204 that she went into Resident #42's room to ask STNA #200 to help her with a transfer, the room was dark, and she could see his pants were down and she could see that he was masturbating. RN #205 revealed STNA #203 then was going to the charge nurse, but had to help another STNA with a transfer, so she came to her and RN #204 after the transfer to report the incident. RN #205 revealed she went down Resident 42's hall right away, and STNA #200 was not near the resident's room, but was transporting a different resident in a wheelchair down the same hallway. RN #205 revealed she went into Resident #42's room and the resident was sleeping. RN #205 revealed she then headed down the hall and saw Scheduler #206 and STNA #200's brother walking down the hall. RN #205 than saw STNA #200 walking down another hall and STNA #200 left with his brother. RN #205 revealed shortly before 10:00 [NAME]M. the incident was reported to Administrator #202. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/10/18, revealed it is the facility policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation or Resident Property, Exploitation and Mistreatment, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. All incident and allegations of abuse must be reported immediately to the Administrator. The Administrator or his/her designee will notify the Ohio Department of Health of all alleged violations involving abuse or serious bodily injury as soon as possible and within two hours. But in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency substantiates Complaint Number OH 406.

Based on review of the medical record, facility Self-Reported Incident (SRI) history, facility abuse policy and procedure and interviews with staff, the facility failed to investigate an allegation of abuse involving one resident (Resident #42), and failed to ensure 12 additional residents (Resident #20, Resident #58, Resident #59, Resident #62, Resident #63, Resident #64, Resident #65, Resident #66, Resident #67, Resident #68 Resident #69, and Resident #70) were protected after the alleged incident occurred. This resulted in Immediate Jeopardy and the likelihood of serious emotional harm on 09/24/19 when State tested Nursing Assistant (STNA) #200 was alleged to perform a sexual act in Resident #42 ' s room. On 10/01/19 at 5:00 P.M., Owner #201, Administrator #202, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/24/19 at 7:00 [NAME]M. when STNA #200 was allegedly found in Resident #42 ' s room performing a sexual act. The Immediate Jeopardy was removed on 10/02/19 at 4:00 P.M. when the facility implemented the following corrective action: · On 10/01/19 from 5:31 P.M. to 10/02/19 at 12:00 P.M., all staff were in-serviced by Assistant Director of Nursing (ADON) #208, ADON #209, the Director of Nursing (DON), and Registered Nurse (RN) #105 on the facility Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy and procedures. · On 10/01/19 at 6:30 P.M. local law enforcement was notified of the allegation of abuse and was dispatched to the facility at 6:45 P.M. · On 10/02/19 at 9:00 [NAME]M. the Medical Director was notified of the allegation of abuse. · On 10/02/19 at 11:00 [NAME]M., Owner #201 in-serviced Administrator #202 and RN #205 on the facility's Crime Reporting policy and the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure including completion of thorough investigations of all allegations of abuse within the required time frames. · On 10/02/19 at 1:30 P.M. a quality assurance performance improvement meeting was held, which included a plan that all abuse allegations will be reported immediately per their abuse prevention policy to a supervisor or the Administrator. All allegations involving abuse or serious bodily injury will be reported immediately or within two hours. The Administrator will complete an SRI immediately but no later than 24 hours. · On 10/02/19 at 1:30 P.M. a quality assurance performance improvement meeting was held, which includes a plan that that all abuse allegations will be tracked and reviewed monthly. The plan for improvement includes the facility will follow Abuse Prevention Policy including but not limited to: Allegations reported immediately to supervisor or Administrator and the Administrator will report to local law enforcement per Elder Justice Crime Reporting and Abuse Prevention Policy guidelines. The Owner/Health Services Executive will review the SRI upon its initiation and completion. These will be reviewed in this manner for six months from 10/02/19. Although the Immediate Jeopardy was removed on 10/02/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #42 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired and she required extensive assistance with one staff person for transfers, dressing, and personal hygiene and extensive assistance with two staff for bed mobility and toileting. Interview on 10/01/19 at 11:48 [NAME]M. with STNA #203 revealed on 09/24/19 between approximately 7:00 [NAME]M. and 7:30 [NAME]M. she walked into Resident #42 ' s room to find staff to help her with a resident transfer. After opening the door, she had to close the bathroom door a little to see inside the room. The room was dark, but she said she could see STNA #200 slouched in a chair at the foot of Resident #42 ' s bed. STNA #203 said STNA #200 ' s stomach was exposed, his pants were pulled down, exposing parts of his legs, and he was masturbating. STNA #203 said Resident #42 was sleeping, but if awakened she could have seen STNA #200 masturbating. STNA #203 said she told STNA #200 that she needed assistance when he had time and then left the room. STNA #203 revealed she reported the incident to, Registered Nurse (RN) #204 and RN #205 on 09/24/19, approximately 10 minutes after her observation. Interview on 10/01/19 at 11:31 [NAME]M. with RN #204 revealed last week STNA #203 reported to her and RN #205 that STNA #200 was masturbating in Resident #42 ' s room. RN #204 said STNA #203 reported she was looking for someone to help assist with a transfer and she walked in on STNA #200 performing a sexual act on himself in Resident #42 ' s room. RN #204 indicated STNA #203 reported the resident was sleeping when it occurred. RN #204 revealed STNA #203 reported it to her about 7:30 [NAME]M. RN #204 said she attempted to contact Administrator #202 by phone at 9:00 [NAME]M. to report the incident but was unable to reach her. RN #204 said she reported the allegation to Administrator #202 at 10:00 [NAME]M. Interview on 10/01/19 at 12:02 P.M. with Administrator #202 revealed RN #205 came to her after morning rounds, around 9:30 [NAME]M., gave her a note which said for her to come to her office. At that time, she went to her office and she was notified that STNA #203 reported entering Resident #42 ' s room about 7:00 [NAME]M. and observed STNA #200 masturbating. STNA #200 was in the dark, but the light was shining from the bathroom. STNA #203 reported she then closed the door and reported it to RN #205. After discussing the incident with STNA #203 and RN #205, Administrator #202 went to Staffing Coordinator #206 and learned STNA #200 left the facility for a family emergency. Administrator #202 said she called STNA #200 twice and then left a message informing him his employment would be terminated. Administrator #202 verified Resident #42 was not assessed or interviewed regarding this abuse allegation. Administrator #202 explained that since STNA #203 reported the resident was sleeping when she observed STNA #200 masturbating, the facility did not investigate the allegation of sexual abuse. Administrator #202 verified she did not interview any staff or residents and did not attempt to obtain any witness statements. Administrator #202 said STNA #200 was terminated due to attendance issues and leaving work early on 09/24/19. Administrator #202 confirmed, as of 10/01/19, the facility did not identify the allegation as a potential sexual abuse situation because the room was dark, and the resident was sleeping. Interview on 10/01/19 at 12:15 P.M. with RN #205 revealed on 09/24/19, close to 8:00 [NAME]M., STNA #203 reported to her and RN #204 that she went into Resident #42 ' s room to ask STNA #200 to help her with a transfer. She said the room was dark, but she could see STNA #200 ' s pants were pulled down and she could see that he was masturbating. RN #205 said STNA #203 than went to the charge nurse, but before she reported the observation, she went to help another STNA transfer a different resident. She said STNA #203 then came to her and RN #204 to report the incident, which allowed STNA #200 to continue to provide resident care. RN #205 revealed she went down Resident 42 ' s hall right away, and STNA #200 was not near the Resident #42 ' s room, but he was observed escorting a different resident in a wheelchair down the same hallway. RN #205 said she went into Resident #42 ' s room and the resident was sleeping. RN #205 stated she went down the hall and saw Staffing Coordinator #206 and STNA #200 ' s brother. RN #205 than saw STNA #200 walking down another hall and then he left the facility with his brother. RN #205 verified it was shortly before 10:00 [NAME]M. when the incident was reported to Administrator #202. Interview on 10/01/19 at 1:14 P.M. with STNA #203 revealed after she observed STNA #200 performing the sexual act in Resident #42 ' s room, she went to the charge nurse, but before she could report the incident, she went to help another STNA transfer a different resident. STNA #203 said it was approximately ten minutes after she observed STNA #200 masturbating in Resident #42 ' s room that she actually reported the incident to RN #204 and RN #205. Interview on 10/01/19 at 4:22 P.M. with Administrator #202, with Owner #201 present, revealed the facility did not consider the observed incident an allegation of abuse because STNA #203 and RN #105 said Resident #42 was sleeping. Administrator #202 said the facility did not feel an investigation should be completed as the incident was not purposeful, and the resident did not request to speak with any staff about the situation. Interview on 10/02/19 at 9:12 [NAME]M. with STNA #203 revealed STNA #200 was seating in a chair in front of the window, near the foot of Resident #42 ' s bed. The privacy curtain between Resident #42 and her roommate was closed. STNA #203 confirmed STNA #200 was seated where he would be seen if Resident #42 had awakened during the sexual act. Review of STNA #200 ' s assignment sheet, dated 09/24/19, confirmed he and STNA #203 were assigned to the hall where Resident #42 resided. STNA#200 was assigned to provide care to 12 other residents, Resident #20, Resident #58, Resident #59, Resident #62, Resident #63, Resident #64, Resident #65, Resident #66, Resident #67, Resident #68 Resident #69, and Resident #70, in addition to Resident #42. Review of STNA #200 ' s Timecard Editor form, revealed he clocked in to work at 6:32 [NAME]M. and clocked out at 8:13 [NAME]M. Review of Resident #42 ' s medical record revealed no evidence the resident was assessed, or the facility interviewed the resident regarding the allegation of sexual abuse on 09/24/19. Review of the facility Self-Reported Incident (SRI) history revealed no allegations of sexual abuse had been reported to the State Agency. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/10/18, revealed the facility is to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Facility staff should immediately report all allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. In cases where a crime is suspected, the Administrator will report to local law enforcement in accordance with the Crime Reporting policy. The policy indicated, the initial response when a staff member is accused or suspected of abuse, is to immediately remove the staff member from the facility. All incident and allegations of abuse must be reported immediately to the Administrator or designee. The Administrator or his/her designee will notify the Ohio Department of Health of all alleged violations involving abuse as soon as possible, but in no event later than 24h hours from the time the incident/allegation was made known to the staff member. All allegations involving allegations of abuse or serious bodily injury were to be reported within two hours. Once the Administrator and ODH are notified, an investigation of the allegation violation would be conducted and completed within five working days. The investigation protocol included interviewing the resident involved, the accused, and all witnesses. The protocol indicated they would obtain a statement from the involved resident, if possible, the accused, and each witness and evidence of the investigation should be documented. This deficiency substantiates Complaint Number OH 406.

Based on observation, record review, staff interview, review of fall incident reports, hospital records and the mechanical lift operating manual, the facility failed to ensure safety measures were in place to prevent accidents from occurring for three residents (Resident #117, Resident #118, and Resident #93). This affected three of six residents reviewed for falls and resulted in actual harm for Resident #117 who sustained a fractured humerus and Resident #118 who sustained a head laceration as the result of improper transfers with a mechanical lift. Findings include: 1. Review of Resident #117's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #117's Minimum Data Set Assessment 3.0 ((MDS) dated [DATE], revealed Resident #117 was totally dependent on two staff members for transfers. Review of the physician orders [REDACTED].#117 included to use a mechanical lift (Hoyer) with two persons for transfers. Review of nurse's notes dated 11/21/14 at 2:30 P.M. revealed Resident #117 slid out of the sling during a Hoyer lift transfer. The note revealed Resident #117 had complaints of pain to the right elbow and shoulder. The nurses' note did not indicate the range of motion for the upper right extremity. Review of the nurses' note dated 11/21/14 at 6:40 P.M. revealed the nurse received a report of Resident #117 sliding out of the Hoyer lift sling. The nurses' note indicated Resident #117 was sent out by ambulance to the hospital. The date and time the resident was sent out was not listed. Review of the incident report dated 11/21/14 revealed the location of the incident was Resident #117's room. The incident occurred on 11/21/14 at 2:00 P.M. while transferring Resident #117 with the Hoyer lift and two person assistance. The description of the incident revealed Resident #117 was being transferred from a Broda chair (a specialized wheelchair) to the bed when one of the four loops from the Hoyer lift pad slipped off. The report stated Resident #117 was gently lowered and guided toward the bed. Resident #117's body began to shift and Resident #117's lower body slid out of the Hoyer lift pad with the right arm through the Hoyer sling. The note revealed the State-tested nurse aide (STNA) lowered Resident #117 to the floor and positioned the resident with pillows. The report revealed Resident #117 had complaints of pain to the right elbow and shoulder with range of motion. Review of STNA #12's statement for the incident dated 11/21/14 at 2:00 P.M. revealed STNA #12 went into the room to assist Resident #117 during a transfer from the wheelchair to the bed using the Hoyer lift. The Hoyer pad was hooked up and Resident #117 was raised slightly off the wheelchair. After raising Resident #117 up, one hook slid off the Hoyer. Resident #117 was lowered and guided towards the bed. Resident #117's right arm was hanging out of the Hoyer lift and Resident #117's body began to slide downward. The statement revealed staff assisted the resident to the floor and the resident was positioned with pillows. Review of STNA #14's statement for the incident dated 11/21/14 revealed STNA #12 had requested one assistance with the Hoyer lift transfer for Resident #117. STNA #14 entered the room first and placed the Hoyer device over the resident and fastened the loops of the Hoyer pad to the Hoyer lift. Resident #117 verbalized that the Hoyer lift was uncomfortable so STNA #14 raised it slightly for comfort. The statement indicated the loops were attached at that point. While Resident #117 was being lifted a loop came off the Hoyer. Resident #117's right arm was holding the side of the sling preventing the resident from falling and at the same time STNA #12 lowered her to the floor. Review of the hospital records revealed Resident #117 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the history and physical from the hospital record revealed Resident #117 presented after a fall at the nursing home. The record revealed the emergency medical staff and Resident #117's daughter stated Resident #117 was being lowered to the floor from a Hoyer lift when Resident #117's right arm and shoulder got caught on the Hoyer. The record revealed Resident #117 had pain in the right elbow and shoulder. Review of the X-ray of the right humerus dated 11/21/14 at 5:00 P.M. revealed a displaced angulated, segmental fracture of the distal right humeral shaft. Review of the record revealed Resident #117 had an open reduction internal fixation of the right humerus on 11/23/14. Interview on 03/02/15 at 12:24 P.M. with the Director of Nursing (DON) confirmed there was no evidence of malfunction with the Hoyer and the Hoyer sling was intact with no fraying. The DON indicated the STNAs had raised Resident #117 up with the Hoyer lift to transfer the resident from the Broda chair to the bed. The left lower loop of the Hoyer pad released during the transfer and Resident #117's right arm was holding the resident in the sling. The DON indicated when the STNAs saw the resident start to slide they grabbed the resident and lowered the resident down. The DON indicated the STNAs did raise the resident up "a little bit" prior to the transfer. The DON indicated she was unsure if they raised her up enough. The DON indicated she was unsure if it looked like the loop was secure on the Hoyer lift but apparently the loop was not on completely. The DON confirmed once the Hoyer is lifted up the loops on the Hoyer are weighted down on the machine when applied properly. The DON confirmed the weight of the resident held the loops in place on the Hoyer lift. The DON indicated it is "kind of fool proof." The DON stated Resident #117 was transferred to the hospital at approximately 3:45 P.M. because the resident's arm began to swell and the pain in the right arm was getting worse. The DON stated Resident #117 fractured her arm and confirmed Resident #117 did not return to the facility following the transfer. An interview on 03/03/15 at 9:29 A.M. with STNA #14 revealed the STNAs "could not react fast enough" to get Resident #117 to the bed when the loop slipped off the Hoyer. STNA #14 stated there was an emergency release button on the Hoyer but confirmed this button was not used to release the resident as Resident #117's lower half of the body was already on the floor. STNA #14 confirmed the Hoyer was not used to lower the resident when the resident began to slide from the sling. STNA #14 confirmed Resident #117 did have limited mobility of the right arm as it was contracted at the elbow area but the resident was seen grasping the side of the sling. STNA #14 stated Resident #117's arm came off the side of the sling when STNA #12 manually lowered her to the floor. STNA #14 indicated the bottom left loop was the one that came unsecured from the Hoyer lift. STNA #14 stated the loops of the pad do come "loose" on the Hoyer occasionally. STNA #14 stated that is why there is a spotter to make sure the loops of the pad do not come off. Observation was made on 03/03/15 at 10:00 A.M. with STNA #14 of the Hoyer lift used to transfer Resident #117. The Hoyer lift had three areas on each side where the Hoyer pad loops could be connected. STNA #14 connected the Hoyer pad to the Hoyer lift. When the Hoyer pad loops were placed correctly on the lift and weight was applied in the sling the loops and the sling were weighted down on the machine. STNA #14 confirmed this observation. STNA #14 indicated when the loops are placed improperly and the loops are turned in an inside out fashion they slip off the machine. Interview on 03/03/15 at 2:40 P.M. with Staff Development #16 revealed there was potential for the Hoyer loops to slip off if not secured properly. Staff Development #16 indicated that she was unaware of any circumstances of the loops sliding off the Hoyer when properly secured. Staff Development #16 indicated that the staff are encouraged to move slowly when transferring to monitor the loops in case they were slipping off. Review of the mechanical lift 'Owner's Installation and Operating Instructions' revised July 2001, revealed a boxed warning that indicated when elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the bed and correct the problem. Adjustments for safety and comfort should be made before moving the patient. Patient's arms should be inside of the straps. 2. Review of Resident #118's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#118's physician orders [REDACTED]. Review of a nursing note dated 11/24/14 at 8:00 P.M. revealed the nurse was called into Resident #118's room and Resident #118 was lying on the floor with a small amount of blood from the back of the head. Resident #118 was alert and oriented and his feet were on his desk when the nurse entered the room. Review of a nurses' note dated 11/24/14 at 10:00 P.M. revealed Resident #118 sustained a two centimeter laceration to the back of the head. Review of the incident report dated 11/24/14 at 8:00 P.M. revealed STNA #17 and STNA #18 were transferring Resident #118 with the Hoyer lift and Resident #118 fell to the floor backwards head first. There was a small amount of blood from the back of the head. The incident report indicated the Hoyer pad was not far enough up on Resident #118's back. When the Hoyer lift was turned Resident #118 tipped back and fell out of the lift. All straps of the crossover Hoyer pad were intact and connected to the Hoyer properly. Review of STNA #18's statement of the incident dated 11/26/14 at 9:00 A.M. revealed the Hoyer did not tilt or buck in any fashion. STNA #18 stated the Hoyer pad was not up behind the head and top of shoulders of Resident #118. Interview on 03/03/15 at 8:58 A.M. with the DON confirmed Resident #118 fell backward out of the Hoyer lift. The DON stated Resident #118 was using a special pad called a crossover pad which had not been used at the facility prior to Resident #118 requesting a special sling. The DON stated that all staff were required to be inserviced prior to the use of the crossover pad. Review of the inservice dated 11/24/14 revealed a Hoyer transfer in-service with no evidence STNA #18 had attended the inservice. Interview on 03/03/15 at 12:15 P.M. with Registered Nurse (RN) #19 confirmed STNA #18 was not inserviced prior to the use of the crossover Hoyer pad used during the transfer of Resident #118 on 11/24/14. 3. Review of Resident #93's medical record revealed an admission date of [DATE]. Review of Resident #93's fall risk assessment dated [DATE] revealed Resident #93 was at high risk for falls. Review of Resident #93's initial plan of care with revision on 10/06/14 revealed Resident #93 was at risk for falls with interventions including to apply a personal alarm to the bed to alert staff of unassisted rising. The intervention included to check that the alarm was working properly every shift and was applied as ordered. Review of the current physician order [REDACTED]. Review of a nursing note dated 02/22/15 at 3:45 P.M. revealed Resident #93 was witnessed falling in the hallway at 2:30 P.M. between Room #109 and #108. Review of the note revealed no alarms were sounding. Review of Resident #93's incident investigation dated 02/22/15 revealed Resident #93 was witnessed by STNAs falling in the hallway. Review of the predisposing situation factors section of the investigation revealed Resident #93 had ordered alarms, however the STNA failed to ensure the bed sensor alarm was attached to the box and the pull away alarm was on bedside table. Review of STNA #20's statement for the incident dated 02/22/15 at 2:30 P.M. revealed STNA #20 laid Resident #93 down and forgot to place the alarms on the resident. Interview on 03/02/15 at 2:32 P.M. with the DON confirmed the bed sensor alarm was not attached to the pad and STNA #20 forgot to put the alarms on when placing the resident in bed prior to the fall. This deficiency substantiates Complaint Number OH 802.