Every finding on record at Riverside Nursing and Rehabilitation Center

Based on review of medical records, interviews with staff, residents, and family, review of video footage from electronic monitoring device, and policy review, the facility failed to provide adequate supervision to prevent two cognitively impaired residents (#49 and #160) from continuing to engage in sexually aggressive behaviors in the female resident's room (#160). This resulted in Immediate Jeopardy and the potential for serious, physical, mental, and/or psychosocial negative outcomes for two residents (#49 and #160) when the facility failed to supervise and intervene to prevent Resident #49 from entering Resident #160's room and engaging in sexual activity. On 04/28/25, Resident #49 entered Resident #160's room numerous times throughout the day. Resident #49 was observed touching Resident #160's breast outside the shirt and kissing her lips. After numerous times of Resident #49 entering and leaving Resident #160's room, the residents were observed engaging in oral sex on each other. At no time was staff observed checking on the residents or redirecting Resident #49 out of Resident #160's room from 9:42 A.M. to 3:28 P.M. At approximately 3:28 P.M., Licensed Practical Nurse (LPN) #491 and Certified Nursing Assistant (CNA) #436 walked into Resident #160's room where they found Resident #160 on her bed with her pants and depends on the ground and Resident #49 standing in front of her. Resident #49 was redirected out of the room. The facility failed to complete an investigation, failed to complete a Self-Reported Incident (SRI), and failed to initiate/update residents' care plans to address the sexually inappropriate behavior. This affected two (#49 and #160) of two residents reviewed for supervision. The facility census was 164. On 08/13/25 at 4:46 P.M., Regional Director of Operations (RDO) #750, the Director of Nursing (DON), and Divisional Director of Clinical Operations (DDCO) #751 were notified Immediate Jeopardy began on 04/28/25 when Resident #49 entered Resident #160's room at 9:42 A.M. and was observed touching her breast and kissing her lips. After numerous times of Resident #49 entering and leaving Resident #160's room, the residents were observed engaging in oral sex on each other. At no time was staff observed checking on the residents or redirecting Resident #49 out of Resident #160's room from 9:42 A.M. to 3:28 P.M. At approximately 3:28 P.M., Licensed LPN #491 and CNA #436 walked into Resident #160's room where they found Resident #160 on her bed with her pants and depends on the ground and Resident #49 standing in front of her. Resident #49 was redirected out of the room. The Immediate Jeopardy was removed on 08/14/25 when the facility implemented following corrective actions: On 04/28/25 at 3:28 P.M., CNA #436 was completing room rounds and went into Resident #160's room. Resident #160 was in bed with her pants to her knees. Resident #49 was in the room with clothes on. On 04/28/25 at 3:45 P.M., the [NAME] Unit Manager (UM) [LPN #406] called Resident #160's daughter and informed her of Resident #49 being in Resident #160's room and Resident #160 having her pants around her knees. On 04/28/25 at 5:30 P.M., the DON and the Administrator called Resident #160's daughter to ask if she could look at the video in the room. The daughter stated she had already looked at it and there was nothing on it. On 08/08/25 at 1:24 P.M., Resident #160's daughter sent a text message to [NAME] UM LPN #406 informing her that she finally looked at the video and Resident #160 had been assaulted several times on 4/28/25 by another resident. On 08/08/25 at 1:26 P.M., [NAME] UM LPN #406 notified the Administrator and the DON of an allegation of resident-to-resident sexual abuse. On 08/08/25 at 1:30 P.M., the DON notified Division Director of Risk Management (DDRM) #725 and RDO #750 of an allegation of resident-to-resident sexual abuse. On 08/08/25 at 1:35 P.M., the Administrator submitted a Self-reported Incident (SRI) with the State Agency (SA). On 08/08/25 at 2:00 P.M., the family of Resident #49, who no longer resides at the facility, was made aware of the allegation of resident-to-resident sexual abuse. Resident #49 was transferred on 08/06/25 per family's request to be closer to family. On 08/08/25 at 2:15 P.M., [NAME] UM LPN #406 called the police to report the allegation of resident-to-resident sexual abuse. On 8/08/25 at 2:25 P.M., the DON called Resident #160's daughter and asked what was on the video. The daughter stated, my mom was being assaulted. The DON requested to see the video. The daughter stated that she couldn't come up today but would meet the DON on 8/09/25 at 1:00 P.M. The daughter refused to have Resident #160 sent to hospital for an examination. On 08/08/25 at 2:30 P.M., [NAME] UM LPN #406 notified Nurse Practitioner (NP) #800 of the allegation of resident-to-resident sexual abuse involving Resident #160. No new orders were given. On 08/08/25 at 2:37 P.M., DDRM #725 notified the current facility of Resident #49 of resident-to-resident sexual abuse allegation. On 08/08/25 at 2:45 P.M., [NAME] UM LPN #406 completed a skin assessment on Resident #160 with no concerns noted. On 08/08/25 at 4:00 P.M., the local Sheriff's Department arrived at the facility and took a report and informed the DON to please call them when Resident #160's daughter arrives on 08/09/25 as they would like to come to the facility and see the video. On 08/09/25 at 2:00 P.M., the DON called Resident #160's daughter to ask about her where abouts. Resident #160's daughter informed the DON that she would not be able to come to the facility today, but she would try to make it sometime next week. On 08/11/25 at 4:00 P.M., Resident #160 was placed on 1:1 supervision until the physician deems it is not needed and discontinues the order. On 08/13/25 from 5:00 P.M. to 8:00 P.M., the DON interviewed staff regarding knowledge of any residents that have a sexual relationship and or any inappropriate sexual behaviors. Any resident found to be having sexual relations with other residents would be reviewed by the physician and Interdisciplinary Team (IDT) to discuss the risks/benefits of sexual behavior and this would be discussed with the resident's guardian/representative and a plan of care would be developed. There were no other residents that were identified to be having a sexual relationship and there were no additional resident-to-resident sexual occurrences found. The DON reviewed all residents' charts with no findings. On 08/13/25 from 6:00 P.M. to 9:00 P.M., the DON educated 155 staff members on the facility's abuse and neglect policy which included: (a) What constitutes abuse and types of abuse and neglect; (b) Identification of signs and symptoms in residents and staff of potential abuse and abusers; (c) Actions to take when abuse is witnessed, suspected, or alleged; (d) Timely and appropriate reporting of witnessed, suspected, or alleged abuse to all responsible parties per facility policy; (e) Protection of resident while conducting a thorough investigation of alleged abuse; (f) Proper assessment of residents who have been or suspected to be abused; (g) Prevention of future incidents of abuse from occurring; (h) Sexual activity between residents including what constitutes sexual abuse per Centers for Medicare and Medicaid Services (CMS) guidelines and what to do when you identify inappropriate sexual behaviors including reporting to your supervisor, DON, or Administrator and holding a meeting with physicians, IDT and family to develop a plan of care for the resident. Staff were also educated on supervision of residents using the policy titled Unit Supervision with emphasis on rounding and checking on residents every two hours. Staff was educated in person, via OnShift software and via phone calls. On 08/13/25 from 6:00 P.M. to 8:00 P.M., the DON started additional skin checks on all residents and completed interviews with residents who have a BIMS of 13 or higher. On 08/13/25, Minimum Data Set (MDS) Nurse #426 updated Resident #160's care plan to reflect sexual behaviors. On 08/13/25 at 8:30 P.M., the Administrator held an ad hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the Immediate Jeopardy and abatement plan, the facility's abuse policy, and the resident-to-resident sexual abuse allegation and unit supervision. Staff present included the Administrator, the DON, the Assistant Director of Nursing (ADON), UM/LPN #502, UM/LPN #406, UM/RN #429, DDRM #725, Social Service Director (SSD) #447, RDO #750, Divisional Director of Clinical Operations (DDCO) #752, and Medical Director (MD) #801 attended the meeting via phone. Beginning 08/14/25, SSD #447 will continue offering support to Resident #160 by weekly visits for four weeks then as needed. The DON will observe five residents weekly for four weeks, then three residents weekly for four weeks, then two residents weekly for four weeks to look for any inappropriate sexual behaviors between residents. The DON will complete observation rounds throughout the facility to verify that appropriate supervision is consistently being provided five times a week for four weeks, then three times a week for four weeks, then two times a week for four weeks. The Administrator will interview five staff members weekly for four weeks, then three staff members weekly for four weeks, then two staff members weekly for four weeks to determine if there have been any inappropriate sexual behaviors between residents. The Administrator or DON will monitor compliance with the above during monthly QAPI meetings for three months, then as needed for one year. Interviews on 08/18/25 from 8:55 A.M. through 12:00 P.M. with CNA #413, CNA #482, CNA #543, LPN #406, and Registered Nurse (RN) #448, and RN #562 revealed education was completed on abuse and supervision of residents on 08/13/25. Additional medical record review for Residents #18, #48, and #65 revealed no identified concerns. Although the Immediate Jeopardy was removed on 08/14/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. Review of the plan of care for Resident #160 revealed there was no care plan in place with interventions for sexual behaviors. Review of the progress note dated 04/28/25 at 4:25 P.M. revealed LPN #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area. Review of the progress note dated 05/01/25 at 9:58 A.M. revealed SSD #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed. Review of the weekly skin check completed 04/28/25 at 2:28 P.M. revealed Resident #160 had no skin issues during sexual encounters. Review of the skin assessment dated [DATE] revealed Resident #160 had no skin issues noted. Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers. Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors. Review of the progress note dated 05/01/25 at 10:05 A.M. revealed SSD #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Observations from the electronic monitoring device dated 04/28/25 revealed the following: At 9:42 A.M. to 9:43 A.M., Resident #160 was in her wheelchair at the doorway when Resident #49 approached her. He kissed her lips and placed his hand inside her shirt to touch her breasts. Resident #49 walked in front of Resident #160 and attempted to touch her genital area. Resident #160 backed up in her wheelchair, and Resident #49 left the room. At 10:31 A.M. through 10:37 A.M., Resident #160 was seen sitting in her wheelchair by the window when Resident #49 startled her. Resident #49 rubbed Resident #160's right breast on the outside of her shirt and attempted to reach inside but she pulled away. Resident #49 attempted again to feel her breast and then kissed her. Both residents continue to engage in sexual activity. Resident #49 left the room. At 10:42 A.M., Resident #49 was seen re-entering the room where Resident #160 was lying on the bed with no pants and her depends down. Resident #49 began touching her genital area. Resident #49 pulled his penis out of his pants and placed her hand on it. At 10:43 A.M., Resident #49 was seen leaving the room. At 10:48 A.M., Resident #49 was seen walking by her room, and then comes into her doorway and sees Resident #160 lying in bed with no pants on and then turned around and leaves. At 10:56 A.M., Resident #160 was shown standing up on the side of the bed pulling up her depends and getting into her wheelchair. At 1:17 P.M. through 1:19 P.M., Resident #160 was in her room eating lunch when Resident #49 came into her room and attempted sexual advances towards Resident #160 and then left the room. At 1:29 P.M. through 1:30 P.M., Resident #49 entered Resident #160's room, kissed her and then reached down her shirt to touch her breasts. Resident #160 moved away. Resident #49 continued to try to kiss her and touch her, and then he left the room. At 2:35 P.M. through 2:37 P.M., Resident #160 entered the room in her wheelchair. Resident #49 entered a few seconds later and leaned down and kissed Resident #160 and started to place his hand in her shirt. Resident #160 appeared to be touching Resident #49's genital area. Resident #160 moved her wheelchair away, and Resident #49 left the room. At 3:21 P.M. through 3:28 P.M., Resident #160 was sitting on her bed when Resident #49 entered her room, gave her a piece of candy, and kissed her. He fondled her breast and then motioned her to feel his genital area. Both residents engaged in oral sex. Two staff members, LPN #491 and CNA #436 opened the door to Resident #160's room. Resident #49 quickly pulled up his pants and was motioned to leave the room by staff. Interview on 08/06/25 at 9:03 A.M. with CNA #471 revealed Resident #160 and Resident #49 continued to have inappropriate sexual behaviors after the incident on 04/28/25 including kissing each other. Interview on 08/06/25 at 9:07 A.M. with CNA #437 revealed Resident #160 and Resident #49 were witnessed kissing in the dining room and touching each other inappropriately in between each other's thighs. Interview on 08/06/25 at 10:41 A.M. with Resident #160 reported she did not have a male friend and did not recall being sexually active in the facility. Interview on 08/06/25 at 11:47 A.M. with Resident #49 revealed he had lots of lady friends but did not recall who Resident #160 was and denied being sexually active. Interview on 08/06/25 at 11:53 A.M. with the DON reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and CNA #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it to this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH). Interview on 08/06/25 at 2:48 P.M. with Resident #160's daughter revealed she never watched the video from 04/28/25. Resident #160's daughter stated UM #406 called her and told her Resident #160 and Resident #49 were found in her room with their pants off. Resident #160's daughter reported SSD #447 called her the following day and asked her to give consent to Resident #160 having sexual activity. Resident #160's daughter did not give consent. Interview on 08/06/25 at 3:31 P.M. with LPN #491 revealed CNA #436 was completing rounds when she called LPN #491 into Resident #160's room. LPN #491 stated Resident #160 was sitting on her bed with no pants or depends on, and Resident #49 was standing in front of her about two feet apart. Resident #49 was fully clothed and was asked to leave the room. LPN #491 explained she educated both residents and completed a head-to-toe assessment on Resident #160 with no negative findings. LPN #491 stated she tried to ensure Resident #160 and Resident #49 were separated the rest of the shift. Interview on 08/14/25 at 1:55 P.M. with UM/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on, sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete an SRI for the incident. UM/LPN #406 also stated an incident report was not completed. Interview on 08/14/25 at 3:22 P.M. with MD #801 verified Resident #160 had memory loss and some cognitive and behavioral issues. MD #801 reported Resident #49 had vascular dementia and post-traumatic stress disorder (PTSD). MD #801 stated Resident #49 had memory loss as well. MD #801 stated both residents had memory issues and could not state if she felt that either resident could give consent to sexual activity. Interview on 08/14/25 at 3:52 P.M. with CNA #436 reported on 04/28/25 she came onto shift at 3:00 P.M., and Resident #49 and Resident #160 were in the common area watching television. About 15-20 minutes later, CNA #436 walked by, and both residents were gone. CNA #436 stated she saw Resident #160's door was closed to her room, which wasn't unusual, but she had a gut feeling to go in and check. CNA #436 knocked on her door and went in and found Resident #160 on her bed with her pants halfway down her legs, and Resident #49 standing in front of her fully clothed. CNA #436 stated Resident #49 was asked to leave the room. CNA #436 explained Resident #160 became aggressive and started calling her names. CNA #436 reported neither resident was placed on a 1:1. Review of the facility policy titled, Unit Supervision, revealed the policy of the facility was to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff, and visitors. The Unit Supervisor was a licensed nurse with the skills and competency to safely and appropriately monitor and delegate tasks to others and perform duties consistent with safe and effective care and treatment of the assigned residents. Supervision responsibilities were assigned by the DON or designee to provide for the care and treatment of the residents, direct services of on-duty staff, and assume responsibility for a safe environment during the time the nurse was working the shift for the specific unit the nurse was assigned. This deficiency represents non-compliance investigated under Complaint Numbers 1259562 and 2585469.

Based on review of documentation from an employment agency, review of documentation from Board of Executives of Long-Term Services and Supports (BELTSS), interview with Board Administrator at BELTSS, and staff interview, the facility failed to ensure Administrator had a valid Nursing Home Administrator (NHA) license. This had the potential to affect all the residents. The facility census was 164. Interview on 08/05/25 at 10:09 A.M. with Regional Director of Operations (RDO) #750 confirmed the facility had employed interim NHA #630 from 05/12/25 through 06/10/25. RDO #750 stated interim NHA #630 had been hired through an employment agency and provided documentation interim #630 had an active NHA license. Interview on 08/06/25 at 4:15 P.M. with Board Administrator #635 stated BELTSS was notified of a concern about the validity of interim NHA #630's license. Board Administrator #635 stated after an investigation it was determined that interim NHA #630 had used the license number for NHA ##700 to obtain a position as a NHA. Board Administrator #635 stated interim NHA #630 and NHA #700 had similar names but different Social Security Numbers, addresses, and date of birth s. Board Administrator #635 confirmed interim NHA #630 did not have a valid NHA license. Review of the documentation from the employment agency provided to the facility revealed interim NHA #630's date of birth was 10/23/73 and resided in Cincinnati. Review of the documentation revealed interim NHA #630 had used NHA license number 7258. Review of documentation from BELTSS revealed NHA #700 had an active license of number 7258, a date of birth of [DATE] and resided in Englewood. Review of BELTSS documentation revealed interim NHA #630 was registered as an Administrator in Training and did not have an active NHA license. This deficiency represents non-compliance investigated under Complaint Number 2578224.

Based on observations and staff and resident interviews, the facility failed to ensure a clean, comfortable, and homelike environment. This affected five (Residents #14, #36, #20, #65, and #112) of nine residents reviewed for environment. The facility census was 164.1.Review of the medical record for Resident #14 revealed an admission date of 11/25/24 with medical diagnoses of Parkinson's disease, schizophrenia, bipolar disorder, and hypertension. Review of the medical record for Resident #14 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #14 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers, and partial/moderate staff assistance with bathing. Observation and interview on 08/05/25 at 7:25 A.M. revealed water leaking from the toilet in Resident #14's bathroom onto the bathroom floor, floor in the room outside of bathroom, and to the threshold of the room to the hallway. Resident #14 stated the toilet had been leaking for several weeks and staff were aware. Interview on 08/05/25 at 7:35 A.M. with Housekeeping #609 confirmed the toilet in Resident #14's room was leaking water onto the bathroom floor, floor in the room outside the bathroom, and to the threshold of the room to the hallway. Housekeeping #609 confirmed the toilet had been leaking for “a while” and stated he would clean up the water right away. 2. Observations of the [NAME] Unit on 08/04/25 at 9:30 A.M. revealed the unit smelled like urine. At 2:06 P.M. the unit still smelled of urine. Observations on 08/06/25 at 7:40 A.M. and 12:02 P.M. the [NAME] Unit still smelled of urine. Observation of 08/07/25 at 9:00 A.M. the [NAME] Unit still smelled of urine. Interview with Housekeeping #602 on 08/07/25 at 9:07 A.M. confirmed the [NAME] unit smelled of urine. 3. Observation of the bathroom for Resident #36 on 08/04/25 at 11:57 A.M. revealed the light was hanging off the medicine cabinet with light socket exposed. The handle going into the bathroom was jiggly and about to fall off the door. Interview and observation of Resident #20's room on 08/04/25 at 12:42 P.M. revealed his room was dark and the lights were burned out in his overhead light. He had no lights in his room. The string to the light was short and the resident couldn't reach it. The resident stated the lights have been burned out for some time now and his string was not long enough for him to reach it. Interview and observation of Resident #65's room on 08/05/25 at 7:36 A.M. revealed the string to his light on the back wall behind his bed was short and the resident could not reach it because he was bed bound. There were gouges out of the wall behind his bed and to the side of it. There were missing hooks off his privacy curtain and the curtain is hanging in that area. The resident stated he doesn't get out of bed, and he isn't able to reach his light to be able to turn his light on and off from his bed because the cord wasn't long enough. Interview with the Maintenance Director #499 on 08/07/25 at 2:57 P.M. toured the above-mentioned rooms and confirmed the problems in the rooms. 4. Review of the medical record for Resident #112 revealed an admission date of 02/19/24. Diagnoses included dementia, anxiety disorder, and cerebrovascular accident. Review of the MDS assessment dated [DATE] revealed Resident #112 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and dressing, and supervision with transfers. Observation on 08/04/25 at 1:38 P.M. revealed five gashes about 12 inches in length behind the headboard of Resident #112's bed. Interview on 08/07/25 at 9:10 A.M. with Maintenance Director #499 verified the gashes behind the headboard of Resident #112's bed. This deficiency represents non-compliance investigated under Complaint Numbers 1259570 and 2573764.

Based on review of the Resident Council Minutes, and staff and resident interviews, the facility failed to ensure the residents had access to the state and local advocacy organizations. This affected three residents (#117, #59 and #128) and all residents residing on the South and [NAME] units. The census was 164.Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 revealed there was no evidence the state or local advocacy group contacts were reviewed at monthly Resident Council meetings. Observation on 08/07/25 at 2:30 P.M. of secured [NAME] and South units revealed no evidence of postings or available documents of state or local advocacy group contacts. Interviews with Residents #128, #59 and #117 during a surveyor led Resident Council Meeting on 08/05/25 at 2:06 P.M. revealed they did not know of any contact information of state or local advocacy groups. The residents stated in monthly Resident Council meetings, the state or local advocacy groups were not reviewed. The residents stated they would like to know the contact information and, in the past, had to ask staff for the contact information, which made them feel uncomfortable due to possible retaliation. Interview on 08/05/25 at 2:44 P.M. the Administrator confirmed the contact information of state or local advocacy groups were not documented on the monthly Resident Council meeting. The Administrator verified the contact information of state or local advocacy groups should be posted and available to residents on the secured units. Interview on 08/05/25 at 2:34 P.M. the Director of Nursing (DON) verified the contact information of state or local advocacy groups were not available on the secured [NAME] and South units.

Based on medical record review, staff interviews, and policy review, the facility failed to develop comprehensive care plans in a timely manner. This affected two (Residents #160 and #49) of 32 residents sampled for care plans. The census was 165. 1. Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors. Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area. Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed. Interview on 08/07/25 10:26 AM with MDS Nurse #426 verified Resident #49 was not care planned for inappropriate sexual behaviors. 2. Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers. Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors. Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse. Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH). Interview on 08/07/25 10:24 AM with MDS Nurse #426 verified there was no care plan for Resident #160 for inappropriate sexual behaviors. Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed. Review of the policy titled Plan of Care Overview not dated, revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines and goals to potentially return to a community setting.

Based on medical record review, Nurse Practitioner (NP) interview, and policy review, the facility failed to administer medication as ordered which resulted in a significant medication error. This affected one (#02) resident out four residents reviewed for medication administration. The facility census was 164. Review of the medical record for Resident #02 revealed an admission date of 02/09/23 with medical diagnoses of right hemiplegia, chronic obstructive pulmonary disease, end stage renal disease, dependence on dialysis, and bipolar disorder. Review of the medical record for Resident #02 revealed a Minimum Data Set (MDS) assessment, dated 07/07/25, which indicated Resident #02 was cognitively intact and was dependent upon staff for toilet hygiene, showers/bathes, transfers and bed mobility. Review of the medical record for Resident #02 revealed a physician order dated 11/30/24 for Midodrine (hypotension medication) oral tablet 2.5 milligram (mg) one tablet by mouth every eight hours as needed for hypotension. Hold if systolic blood pressure (SBP) is greater than 110 and administer if SBP is less than 110. Review of the medical record for Resident #02 revealed a blood pressure reading on 06/03/25 of 97 (SBP)/50 diastolic blood pressure (DPB) milliliters in mercury (mmHg). Review of the medical record revealed pre-dialysis assessments on 07/24/25 with a documented blood pressure of 105/78 mmHg, on 07/31/25 with documented blood pressure of 106/64 mmHg, and on 08/05/25 with a documented blood pressure of 104/67 mmHg. Review of the medical record for Resident #02 revealed the Medication Administration Records (MAR) for June, July and August 2025 did not have documentation to support Midodrine was administered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25. Interview on 08/07/25 at 10:23 A.M. with NP #800 stated the order was supposed to be entered to administer Midodrine 2.5 mg one tablet every eight hours for hypotension and to hold if SBP is greater than 110 and to administer if SBP less than 110. NP #800 stated Resident #02 should have her blood pressure checked three times per day for the facility to monitor her for possible Midodrine administration. NP #800 also stated the facility staff should have administered Midodrine as ordered prior to dialysis. NP #800 confirmed the facility had not administered Midodrine as ordered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25. Review of the facility policy titled, Medication Administration, revealed the facility is to provide resident centered care the meets the psychosocial, physician, and emotional needs and concerns of the residents. The policy continued to state staff are to administer medication only as prescribed by the provider. This deficiency represents non-compliance investigated under Complaint Number 1259566.

Based on observation, interview, medical record review, and policy review, the facility failed to ensure enteral feeding supplies were replaced according to professional standards. This affected one (Resident #11) of two residents sampled for enteral feedings. The census was 164.Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, unspecified major depressive disorder, unspecified moderate dementia with psychotic disturbance, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severely impaired dementia, had self-directed behaviors, did not wander, and did not reject care. Review of the care plan dated 02/24/23 revealed Resident #11 had g-tube status. Interventions included administer medications via g-tube per orders, administer flushes as per protocol, enhanced barrier precautions, check for placement and residuals, and provide tube feeding as ordered. Review of the medical record revealed Resident #11 had physician orders dated 07/27/25 for Jevity 1.5 at 70 milliliters (ml) per hour for eight hours nocturnally from 9:00 P.M. to 5:00 A.M. for a total of 560 ml's per eight hours daily. Observation on 08/07/25 at 2:10 P.M. revealed a Kangaroo pump bag was hanging at bedside and contained a brown liquid that was labeled Jevity 1.5 and was dated 08/05/25. Interview on 08/07/25 at 2:34 P.M. Licensed Practical Nurse (LPN) #434 verified the tube feeding bag hanging at Resident #11's bedside was dated 08/05/25. LPN #434 stated unused tube feeding solution should be discarded 24-hours after opening. Review of policy titled, Enteral General Nutritional (tube feeding) Guidelines, not dated, revealed staff changed syringes, tubing, and bottles used for tube feeding daily and labeled and dated items.

Based on medical review, staff interview, and policy review, the facility failed to monitor a resident's weight as ordered. This affected one (#01) resident out of four residents reviewed for nutritional status. The facility census was 164.Review of the medical record for Resident #01 revealed an admission date of 07/09/19 with medical diagnoses of left hemiplegia, chronic obstructive pulmonary disease, left above the knee amputation (AKA), hypertensive heart and chronic kidney disease. Review of the medical record revealed Resident #01 had discharged to the hospital on [DATE] and readmitted to the facility 07/08/25. Review of the medical record for Resident #01 revealed a quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, which indicated Resident #01 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, and bed mobility. Review of the MDS revealed Resident #01 did not transfer and did not indicate any weight loss. Review of the medical record for Resident #01 revealed a physician order dated 07/16/25 for weight to be obtained for four weeks upon admission and an order dated 08/03/25 for monthly weights. Review of the medical record for Resident #01 revealed no documentation to support the facility obtained weights 07/16/25, 07/23/25, 07/30/25, and 08/03/25. Review of the medical record revealed the last weight documented was on 06/20/25 at 158 pounds. Review of the medical record for Resident #01 revealed a weight entry note dated 08/03/25 at 12:14 P.M. which stated, unable to obtain weight. Interview on 08/07/25 at 9:26 A.M. with Dietician #710 stated Resident #01 was at risk for weight loss due to multiple medical conditions and pressure ulcers. Dietician #710 stated Resident #01's weights were not obtained in July or August 2023 due to the Hoyer (mechanical) lift weight broken and staff did not have a way to weight Resident #01. Review of the facility policy titled, Resident Height and Weight, stated staff are to obtain weekly weight times four weeks for baseline and for stable residents will be weighted monthly thereafter, unless physician or diagnosis indicates otherwise

Based on medical record review, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed accurately upon admission. This affected one (#07) resident out of two residents reviewed for PASARR. The facility census was 164.Review of the medical record for Resident #07 revealed an admission date of 10/18/24 with medical diagnoses of diabetes mellitus, hypertension, post traumatic stress disorder (PTSD), bipolar disorder, and chronic kidney disease. Review of the medical record for Resident #07 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/09/25, which indicated Resident #07 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, supervision with bed mobility and transfers, and set-up assistance with eating and bathing. Review of the medical record for Resident #07 revealed a PASARR dated 10/10/24 which revealed a diagnosis of panic or other severe anxiety disorder was documented. Review of the PASARR revealed no other mental health diagnoses were indicated. Review of PASARR notice dated 10/10/24 revealed there were no indications of serious mental health illness and/or developmental disability. Interview on 08/07/25 at 1:32 P.M. with the Administrator stated the Social Service department are to review all resident PASARRs upon admission to ensure all mental health medical diagnoses were included. The Administrator confirmed the PASARR for Resident #07 did not have documentation to support bipolar disorder. Review of the facility policy titled, Pre-admission Screening and Resident Review, stated a PASARR is a mandate of Omnibus Budget Reconciliation Act (OBRA) 1987 Nursing Home Reform Act while requires states to identify and evaluate all individuals admitted to Medicaid certified nursing facilities for evidence of Severe Mental Illness (SMI), Intellectual or Development Disabilities (ID/DD) or related condition to ensure needs are met in most appropriate setting. This prohibits nursing facilities from admitting or retaining an individual with SMI or ID/DD unless the individual requires level of services of a nursing facility (NF), receives adequate services to meet needs and is in the least restrictive setting. The policy stated all individuals must be screened for indications of serious mental illness and ID/DD unless they meet the requirements for a hospital discharge exemption regardless of pay type. The policy stated any new admission with inaccurate information (clean Level 1 and needs Level 2) will have a Resident Review initiated immediately by the social service or designee as assigned by the Executive Director.

Based on review of medical records and staff interviews, the facility failed to timely investigate an allegation of resident to resident sexual abuse. This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164.Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors.Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area.Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed.Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.Review of the MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers.Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors.Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse.Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH).Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed. This deficiency represents non-compliance investigated under Complaint Numbers 1259568 and 1259561.

Based on review of medical records and staff interviews, the facility failed to timely report an allegation of resident to resident sexual abuse to the State Agency (SA). This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164.Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors.Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area.Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed.Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers.Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors.Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse.Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) revealed Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH).Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed.This deficiency represents non-compliance investigated under Complaint Numbers 1259568 and 1259561.

Based on review of the Resident Council Minutes, staff and resident interviews, and policy review, the facility failed to ensure concerns were addressed in a timely manner or resolved. This affected three residents (#117, #59 and #128) of three residents reviewed for Resident Council Meetings. The census was 164. Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 revealed the following concerns: 08/15/24 missing clothing, multiple food concerns by individual residents.10/07/24 call light response, missing clothing.11/18/24 multiple food concerns by multiple residents.12/10/24 multiple food concerns by multiple residents.03/03/25 food condiments missing, multiple food concerns by multiple residents, missing clothing.04/07/25 missing clothing, call light response time.05/12/25 missing clothing concerns by multiple residents, multiple food concerns by multiple residents.06/02/25 multiple food concerns by multiple residents, missing clothing.07/07/25 food condiments, multiple food concerns by multiple residents, missing clothing. Review of Grievance Logs revealed:September 2024 Log had no follow up on food concerns to the August meeting.November 2024 Log had no follow up to the call light response and missing clothing to the October meeting.December 20 Log had no follow up on food concerns to the November meeting.January 2025 Log had no follow up on food concerns to the December meeting.April 2025 Log had no follow up on food condiments missing and multiple food concerns by multiple residents to the March meeting. May 2025 Log had no follow up on call light response time to the April meeting.June 2025 Log had no follow up on missing clothing concerns by multiple residents, multiple food concerns by multiple residents to the May meeting.July 2025 Log had no follow up on multiple food concerns by multiple residents, missing clothing to the June 2025 meeting. Interview with Residents #128, #59, and #117 during a surveyor led Resident Council Meeting on 08/05/25 at 2:06 P.M. revealed the residents didn't feel like complaints were getting addressed in a timely manner by the administration. They revealed the concerns of food service, food condiments, and missing clothing had been going on for months with no resolution. The concerns were not just repeated by the same residents at each of the meetings but by multiple residents. The call lights are not being answered in a timely manner which has been going on for months with no resolution. The residents stated they felt like they were not being heard by the administration regarding their concerns regarding the food services and laundry services. Interview with Activities Director (AD) #418 on 08/05/25 at 11:50 A.M. verified the residents' concerns discussed in the meeting were verbally relayed to the respective department heads and a resolution was not discussed at the next resident council meeting. She stated she had no evidence the concerns had been addressed by the department head to resolve the residents' issues. Interview on 08/05/25 at 2:44 P.M. the Administrator confirmed there were months in which residents' concerns resolutions were not addressed and listed on the grievance log. The Administrator stated the concerns from Resident Council should be listed in the Grievance Log to show the residents' concerns have been resolved. Review of the policy titled, Resident Council, undated, revealed the Activity Director is designated the liaison to the Resident Council and provides assistance to the council such as correspondence. The facility documents the resident council meeting on the Resident Council Minutes form. Any concerns at the meeting should be documented on the Concern Form and distributed to the appropriate Department Head. The facility follows the Resident Grievance Procedure for any concerns identified.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of facility investigation, and review of facility policy, the facility failed to ensure a resident was properly transferred from the bed to the wheelchair. This resulted in Actual Harm when Resident #04 was transferred without the use of a Hoyer (mechanical lift) by Certified Nursing Assistant (CNA) #200 and the resident sustained a left femoral head fracture requiring hospital admission and surgical repair. This affected one (#04) of three residents reviewed for accidents. The census was 169. Findings include: Review of Resident #04's medical record revealed an admitted [DATE]. Diagnoses listed included convulsions anxiety disorder, psychotic disorder, decreased mobility, and legal blindness. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired and had bilateral upper and lower extremity impairments. Review of a care plan dated revised 11/19/24 revealed Resident #04 is at risk for falls as evidenced by disease process, incontinence, medications, safety awareness, and being unaware of self-care needs or safety awareness. Resident #04 was dependent on staff for transfers. Resident #04 requires a Hoyer lift for transfers with two-person assistance. Review of Resident #04's physician orders revealed an order dated 03/27/23 for Hoyer lift transfers requiring two people. Review of progress notes revealed Resident #04 started displaying left hip pain on 02/18/25. Resident #04 was assessed by a nurse practitioner (NP) and X-radiation (X-ray) was ordered. Resident #04 was sent to the emergency roiagnom on [DATE]. Review of X-ray results dated 02/21/25 revealed irregularity of the left femoral neck is identified just beneath the femoral head. This may represent a non-displaced fracture. The fracture does not involve the articular surface. The femoral head is well seated within the acetabulum. Moderate degenerative changes are noted. Mild soft tissue swelling is noted. Review of hospital records revealed Resident #04 was admitted to the hospital on 02/21/25 with an impacted angulated left femoral neck fracture. Resident #04 required surgical repair on 02/22/25 and was discharged on [DATE]. Review of the facility's investigation dated 02/24/25 revealed staff members were interviewed about Resident #04's condition and the care they had provided. CNA #200 confessed during a phone interview with the Administrator on 02/25/25 to improperly transferring Resident #04 from the bed to wheelchair. CNA #200 reported lifting Resident #04 by going to the side of the bed and placing his arms under his legs and back and placing him into his wheelchair. CNA #200 had previously denied any concerns with care or transfers. An interview with the Director of Nursing (DON) on 04/08/25 at 2:10 P.M. revealed during an investigation into Resident #04's left femur and hip fracture it was discovered that CNA #200 incorrectly transferred Resident #04 from his bed to his wheelchair. CNA #200 picked Resident #04 up like a baby and put him into his wheelchair. CNA #200 was aware that Resident #04 was a Hoyer lift transfer. An interview with the Administrator on 04/08/25 at 2:28 P.M. revealed CNA #200 confessed to improperly transferring Resident #04. CNA #200 had previously denied any care concerns when interviewed regarding Resident #04. Review of the facility's undated policy titled, Mechanical Lifts and Transfer revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The use of mechanical lifts requires a competent and skilled user and requires the use of two (2) employees to perform the lift safely, for both resident and employees. As a result of the incident, the facility took the following actions to correct the deficient practice by 03/01/25: CNA #200 was terminated from employment at the conclusion of the facilities investigation on 02/24/25. All [NAME] unit residents were interviewed by the Administrator regarding any care concerns by 03/01/25 and no concerns were identified. All nurses were educated by 03/01/25 by the DON on resident pain monitoring and pain assessment. All nurses and CNA's were educated by the DON by 03/01/25 on resident transferring and repositioning. Weekly audits were initiated on 03/01/25 by the DON for mechanical lift transfers and resident repositioning. Weekly interviews with residents were initiated on 03/01/25 and will be completed by the DON or designee. This deficiency represents non-compliance investigated under Complaint Number OH00163988.

Based on observations, staff interviews, record review, review of facility policy and review of online resources from the Centers for Disease Control (CDC), the facility failed to provide a safe and sanitary environment. This had the potential to affect all 44 Residents (#128, #129, #130, #131, #132, #133, #134, #135, #136, #137, #138, #139, #140, #141, #142, #143, #144, #145, #146, #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, #159, #160, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, and #171) who resided on the 200-hall (East). The facility census was 172. Findings include: Review of medical record for Resident #128 revealed the resident was admitted on [DATE]. Diagnoses included dementia, polyneuropathy, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), diabetes mellitus, anxiety disorder, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #128 had impaired cognition. Resident #128 required supervision from staff with transfers and ambulation. Review of the care plan revised on 05/08/24 revealed Resident#128 had impaired skin integrity related to incontinence and infection-cellulitis, a behavior problem related to refusing care, being non-compliant with treatments and required an enhanced barrier precaution related to seeping /drainage. Interventions included for staff to intervene with behaviors to protect the rights and safety of others, administer treatments per medical providers orders, utilize EBP with utilization of the appropriate personnel protective equipment (PPE) during high contact care related to chronic seeping of the resident's bilateral lower extremities and the resident was not isolated to his room and allowed to freely move about the facility Review of the physician orders for Resident #128 dated 05/17/24, revealed the resident was ordered to have Enhanced Barrier Precautions (EBP) related to chronic seeping bilateral lower extremities. The resident was ordered to have bilateral legs washed and four-layer compression wraps and tubi-grip applied every three days and as needed (PRN). Orders dated 09/25/24 revealed the resident was ordered Doxycycline (antibiotic) 100 milligrams (mg) twice daily for 10 days for cellulitis infection. Observation of the 200-hall (East) on 09/25/24 at 11:15 A.M., revealed Resident #128 was seated in a portable chair in common area for residents with no socks in place and a large puddle of fluids under the chair. Observation revealed a wet [NAME] steps in the hallway leading from the resident's room to where he was seated. A wet floor sign was observed near Resident #128. There were numerous residents walking in/around the area. Interview with Resident #128's Guardian on 09/26/24 at 1:01 P.M., revealed Resident #128's legs would not be bandaged, and his legs would seep fluid all over the floor and leave puddles of fluid where he walked. Resident #128's Guardian stated Resident #128 had cellulitis infection in his legs and the resident would take the bandages off and let his legs seep everywhere. Resident #128's guardian stated Resident #128 could not sleep in his bed because his bed was broken. Observation of the 200-hall (East) on 09/26/24 at 4:49 A.M., revealed Resident #128 walking in the hallway with clear fluids seeping from his legs and a trail of seeping fluids from his room to the common area near the nurse's station. STNA #357 was attempting to clean up the trail of fluids with a bath blanket; however, she was creating more wet footprints from the fluids. STNA #357 indicated Resident #128's legs wept fluids and the resident would leave puddles on the floor and the other residents would walk through the puddles. Observation of the 200-hall (East) on 09/30/24 at 12:15 P.M., revealed wet footprints down the hallway approximately 25 feet ending at Resident #128's room. STNA #205 verified the trail of wet footprints, and the trail ended at Resident #128's room. STNA #205 stated Resident #128 had an infection in his legs, and it caused them to leak puddles on the floor and the other residents had to walks through the puddles. Interview with the Administrator on 09/30/24 at 12:25 P.M. verified Resident #128 was seated in the common area near the nurse's station and his legs were seeping fluid on to the floor and there was a trail of fluid leading to the resident's room. Interview with the Director of Nursing (DON) on 09/30/24 at 5:07 P.M. revealed the staff attempted to keep Resident #128's legs bandaged. The DON stated the facility had tried different types of wraps. The DON stated Resident #128 would unwrap his legs which caused his legs to seep, and the resident would leave puddles on the floor where the resident walked or sat. The DON verified Resident #128 had cellulitis - infection in his legs and they should always be bandaged to prevent the seeping. Review of the facility policy titled, Infection Prevention Program, undated revealed the residents of the facility have the right to reside in a safe environment that promotes health and reduces the risk of acquired infections. Further review of the policy revealed the facility will monitor the occurrences of infection and implement appropriate control measures. Review of online resources from the CDC (https://www.cdc.gov/infection-control/hcp/environmental-control/index.html), titled Guidelines for Environmental Infection Control in Health-Care Facilities and Cleaning Strategies for Spills of Blood and Body Substances, updated July 2019, revealed to keep housekeeping surfaces (e.g., floors, walls, and tabletops) visibly clean on a regular basis and clean up spills promptly using a one-step process and an Environment Protection Agency (EPA)-registered hospital disinfectant/detergent designed for general housekeeping purposes in patient-care areas when uncertainty exists as to the nature of the soil on these surfaces [e.g., blood or body fluid contamination versus routine dust or dirt or uncertainty exists regarding the presence or absence of multi-drug resistant organisms (MDRO) on such surfaces. Prompt removal and surface disinfection of an area contaminated by either blood or body substance are sound infection control practices and Occupational Safety and Health Administration (OSHA) requirements. This deficiency represents non-compliance investigated under Complaint Number OH00158218 and OH00158074.

Based on observation, staff interview, and record review, the facility failed to provide a safe, clean, and homelike environment. This affected four (#10, #128, #138, and #149) out of the five residents reviewed. The facility census was 172. Findings include, 1) Review of medical record for Resident #10 revealed the resident was admitted on [DATE]. Diagnoses included diabetes mellitus, hypertension, squamous cell carcinoma, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, conversion disorder, dysphasia, bipolar disorder, osteoarthritis, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment for Resident #10, dated 07/18/24, revealed she was mildly cognitively impaired. Resident #10 required supervision for activities of daily living (ADLs). Observation of Resident #10's on 09/24/24 at 8:50 A.M., revealed the resident was lying in bed. There was an oxygen concentrator across the room with an attached nasal cannula laying across the floor and not on the resident. There was a pair of dirty pants and a soiled incontinence brief with gnats flying around the soiled brief lying on the floor near the end of the nasal cannula. Interview with Licensed Practical Nurse (LPN) #331 on 09/24/24 at 8:50 A.M. verified Resident #10 's oxygen nasal cannula was lying on the floor, a dirty pair of dirty pants and a soiled incontinence brief lying on the with gnats flying around the brief. 2) Record review for Resident #128 revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, polyneuropathy, schizoaffective disorder, COPD, diabetes mellitus (DM) 2, anxiety disorder, and edema. Review of the MDS assessment, dated 07/30/24, revealed Resident #128 had impaired cognition. Resident #128 required supervision for ADLs. Observation of Resident #128's room on 10/01/24 at 12:38 P.M., revealed the resident's bed did not have any sheets on it and the mattress was dirty and the outer lining was shredded with holes in it. There were numerous gnats flying around and crawling on the mattress. There was a 12-inch gap between the mattress and the headboard. There was a metal box hanging from the wall with exposed wiring behind the box. Interview with LPN #525 at the same time verified the condition of Resident #128's bed and the room. LPN #525 stated Resident #128 is incontinent, and his legs wept fluids from a cellulitis infection. 3) Review of medical record for Resident #149 revealed the resident was admitted on [DATE]. Diagnoses included thyroid disorder, schizophrenia, bipolar disorder, anxiety disorder, anemia, dysphasia, dementia, schizoaffective disorder, and essential primary hypertension. Review of the MDS assessment for Resident #149 on 08/02/24, revealed she was cognitively intact. Resident #149 required supervision for ADLs. Observation of Resident #149's room on 09/30/24 at 12:20 P.M., revealed the toilet was clogged with waste and toilet paper in the bowl and a plunger sitting next to the toilet. There was a window unit air conditioner in place and the thermostat control panel was missing with exposed wires Interview with Resident #149 at the same time, indicated her toilet had been stopped up and she had tried to plunge it several times. Interview with the Administrator on 09/30/24 at 12:24 P.M. verified the window unit air conditioners thermostat panel was missing with exposed wires. The Administrator reported the toilet was working as he attempted to flush the toilet. When the toilet didn't flush, the Administrator reached for the plunger and started using the plunger to get the toilet to flush. The toilet never flushed. 4) Review of medical record for Resident #138 revealed the resident was admitted on [DATE]. Diagnoses included schizophrenia, anxiety disorder, major depressive disorder, COPD, anemia, and pseudobulbar affect. Review of the MDS assessment for Resident #138, dated 08/31/24, revealed she had impaired cognition. Resident #138 required supervision for ADLs. An observation of Resident #138's room on 09/30/24 at 12:27 P.M. revealed the resident's foot board had fallen off the bed and was lying on her floor. Interview with LPN #209 on 09/30/24 at 12:28 P.M., verified the foot board had fallen off Resident #138's bed and was lying on the floor. This deficiency represents non-compliance investigated under Complaint Number OH00158218 and OH00158074. This is an example of continued non-compliance from the survey dated 09/05/24.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a resident's guardian and physician were notified timely following a change in condition. This affected one (#10) out of three residents reviewed. The facility census was 172. Findings include: Review of medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, squamous cell carcinoma, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, conversion disorder, insomnia, dysphasia, bipolar disorder, osteoarthritis, and major depressive disorder. The resident had a guardian on file. Review of the most recent Minimum Data Set (MDS) assessment for Resident #10, dated 07/18/24, revealed the resident mildly cognitively impaired. Resident #10 required supervision for activities of daily living (ADLs). Review of a census record for Resident #149, revealed the resident was moved to Resident #10's room on 09/06/24. Review of medical record for Resident #10, revealed no documented evidence that Resident #10's guardian was notified when Resident #10 received a roommate. Review of a nurse's progress notes for Resident #10 dated 09/23/24 at 10:44 P.M., revealed Resident #10 arrived back to the facility from the hospital and one-on-one (1:1) supervision was initiated and the resident reported a sexual assault. Review of a nurse's progress for Resident #10 dated 09/24/24, revealed the resident remains on 1:1 supervision and the resident's guardian was in to speak with the resident. Review of nurse's progress note for Resident #10 dated 09/25/24 and recorded as a late entry for 09/23/24 revealed Resident #10 approached the nurse around on 09/23/24 around 9:45 A.M. and reported she was going out. The nurse confirmed she did not have an appointment, and Emergency Medical Transport (EMT) arrived at the facility. The EMT reported to the nurse that Resident #10 called 911 herself because her stomach hurt, and she may be pregnant with a fetus. Resident #10 was transferred to the hospital. There was no documented evidence the resident's physician and the guardian was notified. Review of a nurse's progress note for Resident #10 dated 09/26/24 and recorded as a late entry for 09/25/24 at 3:00 P.M., revealed the facility discontinued the 1:1 sitter for Resident #10 for the psychosocial monitoring related to the sexual abuse allegation that occurred on 09/23/24. There was no documented evidence the resident's guardian was notified. Interview with Licensed Practical Nurse (LPN) #331 on 09/26/24 at 8:50 A.M. revealed Resident #10 was no longer ordered to be a 1:1 supervision. Interview with Resident #10's guardian on 09/26/24 at 1:01 P.M., indicated she was upset related to the lack of communication by the facility. Resident #10's guardian stated she was never notified by the facility when Resident #10 received a roommate on 09/06/24 and when the resident was sent to the hospital on 09/23/24. Resident #10's guardian stated she was not aware of the resident going to hospital emergency room (ER) until the ER contacted her for permission to treat Resident #10. Resident #10's Guardian stated she also found out about the new roommate when she visited Resident #10 while at the hospital. Resident #10's guardian stated she was told by the staff that Resident #10 would remain on a 1:1 observation until the guardian could find the resident a new facility. Resident #10's guardian indicated she was not aware of the 1:1 supervision ended for the resident. Observation of Resident #10 on 09/26/24 at 1:27 P.M., revealed the resident was in her room and not on a 1:1 supervision. Interview with LPN #331 at the same time, indicated she was the nurse for Resident #10 and was informed during their morning report that Resident #10 was no longer to be on a 1:1. LPN #331 verified Resident #331 was not on 1:1 observation. Interview with the Director of Nursing (DON) on 09/30/24 at 5:07 A.M. verified there was no documented evidence of Resident #10's guardian being notified when Resident #10 received Resident #140 as a roommate on 09/06/24. The DON verified there was no documented evidence the Guardian was notified when Resident #10 went to theER on [DATE]. Review of the facility policy, Resident Room Change Policy, undated, revealed Social Services will complete the notification of room change and new roommate notification forms. The facility social worker will discuss room changes with both residents and resident representatives and document the discussion. Social Service will make routine visits after a room change to ensure both residents are adjusting positively to the new situation. Review of the facility policy titled, Notification of Change in Condition, undated, revealed the facility must inform the resident, consult with the resident's physician, and notify the resident's representative, authorized family member, or legal guardian where there is a change of condition. The notification of change included, accidents, change in a resident's physical, mental, or psychosocial condition, new treatments, discontinuation of treatments, transfer or discharge, and change of room or roommate assignment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to treat residents with dignity and respect. This affected two (#70 and #73) out of three residents reviewed. The facility census was 172. Findings include: 1) Review of medical record for Resident #70 revealed an admitted d of [DATE] and expired at the facility with hospice services in place on [DATE]. Diagnoses included, amnesia, malignant neoplasm of bone, chronic hepatitis, essential primary hypertension, chronic kidney disease, hydronephrosis, anemia, gout, vascular dementia, anxiety, gastro-esophageal reflux disease (GERD), and dysphasia. Review of the Minimum Data Set (MDS) assessment for Resident #70, dated [DATE], revealed the resident was severely cognitively impaired. Resident #70 was dependent on staff for activities of daily living (ADLs). Observation of Resident #70 on [DATE] at 9:59 A.M. revealed the resident was seated in a wheelchair at a table in the common area for other residents. Resident #70 was only wearing a hospital type gown that was hanging off his shoulders with part of his upper chest exposed. Resident #70's soiled wheelchair cushion was lying on the floor under the foot pedals of the wheelchair. Resident #70 had an new incontinence brief hanging from one arm of the wheelchair and a pair of pants with a shirt on the other handle. Resident #70 was not wearing any shoes or socks. STNA #206 was seated across from him and entering information on a tablet. Interview with Registered Nurse (RN) #201 verified the resident was seated in the common area with his gown hanging from his shoulder and exposing his chest , the new incontinent brief and clothes hanging from the handles and no shoes or socks in place. RN #201 verified Resident #70's soiled wheelchair cushion was on the floor in front of Resident #70's foot. Observation at the same time, revealed RN #201 picked up the wheelchair cushion identified the food and debris splattered all over the wheelchair cushion and placed the cushion back on the floor. RN #201 indicated she wouldn't want to sit in a common area with only a hospital type gown on, no shoes or socks on and an incontinence brief hanging from the handle. She questioned State tested Nurse Aide (STNA) # 206 why Resident #70 was in the common room area. Interview with STNA #206 on [DATE] at 10:01 A.M., revealed Resident #70 was seated in the common area because he was waiting on shower from the shower aide. STNA #206 stated she placed Resident #70 in the common area to help the shower aide. STNA #206 indicated she would not want to be in common area with an incontinent brief and clothes hanging from the wheelchair; however, it was more convenient for the staff to complete showers this way. 2) Review of the medical records for Resident #73 revealed an admitted [DATE]. Diagnoses included unspecified intellectual disabilities (ID), psychosis, major depressive disorder, encephalopathy, anxiety disorder, schizophrenia, dysphasia, bipolar disorder, hyperlipidemia, and insomnia. Review of the MDS assessment, dated [DATE], revealed Resident #73 had impaired cognition. Resident #73 was dependent on staff for ADLs and supervision for eating. Review of care plans for Resident #73's revealed the resident had behavioral problems including eating non-edible items. The interventions listed included, approach and speak in a calm manner, intervene as necessary to protect the rights and safety of others, and intervene as necessary. Observation of Resident #73 on [DATE] at 9:51 A.M. revealed Resident #73 was walking down the hallway, directly past several staff members with a non-skid sock hanging from his mouth and he was chewing and appeared to be eating the sock. Interview with Registered Nurse (RN) #201 verified Resident #73 had a non-skid sock hanging from his mouth as he walked past several staff members in the hallway. RN #201 stated this was just something Resident #73 does. RN #201 stated Resident #73 should have been redirected by staff regarding the non-skid sock being in his mouth. Review of the facility policy titled, Resident Rights, undated, confirmed the facility policy is to provide Residents with centered care that meets the psychosocial physical and emotional needs and concerns of the residents. The purpose of the policy to is to guide employees in the general principles of dignity and respect of caring for residents. Further review of the policy revealed, the Residents will be treated with dignity and respect related to care needs. This deficiency represents non-compliance investigated under Complaint Number OH00158218 and OH00158074. This is an example of continued non-compliance from the survey dated [DATE].

Based on observations, staff interviews, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affected one (#68) of the five residents reviewed for dining. The facility census was 172. Findings include: Record review for Resident #68 revealed she was admitted on [DATE]. Diagnoses included anemia, hypothyroidism, hyperlipidemia, major depressive disorder, anxiety, Alzheimer's disease, insomnia, sleep antenna, essential primary hypertension, and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 had impaired cognition. Resident #68 required supervision from staff with eating. Observation of the main dining room on 10/01/24 at 12:39 P.M. revealed State tested Nursing Assistant (STNA) #348 deliver a food tray to Resident #68. STNA #328 removed her N-95 respirator and used her teeth to open a package of ranch dressing for Resident #68. STNA #328 handed the package of ranch dressing to Resident #68, who squeezed the dressing packet onto her salad. Interview with STNA #348 on 10/01/24 at 12:40 P.M. verified she pulled her N-95 respirator down, used her teeth to open a ranch dressing packet then handed the dressing packet to Resident #68 to put on her salad. Review of a facility policy titled Infection Prevention Program undated, revealed residents had a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections.

Based on observation, interview and policy review, the facility failed to ensure a refrigerator was provided for residents to use if they wished. This affected six (Residents #71, #43, #69, #173, #88 and #90) of six residents reviewed for the storage of resident food. The census was 170. Findings include: During an interview on 09/04/24 at 1:11 P.M., Resident #88 stated her family brought in a bottle of homemade lemonade. She asked the kitchen if they could keep it cold for her and they said yes. She stated an aide brought the lemonade back to her and yelled at her because the lemonade was in the kitchen. She said she had to throw out the lemonade. She stated there wasn't a place to store something cold for the residents. During an interview on 09/04/24 at 1:24 P.M., Resident #173 stated there was a refrigerator at the nursing station, but there was limited space for resident's food and the residents aren't permitted to have appliances in their rooms. During an interview on 09/04/24 at 2:35 P.M., Resident #71 stated she had bottles of soda sitting in her room. She stated the facility doesn't provide a refrigerator to store any items for the residents. During an observation on 09/04/24 at 3:30 P.M., the refrigerator on the 100 hall contained meals, soda and condiments in it. Nothing was labeled or dated. During an interview on 09/04/24 at 3:50 P.M., Dietary Manager (DM) #214 stated the facility doesn't store anything that comes in from the outside, because the facility doesn't know what it is. There are refrigerators on the units but the resident's food wasn't stored in those. During an interview on 09/05/24 at 8:39 A.M., Resident #69 stated he asked the Administrator if there was a refrigerator to put food in and he said yes. He said when he asked the staff they told him there wasn't enough room in the refrigerator for his food. The staff member also told him it was for the staff to use and he had to stop buying food because there isn't enough room to store it. During an interview on 09/05/24 at 8:44 A.M., Resident #90 stated he could have something stored that was cold if there was enough space in the refrigerator. He stated the staff doesn't like the residents to put cold food in the refrigerator. During an interview on 09/05/24 at 8:50 A.M., Resident #43 stated there wasn't a refrigerator for residents to keep food or drinks in. Review of the policy titled Storage of Resident Food, undated, stated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have the option of bringing food into the facility or have family or friends bring food into the facility as long as safe storage guidelines are followed to protect the resident and other residents in the facility. Safety for all residents is a priority for food handling, including when residents have their own food brought into the facility. This policy does not infer that residents need to or are required to supplement their nutritional needs, but that food is recognized for its social, psychological and emotional health as well as nutritional and health benefits. The facility recognizes and supports resident's need and right to bring in food from outside sources but still maintain safety and sanitary conditions for storage and consumption. The amount of food brought into the facility will be based on storage availability. The facility will provide properly sealed storage containers as needed. This deficiency represents non-compliance investigated under Complaint Number OH00157418.

Based on observation and interview, the facility failed to provide a homelike environment. This affected seven (Residents #34, #170, #153, #136, #10, #131, and #171) of seven residents reviewed for homelike environment. The census was 170. Findings include: 1. During an observation on 08/28/24 at 12:45 P.M., Resident #34;s room had an outlet behind the head of the bed that was dangling on the wall. During an interview at the time of the observation, Resident #34 stated she reported it to the maintenance man and he didn't come and fix it. During an interview on on 08/28/24 at 3:00 P.M., Maintenance Man (MM) #252 confirmed the resident told him about the dangling outlet and he had not fixed it yet. 2. During an observation on 08/28/24 at 1:03 P.M., Resident #170's had a brown substance on the floor, the top of the heater was rusted, the wall in the bathroom had holes by the paper towel holder and a light bulb was out. The paint on the ceiling was peeling. 3. During an observation on 08/28/24 at 1:10 P.M., Resident #153's room had scuff marks by the right side of her bed and the window blind was torn. 4. During an observation on 08/28/24 at 1:15 P.M., Resident #136's room had torn window blinds, the walls were scuffed up, the light behind his bed had a light bulb missing and there was no covering to the lights. The covering to the heater next to the bed was coming off. 5. During an observation on 08/28/24 at 1:20 P.M., Resident #10's window blinds were broken, the walls behind the bed were scuffed and the molding behind the bed was off the wall. 6. During an observation on 08/28/24 at 1:25 P.M., Resident #131's window blinds were torn. 7. During an observation on 09/03/24 at 9:50 A.M., Resident #171's room had a light out on the vanity, a yellow circle on the ceiling in the bathroom and a yellowish brown substance in the corners of the bathroom. The toilet has a big area of rust inside the bowl. During an interview on to the above mentioned rooms on 08/28/24 at 3:00 P.M., MM #252 confirmed all of the issues in the above mentioned rooms. and thought his assistant was working on all of the problems in the rooms. This deficiency represents non-compliance investigated under Complaint Number OH00157011 and OH00156598.

Based on medical record review, review of the facility investigation, resident interview, staff interview, and review of the facility policy, the facility failed to provide appropriate supervision and assistance with resident transfers which resulted in Actual Harm on 06/03/24 when Resident #66 was transferred out of a shower chair into bed by two staff members without the use of a Hoyer lift as ordered, resulting in the resident sustaining a fracture to the left humerus during the transfer. This affected one (Resident #66) of three residents reviewed for accidents. The facility census was 169 residents. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction. Review of the care plan for Resident #66 dated 11/10/23 revealed staff should use a Hoyer lift for all transfers with the assistance of two staff. Review of physician's orders for Resident #66 revealed an order dated 02/12/24 for the resident to transfer using Hoyer lift with the assistance of two staff. Review of the Minimum Data Set (MDS) assessment for Resident #66 dated 04/19/24 revealed the resident was cognitively intact, had impairment on one side of her upper and lower extremities, required supervision assistance with eating and was dependent on staff assistance for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and wheelchair mobility. Review of the progress note for Resident #66 dated 06/03/24 timed at 4:00 P.M. revealed the nurse informed the attending physician's office the resident was complaining of pain to the left shoulder and elbow. The nurse practitioner (NP) ordered a stat x-ray to the resident's left arm. Review of the progress note for Resident #66 dated 06/03/24 timed at 6:30 P.M. revealed a State tested Nursing Assistant (STNA) stated after the resident received her shower, the STNA and another aide were repositioning the resident while in the shower chair the resident's buttock had gotten stuck in the hole in the center of the shower chair. The STNA had then put her arm around the resident's chest to get her centered and then the two aides manually transferred Resident #66 from the shower chair to her bed. Review of progress note for Resident #66 dated 06/03/24 timed at 8:29 P.M. revealed the x-ray to the resident's left arm showed an irregularity of the proximal humerus which might represent an acute nondisplaced fracture versus prior trauma. Review of progress note for Resident #66 dated 06/03/24 timed at 9:55 P.M. revealed the nurse spoke with the on-call physician and received an order for the resident to follow up with an orthopedic doctor and to wear a sling due to left humerus fracture. Review of investigation file for Resident #66 regarding the incident dated 06/03/24 revealed on 06/03/24 at 4:00 P.M. when two STNAs transferred the resident to bed without use of a Hoyer lift the resident reported she heard a pop to her left arm and shoulder area. Review of the witness statement per STNA #187 dated 06/03/24 revealed Resident #66 was in her shower chair and began to complain the shower chair was cutting into her butt, so she pushed the resident to her room in the shower chair. Further review of the statement revealed the Hoyer lift was not working, so STNAs #187 and #188 manually transferred the resident to bed. Then Resident #66 complained of hearing a pop to her left shoulder area. Review of the witness statement from STNA #188 dated 06/03/24 revealed STNA #187 and #188 transferred Resident #66 from the shower chair to the bed with STNA #188 holding the resident's legs and STNA #187 holding the resident's chest. Interview on 07/24/24 at 1:06 P.M. with Resident #66 confirmed she had a broken left upper arm that occurred after two STNAs failed to use a Hoyer lift last month to transfer her. Interview confirmed the Hoyer battery was dead when they attempted to use it, so they picked the resident up and put her in bed. Resident #66 further confirmed during the transfer she told the aides she heard and felt something pop in her left arm. Interview on 07/25/24 at 3:15 P.M. with STNA #188 confirmed on 06/03/24 she assisted STNA #187 with a transfer of Resident #66 from the shower chair to the bed. STNA #188 confirmed they were supposed to use a Hoyer lift to transfer the resident, but the lift wasn't working so they manually transferred the resident. STNA #188 confirmed she picked up the resident by her legs and STNA #187 picked up the resident by her chest. STNA #188 confirmed Resident #66 reported she heard a pop in her left shoulder area during the transfer. Interview on 07/25/24 at 4:11 P.M. with the Director of Nursing (DON) confirmed STNAs #187 and STNA #188 manually transferred Resident #66 from the shower chair to the bed 06/03/24 at 4:00 P.M. when the Hoyer lift was not working. The DON confirmed Resident #66 had a physician's order to be transferred via Hoyer lift only. The DON confirmed Resident #66 sustained a fracture to the left humerus during the manual transfer on 06/03/24. Interview on 07/31/24 at 2:02 P.M. with the Administrator confirmed he was not aware of the manual transfer of Resident #66 on 06/03/24 in which the resident sustained a broken humerus. Review of the facility policy titled Mechanical Lifts and Transfer undated revealed safety was a primary concern for residents, staff and visitors. The use of mechanical lifts required a competent and skilled user and required the use of two employees to perform the lift safely, for both the resident and the employees. This deficiency represents noncompliance investigated under Complaint Number OH00155630.

Based on observations, staff interviews, interview with the Local Health Department (LHD), review of medical records, review of the facility census, review of a list of Coronavirus Disease 2019 (COVID-19) positive residents, review of the facility's floor plan identifying COVID-19 positive rooms, review of facility's infection surveillance, review of a list of new admissions, review of facility policies, review of the Centers for Disease Prevention and Control (CDC) recommendations, and review of Centers for Medicare and Medicaid (CMS) recommendations, the facility failed to implement effective and recommended infection control practices to prevent the spread of infectious disease and move COVID-19 positive residents out of rooms or units with COVID-19 negative residents. With positive and negative residents cohorting, the likelihood exists for serious life-threatening harm or death related to the spread of COVID-19 throughout the facility as the facility failed to operationalize their infection control policies and procedures. This resulted in Immediate Jeopardy when the facility received results of their in-house point-of-care (POC) [MEDICATION(S)] rapid COVID-19 testing and allowed six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 to cohort in the same rooms as six (#162, #167, #137, #145, #153, and #142) residents positive for COVID-19. On 01/31/22, the facility had 28 (#54, #55, #137, #145, #147, #152, #155, #153, #167, #162, #168, #169, #170, #36, #23, #24, #26, #42, #33, #34, #37, #38, #41, #25, #157, #142, #148, and #29) active cases of residents' positive for COVID-19 and failed to implement their policy to establish a designated unit/area in the facility for COVID-19 positive residents. Additionally, the facility staff failed to utilize Personal Protective Equipment (PPE) properly when coming into contact with COVID-19 positive residents, the facility failed to ensure staff practiced hand hygiene after coming into contact with COVID-19 positive residents, the facility failed to have proper signage posted for COVID-19 positive rooms, the facility failed to have trash bins available for staff to throw away used PPE after coming into contact with COVID-19 positive residents, and the facility allowed COVID-19 positive residents to wander the facility without facemasks or redirection back to their room. Furthermore, the facility failed to quarantine new admissions who were unvaccinated for COVID-19 and implement Transmission-Based Precautions (TBP) for four (#105, #104, #108, and #56) residents. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 171 residents at risk for the likelihood of serious harm, negative health outcomes/complications and/or death. The facility census was 171. On 02/01/22 at 12:34 P.M., the Interim Administrator, Vice President (VP) of Clinical Operations and Regional Nurse #700 were notified Immediate Jeopardy began on 01/26/22 when 22 (#55, #137, #145, #147, #152, #155, #153, #167, #162, #168, #169, #170, #36, #23, #24, #26, #42, #33, #34, #37, #38, and #41) residents tested positive for COVID-19 and allowed six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 to cohort in the same rooms as six (#162, #167, #137, #145, #153, and #142) residents positive for COVID-19. Additionally, the facility staff failed to utilize PPE properly when coming into contact with COVID-19 positive residents, failed to ensure staff practiced hand hygiene after coming into contact with COVID-19 positive residents, failed to have proper signage posted for COVID-19 positive rooms, failed to have trash bins available for staff to throw away used PPE after coming into contact with COVID-19 positive residents, and the facility allowed COVID-19 positive residents to wander the facility without facemasks or redirection back to their room. The facility also failed to quarantine new admissions who were unvaccinated for COVID-19 and implement TBP for four (#105, #104, #108, and #56) residents. The Immediate Jeopardy was removed on 02/02/22 when the facility implemented the following corrective actions: · On 02/01/22, the facility separated the six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 from the six (#162, #167, #137, #145, #153, and #142) positive COVID-19 residents who were cohorted in the same rooms from 01/26/22 to 02/02/22. · On 02/01/22, the facility posted proper signage to COVID-19 positive rooms to identify PPE and infection control measures to be utilized. · On 02/01/22, the Administrator, Director of Nursing (DON) or designee placed trash bins for doffing (taking off) PPE at the entrance/exit of the COVID-19 positive rooms. · On 02/01/22, the DON, Regional Nurse #700 or designee began all staff education on PPE use, education to residents on mask use, and proper signage. The education was completed on 02/02/22. · The DON will conduct daily rounds on each shift to ensure staff and residents in TBP are applying all required PPE. Rounds will include verification of trash receptables for PPE, handwashing, disinfecting eye protection when exiting a positive room, and donning (putting on) and doffing PPE. Monitoring will continue daily for at least four weeks. · On 02/02/22 from 11:00 A.M. to 11:25 A.M., observations confirmed the facility separated the six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 from the six (#162, #167, #137, #145, #153, and #142) positive COVID-19 residents who were cohorted in the same rooms from 01/26/22 to 02/02/22. · On 02/02/22 from 11:00 A.M. to 11:25 A.M., observations revealed there were no infection control concerns noted. Staff were utilizing PPE appropriately, and signage for quarantine and isolation rooms was appropriately posted. · On 02/02/22 from 11:00 A.M. to 11:25 P.M., interviews with Licensed Practical Nurse (LPN) #500, LPN #505 and LPN #522 confirmed they were trained on infection control measures and were knowledgeable. · Observations on 02/02/22 from 11:00 A.M. to 11:25 A.M. revealed four (#105, #104, #108, and #56) new admission residents were placed on quarantine with TBP in place. Residents #105, #104, #108 and #56's rooms had signs indicating the residents were in TBP and PPE was available to staff. Although the Immediate Jeopardy was removed on 02/02/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings included: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20, revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported [42 CFR 483.80 (a) (2) (i) and (ii)]. Interview on 01/31/22 at 9:30 A.M. with Receptionist #501 revealed the facility had approximately two or three COVID-19 positive residents. Receptionist #501 was unaware if the facility had a designated COVID-19 unit but believed COVID-19 positive rooms were labeled with red signs. Observations on 01/31/22 from 9:45 A.M. to 9:59 A.M. and from 11:01 A.M. to 11:40 A.M. revealed the facility had two floors with four units, two units on each floor. The first-floor units were named North Hall and [NAME] Hall 1 and [NAME] Hall 2. The second-floor units were named East Hall 1 and East Hall 2 and West Hall 1 and West Hall 2. Throughout the building there were a few red signs posted outside the doors of resident rooms. The doors of the labeled rooms were either opened or closed and not consistent. Some of the labeled rooms had PPE available outside the room and others did not. The observations revealed it was unclear how to determine which rooms housed COVID-19 positive residents. During an interview on 01/31/22 at 11:08 A.M., LPN #503 reported he was the Unit Manager for the second floor West Halls 1 and 2. LPN #503 reported there were approximately 11 COVID-19 positive residents housed on the second floor West Halls. Observations of the West Halls revealed multiple doors labeled with red signs with doors open and multiple residents throughout the hallway, some wearing masks, some not. It was hard to determine which residents were positive and which were negative for COVID-19 due to multiple COVID-19 positive rooms missing proper red signage on the room doors. Observation on 01/31/22 at 11:10 A.M. revealed LPN #502 was working with COVID-19 positive residents on the second floor West Halls. LPN #502 was not wearing her N95 mask correctly. The observations revealed LPN #502's N95 mask straps were not placed around her head. LPN #502 had a surgical mask overtop the N95 mask, which was holding the N95 mask against her face, so the N95 mask did not have a proper seal on LPN #502's face. LPN #502 verified she was caring for COVID-19 positive residents throughout her shift. Observation on 01/31/22 at 11:15 A.M. revealed State tested Nurse Aide (STNA) #504 was not wearing her N95 mask correctly. STNA #504's N95 mask was modified, the head bands had been cut and tied and the bands were placed behind her ears like a surgical mask. STNA #504 was working on the second floor East Halls, which had COVID-19 positive residents. LPN #500 verified there were COVID-19 positive residents residing on the second floor East Halls. Interview on 01/31/22 at 11:20 A.M. with LPN #505 reported she was working on the first floor, [NAME] Halls 1 and 2, and there were approximately 10 residents' positive for COVID-19 in that area of the facility. Observations of [NAME] Halls revealed there were three rooms with red signs. Further observations with LPN #505 revealed the total number of signs posted outside resident rooms indicating they housed COVID-19 positive residents did not reflect all 10 COVID-19 positive residents residing on the [NAME] Halls. Review of the facility list of active COVID-19 positive residents as of 01/31/22 revealed there were 28 (#54, #55, #137, #145, #147, #152, #155, #153, #167, #162, #168, #169, #170, #36, #23, #24, #26, #42, #33, #34, #37, #38, #41, #25, #157, #142, #148, and #29) COVID-19 positive residents residing at the facility. Signage throughout the facility did not reflect 28 COVID-19 positive cases. Observations on 01/31/22 from 2:22 P.M. to 3:05 P.M. revealed there were six (#162, #167, #137, #145, #153, and #142) COVID-19 positive residents cohorting in the same room as six (#163, #166, #136, #146, #154, and #143) COVID-19 negative residents. Review of Resident #162's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #162 tested positive for COVID-19 on 01/26/22. Resident #162 shared a room with Resident #163 who was negative for COVID-19. Review of Resident #163's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #163 tested negative for COVID-19 on 01/21/22 and 02/02/22. Resident #163 shared a room with Resident #162 who was positive for COVID-19 on 01/26/22. Review of Resident #167's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #167 tested positive for COVID-19 on 01/26/22. Resident #167 shared a room with Resident #166 who was negative for COVID-19. Review of Resident #166's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #166 tested negative for COVID-19 on 01/21/22 and 02/01/22. Resident #166 shared a room with Resident #167 who was positive for COVID-19. Review of Resident #137's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #137 tested positive for COVID-19 on 01/26/22. Resident #137 shared a room with Resident #136 who was negative for COVID-19. Review of Resident #136's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #136 tested negative for COVID-19 on 01/21/22 and 02/01/22. Resident #136 was not vaccinated for COVID-19. Resident #136 shared a room with Resident #137 who was positive for COVID-19. Review of Resident #145's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #145 tested positive for COVID-19 on 01/26/22. Resident #145 shared a room with Resident #146 who was recovered from COVID-19. Review of Resident #146's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #146 tested positive for COVID-19 on 01/12/22 and was recovered. Resident #146 moved rooms and resided with Resident #145 on 01/25/22. Resident #145 tested positive for COVID-19 on 01/26/22 and Resident #146 continued to reside in the same room. Review of Resident #153's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #153 tested positive for COVID-19 on 01/26/22. Resident #153 shared a room with Resident #154 who was negative for COVID-19. Review of Resident #154's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #154 tested negative for COVID-19 on 01/21/22 and 02/01/22. Resident #154 shared a room with Resident #153 who was positive for COVID-19. Review of Resident #142's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #142 tested positive for COVID-19 on 01/26/22. Resident #142 shared a room with Resident #143 who was negative for COVID-19. Review of Resident #143's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #143 tested negative on 01/21/22 and 02/01/22. Resident #143 was not vaccinated for COVID-19. Resident #143 shared a room with Resident #142 who was positive for COVID-19. Observations made with LPN #505 on 01/31/22 from 2:22 P.M. to 2:39 P.M. revealed six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 were cohorted in the same rooms as six (#162, #167, #137, #145, #153, and #142) residents positive for COVID-19. Observation on 01/31/22 at 2:39 P.M. revealed Resident #167 (positive for COVID-19) was not in his room. LPN #505 reported he was most likely seated in the common area or using the residential phone. Resident #167 was observed in the common area using the residential phone with a surgical mask pulled down under his chin. Resident #167 was never redirected back to his room, even after he was finished with his phone call. The phone was never observed to be disinfected by staff after his use. Observation on 01/31/22 at 2:54 P.M. revealed Resident #36 (positive for COVID-19) was wandering the second floor West Hall 2 without a mask on. Resident #36 was not offered redirection from staff to return to his room. LPN #503 verified Resident #36 was positive for COVID-19 and never redirected him back to his room or provided education to Resident #36 about putting on a mask. During an interview on 01/31/22 at 3:27 P.M., Regional Director of Operations (RDO) #99 was adamant the facility did not have COVID-19 positive and COVID-19 negative residents cohorting in the same rooms. Surveyor showed RDO #99 rooms with both COVID-19 positive and negative residents cohorted together. RDO #99 did not know who each resident was. LPN #503 told RDO #99, Resident #162 (positive for COVID-19) was cohorted in the same room as Resident #163 (negative for COVID-19), Resident #167 (positive for COVID-19) was cohorted in the same room as Resident #166 (negative for COVID-19), Resident #137 (positive for COVID-19) was cohorted in the same room as Resident #136 (negative for COVID-19), Resident #145 (positive for COVID-19) was cohorted in the same room as Resident #146 (negative for COVID-19), Resident #153 (positive for COVID-19) was cohorted in the same room as Resident #154 (negative for COVID-19), and Resident #142 (positive for COVID-19) was cohorted in the same room as Resident #143 (negative for COVID-19). RDO #99 reported if a resident was COVID-19 positive and asymptomatic, they were allowed to cohort in the same room as a COVID-19 negative resident. When questioned who told her that was allowed, RDO #99 did not answer the question and then stated if a resident tested positive for COVID-19 with a rapid test, the facility would follow up with a Polymerase Chain Reaction (PCR) test to confirm the positive result. If the PCR test was positive as well, the COVID-19 positive resident would then be moved to a different room. RDO #99 reported PCR tests were conducted, but they had not received the results yet and were unaware of when they would receive the results. Observations on 01/31/22 at 4:33 P.M. revealed new white signs alerting staff to wear full PPE were posted on all COVID-19 positive resident rooms. LPN #503 verified the signs had just been posted and were not posted that morning. Observations on 01/31/22 from 4:30 P.M. to 4:41 P.M. revealed STNA #508 and STNA #509 assisting multiple COVID-19 positive residents with smoking outside (STNA #508 and #509 verified all residents outside, which was approximately six residents, were positive for COVID-19). STNA #508 and #509 were wearing N95 masks and goggles only (no gown or gloves). STNA #508 and #509 were within six feet of residents and assisted residents with lighting their cigarettes. STNA #509's N95 was not applied correctly, the top strap of the N95 was not placed behind her head, and it was dangling in the front of the mask. STNA #509's mask did not have a proper seal as her nose kept becoming exposed showing a loose fit. STNA #509 verified her N95 was not applied on her face properly and adjusted it. After assisting COVID-19 positive residents with smoking, neither STNA #508 or #509 changed their N95 masks, disinfected their goggles, or practiced hand hygiene. Interview on 01/31/22 at 4:41 P.M., STNA #508 verified herself and STNA #509 had not worn gown or gloves when assisting COVID-19 positive residents with smoking. STNA #508 further verified herself and STNA #509 did not change their N95 masks or disinfect or change their goggles. STNA #508 verified when having contact with COVID-19 positive residents or entering a COVID-19 positive room, staff were to wear full PPE of a gown, gloves, mask, and goggles. Observation on 01/31/22 at 4:49 P.M. noted STNA #508 and STNA #509 entered Resident #167's room who was COVID-19 positive. STNA #508 and #509 had on N95 masks, and goggles, (the same N95 masks and goggles worn to assist COVID-19 positive residents with smoking earlier) and donned gowns and gloves. STNA #508 and #509 repositioned Resident #166 (negative for COVID-19, sharing a room with Resident #167 who was positive for COVID-19) in his wheelchair. Resident #166 and Resident #167 were seated next to each other within six feet. Resident #167 was not wearing a mask. Resident #166 had a surgical mask on, but it was not covering his nose. STNA #508 and #509 continued to allow Resident #166 and Resident #167 to sit next to each other. STNA #508 and #509 were within six feet of Resident #167. STNA #508 and #509 went to exit the room and began doffing their gowns and gloves. There was no trash bin to place used PPE. STNA #509 left the room to get a trash bag. STNA #508 and #509 placed used PPE in the trash bag and carried the trash bag to the linen closet down the hall to throw away. STNA #508 and #509 never doffed their N95 masks or goggles upon exiting the room. STNA #508 and #509 also did not disinfect their goggles or practice hand hygiene. Interview on 01/31/22 at 4:49 P.M., STNA #508 and STNA #509 verified they wore the same N95 masks throughout their shift and did not switch them out between resident encounters (even after having contact with COVID-19 positive residents). STNA #508 and #509 reported N95 masks were available to them in the front of the building. STNA #508 and #509 reported they never disinfected their goggles or switched them out in-between resident encounters and were not knowledgeable of this requirement. STNA #508 and #509 verified there was no trash bin to throw away used PPE in COVID-19 positive rooms. Observations of other multiple COVID-19 positive rooms revealed lack of available trash bins to dispose of soiled PPE. On 01/31/22 at 5:15 P.M., RDO #99 stated the LHD said COVID-19 positive residents and COVID-19 negative residents could cohort in the same room if the COVID-19 positive resident was asymptomatic. When asked who RDO #99's contact was at the LHD, she reported she did not speak with anyone from the LHD directly and called Regional Infection Preventionist (RIP) #100. RIP #100 also claimed the LHD said the facility could allow COVID-19 positive residents and COVID-19 negative residents to cohort in the same room if the COVID-19 positive resident was asymptomatic. When asked who RIP #100 spoke with at the LDH, she reported she had not spoken to anyone directly. RDO #99 reported the facility was transitioning a new staff member to become the facility's Infection Preventionist and she would call the Previous Infection Preventionist who recently resigned. Phone call with the Previous Infection Preventionist (LPN #513) revealed LPN #513 recently resigned from being the facility's Infection Preventionist on 01/28/22. LPN #513 verified she spoke with LHD Personnel #700 regarding the facility's current COVID-19 outbreak. LPN #513 verified LHD Personnel #700 never told her COVID-19 positive, and COVID-19 negative residents could be cohorted in the same room, even if the COVID-19 positive resident was asymptomatic. RDO #99 was asked why residents negative for COVID-19 continued to be cohorted and exposed to COVID-19 positive residents and she reported the facility ran out of rooms to move residents. Review of facility census dated 01/26/22 revealed the facility's census was 166. Review of facility census dated 01/31/22 revealed it was 171. RDO #99 verified the facility's capacity was 180. When asked why COVID-19 positive residents were not moved into rooms together and exposed roommates moved into rooms together upon discovery of additional cases on 01/26/22, RDO #99 had no answer. Observations on 02/01/22 at 7:54 A.M. revealed six (#163, #166, #136, #146, #154, and #143) residents negative for COVID-19 continued residing in the same rooms as six (#162, #167, #137, #145, #153, and #142) residents positive for COVID-19. There had been no room changes. Interviews on 02/01/22 at 7:54 A.M. with LPN #505 and LPN #511 verified COVID-19 positive residents and COVID-19 negative residents were cohorted in the same rooms together and there had been no room changes. Interview on 02/01/22 at 8:31 A.M., LHD Personnel #700 verified she had been in contact with facility staff regarding their COVID-19 outbreak. LHD Personnel #700 reported she instructed staff on multiple occasions to separate COVID-19 positive residents from COVID-19 negative residents and reminded the facility COVID-19 positive residents and COVID-19 negative residents could not be cohorted in the same room together (even if the COVID-19 positive resident was asymptomatic). LHD Personnel #700 told facility staff it would be a huge issue if they housed COVID-19 positive and COVID-19 negative residents in the same room. LHD Personnel #700 reported she specifically instructed facility staff to follow CDC and CMS requirements. Additional observations of non-compliance made on 02/01/22 at 12:07 P.M. revealed there were four (#105, #104, #108, and #56) residents who were new admissions with no TBP in place, no signs posted on doors, and no PPE available outside of their rooms. Registered Nurse (RN) #22 and LPN #21 verified Residents #105, #104, #108 and #56 were new admissions and there was no PPE outside their doors or signage indicating what PPE was to be worn when entering the rooms. Review of Resident #105's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #105 had not received the COVID-19 vaccine. Further medical record review revealed there was no evidence Resident #105 was placed on quarantine or TBP. Review of Resident #104's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #104 had not received the COVID-19 vaccine. Further medical record review revealed there was no evidence Resident #104 was placed on quarantine or TBP. Review of Resident #108's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #108 had not received the COVID-19 vaccine. Further medical record review revealed there was no evidence Resident #108 was placed on quarantine or TBP. Review of Resident #56's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56 received the Moderna Step One COVID-19 vaccine, but there was no evidence he received the Step Two dose. Further medical record review revealed there was no evidence Resident #56 was placed on quarantine or TBP. Review of facility list of COVID-19 positive residents for January 2022 revealed the facility had 116 residents test positive for COVID-19 from 01/10/22 to 01/30/22. Review of facility infection surveillance for January 2022, revealed 116 residents tested positive for COVID-19 from 01/10/22 to 01/30/22. Review of the facility list of new admission for January 2022 revealed the facility admitted seven residents from 01/11/22 to 01/31/22. Review of facility highlighted floor plan for 01/31/22 revealed there were 22 COVID-19 positive rooms throughout the facility. Review of the facility policy titled, Criteria for COVID-19 Requirements and Resident Placement, revised 01/27/22 revealed residents with COVID-19 symptoms should be placed on droplet precautions and isolate in a private room. Roommate should be placed in at risk unit in a private room if available or shelter in place with TBP's. If three or more residents are identified as COVID-19 positive, a COVID-19 unit could be set up. Criteria for admitting residents to the COVID-19 unit included residents who had a positive PCR or POC (rapid test) test results. When caring for COVID-19 positive residents, gown, gloves, N95 mask would be discarded prior to exiting the room and face shield would be discarded or disinfected after each patient encounter. Appropriate signage would be placed on or around the COVID-19 positive resident's room door. Full PPE was required when entering a COVID-19 positive room and PPE was required to be changed upon exiting. Eye protection should be cleaned between each patient encounter. Hand hygiene would be performed before/after care and donning/doffing of PPE. New admissions who were not fully vaccinated would be placed on a 14-day quarantine with TBP's in place, including use of full PPE. Proper signage would be posted. Review of CDC, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, guidance updated 02/02/22 revealed TBP/quarantine was recommended for residents who were newly admitted to the facility if they are not up to date with recommended COVID-19 vaccine doses. Facilities should identify space in the facility that could be dedicated to care for COVID-19 positive residents. Health Care Personnel (HCP) should use full PPE (gowns, gloves, eye protection, and N95) when caring for COVID-19 positive residents. Doors of COVID-19 positive resident rooms should be closed, especially when caring for COVID-19 positive residents outside of the COVID-19 unit. Residents who are not up to date with COVID-19 vaccines and have had close contact with someone who has COVID-19, should be placed in quarantine and full PPE should be utilized. Review of CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic, guidance updated 02/02/22 revealed patients who had close contact with other patients with confirmed COVID-19, should not be cohorted together. Only patients with the same respiratory pathogen should be housed in the same room. Facilities should limit transport and movement of patients outside of the room to medically essential purposes. This deficiency represents ongoing noncompliance from the survey dated 01/19/22.

Based on medical record review, physician interview, review of the facility policy, and review of the hospital records, the facility failed to ensure laboratory (lab) values were obtained and interventions were implemented for a resident with subtherapeutic levels of an anti-[CONDITION(S)] medication. This resulted in actual harm when Resident #146 was hospitalized for a breakthrough [CONDITION(S)] related to subtherapeutic levels and required a loading dose of the anti-[CONDITION(S)] medication. This affected one (#146) of three residents receiving anti-[CONDITION(S)] medications. The facility census was 154. Findings include: Review of the medical record for Resident #146 revealed the resident was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required supervision/oversight with all Activities of Daily Living (ADL). Review of the July 2021 physician orders revealed Resident #146 was prescribed, [MEDICATION(S)] (anti-[CONDITION(S)] medication) 200 milligrams (mg) at 9:00 A.M. and 9:00 P.M. for [CONDITION(S)]. Review of the lab results for [MEDICATION(S)] level for 02/11/21 was 3.8 microgram/milliliter (ug/ml), therapeutic range is 10 to 20 ug/ml. Further review of the medical record revealed there were no [MEDICATION(S)] levels obtained in March 2021 and April 2021. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital encounter report dated 05/01/21 at 12:59 P.M. revealed Emergency Department (ED) Physician #102 documented the following: Male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] level was subtherapeutic level at 3.5 ug/ml, therapeutic range 10 to 20 ug/ml. Further review of the hospital report revealed Resident #146 was administered a loading dose of [MEDICATION(S)] in the ER. Review of the nurses' notes dated (late entry) 05/01/21 at 1:24 P.M. revealed Licensed Practical Nurse (LPN) #56 documented the resident was observed laying on the bed with his hand under his head, unresponsive, and had froth coming from his mouth. The resident's blood sugar was 115 milligrams per deciliter (mg/dL) and the resident had shallow respirations. Nine-one-one was called and transported the resident to the local hospital. During a telephone interview on 07/19/21 at 4:09 P.M., Physician #200 stated [MEDICATION(S)] levels should be done at least every other month. Physician #200 stated therapeutic levels of [MEDICATION(S)] are not only based on lab levels but include [CONDITION(S)] activity and Resident #146 had no reported [CONDITION(S)] activity prior to 05/01/21. Review of the facility policy titled Critical Laboratory Value Management revised 12/07/18 revealed laboratory values that are outside the parameter of normal that to a degree, may constitute an immediate health risk to the individual and may require immediate action from the physician. Laboratory values considered critical or out-of-range are standardized for most laboratory reporting using reference range per laboratory regulatory requirement. The physician will indicate in the orders when they want to be notified when the specific laboratory value is out-of-range.

Based on review of a closed medical record, review of the Emergency Medical Service (EMS) record, review of the facility's [MEDICAL TREATMENT] policy, review of hospital records, review of [MEDICAL TREATMENT] center records, review of in-service records, physician interview, staff interviews and interview with [MEDICAL TREATMENT] center staff, the facility failed to ensure Resident #01 with End Stage [MEDICAL CONDITIONS] received scheduled [MEDICAL TREATMENT] treatments as ordered by the physician to sustain life. This resulted in Immediate Jeopardy and serious life-threatening harm when the resident went nine days without [MEDICAL TREATMENT] treatments after testing positive for COVID-19 due to the facility's failure to communicate and coordinate continuity of care with the [MEDICAL TREATMENT] center; failure to notify the physician of the resident not receiving ordered treatments; failure to notify the family of treatments not being provided as ordered; failure to transport the resident to [MEDICAL TREATMENT] treatments and failure to accurately document care and treatment of [REDACTED].#01 was transported to the hospital and subsequently passed away while receiving emergent [MEDICAL TREATMENT] on 11/09/20. This affected one (Resident #01) of a total of three residents reviewed for receiving [MEDICAL TREATMENT] in an outpatient setting. The current facility census is 149. On 11/19/20 at 12:50 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 11/04/20 when Resident #01 missed the second scheduled [MEDICAL TREATMENT] appointment after testing positive for COVID-19 and the physician was misinformed when the resident would be receiving the next [MEDICAL TREATMENT] treatment. Resident #01 continued to miss scheduled [MEDICAL TREATMENT] treatments until 11/09/20, when the resident was transported to the hospital and passed away while receiving emergency treatment. The Immediate Jeopardy was removed on 11/19/20 when the facility implemented the following corrective actions: · On 11/19/20, an audit was conducted by the DON and/or the ADON of all residents with orders to receive [MEDICAL TREATMENT] dating on or after 11/09/20 to ensure no other residents were affected by the deficient practice. · On 11/19/20 beginning at 1:00 P.M. and ending at 5:15 P.M., the DON and/or designee provided education for all licensed nurses regarding facility policy and procedures to address coordination of care with the [MEDICAL TREATMENT] center, including COVID-19 positive residents, how and when the physician is to be notified of missed treatments, how new appointments are to be scheduled and documentation in the medical record of the coordination of care to ensure treatment is being provided. Review of sign-in sheets for the in-service revealed all nurses were provided the education. · On 11/19/20 beginning at 1:00 P.M. and ending at 5:15 P.M., the DON and/or designee provided education for all licensed nurses regarding how to provide education to resident's and resident's representatives when [MEDICAL TREATMENT] is refused. The nurses were educated to notify the DON, ADON, or Administrator if a resident refuses a [MEDICAL TREATMENT] treatment. · Beginning on 11/19/20, the DON or designee will ensure any resident admitted /readmitted on or after 11/19/20 with an order for [REDACTED]. The assigned Nurse, Unit Manager and DON will be responsible for the care coordination of residents with [MEDICAL TREATMENT] orders. · Beginning on 11/19/20, the DON or designees will initiate audits three times a week for six weeks to ensure the physicians are being notified, residents are receiving education when refusing [MEDICAL TREATMENT] treatments, and follow-up appointments with transportation is scheduled for next treatments. Results of the monitoring will be reviewed in the Quality Assurance meetings to determine if compliance is being achieved. · Beginning on 11/19/20, all newly hired nurses will be provided education during orientation on Riverside Healthcare Center's [MEDICAL TREATMENT] Care and Monitoring policy and Notification of Changes in Condition policy. · On 11/25/20 at 12:10 P.M., interview with Resident #05 revealed the resident has not missed any [MEDICAL TREATMENT] treatments sine 11/19/20. Resident #05 stated the facility has arranged for his transport to the [MEDICAL TREATMENT] center and when the [MEDICAL TREATMENT] center was closed on 11/21/20, the facility sent him to the hospital for [MEDICAL TREATMENT] treatment. Resident #05 denied any concerns with his [MEDICAL TREATMENT] treatments or transport to the appointments. · On 11/25/20 at 11:33 P.M. and 12:40 P.M., interviews with Licensed Practical Nurse (LPN) #250 and LPN #265 revealed the nurses received education on 11/19/20 regarding communication with the [MEDICAL TREATMENT] center, policy for notifications of missed appointments, and documentation of the communication regarding [MEDICAL TREATMENT] appointments. Although the Immediate Jeopardy was removed on 11/19/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan including monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was transferred on 11/09/20 to the hospital and passed away the same day. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/01/20, revealed the resident had impaired cognition and was to receive [MEDICAL TREATMENT]. Review of Resident #01's care plans dated 02/17/17, revealed a care plan for [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. The resident is to attend [MEDICAL TREATMENT] at the DaVita Five Rivers facility on Monday, Wednesday and Fridays at 6:45 A.M. with Integrity Transport to pick up at 5:45 A.M. Interventions included encourage resident to attend regular appointments, monitor catheter per order, 1500 milliliter fluid restriction daily, monitor for signs and symptoms of [MEDICAL CONDITION] which include changes in levels of consciousness and changes in heart and lung sounds. Per the plan of care, the last revision was completed on 11/13/20, after the resident had passed on 11/09/20. Review of Resident #01's physician's orders [REDACTED].#01 was ordered to receive [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 6:00 A.M. at the DaVita Five Rivers facility. Review of the Medication Administration Record [REDACTED]. Review of a verbal order physician sheet dated 11/05/20 revealed Resident #01's [MEDICAL TREATMENT] appointments were changed to DaVita Dayton South facility on Tuesday, Thursday and Saturday with the first appointment to be on 11/07/20 for two weeks. Further review of the electronic medical records and MARs revealed no change order for [MEDICAL TREATMENT] treatments was noted in the electronic record. Upon further review of Resident #01's MAR, dated November 2020, revealed the resident was documented as receiving the scheduled [MEDICAL TREATMENT] treatments on 11/04/20 and 11/06/20. Review of Resident #01's [MEDICAL TREATMENT] center records revealed for the month of November 2020, the resident was scheduled to receive [MEDICAL TREATMENT] on Monday, Wednesday and Friday at the DaVita Five Rivers facility. The records document Resident #01 missed the 11/02/20, 11/04/20, and 11/06/20 appointments. Review of the DaVita Dayton South facility records revealed on Tuesday, Thursday and Saturdays, the resident missed the 11/05/20 and 11/07/20 appointments. Per the [MEDICAL TREATMENT] records, the resident did not receive any [MEDICAL TREATMENT] treatments from 10/31/20 to 11/09/20. Review of progress notes from the [MEDICAL TREATMENT] center dated 11/07/20, the [MEDICAL TREATMENT] center nurse contacted the facility to inform the facility, Resident #01 needed to be taken to the emergency room due to not having any [MEDICAL TREATMENT] since 10/30/20. Per the note, the facility's representative did not have access to the isolated COVID-19 unit, but the message was passed on to the charge nurse. Review of the progress note dated 11/09/20, the [MEDICAL TREATMENT] nurse received a phone call from Registered Nurse (RN) #100 asking if Resident #01 needed to go to the emergency room prior to receiving [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center informed RN #100, the resident needed to be sent to the emergency room and the nurse was educated on the issues with a resident missing so many [MEDICAL TREATMENT] appointments. Further review of Resident #01's medical record revealed there were no nursing assessments, vital signs, or documentation of the resident's condition on 11/08/20 or 11/09/20. Review of the Emergency Medical Services (EMS) report dated 11/09/20, revealed Resident #01 was assessed at 12:29 P.M. by the EMS staff. Per the report, Resident #01 was found to be hypoxic (diminished oxygen levels) with rapid breathing on supplemental oxygen. Furthermore, the report indicated the facility staff reported to the EMS, the resident has been declining over the past couple days and has missed all [MEDICAL TREATMENT] appointments since 10/30/20. The resident's cardiac monitoring was showing [MEDICAL CONDITION] (low heart rate) with mild [MEDICAL CONDITION] (low blood pressure). Review of the hospital medical records, dated 11/09/20, revealed Resident #01 presented with the complaint of shortness of breath and was unresponsive from the extended care facility. Resident #01 required increased oxygen and had altered mental status upon admission to the emergency room triage on 11/09/20 at 1:06 P.M. Per the documentation, the resident's chief complaint was, unresponsive. Upon examination, the resident had a chest x-ray showing infiltrates and crackles were heard throughout the lungs. Per the emergency room documentation, the resident was admitted to the hospital's COVID-19 unit for further treatment. Further review of the hospital physician documentation revealed the resident was admitted to the hospital for COVID-19 pneumonia and mental status change. The resident was found to be hyperkalemic (elevated level of potassium levels in the blood) and uremic (accumulation of toxic waste products) upon admission. Nephrology was consulted. During emergent [MEDICAL TREATMENT], the resident began displaying [MEDICAL CONDITION] (slower than normal heart rate), with a heart rate in the 30's and went into [MEDICAL CONDITION] immediately per the hospital physician. Further review of Resident #01's hospital record revealed the resident's last recorded vital signs were blood pressure 100/40 (low blood pressure) and her heart rate was 40 beats per minute. Review of the hospital laboratory report, dated 11/09/20, revealed the resident's lactic acid level was 2.1 millimoles (mM) per liter on a normal scale of 0.5-2.2. Per the report, any result greater than 2.0 indicated [MEDICAL CONDITION]. Per the results, the resident's potassium level was 6.5 milliequivalents per liters (mEq/L) indicating a critically high potassium level, with 3.4-5.3 mEq/L being the normal range. The Blood Urea Nitrogen (BUN) level was 165 milligrams per deciliter (mg/dl), indicating a high level, with 3-29 mg/dl being a normal range. The Creatinine levels were 17.2 mg/dl, which is a high level, with a 0.5-12 mg/dl being a normal range. The laboratory reported the critical laboratory results to the emergency room nurse on 11/09/20 at 2:42 P.M. Interview on 11/17/20 at 10:50 A.M. with the [MEDICAL TREATMENT] Center Registered Nurse (DCRN) #400, revealed Resident #01 was scheduled in one facility, the DaVita Five Rivers facility. Once the resident tested positive for COVID-19 on 11/03/20, the resident was to be rescheduled to another [MEDICAL TREATMENT] facility (DaVita Dayton South) that is equipped to care for COVID-19 positive patients. DCRN #400 stated Resident #01 missed the appointment for 11/02/20 at the DaVita Five Rivers [MEDICAL TREATMENT] center before the change in [MEDICAL TREATMENT] centers due to the COVID-19 positive results. DCRN #400 was unaware of the reason for the missed appointment due to lack of communication from facility. Resident #01 missed scheduled appointments on 11/05/20 and 11/07/20. He stated there were multiple attempts made by the DaVita staff to contact the nursing home and inquire why the resident was missing the scheduled appointments. DCRN #400 stated, on 11/07/20, he personally called the facility and asked why the resident had missed 11/02/20, 11/05/20 post change, and the 11/07/20, with no answer from the facility. He stated he tried multiple times to speak to a nurse at the facility but was unsuccessful in contacting floor staff to let the facility know the resident needed to be sent to the emergency room for evaluation. On 11/09/20, the facility's nurse contacted the [MEDICAL TREATMENT] center to reschedule the [MEDICAL TREATMENT] treatments and then the [MEDICAL TREATMENT] staff informed the nurse at the facility, Resident #01 had gone too long without treatment and needed an emergent transfer to the hospital. During an interview on 11/17/20 at 10:30 A.M., the DON stated Resident #01's daughter stated on 11/07/20, she did not want Resident #01 to be taken to [MEDICAL TREATMENT] any longer because the resident continued to go unresponsive at the [MEDICAL TREATMENT] appointments. Per the DON, the resident tested positive for COVID-19 on 11/03/20. The DON verified there was documentation Resident #01 went out of the facility for [MEDICAL TREATMENT] on 11/04 and 11/06, even though the resident did not go. Per the DON, on 11/05/20, the [MEDICAL TREATMENT] center called and changed the dates and place for Resident #01 due to her COVID-19 positive results and she was scheduled to go on Tuesday, Thursday, and Saturday starting 11/07/20 - Saturday. The DON stated the resident's daughter had refused the resident to go to the new [MEDICAL TREATMENT] facility because Resident #01 always 'coded' at the [MEDICAL TREATMENT] treatment center. Per the DON, the floor nurse called the [MEDICAL TREATMENT] center on Monday 11/09/20 to reschedule the appointment and was told by the [MEDICAL TREATMENT] staff that because the resident missed an appointment she needed to go to hospital. The DON verified this is not charted anywhere in the medical record. The DON stated the family was made aware and the resident was transferred to the hospital on [DATE]. Interview on 11/17/20 at 11:40 A.M. with Licensed Practical Nurse (LPN) #222 revealed she was taking care of Resident #01 on 11/06/20. She documented the resident did receive [MEDICAL TREATMENT] treatment in the November 2020 MAR by mistake because the resident did not leave the facility for [MEDICAL TREATMENT] on 11/06/20. LPN #222 stated she was unaware of the last time the resident did receive [MEDICAL TREATMENT] but stated she was sure Resident #01 had not received any [MEDICAL TREATMENT] treatment in November 2020. She stated she did not notify the physician the resident had missed the 11/06/20 [MEDICAL TREATMENT] appointment. She stated she was only working on the unit due to staffing levels being low. She did assess Resident #01 on 11/06/20 and found the resident to not have any signs or symptoms of fluid overload. LPN #222 stated she was unsure of when the next [MEDICAL TREATMENT] appointment was scheduled for Resident #01 and did not pass on in report any information regarding the missed [MEDICAL TREATMENT] appointment. Interview on 11/17/20 at 11:50 A.M. with Registered Nurse (RN) #100 revealed the nurse documented the resident did go to [MEDICAL TREATMENT] on 11/04/20 but stated the resident did not go out because she was positive for COVID-19. RN #100 stated she did not document in the medical record the resident did not receive [MEDICAL TREATMENT] on 11/04/20. The nurse stated she did not notify the physician of the missed [MEDICAL TREATMENT] appointment on 11/04/20. The nurse stated she did not document the changes in the electronic medical record. RN #100 stated it was facility procedure to document all notifications of family and physician in the electronic medical chart of any missed treatments. RN #100 stated she did contact the [MEDICAL TREATMENT] center on 11/09/20 and tried to schedule another [MEDICAL TREATMENT] appointment for Resident #01. When the [MEDICAL TREATMENT] center stated they couldn't treat the resident and the resident should be transferred to the hospital for evaluation, RN #100 stated she notified the daughter and the resident was sent out by squad to the hospital on [DATE]. RN #100 stated the only reason the resident was sent to the emergency room was on the advice of the [MEDICAL TREATMENT] center. Interview on 11/18/20 at 10:00 A.M. with the DON revealed the hand-written physician order [REDACTED]. The DON stated the order was given to the floor nurse caring for Resident #01 and the DON verified the order was not added to the electronic medical record changing the dates in the MAR. The DON stated on 11/05/20, she called the physician and notified her of the change of the [MEDICAL TREATMENT] center due to COVID-19 positive results and the first [MEDICAL TREATMENT] appointment was scheduled for 11/07/20. Per the DON, the physician did not give any new orders for laboratory tests or transfer to the hospital on [DATE] for Resident #01. The DON stated the resident was receiving Hospice services and the resident's daughter was refusing [MEDICAL TREATMENT] due to the resident's recent blood pressure changes during previous [MEDICAL TREATMENT] treatments. The DON verified there was no documentation in the electronic medical record of Hospice services, the refusals by the resident's daughter for the [MEDICAL TREATMENT] treatments or the notification to the physician from 11/02/20 to 11/09/20. Interview on 11/18/20 at 10:40 A.M. with the DON verified the physician did assess Resident #01 on 11/04/20 and stated it was not medically necessary to order laboratory tests or transfer to the hospital at that time because Resident #01 was expected to receive [MEDICAL TREATMENT] within 24 hours. Per the DON, the physician still did not order laboratory tests on 11/05/20, when she said she notified the doctor that the next [MEDICAL TREATMENT] appointment for Resident #01 was not until 11/07/20. Per the DON, the resident's daughter had refused the [MEDICAL TREATMENT] treatment for [REDACTED]. The DON stated the physician was notified by the nurse of the missed appointment and no new orders were received by the physician on 11/07/20. The DON verified the notification of the physician and the refusal of the daughter were not documented in the medical record for 11/07/20. The DON stated she had written the daughter's refusal on 11/05/20, in a handwritten note that was part of the paper medical record but not in the electronic medical record. Review of the clinical note dated 11/05/20 at 10:30 A.M. revealed the daughter was notified of the change in [MEDICAL TREATMENT] days and location. Per the note, the daughter requested the resident not be sent to the [MEDICAL TREATMENT] due to increased weakness and being COVID-19 positive. The note also documented the [MEDICAL TREATMENT] center was notified and stated they will notify the physician and call with follow-up. Per the note, the daughter's request was honored. Interview on 11/18/20 at 11:30 A.M., with Resident #01's primary Physician #50 revealed on 11/04/20, the physician did see Resident #01 and was notified by staff the resident had missed one [MEDICAL TREATMENT] appointment. Physician #50 stated she did not order any laboratory tests or transfer to the hospital for evaluation. The resident's nurse and the DON informed her the [MEDICAL TREATMENT] center was rescheduling the [MEDICAL TREATMENT] appointments due to the COVID-19 positive results on 11/03/20 and the resident would receive [MEDICAL TREATMENT] within 24 hours. Physician #50 stated any more than one missed [MEDICAL TREATMENT] and she would have ordered laboratory tests for monitoring. She stated she was informed by the DON the resident would be receiving [MEDICAL TREATMENT] treatment within 24-hours, so it was not clinically necessary for the resident to be sent to the hospital or receive laboratory tests for one missed [MEDICAL TREATMENT] appointment. The physician stated she did not recall any further notifications until 11/09/20, when Resident #01 was sent to the hospital. Physician #50 denied any knowledge the resident had gone nine days without [MEDICAL TREATMENT] treatment. Interview on 11/18/20 at 3:20 P.M. with Licensed Social Worker (LSW) #60 revealed there was no legal documentation in Resident #01's record for a medical Power of Attorney (POA). LSW #60 stated the resident's daughter was permitted by the resident to attend care conferences and make decisions on the medical care for the resident. LSW #60 stated the daughter had attended the most recent meeting for Resident #01 on 10/07/20 and stated she wished to continue all care. LSW #60 stated there was no mention of withdrawing any treatments or placing Resident #01 in Hospice end of life status at the time the resident was sent to the hospital on [DATE]. LSW #60 stated she had no knowledge of the daughter requesting the resident not receive the [MEDICAL TREATMENT] treatments and there was no mention of withdrawal of the [MEDICAL TREATMENT] treatment during the conferences with the daughter. She verified there wasn't any documentation from the social worker department in the medical record regarding refusals of [MEDICAL TREATMENT] treatments or Hospice request by the family representative. Interview on 11/18/20 at 3:40 P.M. with Resident #01's Family Representative (FR) #700, revealed the facility did update FR #700 when the resident was transferred to the COVID-19 unit on 11/03/20. FR #700 stated she was unaware if the [MEDICAL TREATMENT] appointments were to be changed on 11/03/20. She stated she knew the resident had one missed appointment for [MEDICAL TREATMENT] and when she asked why, she was informed by the nurse the resident was changing [MEDICAL TREATMENT] centers due to the COVID-19 positive results. FR #700 stated when she asked when the last appointment the resident received [MEDICAL TREATMENT] occurred, she was upset because the resident had already missed two appointments of [MEDICAL TREATMENT]. She stated it was the treatments that were saving the resident's life. She denied refusing the 11/07/20 [MEDICAL TREATMENT] treatment. FR #700 stated she was in the facility and talked with the nurse on 11/09/20 and asked for the resident to be sent to the hospital because the resident had a fever and was declining. FR #700 again denied any refusals of any of the [MEDICAL TREATMENT] treatments. She stated she requested Resident #01 to be sent to the hospital on [DATE], when she visited the resident and noted her to be having a fever and decreased cognition. FR #700 stated she told the nurse because they said the resident hadn't had [MEDICAL TREATMENT] in days and was declining, she told the nurse to send Resident #01 out to the hospital for treatment. Interview on 11/19/20 at 10:10 A.M. with the DON and the Administrator revealed the DON denied telling the surveyor the physician was updated on 11/04/20 that Resident #01 would receive [MEDICAL TREATMENT] treatment within 24-hours. The DON stated she told the physician on 11/04/20, the resident would be scheduled for an appointment within 24-hours. The DON stated once the [MEDICAL TREATMENT] center called her on 11/05/20, she then updated the physician with the information of Resident #01's next scheduled [MEDICAL TREATMENT] appointment being 11/07/20. The physician did not give any new orders to the DON. The DON stated the physician was again updated on 11/05/20, when the daughter refused the [MEDICAL TREATMENT] treatment on Saturday, and the physician did not give any new orders at that time. The DON stated the physician stated the DON should contact and follow-up with the [MEDICAL TREATMENT] center. The DON stated there is no documentation of notification of the physician in the medical record. The DON stated she called the [MEDICAL TREATMENT] center on 11/05/20 and was told to follow-up on Monday, 11/09/20. The DON stated on 11/09/20, the floor nurse contacted the [MEDICAL TREATMENT] center who told the facility they would not accept the resident for treatment, and she needed to be taken to the hospital for evaluation. The DON stated the only reason the resident went to the hospital was on the advice of the [MEDICAL TREATMENT] center. The Administrator stated the [MEDICAL TREATMENT] center failed to contact the facility with updated changes to Resident #01's plan after they were notified on 11/03/20 of the COVID-19 results. The Administrator further stated the primary physician failed to provide orders when updated on 11/04/20, 11/05/20, and 11/07/20, when Resident #01 had not received the [MEDICAL TREATMENT] treatments. The Administrator also stated the resident's daughter, despite not having legal documentation of being Resident #01's POA, had refused the [MEDICAL TREATMENT] appointment on 11/07/20 and the facility honored the daughter's request. Review of the facility in-service titled [MEDICAL TREATMENT] dated 11/19/20, revealed the first line read, All residents will and must be dialyzed on days scheduled no exceptions!!!!!! The in-service include bullet points as follows: If resident is sick, refuse to go or transportation issues, family, medical doctor, DON and Executive Director (ED) must be notified ASAP .Documentation a Must. If the resident is a self-notifier and is unable to make the decisions to go or refuse [MEDICAL TREATMENT], YOU (the nurse) must call #1 contact and document conversation. No resident is to miss any scheduled [MEDICAL TREATMENT] appointments. If resident is unable to get to appointment the resident must be sent to the hospital ASAP and YOU MUST call family (POA, Guardian), DON and ED and document all conversations. All missed [MEDICAL TREATMENT] appointments must be rescheduled immediately with family (POA, Guardian, #1 contact), DON and ED must be notified .reason why the delay must be documented. Review of the facility's policy titled, [MEDICAL TREATMENT] Care and Monitoring, dated 05/28/20, revealed the facility will provide residents centered care to meet the needs for [MEDICAL TREATMENT], provide a method for coordination and collaboration between the nursing home and [MEDICAL TREATMENT] facility, and provide a method for on-going communication and collaboration for development of the [MEDICAL TREATMENT] care plan will be established. Per the policy, the facility remains responsible for the overall quality of care the resident receives. This deficiency substantiates the allegations in Complaint Numbers OH 188 and OH 549.

Based on observation, record review, staff and resident interview, and review of facility abuse and neglect policy, the facility failed to prevent the physical abuse of Resident (#33) by another Resident (#85), which resulted in actual physical harm to Resident #33 including bilateral nasal bone fractures and a laceration to his left temple. This affected one (#33) of three residents reviewed for abuse. The census was 171. Finding include: Resident #33 was admitted to the facility on [DATE] from a behavioral health unit at a local hospital. The resident had [DIAGNOSES REDACTED]. The facility completed an admission minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 08/27/18. The 08/27/18 assessment identified the resident as having significant cognitive impairments, inattention and disorganized thinking at times which varied in severity, wandering behaviors at times, and requiring the limited assistance of one staff person to complete most all activities of daily living. Resident #33 was identified as being able to ambulate with the assistance of a two wheeled walker per a physical therapy assessment and plan of care dated 08/21/18. The resident had a current plan of care to address behaviors of wandering, refusing medications, and threatening others. Resident #33 was out of the facility at the time of the investigation receiving treatment at a behavioral health hospital. Resident #85 was originally admitted to the facility in (MONTH) of 2013, and most recently re-admitted to the facility on [DATE] after a stay on a behavioral health unit at a local hospital. The resident had [DIAGNOSES REDACTED]. The facility completed a MDS assessment of the resident's cognitive and physical functioning dated 10/19/18. The 10/19/18 assessment identified the resident as having mild cognitive deficits, no hallucinations or delusion, no behavioral symptoms, and requiring limited assistance for bed mobility and transfer, but able to walk in his room, and used a wheel chair or walker when out of his room. Resident #85 had a current plan of care to address behavioral and mood changes, and having poor impulse control, and the need to monitor the resident for escalating behaviors. The resident was at the facility through the late afternoon on 11/13/18 until he was accepted and transferred to a behavioral health hospital for evaluation and treatment. The resident was receiving one on one supervision at the time of his discharge. Resident #33 and Resident #85 were roommates on one of the facility's secured units for residents with behavioral problems/needs directed towards selves or others; East Unit. They had been roommates since Resident #33's admission to the facility in (MONTH) of (YEAR). Review of Resident #33's nursing progress notes dated 11/08/18 at 4:29 P.M. revealed Registered Nurse (RN) #210 documented that Resident #33 continued to show verbal aggression towards staff and redirection towards positive diversional activities to reduce negative behavior towards roommate. Resident #33 liked to block the entrance area to roommates side of the room with a walker, used verbal aggression to try and have his way because he wanted his own room. RN #210 noted Resident #33 was interviewed by herself and he stated he would like to have a newspaper daily. Redirection was effective and the resident was watching television. RN #210 documented that staff would continue to offer activities. Resident #33's nursing progress notes dated 11/09/18 at 12:20 A.M., for 11/08/18 at 10:00 P.M., were reviewed. On 11/09/18, at 12:20 A.M., RN #300 documented the following: The nurse entered the resident's room and noted the resident resting his back against the wardrobe, with his legs sticking out in front of him, both arms to the side, right top hand noted bruised with blood noted on it, resident holding his head slightly leaning to the left. The right side of the resident's face was noted bruised, light red in color with blood underneath his eye, left side of resident's face was swollen, left eye closed dark purple/burgundy in color. Blood was noted covering the left side of his face. Resident #33's nose was swollen with bruising noted. Resident #33 was noted still yelling at his roommate about this being his house and he (the roommate) not belonging here when staff entered the room. Resident #33 was noted very difficult to redirect at this time. The resident's room was noted to have blood splatter on the resident's privacy curtain, bed sheets, and wall. Resident #33 stated he's in my house, get the h--- out of my house repeatedly. Resident #33 was unable to answer questions regarding what took place. Resident #33 was removed from the situation at this time, and assessed with [REDACTED]. Resident #33 was unstable at this time, unable to follow simple commands or answer simple questions being asked at this time. RN #300 documented she contacted the physician assistant (PA) on call for the physician and made her aware of the situation. The resident was sent out to the emergency department of a local hospital at 10:05 P.M. RN #300 also noted the family of the resident was notified. Review of hospital records for Resident #33 dated 11/08/18 revealed the resident was admitted to the hospital on [DATE] at 10:30 P.M. and treated for [REDACTED].#33 sustained bilateral nasal bone fractures, a large amount of periorbital swelling, and a laceration on the left temple area which was closed with five sutures. Resident #85's nursing progress notes dated 11/09/18 at 1:06 A.M., for 11/08/18 at 10:01 P.M. were reviewed. On 11/09/18 at 1:06 A.M., RN #300 documented the following: Resident #85 was noted loud talking with his roommate, which alerted staff to enter the room. At the time the State tested Nurse Aide (STNA) entered the room, resident was noted standing in the door way with a blank puzzled stare, his roommate (Resident #33) was noted sitting on the floor with his back against the wardrobe. Staff alerted this nurse. Resident #85 noted to have blood over his left knuckles, and his shirt seemed pulled around the collar. When head to toe assessment was completed the resident's upper chest/neck area were noted slightly red, no open areas noted, and his skin was intact. Resident refused wanting to go to the emergency room for further evaluation and denied pain or discomfort. The resident's room was noted to have blood splatter on the roommate's privacy curtain, bed sheets, and wall. Resident #85 stated he was laying in bed when his roommate started yelling about the television (TV) needing to be cut off, and he (Resident #85) told his roommate to be cool that he was watching it. Roommate (Resident #33) then got up walking to his side of the bed yelling, this is my house and you need to cut the TV off. Resident #85 stated he continued to tell his roommate to just be cool, then Resident #33 punched him in his upper chest. Resident #85 got up and hit his roommate back. They both ended up on Resident #33's bed fighting and then towards the door. Resident #85 then stated he was sorry that he didn't mean to do it, that he had been asking for the last two weeks for his room to be changed because his roommate had been hounding him. RN #300 documented that Resident #85's range of motion was within normal limits and a neurological check was completed with no abnormalities noted. She noted that the PA on call for the physician was notified and new orders were obtained to send Resident #85 to a behavioral health hospital for evaluation and treatment, and to provide Resident #85 with one on one supervision while awaiting placement and transfer. An interview could not be conducted with Resident #33 at the time of the investigation as he was still out of the facility at a behavioral health hospital. An interview was conducted with Resident #85 on 11/13/18 at 11:20 A.M. in the resident's room. Prior to the interview there was a staff person sitting with the resident in the room providing one on one supervision. The staff person excused himself during the interview. The resident was calmly laying in bed, and exhibiting no behavioral symptoms at the time. Resident #85 was asked if he would share what happened between himself and his roommate, Resident #33, during the evening of 11/08/18. Resident #85 first stated that he would, rather not get into it. The resident was asked if he and Resident #33 ever had any previous problems before the evening of 11/08/18. Resident #85 stated they had slight run-ins, only verbal never physical, then his roommate (Resident #33) took his walker and hit him. He shared that they had been roommates for a month or two, or longer, and that he had asked for a roommate change but nothing was ever done. Resident #85 then went on to state again that he and his roommate had arguments but nothing physical, then his roommate came over to his side of the room telling him to shut the TV off and to leave the room that it was his room and he (Resident #85) had to leave. He reported that when his roommate hit him, it got physical, just got bad. When asked if he had ever requested a room/roommate change he said he had, that he had told Licensed Practical Nurse (LPN) #191 and Licensed Social Worker (LSW) #206. Resident #85 denied any physical abuse by other resident's or staff, or having problems with any other residents. He reported he felt safe at the facility when asked. Interviews were conducted with LPN #191 on 11/13/18 at 11:50 A.M., and on 11/14/18 at 10:32 A.M., and with LSW #206 on 11/13/18 at 12:11 P.M. regarding Resident #85's request for a roommate or room change. Both LPN #191 and LSW #206 reported they had never been made aware of any reports by Resident #85 verbalizing that he wanted a roommate/room change. LSW #206 stated that if Resident #85 had made a request for a roommate/room change the facility would have tried to find a suitable arrangement for the resident, and with his permission and the guardian's permission he would have been moved. An interview was conducted with LPN #191 on 11/13/18 at 11:50 A.M. and on 11/14/18 at 10:32 A.M. regarding Resident #33 and Resident #85's behaviors. She shared that Resident #33 was confused. He was alert and oriented to his self only. She shared most days he was pleasant and stayed to himself. LPN #191 reported that Resident #85 was mostly alert and oriented, and as far as behaviors, he had not had any behaviors in quite a while. She reported that there were roommate problems (verbal) between Resident #33 and Resident #85 and she had documented her observations. She shared that Resident #33 thought the room was his house and he did not understand why he had a roommate. He would fuss at Resident #85 and tell him he had to get out of the room. LPN #191 stated that he would sometimes get in Resident #85's bed and would have to be redirected. She stated there had been no physical problems between the two resident's, only words. LPN #191 shared that the two residents had been roommates for a few months, and in the beginning there were no problems and then just one day Resident #33 started yelling at Resident #85 telling him he had to leave the room as it was his house. An interview was conducted with STNA #180 on 11/13/18 at 3:38 P.M. regarding the 11/08/18 physical altercation between Residents #33 and #85. She reported she was working the evening shift (3:00 P.M. to 11:00 P.M.) on 11/08/18 on the East unit and was present at the time the incident occurred. STNA #180 stated she worked the East unit often and was familiar with both residents. STNA #180 communicated that Resident #33 was generally quiet, could ambulate independently with a walker, but would pick at his roommate (Resident #85) at times telling him that it wasn't his room. STNA #180 shared he did not do it everyday maybe two to three times a week. STNA #180 also communicated that Resident #85 was generally quiet and laid back and did not recall seeing or hearing of the resident being physically aggressive towards others. She denied ever hearing Resident #85 asking for a new room/roommate. Regarding the night of 11/08/18, STNA #180 reported that she was collecting trash from resident rooms on the opposite hall and heard a nurse call over the loud speaker to come to the East unit stat. She followed a nurse into the residents' room and saw Resident #33 sitting on the floor, his face was all bloody and his eyes were swollen shut. STNA #180 shared that the nurses in the room started asking both residents what happened, and Resident #33 wouldn't say anything. Resident #85 said that Resident #33 pushed him and that's when he hit him. She reported that Resident #33 was then sent out to the hospital, and Resident #85 stayed in his room with one on one supervision. STNA #180 offered that she thought that Resident #85 might have gotten tired of Resident #33 telling him to get out of his own room and he just went off. She reported in her 11/09/18 witness statement that she had seen Resident #33 about an hour before the incident and he was not having any behaviors. An interview was conducted with RN #300 on 11/13/18 at 4:57 P.M. regarding the 11/08/18 incident between Residents #33 and #85. She reported she was in the medication room on the unit when STNA #109 came and got her. STNA #109 shared that she and STNA #203 had gone to the residents' room due to hearing something. STNA #203 stayed in the room with the residents while STNA #109 came to get her. RN #300 stated that when she got to the room, Resident #85 was standing in the doorway of the room with a blank stare, he looked lost, while Resident #33 was sitting on the floor against the wardrobe. Resident #33 was argumentative saying this was his house, and she tried to clean up his face to assess his bleeding/injuries, but he was not cooperative. RN #300 shared she called the PA who was taking calls for the physician to notify her of the incidents. She sent Resident #33 out right away via emergency services to the emergency department. She reported that Resident #85 told her that Resident #33 was walking over to his side of the room telling him to turn his TV off and get out of his house/room, and then he hit him. RN #300 shared that Resident #85 communicated to her that they fought on Resident #33's bed and towards the door. She confirmed she was not able to get information regarding the incident from Resident #33. She reported that she had been passing medications on the hallway where Residents #33 and #85 resided and had seen them in their room quiet with no concerns sometime between 9:00 P.M. and 9:30 P.M., probably less than an hour before the incident occurred. RN #300 reported that she was not witness to, or made aware of, any physical altercations between the two residents prior to the incident on 11/08/18. The facility's policy titled Abuse & Neglect last revised on 02/01/17 was reviewed. The policy specified it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of resident or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegation of abuse, neglect or misappropriation of their property. This deficiency substantiates Complaint Control Number OH 113.

Based on observation, record review, staff and resident interview, and review of the facility's Abuse & Neglect policy and procedure the facility failed to ensure the policy was implemented as written to ensure the abuse of one resident by another resident did not occur. This resulted in actual physical harm to Resident #33 including bilateral nasal bone fractures and a laceration to his left temple. This involved one resident (#33) of three residents reviewed for abuse. The facility census was 171. Findings include: Resident #33 was admitted to the facility on [DATE] from a behavioral health unit at a local hospital. The resident had [DIAGNOSES REDACTED]. The facility completed an admission minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 08/27/18. The 08/27/18 assessment identified the resident as having significant cognitive impairments, inattention and disorganized thinking at times which varied in severity, wandering behaviors at times, and requiring the limited assistance of one staff person to complete most all activities of daily living. Resident #33 was identified as being able to ambulate with the assistance of a two wheeled walker per a physical therapy assessment and plan of care dated 08/21/18. The resident had a current plan of care to address behaviors of wandering, refusing medications, and threatening others. Resident #33 was out of the facility at the time of the investigation receiving treatment at a behavioral health hospital. Resident #85 was originally admitted to the facility in (MONTH) of 2013, and most recently re-admitted to the facility on [DATE] after a stay on a behavioral health unit at a local hospital. The resident had [DIAGNOSES REDACTED]. The facility completed a MDS assessment of the resident's cognitive and physical functioning dated 10/19/18. The 10/19/18 assessment identified the resident as having mild cognitive deficits, no hallucinations or delusion, no behavioral symptoms, and requiring limited assistance for bed mobility and transfer, but able to walk in his room, and used a wheel chair or walker when out of his room. Resident #85 had a current plan of care to address behavioral and mood changes, and having poor impulse control, and the need to monitor the resident for escalating behaviors. The resident was at the facility through the late afternoon on 11/13/18 until he was accepted and transferred to a behavioral health hospital for evaluation and treatment. The resident was receiving one on one supervision at the time of his discharge. Resident #33 and Resident #85 were roommates on one of the facility's secured units for residents with behavioral problems/needs directed towards selves or others; East Unit. They had been roommates since Resident #33's admission to the facility in (MONTH) of (YEAR). Review of Resident #33's nursing progress notes dated 11/08/18 at 4:29 P.M. revealed Registered Nurse (RN) #210 documented that Resident #33 continued to show verbal aggression towards staff and redirection towards positive diversional activities to reduce negative behavior towards roommate. Resident #33 liked to block the entrance area to roommates side of the room with a walker, used verbal aggression to try and have his way because he wanted his own room. RN #210 noted Resident #33 was interviewed by herself and he stated he would like to have a newspaper daily. Redirection was effective and the resident was watching television. RN #210 documented that staff would continue to offer activities. Resident #33's nursing progress notes dated 11/09/18 at 12:20 A.M., for 11/08/18 at 10:00 P.M., were reviewed. On 11/09/18, at 12:20 A.M., RN #300 documented the following: The nurse entered the resident's room and noted the resident resting his back against the wardrobe, with his legs sticking out in front of him, both arms to the side, right top hand noted bruised with blood noted on it, resident holding his head slightly leaning to the left. The right side of the resident's face was noted bruised, light red in color with blood underneath his eye, left side of resident's face was swollen, left eye closed dark purple/burgundy in color. Blood was noted covering the left side of his face. Resident #33's nose was swollen with bruising noted. Resident #33 was noted still yelling at his roommate about this being his house and he (the roommate) not belonging here when staff entered the room. Resident #33 was noted very difficult to redirect at this time. The resident's room was noted to have blood splatter on the resident's privacy curtain, bed sheets, and wall. Resident #33 stated he's in my house, get the h--- out of my house repeatedly. Resident #33 was unable to answer questions regarding what took place. Resident #33 was removed from the situation at this time, and assessed with [REDACTED]. Resident #33 was unstable at this time, unable to follow simple commands or answer simple questions being asked at this time. RN #300 documented she contacted the physician assistant (PA) on call for the physician and made her aware of the situation. The resident was sent out to the emergency department of a local hospital at 10:05 P.M. RN #300 also noted the family of the resident was notified. Review of hospital records for Resident #33 dated 11/08/18 revealed the resident was admitted to the hospital on [DATE] at 10:30 P.M. and treated for [REDACTED].#33 sustained bilateral nasal bone fractures, a large amount of periorbital swelling, and a laceration on the left temple area which was closed with five sutures. Resident #85's nursing progress notes dated 11/09/18 at 1:06 A.M., for 11/08/18 at 10:01 P.M. were reviewed. On 11/09/18 at 1:06 A.M., RN #300 documented the following: Resident #85 was noted loud talking with his roommate, which alerted staff to enter the room. At the time the State tested Nurse Aide (STNA) entered the room, resident was noted standing in the door way with a blank puzzled stare, his roommate (Resident #33) was noted sitting on the floor with his back against the wardrobe. Staff alerted this nurse. Resident #85 noted to have blood over his left knuckles, and his shirt seemed pulled around the collar. When head to toe assessment was completed the resident's upper chest/neck area were noted slightly red, no open areas noted, and his skin was intact. Resident refused wanting to go to the emergency room for further evaluation and denied pain or discomfort. The resident's room was noted to have blood splatter on the roommate's privacy curtain, bed sheets, and wall. Resident #85 stated he was laying in bed when his roommate started yelling about the television (TV) needing to be cut off, and he (Resident #85) told his roommate to be cool that he was watching it. Roommate (Resident #33) then got up walking to his side of the bed yelling, this is my house and you need to cut the TV off. Resident #85 stated he continued to tell his roommate to just be cool, then Resident #33 punched him in his upper chest. Resident #85 got up and hit his roommate back. They both ended up on Resident #33's bed fighting and then towards the door. Resident #85 then stated he was sorry that he didn't mean to do it, that he had been asking for the last two weeks for his room to be changed because his roommate had been hounding him. RN #300 documented that Resident #85's range of motion was within normal limits and a neurological check was completed with no abnormalities noted. She noted that the PA on call for the physician was notified and new orders were obtained to send Resident #85 to a behavioral health hospital for evaluation and treatment, and to provide Resident #85 with one on one supervision while awaiting placement and transfer. An interview could not be conducted with Resident #33 at the time of the investigation as he was still out of the facility at a behavioral health hospital. An interview was conducted with Resident #85 on 11/13/18 at 11:20 A.M. in the resident's room. Prior to the interview there was a staff person sitting with the resident in the room providing one on one supervision. The staff person excused himself during the interview. The resident was calmly laying in bed, and exhibiting no behavioral symptoms at the time. Resident #85 was asked if he would share what happened between himself and his roommate, Resident #33, during the evening of 11/08/18. Resident #85 first stated that he would, rather not get into it. The resident was asked if he and Resident #33 ever had any previous problems before the evening of 11/08/18. Resident #85 stated they had slight run-ins, only verbal never physical, then his roommate (Resident #33) took his walker and hit him. He shared that they had been roommates for a month or two, or longer, and that he had asked for a roommate change but nothing was ever done. Resident #85 then went on to state again that he and his roommate had arguments but nothing physical, then his roommate came over to his side of the room telling him to shut the TV off and to leave the room that it was his room and he (Resident #85) had to leave. He reported that when his roommate hit him, it got physical, just got bad. When asked if he had ever requested a room/roommate change he said he had, that he had told Licensed Practical Nurse (LPN) #191 and Licensed Social Worker (LSW) #206. Resident #85 denied any physical abuse by other resident's or staff, or having problems with any other residents. He reported he felt safe at the facility when asked. Interviews were conducted with LPN #191 on 11/13/18 at 11:50 A.M., and on 11/14/18 at 10:32 A.M., and with LSW #206 on 11/13/18 at 12:11 P.M. regarding Resident #85's request for a roommate or room change. Both LPN #191 and LSW #206 reported they had never been made aware of any reports by Resident #85 verbalizing that he wanted a roommate/room change. LSW #206 stated that if Resident #85 had made a request for a roommate/room change the facility would have tried to find a suitable arrangement for the resident, and with his permission and the guardian's permission he would have been moved. An interview was conducted with LPN #191 on 11/13/18 at 11:50 A.M. and on 11/14/18 at 10:32 A.M. regarding Resident #33 and Resident #85's behaviors. She shared that Resident #33 was confused. He was alert and oriented to his self only. She shared most days he was pleasant and stayed to himself. LPN #191 reported that Resident #85 was mostly alert and oriented, and as far as behaviors, he had not had any behaviors in quite a while. She reported that there were roommate problems (verbal) between Resident #33 and Resident #85 and she had documented her observations. She shared that Resident #33 thought the room was his house and he did not understand why he had a roommate. He would fuss at Resident #85 and tell him he had to get out of the room. LPN #191 stated that he would sometimes get in Resident #85's bed and would have to be redirected. She stated there had been no physical problems between the two resident's, only words. LPN #191 shared that the two residents had been roommates for a few months, and in the beginning there were no problems and then just one day Resident #33 started yelling at Resident #85 telling him he had to leave the room as it was his house. An interview was conducted with STNA #180 on 11/13/18 at 3:38 P.M. regarding the 11/08/18 physical altercation between Residents #33 and #85. She reported she was working the evening shift (3:00 P.M. to 11:00 P.M.) on 11/08/18 on the East unit and was present at the time the incident occurred. STNA #180 stated she worked the East unit often and was familiar with both residents. STNA #180 communicated that Resident #33 was generally quiet, could ambulate independently with a walker, but would pick at his roommate (Resident #85) at times telling him that it wasn't his room. STNA #180 shared he did not do it everyday maybe two to three times a week. STNA #180 also communicated that Resident #85 was generally quiet and laid back and did not recall seeing or hearing of the resident being physically aggressive towards others. She denied ever hearing Resident #85 asking for a new room/roommate. Regarding the night of 11/08/18, STNA #180 reported that she was collecting trash from resident rooms on the opposite hall and heard a nurse call over the loud speaker to come to the East unit stat. She followed a nurse into the residents' room and saw Resident #33 sitting on the floor, his face was all bloody and his eyes were swollen shut. STNA #180 shared that the nurses in the room started asking both residents what happened, and Resident #33 wouldn't say anything. Resident #85 said that Resident #33 pushed him and that's when he hit him. She reported that Resident #33 was then sent out to the hospital, and Resident #85 stayed in his room with one on one supervision. STNA #180 offered that she thought that Resident #85 might have gotten tired of Resident #33 telling him to get out of his own room and he just went off. She reported in her 11/09/18 witness statement that she had seen Resident #33 about an hour before the incident and he was not having any behaviors. An interview was conducted with RN #300 on 11/13/18 at 4:57 P.M. regarding the 11/08/18 incident between Residents #33 and #85. She reported she was in the medication room on the unit when STNA #109 came and got her. STNA #109 shared that she and STNA #203 had gone to the residents' room due to hearing something. STNA #203 stayed in the room with the residents while STNA #109 came to get her. RN #300 stated that when she got to the room, Resident #85 was standing in the doorway of the room with a blank stare, he looked lost, while Resident #33 was sitting on the floor against the wardrobe. Resident #33 was argumentative saying this was his house, and she tried to clean up his face to assess his bleeding/injuries, but he was not cooperative. RN #300 shared she called the PA who was taking calls for the physician to notify her of the incidents. She sent Resident #33 out right away via emergency services to the emergency department. She reported that Resident #85 told her that Resident #33 was walking over to his side of the room telling him to turn his TV off and get out of his house/room, and then he hit him. RN #300 shared that Resident #85 communicated to her that they fought on Resident #33's bed and towards the door. She confirmed she was not able to get information regarding the incident from Resident #33. She reported that she had been passing medications on the hallway where Residents #33 and #85 resided and had seen them in their room quiet with no concerns sometime between 9:00 P.M. and 9:30 P.M., probably less than an hour before the incident occurred. RN #300 reported that she was not witness to, or made aware of, any physical altercations between the two residents prior to the incident on 11/08/18. The facility's policy titled Abuse & Neglect last revised on 02/01/17 was reviewed. The policy specified it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of resident or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegation of abuse, neglect or misappropriation of their property. This is an incidental finding discovered during the course of investigation of Complaint Control Number OH 113.

Based on observation, record review, review of a facility self-reported incident (SRI), staff and resident interview, and review of facility abuse and neglect policy, the facility failed to prevent the physical abuse of Resident #31 by Resident #32. This resulted in actual physical harm when Resident #31 was physically abused and subsequently required hospital evaluation for suturing to a laceration to the top of his scalp and multiple skin tears/abrasions to his nose and other areas of his body. This affected one (#31) of four residents reviewed for abuse. Facility census was 171. Finding include: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed a comprehensive assessment (MDS 3.0) of Resident #31's cognitive and physical functioning dated 12/08/17. The 12/08/17 assessment identified the resident as having short and long term memory problems, severe cognitive skills for daily decision making, other behavioral symptoms that put the resident at risk for physical injury (exit seeking), and required only supervision for bed mobility, transfer, and walking in his room and on the unit. Resident #32 was admitted to the facility on [DATE], and recently readmitted to the facility on [DATE] from a behavioral health hospital, with [DIAGNOSES REDACTED]. The facility completed a comprehensive assessment of the Resident #32's cognitive and physical functioning dated 12/14/17. The 12/14/17 assessment identified the residents as having moderate memory and recall problems, inattention and disorganized thinking at times, delusion, verbal behavioral symptoms, no physical behavioral symptoms, and requiring only supervision for bed mobility, transfer, and walking in his room and on the unit. The resident had a current comprehensive plan of care to address his behavioral symptoms. Resident #32 was discharged from the facility 02/17/18 to a behavioral health hospital, and was served an immediate and emergent notice of discharge by the facility on 02/20/18. Resident #31 and Resident #32 were roommates on one of the facility's secured units for residents with behavioral problems/needs directed towards selves or others; Beacon Unit. Review of Resident #31's medical record revealed a nursing note by Licensed Practical Nurse (LPN) #149 on 02/17/18 for the time of 2:58 P.M. LPN #149 recorded the following information in the nursing note: Staff saw Resident #31 walking out of his room with blood dripping from his nose. He was holding onto the rails on the wall. The resident stopped and turned half way around, and kept looking towards his room. Staff walked up to the resident, including this nurse, and asked what had happened. Resident #31 did not say anything but kept looking at the door. This nurse went into the room and saw the resident's roommate, Resident #32, in the bathroom washing his hands with traces of blood in the sink. There was some liquid all over the bathroom floor. When this nurse asked Resident #32 what happened he stated that Resident #31 had urinate on the floor, and also on his bed. When Resident #32 was asked if he hit his roommate he said no. LPN #149 then documented she did a head to toe assessment of Resident #31, all extremities were within normal limits, vital signs were taken and recorded. She noted the resident's physician and family member were notified, as well as the Administrator, the Director of Nursing (DON), and the police. The nurse received an order to send Resident #31 to the emergency room for evaluation via emergency services. On 02/18/19 for the time of 6:02 P.M., LPN #149 documented that Resident #31 returned to the facility from the local hospital and was re-oriented to the facility. The resident was not complaining of any pain at that time. LPN #149's assessments of the injuries to the resident dated 02/17/18 were reviewed. LPN #149 documented the resident as having the following injuries after the altercation with Resident #32: top of scalp 1.5 centimeter (cm) by 1.0 cm skin tear on the head; face three areas of skin tears on the nose measuring 2.5 cm by 1.0 cm, 1.0 cm by 1.0 cm, and 2.0 cm by 1.0 cm; right outer ankle 2.0 cm by 1.0 cm skin tear; right elbow 3.0 cm by 2.0 cm skin tear; and back of right hand 1.0 cm by 1.0 cm skin tear to the fourth digit of the right hand. The emergency department (ED) hospital records for Resident #31, dated 02/17/18 were reviewed. In the ED the physician assessing the resident noted the Resident #31 had a two centimeter laceration to the top/posterior area of his scalp, and abrasions to his nose. Resident #31 received two sutures to close a two centimeter laceration to the top of his scalp, and was sent to a different hospital for evaluation due to history of subdural hematomas. Review of a facility SRI revealed on 02/17/18 Resident #31 was witnessed by staff with blood on his face. When staff asked him what happened he was not able to tell staff. Staff found his roommate (Resident #32) in their shared bathroom washing his hands with traces of blood in the sink. When staff asked Resident #32 if he had hit Resident #31 he denied it. Both residents were assessed. Resident #31 was sent to the ED for evaluation. Resident #32 was put on one on one with staff for safety precautions. Physician and responsible parties were notified. Staff on duty gave statements. There were no witnesses to any incident. Per staff statements both residents changed their story of what may have happened throughout the shift. Per staff neither resident was having any behaviors prior to the incident. Like residents were asked if they had been abused or seen abuse with no new negative findings. Per chart review Resident #32 last Brief Interview for Mental Status (BIMS) was an 11 out of 15 (moderately impaired). He has a court appointed guardian due to him being found incompetent. He suffers from severe mental illness and resides on a secured behavior unit. He is a poor historian. The SRI also documented the police were notified. An interview was conducted with Resident #31 on 02/22/18 at 10:50 A.M. The resident was lying in bed and appeared in no distress. Resident #31 was alert to himself, was verbal, but spoke very softly. The resident had three or more areas of blood crusted healing abrasions/skin tears on his nose, and a dark bruise under his right eye. When asked how he was injured the resident clearly stated he beat me. When asked who beat him he clearly responded used to be my roommate. The resident denied any pain related to his injuries. When asked if he was treated and not abused by other residents or staff, he stated he was and denied any problems other than with his roommate. When asked if he felt safe at the facility he reported he did. An interview was conducted with LPN #144 on 02/22/18 at 11:57 A.M. regarding the physical altercation between Resident #32 and #31 on 02/17/18. LPN #144 reported she worked the first and second shift on the Beacon Unit on Saturday 02/17/18 the day of the incident. She reported there was a physical altercation between Resident #32 and Resident #31 on 02/17/18, and Resident #32 was the aggressor. However, she affirmed it was no directly witness by anyone other than the Resident. She reported she and another nurse, LPN #149, were assigned and State tested Nurse Aide (STNA's) #77 and #82 were at the nursing station. She communication that she saw Resident #31 walking towards the nursing station, and STNA #82 stated something was on the resident's face. He had blood on his nose, his face, and the top of his head. LPN #144 stated that she and STNA #77 immediately went to the room, along with LPN #149. LPN #144 and STNA #77 tended to Resident #31's injuries, and LPN #149 reported observing Resident #32 washing what appeared to be blood off his hands. She stated she asked Residents #31 and #32 what happened, and Resident #32 was verbally aggressive saying that Resident #31 had urinated in his bed and kicked him, although Resident #31 was the injured party. Resident #31 did not report anything at that time. LPN #144 communicated that LPN #149 had Resident #32 go to the nursing station where he was supervised one on one by the other STNA on the unit #69. She stated LPN #149 made all notifications to Resident #31's physician and representative, notified the Administrator and Director of Nursing, the local police, and set up transportation for Resident #31 to be sent out to the hospital. LPN #144 shared that Resident #32 had just come back three days prior from a behavioral health hospital when he was admitted due to having increased behaviors at the facility. She reported that Resident #32 could become aggressive and yelling loudly, that this was not his first altercation, but was not sure if he had ever struck anyone before. When asked is she believed Resident #32 knew right from wrong she stated she did based on her knowledge of the resident. An interview was conducted with STNA #77 on 02/22/18 at 12:18 P.M. regarding the incident between Residents #32 and #31 on 02/17/18. She reported she worked the first and second shift of duty on the Beacon unit on 02/17/18 and was present when the incident occurred. STNA #77 stated she recalled the nurse on duty gave Resident #31 his medication sometime before lunchtime, and she took his to his room to lay down as he wanted to take a nap before lunch. She shared she wasn't positive Resident #32 was in the room at that very time, as Resident #32 spent a lot of time in the bathroom. The she shut the door to the room after she left as Resident #31 always likes the door shut. STNA #77 communicated that about 20 minutes later, about 11:30 A.M., she observed Resident #31 walking towards the nursing station with blood on his nose and she immediately went to him. She stated Resident #31 appeared to be dazed, from possibly just getting up from lying down or whatever happened in the bed room. STNA #77 stated that she, LPN #149, and LPN #144, took Resident #31 back to his room. When they got Resident #31 back to his room, she asked Resident #32 what happened and he stated that Resident #31 urinated on his bed. However, STNA #77 shared that there was no urine or water on the bed or on the floor of the room, after letting Resident #32 know she found no urine anywhere he said Resident #31 kicked him. Resident #32 was then removed from the room and STNA #69 took the resident to up front to the nursing station and stayed with him one on one while LPN #144 took care of Resident #31. STNA #77 stated she stayed with LPN #144 to help with Resident #31. She reported that the police arrived at the facility and filed a report, emergency services came and took Resident #31 to the hospital, and Resident #32 remained one on one with STNA #69 until around 10:30 P.M. or so when he was also sent out to the hospital. LPN #77 affirmed the incidents was unwitnessed and could state exactly how Resident #31 sustained his wounds, assuming that he had been hit and kicked by Resident #32. When queried about Resident #32's cognitive status and behaviors, STNA #77 reported the resident was alert to self, and had behaviors of screaming out, and would sometimes walk by you a flip his hand at you. She communicated she believed the resident knew right from wrong as later that evening before being sent out to the hospital Resident #32 stated to her I didn't meant to do it. However, Resident #32 did not clarify what it was. An interview was conducted with STNA #69 on 02/22/18, at 12:42 P.M., regarding the incident that occurred between Resident #32 and #31 on 02/17/18. STNA #69 reported she had worked both the first and second shifts of duty on 02/17/18 and was present on Beacon Unit at the time the incident occurred. She stated no one actually witness the incident, but was aware some kind of physical altercation had occurred. STNA #69 shared that she observed Resident #31 in the hallway after the incident and his faced was bruised and had a gash on his head and nose. She reported she was assigned to sit with Resident #32 after the incident until the end of the shift on 02/17/18 at about 11:00 P.M., at that time the nurses were with the resident and transportation was at the facility to take him to the psychiatric hospital. STNA #69 said that Resident #32 never said exactly what had happened, just that he peed on my bed, and rambled on and on which was typical for the resident. She shared that Resident #32 was just readmitted back from the psychiatric hospital, and came back with the same behaviors as when he left. STNA #69 stated she had never witness Resident #32 strike another residents, that he mostly rambled on and was hard to understand, and when he did act out it was more directed towards objects. She shared she believed that Resident #32 was intelligent enough to know right from wrong. STNA #69 stated that Resident #31 was not aggressive at all, was mild mannered, didn't bother anyone, but would try to leave the unit. The facility's abuse and neglect policy with a revision date of 02/01/17 was reviewed . The policy specified it is the intent of this facility to prevent the abuse, mistreatment, or neglect of resident or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegation of abuse, neglect or misappropriation of their property. This deficiency substantiates Complaint Number OH 331.

Based on observation, record review, review of a facility self-reported incident (SRI), staff and resident interview, and review of facility abuse and neglect policy, the facility failed to implement their abuse policy to prevent the physical abuse of Resident #31 by Resident #32. This resulted in actual physical harm when Resident #31 was physically abused and subsequently required hospital evaluation for suturing to a laceration to the top of his scalp and multiple skin tears/abrasions to his nose and other areas of his body. This affected one (#31) of four residents reviewed for abuse. Facility census was 171. Finding include: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed a comprehensive assessment (MDS 3.0) of Resident #31's cognitive and physical functioning dated 12/08/17. The 12/08/17 assessment identified the resident as having short and long term memory problems, severe cognitive skills for daily decision making, other behavioral symptoms that put the resident at risk for physical injury (exit seeking), and required only supervision for bed mobility, transfer, and walking in his room and on the unit. Resident #32 was admitted to the facility on [DATE], and recently readmitted to the facility on [DATE] from a behavioral health hospital, with [DIAGNOSES REDACTED]. The facility completed a comprehensive assessment of the Resident #32's cognitive and physical functioning dated 12/14/17. The 12/14/17 assessment identified the residents as having moderate memory and recall problems, inattention and disorganized thinking at times, delusion, verbal behavioral symptoms, no physical behavioral symptoms, and requiring only supervision for bed mobility, transfer, and walking in his room and on the unit. The resident had a current comprehensive plan of care to address his behavioral symptoms. Resident #32 was discharged from the facility 02/17/18 to a behavioral health hospital, and was served an immediate and emergent notice of discharge by the facility on 02/20/18. Resident #31 and Resident #32 were roommates on one of the facility's secured units for residents with behavioral problems/needs directed towards selves or others; Beacon Unit. Review of Resident #31's medical record revealed a nursing note by Licensed Practical Nurse (LPN) #149 on 02/17/18 for the time of 2:58 P.M. LPN #149 recorded the following information in the nursing note: Staff saw Resident #31 walking out of his room with blood dripping from his nose. He was holding onto the rails on the wall. The resident stopped and turned half way around, and kept looking towards his room. Staff walked up to the resident, including this nurse, and asked what had happened. Resident #31 did not say anything but kept looking at the door. This nurse went into the room and saw the resident's roommate, Resident #32, in the bathroom washing his hands with traces of blood in the sink. There was some liquid all over the bathroom floor. When this nurse asked Resident #32 what happened he stated that Resident #31 had urinate on the floor, and also on his bed. When Resident #32 was asked if he hit his roommate he said no. LPN #149 then documented she did a head to toe assessment of Resident #31, all extremities were within normal limits, vital signs were taken and recorded. She noted the resident's physician and family member were notified, as well as the Administrator, the Director of Nursing (DON), and the police. The nurse received an order to send Resident #31 to the emergency room for evaluation via emergency services. On 02/18/19 for the time of 6:02 P.M., LPN #149 documented that Resident #31 returned to the facility from the local hospital and was re-oriented to the facility. The resident was not complaining of any pain at that time. LPN #149's assessments of the injuries to the resident dated 02/17/18 were reviewed. LPN #149 documented the resident as having the following injuries after the altercation with Resident #32: top of scalp 1.5 centimeter (cm) by 1.0 cm skin tear on the head; face three areas of skin tears on the nose measuring 2.5 cm by 1.0 cm, 1.0 cm by 1.0 cm, and 2.0 cm by 1.0 cm; right outer ankle 2.0 cm by 1.0 cm skin tear; right elbow 3.0 cm by 2.0 cm skin tear; and back of right hand 1.0 cm by 1.0 cm skin tear to the fourth digit of the right hand. The emergency department (ED) hospital records for Resident #31, dated 02/17/18 were reviewed. In the ED the physician assessing the resident noted the Resident #31 had a two centimeter laceration to the top/posterior area of his scalp, and abrasions to his nose. Resident #31 received two sutures to close a two centimeter laceration to the top of his scalp, and was sent to a different hospital for evaluation due to history of subdural hematomas. Review of a facility SRI revealed on 02/17/18 Resident #31 was witnessed by staff with blood on his face. When staff asked him what happened he was not able to tell staff. Staff found his roommate (Resident #32) in their shared bathroom washing his hands with traces of blood in the sink. When staff asked Resident #32 if he had hit Resident #31 he denied it. Both residents were assessed. Resident #31 was sent to the ED for evaluation. Resident #32 was put on one on one with staff for safety precautions. Physician and responsible parties were notified. Staff on duty gave statements. There were no witnesses to any incident. Per staff statements both residents changed their story of what may have happened throughout the shift. Per staff neither resident was having any behaviors prior to the incident. Like residents were asked if they had been abused or seen abuse with no new negative findings. Per chart review Resident #32 last Brief Interview for Mental Status (BIMS) was an 11 out of 15 (moderately impaired). He has a court appointed guardian due to him being found incompetent. He suffers from severe mental illness and resides on a secured behavior unit. He is a poor historian. The SRI also documented the police were notified. An interview was conducted with Resident #31 on 02/22/18 at 10:50 A.M. The resident was lying in bed and appeared in no distress. Resident #31 was alert to himself, was verbal, but spoke very softly. The resident had three or more areas of blood crusted healing abrasions/skin tears on his nose, and a dark bruise under his right eye. When asked how he was injured the resident clearly stated he beat me. When asked who beat him he clearly responded used to be my roommate. The resident denied any pain related to his injuries. When asked if he was treated and not abused by other residents or staff, he stated he was and denied any problems other than with his roommate. When asked if he felt safe at the facility he reported he did. An interview was conducted with LPN #144 on 02/22/18 at 11:57 A.M. regarding the physical altercation between Resident #32 and #31 on 02/17/18. LPN #144 reported she worked the first and second shift on the Beacon Unit on Saturday 02/17/18 the day of the incident. She reported there was a physical altercation between Resident #32 and Resident #31 on 02/17/18, and Resident #32 was the aggressor. However, she affirmed it was no directly witness by anyone other than the Resident. She reported she and another nurse, LPN #149, were assigned and State tested Nurse Aide (STNA's) #77 and #82 were at the nursing station. She communication that she saw Resident #31 walking towards the nursing station, and STNA #82 stated something was on the resident's face. He had blood on his nose, his face, and the top of his head. LPN #144 stated that she and STNA #77 immediately went to the room, along with LPN #149. LPN #144 and STNA #77 tended to Resident #31's injuries, and LPN #149 reported observing Resident #32 washing what appeared to be blood off his hands. She stated she asked Residents #31 and #32 what happened, and Resident #32 was verbally aggressive saying that Resident #31 had urinated in his bed and kicked him, although Resident #31 was the injured party. Resident #31 did not report anything at that time. LPN #144 communicated that LPN #149 had Resident #32 go to the nursing station where he was supervised one on one by the other STNA on the unit #69. She stated LPN #149 made all notifications to Resident #31's physician and representative, notified the Administrator and Director of Nursing, the local police, and set up transportation for Resident #31 to be sent out to the hospital. LPN #144 shared that Resident #32 had just come back three days prior from a behavioral health hospital when he was admitted due to having increased behaviors at the facility. She reported that Resident #32 could become aggressive and yelling loudly, that this was not his first altercation, but was not sure if he had ever struck anyone before. When asked is she believed Resident #32 knew right from wrong she stated she did based on her knowledge of the resident. An interview was conducted with STNA #77 on 02/22/18 at 12:18 P.M. regarding the incident between Residents #32 and #31 on 02/17/18. She reported she worked the first and second shift of duty on the Beacon unit on 02/17/18 and was present when the incident occurred. STNA #77 stated she recalled the nurse on duty gave Resident #31 his medication sometime before lunchtime, and she took his to his room to lay down as he wanted to take a nap before lunch. She shared she wasn't positive Resident #32 was in the room at that very time, as Resident #32 spent a lot of time in the bathroom. The she shut the door to the room after she left as Resident #31 always likes the door shut. STNA #77 communicated that about 20 minutes later, about 11:30 A.M., she observed Resident #31 walking towards the nursing station with blood on his nose and she immediately went to him. She stated Resident #31 appeared to be dazed, from possibly just getting up from lying down or whatever happened in the bed room. STNA #77 stated that she, LPN #149, and LPN #144, took Resident #31 back to his room. When they got Resident #31 back to his room, she asked Resident #32 what happened and he stated that Resident #31 urinated on his bed. However, STNA #77 shared that there was no urine or water on the bed or on the floor of the room, after letting Resident #32 know she found no urine anywhere he said Resident #31 kicked him. Resident #32 was then removed from the room and STNA #69 took the resident to up front to the nursing station and stayed with him one on one while LPN #144 took care of Resident #31. STNA #77 stated she stayed with LPN #144 to help with Resident #31. She reported that the police arrived at the facility and filed a report, emergency services came and took Resident #31 to the hospital, and Resident #32 remained one on one with STNA #69 until around 10:30 P.M. or so when he was also sent out to the hospital. LPN #77 affirmed the incidents was unwitnessed and could state exactly how Resident #31 sustained his wounds, assuming that he had been hit and kicked by Resident #32. When queried about Resident #32's cognitive status and behaviors, STNA #77 reported the resident was alert to self, and had behaviors of screaming out, and would sometimes walk by you a flip his hand at you. She communicated she believed the resident knew right from wrong as later that evening before being sent out to the hospital Resident #32 stated to her I didn't meant to do it. However, Resident #32 did not clarify what it was. An interview was conducted with STNA #69 on 02/22/18, at 12:42 P.M., regarding the incident that occurred between Resident #32 and #31 on 02/17/18. STNA #69 reported she had worked both the first and second shifts of duty on 02/17/18 and was present on Beacon Unit at the time the incident occurred. She stated no one actually witness the incident, but was aware some kind of physical altercation had occurred. STNA #69 shared that she observed Resident #31 in the hallway after the incident and his faced was bruised and had a gash on his head and nose. She reported she was assigned to sit with Resident #32 after the incident until the end of the shift on 02/17/18 at about 11:00 P.M., at that time the nurses were with the resident and transportation was at the facility to take him to the psychiatric hospital. STNA #69 said that Resident #32 never said exactly what had happened, just that he peed on my bed, and rambled on and on which was typical for the resident. She shared that Resident #32 was just readmitted back from the psychiatric hospital, and came back with the same behaviors as when he left. STNA #69 stated she had never witness Resident #32 strike another residents, that he mostly rambled on and was hard to understand, and when he did act out it was more directed towards objects. She shared she believed that Resident #32 was intelligent enough to know right from wrong. STNA #69 stated that Resident #31 was not aggressive at all, was mild mannered, didn't bother anyone, but would try to leave the unit. The facility's abuse and neglect policy with a revision date of 02/01/17 was reviewed . The policy specified it is the intent of this facility to prevent the abuse, mistreatment, or neglect of resident or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegation of abuse, neglect or misappropriation of their property. This deficiency substantiates Complaint Number OH 331.

Based on record review and staff interview the facility failed to provide adequate supervision during care to prevent a fall. This resulted in harm when the resident rolled out of bed during the provision of incontinence care, receiving a laceration to the right forehead that required eight sutures. This affected one resident (#2) of three residents reviewed for falls. The facility census was 175. Findings include: A medical record review for Resident #2 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment dated [DATE] noted Resident #2 as severely cognitively impaired per staff assessment and totally dependent on two staff persons for bed mobility, transfers and toileting. Resident #2's current plan of care, initiated 08/26/13, noted Resident #2 required the total assistance of two staff persons to reposition and turn in bed. A review of Resident #2's bed mobility support provided by staff, as documented in the electronic charting system, on 05/10/15, noted on all three shift bed mobility was provided by one staff person. A review of the progress notes for Resident #2 revealed an incident note dated 05/11/15 at 12:31 A.M. by Licensed Practical Nurse (LPN) #1 reporting that on 05/10/15 at 8:05 P.M. Resident #2 had a fall causing a laceration to her right forehead. LPN#1 assessed the resident's vital signs, range of motion and level of consciousness and signs of pain. A Clinical Meeting progress note dated 05/11/15 at 4:24 P.M. by Registered Nurse (RN) #2 noted Resident #2 was evaluated at a local hospital following the fall on 05/10/15 and received eight sutures to her forehead and was started on Norco 5 milligrams (mg)/325 mg, a narcotic analgesic pain reliever, one tablet every four hours for one week. A review of the facility fall investigation completed by RN #2 recorded that State tested Nurse Assistant #3 was providing incontinence to Resident #2 on 05/10/15 at 8:05 P.M. During this care STNA #3 positioned resident away from her. It was noted that Resident #2 had an air mattress with bolsters and slid out of bed. A statement signed by STNA #3 on 05/10/15 reports that STNA #3 was the only staff member present in Resident #2's room at the time of the fall and was changing Resident #2 when the resident slid off over the bolsters and off the side of the bed. An interview was conducted on 05/26/15 at 1:45 P.M. with RN #2. RN #2 confirmed that Resident #2's plan of care at the time of the fall called for a two person staff assistance to reposition and turn the resident in bed and the fall investigation documentation reflected that only one staff person was present while Resident #2 was being rolled/repositioned in bed for incontinence care at the time of Resident #2's fall on 05/10/15. RN #2 further confirmed that the Resident #2 had sustained a laceration to her right forehead which required eight sutures as a result of the fall. This deficiency substantiates Master Complaint Number OH 080.

Based on record review and interview, the facility failed to ensure a resident was transported safely in a wheelchair to prevent an accident that resulted in a fracture of the leg. This affected one (#17) sampled resident. The sample was 12. Findings include: Resident #17 was admitted to the facility on [DATE]. The May 2011 physician's orders [REDACTED]. Review of the current Minimum Data Set, dated dated [DATE], assessed the resident as cognitively intact. She required total care of two or more staff for transfers. The physical therapy note dated 01/07/11 (no time given), documented Resident #17 did warm up exercises in therapy and her prosthetic legs were applied. The therapist was continuing with the resident's exercises when she insisted the therapist take her outside to smoke, as she did not want to be late for her designated smoke time. Not to disrupt the resident, the therapist pushed Resident #17 in the wheelchair to the smoking area with ongoing instructions to watch and to keep her feet up. While seated in the wheelchair, the resident's prosthetic legs did not reach the floor. Upon going out of the door, the resident's left foot got caught on the door threshold strip, causing her left foot to bend back under the chair. The resident immediately complained of pain. The nurse came immediately to assess the resident. The therapist went back to the door and noted the pavement slanted downward at the threshold where the prosthesis touched. There were no footrests on the wheelchair at the time of the accident, causing the resident's foot to get caught while going over the threshold of the door. Review of the nursing note, dated 1/07/11 at 11:15 A.M., revealed the resident was working in physical therapy. She was up in the wheelchair with her prosthetic legs in place. The prosthetic legs did not reach the floor. While going through the outside door, the resident's left foot dropped down and bent backward causing pain to her left thigh. The resident was assessed for injury and medicated for pain. The physician was called and ordered the resident to have an X-ray to rule out a fracture. There were no further nursing notes written until 9:00 PM at which time Resident #17 was "hollering and crying", complaining of pain in the left leg during the X-ray. She rated the pain a 10 on a 1-10 scale, 10 being severe pain. Pain medication was administered. Assessment revealed the leg was swollen and tender to touch. The resident was moaning and groaning with every turn. At 10:00 PM the resident was in bed, complaining that the pain in her leg was an 8 on a 1-10 scale. The leg was tender to touch and swelling was noted. At 12:30 A.M., the resident was awake and alert, with no complaints of pain or discomfort. At 2:00 A.M., the resident was complaining of pain, stating the pain was a 7 to 8 on a 1-10 scale. Pain medication was repeated. The leg was still swollen. At 3:30 A.M., the resident was resting quietly with no complaints of pain. At 6:40 A.M. the facility received the X-ray results, which showed a displaced fracture of the distal left femur. The bones were osteopenic. The physician was notified and the resident was ordered to be sent to the emergency room , where she was admitted and treated for [REDACTED]. Resident #17 stated during interview on 05/19/11 at 10:50 A.M. she was up in therapy and she had her prosthetic legs on. "He (the physical therapist) took me out the front door and my left leg got bent back under the chair. I told them my leg was hurting so the nurse came right away. They took me back in the building and called the paramedics to take me to the hospital." When asked the time frame from injury until she was taken to the hospital, she stated it was a couple of hours. When asked if she received something for pain, she replied yes, but stated that it did not relieve the pain. The resident stated that she still has pain in her leg. During an interview, on 5/19/11 at 2:00 PM, the Director of Nursing confirmed there were no foot rests on the wheelchair at the time of the accident to prevent the resident's feet from getting caught on the door threshold. She also stated the resident refused surgical intervention for the fracture while in the hospital. This citation substantiated Complaint Number OH 708.