Every finding on record at Riverview Post Acute

Based on staff interview, policy review, observation, and medical record review, the facility failed to develop a care for the resident's care and services for the diagnosis of seizure disorder. This affected one (#2) of 21 residents reviewed for care plans. The facility census was 79. Findings include:Review of the medical record for Resident #2 revealed an admission date of 06/05/25. Diagnoses included epilepsy and vascular dementia. Review of the physician orders dated 09/2025 revealed an order for Levetiracetam (anti-convulsant medication) 500 milligrams (mg) by mouth daily for treatment of seizure disorder and for Resident #2 to wear soft side helmet to protect the head if resident falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had cognitive impairment with physical and verbal behaviors toward others that put the resident at significant risk for physical illness or injury, significantly interfered with resident care, intruded on privacy of others, and significantly disrupted care or the living environment of others. Review of the plan of care initiated on 06/09/25 and last revised on 09/24/25 revealed no plan of care addressing seizure disorder. Observations of Resident #2 on 09/23/25 at 10:06 A.M. and 09/24/25 at 3:12 P.M. revealed no signs and symptoms of seizure activity. Resident #2 was wearing a soft helmet. An interview on 09/25/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #150 revealed the CNA was not aware Resident #2 had a seizure diagnosis. CNA #150 confirmed there was not any instructions in the nursing's kardex or plan of care to address Resident #2 seizure disorder and what to do if resident had a seizure. An interview on 09/25/25 at 12:49 P.M. with Licensed Practical Nurse (LPN) #174 revealed Resident #2 had not had any recent seizure activity. An interview on 09/25/25 at 12:54 P.M. with Unit Manager #159 confirmed Resident #2 had a diagnosis of seizure disorder, received medication for seizure disorder and there was not a plan of care addressing Resident #2 seizure disorder. Review of the facility policy titled Seizures and Epilepsy-Clinical Protocol dated 11/2018 revealed the nursing staff should assess, document and report the following: vital signs, neurological assessment, change in level of consciousness, any seizure activity in detail (location duration, severity and reoccurrence), any injury occurring with a seizure, whether the resident has a known seizure disorder or history of actual seizure activity, date of most recent actual seizure activity, how current seizure activity relates to usual patterns and last blood level of any anti-convulsant medication being administered.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received timely and appropriate nail care. This affected one (#6) of six residents reviewed for ADLs. The facility census was 79. Findings include:Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included diabetes mellitus, heart failure, muscle wasting and atrophy, and vascular dementia. Review of the care plan, dated 02/21/24, revealed the resident had an ADL self-care/mobility/functional ability performance deficit. Interventions included nail care as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition and was dependent on staff with personal hygiene and bathing. Observations on 09/22/25 at 12:50 P.M. and 09/23/25 at 9:45 A.M. and 3:25 P.M. revealed Resident #6 was lying in bed. The resident's fingernails were extremely long and had dark-colored debris caked underneath them. Observation and interview with Registered Nurse (RN) #117 on 09/23/25 at 4:15 P.M. confirmed Resident #6's fingernails were extremely long with dark-colored debris caked underneath them and were in need of being trimmed and cleaned. RN #117 confirmed she was going to get nail clippers and was coming back to trim and clean the resident's nails. Review of the facility policy titled Fingernails/Toenails, Care of revised 02/2018 revealed the purpose of the procedure was to clean the nail bed, to keep the nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. This deficiency represents non-compliance investigated under Master Complaint Number 2608350 and Complaint Number OH00166779 (1282675).

Based on record reviews, interviews, and review of facility policy, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) received timely assessment and care to prevent re-triggering of traumatic events. This affected two (#10 and #12) of four residents reviewed for mood and behavior. The facility census was 79. Findings include:1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included PTSD. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had mildly impaired cognition. Record review revealed there was not an assessment or plan of care available which identified the cause of the resident's PTSD, the potential triggers of the resident's PTSD, or interventions to prevent the retriggering of the resident's PTSD. Interview on 09/25/25 at 3:10 P.M. with Social Services Assistant (SSA) #201 confirmed Resident #10 did not have an assessment or plan of care in place to address the resident's PTSD diagnosis prior to 09/22/25. 2. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included PTSD. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Record review revealed there was not an assessment or plan of care available which identified the cause of the residents PTSD, the potential triggers of the residents PTSD, or interventions to prevent the retriggering of the residents PTSD. Interview with the Director of Nursing on 09/24/2025 at 2:47 P.M. verified no trauma assessment or care plan addressing PTSD was initiated until 09/23/25 for Resident #12. Review of the facility policy titled Trauma Informed Care and Culturally Competent Care revised 08/2022 revealed the purpose was to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Assessment involved an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. Develop an individualized care plan that address the past trauma in collaboration with the resident and family, as appropriate.

Based on medical record review, observation, and staff interview, the facility failed to ensure staff assisted residents with feeding in a dignified manner. This affected two (Residents #8 and #72) of five facility-identified residents who required assistance with eating. The facility census was 100 residents. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including hemiplegia, frontal lobe deficit related to cerebrovascular accident, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #8 dated 07/31/23 revealed the resident had impaired cognition and required moderate assistance with eating. Review of the nutritional assessment for Resident #8 dated 08/01/24 revealed the resident was on a regular diet with pureed textures. Observation on 09/16/24 at 11:43 A.M. revealed Resident #8 was seated in a wheelchair with an over the bed table across her lap. State tested Nurse Aide (STNA) #114 delivered and set up Resident #8's meal tray. STNA #114 then fed Resident #8 her lunch meal while standing over the resident at the resident's side. Interview on 09/16/24 at 11:52 A.M. with STNA #114 confirmed she was standing over Resident #8 while feeding the resident. 2. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus type two, hypertension, and peripheral vascular disease. Review of the MDS assessment for Resident #72 dated 07/25/24 revealed the resident had cognitive impairment and required partial to moderate assistance with eating. Review of the nutritional assessment for Resident #72 dated 06/28/24 revealed the resident was on a pureed diet with regular textures. Resident #72 was a slow eater and required staff assistance as needed. Observation on 09/16/24 at 11:54 A.M. revealed Resident #72 was seated in her wheelchair with an over the bed tray table across her lap. STNA #117 delivered and set up the resident's meal tray. STNA #117 then fed Resident #72 her lunch meal while standing over the resident at the resident's side. Interview on 09/16/24 at 11:59 A.M. with STNA #117 confirmed she was standing over Resident #72 while feeding the resident. Interview on 09/17/24 at 10:45 A.M. with the Director of Nursing (DON) confirmed staff should sit down at eye level when feeding residents. The DON further confirmed that staff standing over a resident while feeding or assisting a resident did not provide the resident a dignified dining experience. This deficiency represents noncompliance investigated under Complaint Number OH00157601.

Based on medical record review, resident interview, staff interview and review of the facility policy, the facility policy failed to notify local health department and visitors to the facility of an outbreak of a stomach virus which infected residents and staff. This affected 19 of 19 residents reviewed for stomach virus symptoms. The facility census was 89 residents. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including cellulitis in left lower extremity, diabetes mellitus type two, depression, morbid obesity, and gastrointestinal reflux disease. Review of the nursing progress notes for Resident #11 dated 06/18/24 to 06/26/24 revealed they did not include information regarding a stomach virus or documentation regarding notification to resident's representatives of an outbreak of a stomach virus. Review of the medical records for Residents #2, #18 and #38 revealed the residents had nausea, vomiting and or diarrhea from 06/15/24 through 06/19/24. There was no documentation regarding resident representative notification of an outbreak of stomach virus. Interview on 06/26/24 at 10:06 A.M. with Resident #2 confirmed she had been sick a couple of weeks ago along with other residents. Resident #2 stated her symptoms included nausea, vomiting and diarrhea. Interview on 06/26/24 at 10:03 A.M. with Resident #18 confirmed she had been sick a couple of weeks ago with nausea, vomiting and diarrhea. Interview on 06/27/24 at 9:15 A. M. with Licensed Practical Nurse (LPN) #156 confirmed she had a stomach virus a couple of weeks ago and she had to call off work due to her symptoms. Interview on 06/27/24 at 9:18 A.M. with State tested Nursing Assistant (STNA) #145 confirmed she had a stomach virus a couple weeks ago and she had to call off work due to her symptoms. Interview on 06/27/24 at 9:22 A.M. with STNA #114 confirmed she had a stomach virus a couple weeks ago and was sent home from work when she developed symptoms. Interview on 06/26/24 at 2:41 P.M. with the Director of Nursing (DON) confirmed the facility had an outbreak of a stomach virus in early June 2024 which infected 19 residents and eight staff members. The DON further confirmed the facility did not notify the local health department of the outbreak of the virus with symptoms including nausea, vomiting and diarrhea, nor had the facility notified visitors and resident representatives of the outbreak. Review of the facility policy titled Outbreak Prevention and Intervention dated 11/23/23 revealed outbreak measures would be instituted whenever there was an incidence of infections above what was normally expected considering seasonal variation. Appropriate notifications would be issued to the medical director, the attending physician, administrator, all departments, and family members at a minimum and to appropriate state and local officials. The facility should determine that an outbreak existed when a commonality of symptoms was evident among residents and or staff with common person, place or time. The facility should educate the staff, residents and visitors of their individual responsibilities and importance of compliance with any isolation requirements. This deficiency represents noncompliance investigated under Complaint Number OH00155114.

Based on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), and congestive heart failure. Review of the plan of care for Resident #87 dated 04/26/21 revealed the resident had exit seeking behavior and was an elopement risk. The resident wandered about the facility in her wheelchair looking for a way home. Interventions included the use of the alert bracelet to her ankle and to calmly redirect to an appropriate area. Review of the physician's orders for Resident #87 revealed an order dated 04/17/23 for a secure bracelet for the resident's ankle to prevent elopement form the facility and order dated 05/26/23 for a regular, soft and bite sized texture diet with minced meats. Interview on 06/24/24 at 1:17 P.M. with Licensed Practical (LPN) #100 confirmed she worked over until 2:00 A.M. on 05/20/24 which was the night Resident #87 was found in the unlocked facility kitchen unattended. LPN #100 confirmed on 05/20/24 around 1:50 A.M. she asked Nursing Assistant (NA) #115 if he had seen the resident, but the aide had not seen Resident #87. On 05/20/24 at approximately 2:00 A.M. NA #115 found Resident #87 in the kitchen with an opened bag of potato chips on her lap. LPN #100 confirmed the kitchen was usually locked and she was unsure why it had been left unlocked. LPN #100 confirmed she reported the incident to Registered Nurse (RN) #110 right after it happened. LPN #100 confirmed RN #100 told her that because Resident #87 did not leave the building, no documentation was necessary. Interview on 06/24/24 at 1:53 P.M. with NA #115 confirmed he worked on night shift on the night Resident #87 was found in the unattended facility kitchen. NA #115 stated Resident #87 was a wanderer and he and he went to look for her after he had not seen her for about 10 minutes. NA #115 confirmed he found Resident #87 eating potato chips in the unlocked and unattended kitchen. NA #115 confirmed when he found Resident #87, she had already consumed a whole snack size bag of baked chips when staff removed the resident from the kitchen. NA #115 further confirmed the kitchen was normally locked and he did not know how it was left unlocked. Interview on 06/24/24 at 1:50 P.M. with the Dietician confirmed Resident #87 was on a diet where all foods were to be soft and bite sized, except meats which were to be minced and moist. The Dietitian confirmed Resident #87 had dysphagia and should not eat potato chips because they not considered a safe texture in keeping with the resident's diet. Interview with on 06/24/24 at 1:35 P.M. with RN #100 confirmed LPN #100 called her on 05/20/24 and told her that Resident #87 had been gone for about 15 minutes when she was found in the unlocked and unattended facility kitchen. RN #100 stated she did not remember being told that she ate anything. RN #100 confirmed the kitchen is normally locked when unattended and residents are not normally allowed in the kitchen. RN #100 confirmed Resident #87 could have gotten hurt if she would have turned the stove on, got out a knife, or ate something not on her diet. RN #100 stated she never told LPN #100 not to document the incident. Interview on 06/24/24 at 2:40 P.M. with the Director of Nursing (DON) confirmed one nurse on night shift had a key to the kitchen and must have went in and failed to lock the kitchen. The DON confirmed Resident #87 had dysphagia and was not safe to eat potato chips, and staff had not informed her Resident #87 had eaten chips when she was found unattended in the facility kitchen on 05/20/24. This deficiency represents noncompliance investigated under Complaint Number OH00154534.

Based on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), and congestive heart failure. Review of the plan of care for Resident #87 dated 04/26/21 revealed the resident had exit seeking behavior and was an elopement risk. The resident wandered about the facility in her wheelchair looking for a way home. Interventions included the use of the alert bracelet to her ankle and to calmly redirect to an appropriate area. Review of the physician's orders for Resident #87 revealed an order dated 04/17/23 for a secure bracelet for the resident's ankle to prevent elopement form the facility and order dated 05/26/23 for a regular, soft and bite sized texture diet with minced meats. Interview on 06/24/24 at 1:17 P.M. with Licensed Practical (LPN) #100 confirmed she worked over until 2:00 A.M. on 05/20/24 which was the night Resident #87 was found in the unlocked facility kitchen unattended. LPN #100 confirmed on 05/20/24 around 1:50 A.M. she asked Nursing Assistant (NA) #115 if he had seen the resident, but the aide had not seen Resident #87. On 05/20/24 at approximately 2:00 A.M. NA #115 found Resident #87 in the kitchen with an opened bag of potato chips on her lap. LPN #100 confirmed the kitchen was usually locked and she was unsure why it had been left unlocked. LPN #100 confirmed she reported the incident to Registered Nurse (RN) #110 right after it happened. LPN #100 confirmed RN #100 told her that because Resident #87 did not leave the building, no documentation was necessary. Interview on 06/24/24 at 1:53 P.M. with NA #115 confirmed he worked on night shift on the night Resident #87 was found in the unattended facility kitchen. NA #115 stated Resident #87 was a wanderer and he and he went to look for her after he had not seen her for about 10 minutes. NA #115 confirmed he found Resident #87 eating potato chips in the unlocked and unattended kitchen. NA #115 confirmed when he found Resident #87, she had already consumed a whole snack size bag of baked chips when staff removed the resident from the kitchen. NA #115 further confirmed the kitchen was normally locked and he did not know how it was left unlocked. Interview on 06/24/24 at 1:50 P.M. with the Dietician confirmed Resident #87 was on a diet where all foods were to be soft and bite sized, except meats which were to be minced and moist. The Dietitian confirmed Resident #87 had dysphagia and should not eat potato chips because they not considered a safe texture in keeping with the resident's diet. Interview with on 06/24/24 at 1:35 P.M. with RN #100 confirmed LPN #100 called her on 05/20/24 and told her that Resident #87 had been gone for about 15 minutes when she was found in the unlocked and unattended facility kitchen. RN #100 stated she did not remember being told that she ate anything. RN #100 confirmed the kitchen is normally locked when unattended and residents are not normally allowed in the kitchen. RN #100 confirmed Resident #87 could have gotten hurt if she would have turned the stove on, got out a knife, or ate something not on her diet. RN #100 stated she never told LPN #100 not to document the incident. Interview on 06/24/24 at 2:40 P.M. with the Director of Nursing (DON) confirmed one nurse on night shift had a key to the kitchen and must have went in and failed to lock the kitchen. The DON confirmed Resident #87 had dysphagia and was not safe to eat potato chips, and staff had not informed her Resident #87 had eaten chips when she was found unattended in the facility kitchen on 05/20/24. The DON confirmed the incident on 05/20/24 involving Resident #87 should have been documented in the resident's medical record. This deficiency represents noncompliance investigated under Complaint Number OH00154534.

Based on medical record review and staff interview, the facility failed to ensure resident Pre-Admission Screening and Resident Review (PASARR) documents accurately reflected resident current conditions and diagnoses. This affected one (Resident #54) of three residents reviewed for PASARR documents. The census was 93. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including were non-Hodgkin's lymphoma, dysphagia, cognitive social or emotional deficits, dementia, anxiety, depression, hypertension, foot drop, suicidal ideations, noncompliance with medical treatment, traumatic brain injury, unspecified psychosis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 09/01/23 revealed the resident had severe cognitive impairment. Review of the PASARR document for Resident #54 dated 10/01/20 revealed it did not include any active psychiatric diagnoses. Interview on 11/30/23 at 11:42 A.M. with the Director of Nursing (DON) confirmed Resident #54 had a new diagnosis of unspecified psychosis which was added on 12/27/21. The DON confirmed an updated PASARR was not completed for this resident after the addition of a new mental health diagnosis in 2021.

Based on medical record review and staff interview the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #54) of three residents reviewed for Pre-Admission Screening and Resident Review (PASARR) documents. The census was 93. Findings Include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including were non-Hodgkin's lymphoma, dysphagia, cognitive social or emotional deficits, dementia, anxiety, depression, hypertension, foot drop, suicidal ideations, noncompliance with medical treatment, traumatic brain injury, unspecified psychosis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 09/01/23 revealed the resident had severe cognitive impairment. Review of the PASARR document for Resident #54 dated 10/01/20 revealed it did not include any active psychiatric diagnoses. Interview on 11/30/23 at 11:42 A.M. with the Director of Nursing (DON) confirmed Resident #54 had a new diagnosis of unspecified psychosis which was added on 12/27/21. The DON confirmed an updated PASARR was not completed for this resident after the addition of a new mental health diagnosis in 2021 and the state mental health agency was not notified of Resident #54's new diagnosis.

Based on medical record review and staff interview the facility failed to timely complete a discharge summary for residents upon discharge from the facility and failed to provide residents and their representatives with discharge instructions. This affected one (Resident #51) of three residents reviewed for discharge. The facility census was 93. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] and diagnoses including displaced intertrochanteric fracture of right femur, atrial fibrillation, atherosclerotic heart disease, heart failure, end stage renal disease, diabetes mellitus, obstructive sleep apnea, major depressive disorder, and a discharge date of [DATE]. Review of the admission Minimum Data Set (MDS) assessment for Resident #51 dated 11/01/23 revealed the resident was moderately cognitively impaired and used a walker and wheelchair to aid in mobility. Review of the MDS for Resident #51 dated 11/22/23 revealed the resident was discharged from the facility with a return not anticipated. Review of the medical record for Resident #51 on 11/29/23 at 3:57 P.M. revealed it did not include a discharge summary or discharge instructions provided to the resident and/or the resident's representative upon discharge. Interview by phone on 11/30/23 at 2:18 P.M. with Registered Nurse (RN) #167 confirmed Resident #51 was discharged to home on 11/22/23 and the facility did not provide the resident with discharge instructions prior to him leaving. RN #167 further confirmed Resident #51's family came to the facility on [DATE] to obtain a list of the resident's medications because it had not been provided at discharge. RN #167 confirmed Resident #51's discharge paperwork was not finalized until 11/30/23.

Based on medical record review, observations, and staff interview the facility failed to provide timely and appropriate nail care for a resident who was dependent upon staff for assistance with activities of daily living (ADLs). This affected one (Resident #254) of two residents reviewed for ADLs. The facility census was 93. Findings include: Review of the medical record for Resident #254 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, acute cystitis without hematuria, retention of urine, and nondisplaced intertrochanteric fracture of right femur. Review of the care plan for Resident #254 dated 11/22/23, revealed the resident had an ADL self-care, mobility, and functional ability performance deficit. Interventions included staff should provide nail care as needed. Observation on 11/27/23 at 2:30 P.M. revealed Resident #254 was lying in bed and was alert and pleasantly confused. The resident fingernails were observed to be long and jagged and to have a layer of black debris caked underneath them. Observation on 11/28/23 at 10:34 A.M. revealed the fingernails of Resident #254 continued to be long and jagged and to have a layer of black debris caked underneath them. Observation on 11/28/23 at 12:15 P.M. revealed Resident #254 was consuming her lunch meal and used her hands to pick up food items off her tray to place them in her mouth. The resident's fingernails continued to be long and jagged and have a layer of black debris caked underneath them. Observation on 11/29/23 at 9:25 A.M. revealed Resident #254 was lying in bed and appeared to have received recent assistance with bathing and grooming. However, the resident's fingernails remained long and jagged and had a layer of black debris underneath them. Interview on 11/29/23 at 11:15 A.M. with State tested Nursing Assistant (STNA) #292 confirmed Resident #254's fingernails were long and jagged and had a layer of black debris underneath them and were in need of being trimmed and cleaned. STNA #292 stated she would obtain the needed supplies and trim and clean them immediately.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care. This affected one (Resident #25) of one resident who was reviewed for positioning during the annual survey. The facility identified two residents with pressure ulcers. The facility census was 93. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including dementia, peripheral vascular disease, heart failure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 09/29/23 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. The resident was assessed to require extensive assistance from staff for bed mobility and toileting and to be dependent upon staff for transfers. Review of the care plan for Resident #25 dated 01/25/22, revealed the resident was at risk for altered skin integrity. Interventions included the staff should apply a Prevalon boot to the left foot while in bed. Observation on 11/27/23 at 11:25 A.M., on 11/29/23 at 10:34 A.M. and on 11/30/23 at 1:08 P.M. revealed Resident #25 was lying in bed with his left leg was placed on a pillow with the heel lying directly on the mattress. There was no Prevalon boot in place to Resident #25's left foot or on the bed. Interview on 11/30/23 at 1:08 P.M. with State tested Nursing Assistant (STNA) #222 confirmed Resident #25 was lying in bed with his left leg placed on a flattened pillow and the resident's left heel was positioned directly on the mattress with no Prevalon boot in place. STNA #222 stated she did not believe the resident needed to have a Prevalon boot and confirmed there was not a Prevalon boot present in the resident's room. Interview on 11/30/23 at 1:55 P.M. with Registered Nurse (RN) #188 on 11/30/23 at 1:55 P.M. verified Resident #25 did not have a Prevalon boot in place to his left foot per his care plan. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk assessment dated [DATE] revealed the facility would identify residents at risk for the development of pressure ulcers and would implement supportive/preventative precautions as appropriate.

Based on medical record review and staff interview the facility to ensure antibiotic medications were prescribed and administered only when necessary. This affected one (Resident #10) of the three residents reviewed for antibiotic use. The facility census was 93. Findings include: Review of the medical record review for Resident #10 revealed an admitted [DATE] with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting. Review of the results of the urinalysis with culture and sensitivity (UA with C&S) for Resident #10 dated 11/22/23 revealed the presence of over 100,000 colony forming units per milliliter (CFU/ml) of mixed pathogens indicating probable contamination of the urine specimen. No further UA C&S testing was completed for Resident #10. Review of the physician's order for Resident #10 dated 11/25/23 revealed an order for 250 milligrams (mg) of vancomycin (an antibiotic medication) to be administered four times a day for five days for possible clostridium difficile (c-diff) infection. Review of the physician's order for Resident #10 dated 11/26/23, revealed an order for one gram of ertapenem Sodium Solution (an antibiotic medication) to be administered intravenously for three days for infection. Review of the results of the stool specimen for Resident #10 dated 11/28/23, revealed the specimen was negative for infection, including c-diff infection. Interview on 11/29/23 at 3:38 P.M with Medical Director (MD) #400 confirmed the antibiotic medication ertapenem was ordered and administered to Resident #10 for a possible urinary tract infection (UTI). MD #400 confirmed the results of the UA with C&S obtained on 11/22/23 revealed probable contamination and did not indicate that Resident #10 had an active UTI. Interview on 11/30/23 at 10:10 A.M. with Registered Nurse (RN) #189 confirmed antibiotic medication vancomycin was ordered and administered to Resident #10 for a possible c-diff infection. RN #189 confirmed results of the stool specimen obtained for Resident #10 on 11/28/23 revealed the resident did not have an infection.

2. Review of the medical record for Resident #84 revealed an admitted [DATE] with diagnoses including neutropenia due to infection, sepsis, myelodysplastic, atrial fibrillation, atherosclerotic heart disease, hyperlipidemia, generalized anxiety disorder, major depressive disorder, dysphagia, hypertension, and cognitive communication deficit. Review of the laboratory test results of the complete blood count (CBC) for Resident #84 dated 10/23/23 revealed the resident's hemoglobin (protein in red blood cells that delivers oxygen to tissues) was low at 8.6 g/dl (grams per deciliter) and the reference range was 14.0 to 18.0. Review of the physician's order for Resident #84 dated 10/24/23 revealed an order to obtain a weekly complete blood count (CBC). Review of the MDS for Resident #84 dated 10/26/23 revealed the resident was cognitively intact and required a walker and wheelchair for mobility. Review of the laboratory results for Resident #84 revealed a CBC was not completed for the resident until11/20/23. Review of the CBC results revealed the resident's hemoglobin level was 8.1 g/dl which was low. Interview with the Director of Nursing (DON) on 11/30/23 at 8:40 A.M. confirmed Resident #84 had an order for a weekly CBC dated 10/24/23, but the CBC was not completed until 11/20/23. Further interview with the DON confirmed the facility did not notify the attending physician of the abnormal lab result (low hemoglobin level) noted on 11/20/23. 42728 Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure physician-ordered laboratory tests and specimens were obtained timely and as ordered. This affected two residents (#10 and #84) out of the eight residents reviewed for antibiotic use and unnecessary medications during the annual survey. The facility census was 93. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting and to be independent for eating. The resident was assessed to have an indwelling foley catheter. Review of the physician's order for Resident #10 dated 11/17/23, revealed an order for a urinalysis with culture and sensitivity (UA with C&S) to be obtained stat (immediately). Review of the UA with C&S result for Resident #10 dated 11/22/23 revealed the specimen showed possible contamination. Review of the physician's order for Resident #10 dated 11/24/23 revealed an order for a stool sample to be obtained to rule out possible clostridium difficile (c-diff) infection and for a UA with C&S to be obtained on 11/27/23. Review of the care plan for Resident #10 dated 11/27/23 revealed the resident had possible clostridium difficile (c-diff) infection. Interventions included the following: follow facility protocols for contact isolation for duration of treatment, give medications per physician order, utilize personal protective equipment (PPE) as appropriate. Observation on 11/27/23 at 11:05 A.M. revealed Resident #10 was in isolation precautions for possible c-Diff infection. The resident was observed to have an indwelling foley catheter in place. Review of the laboratory record for Resident #10 revealed a stool specimen was obtained on 11/28/23, and the results were not yet available. Interview with Medical Director #400 on 11/29/23 at 3:38 P.M. confirmed the UA with C&S ordered for Resident #10 should have been obtained as ordered on 11/17/23 as the resident had an indwelling foley catheter. MD #400 confirmed a stool specimen for possible c-diff infection had been ordered to be obtained on 11/27/23 and he was still awaiting the results to review. Review of the facility policy titled Lab and Diagnostic Tests dated 06/08/22, revealed staff were to check physicians' orders for the test, specimen collection directions, and the date on which the test was due. Staff should mark the word stat on requisitions appropriately to bring the testing time frame to the attention of the laboratory. Stat requests would also be called to the laboratory as soon as ordered.

Based on observation, interview, record review, and facility policy review the facility failed to ensure a Registered Nurse (RN) was providing services to the residents eight consecutive hours, seven days per week. This had the potential to affect all the residents residing in the facility. The facility census was 91. Findings include: Observation of the daily staff postings on 07/31/23 and 08/08/23 revealed no scheduled RN was working. Review of the staffing schedules and daily postings from 07/07/23 through 08/07/23 revealed 16 days without RN working hours: 07/08/23, 07/09/23, 07/10/23, 07/14/23, 07/16/23, 07/17/23, 07/18/23, 07/21/23, 07/22/23, 07/23/23, 07/25/23,07/30/23, 07/31/23, 08/04/23, 08/05/23 and 08/06/23. Interview on 08/07/23 at 1:56 P.M. with Registered Nurse (RN) #11 revealed the RN worked at the facility full time but did not usually work weekends. Interview on 08/07/23 at 2:06 P.M. with RN #69 revealed the RN worked the floor part time and did not work weekends. Interview on 08/07/23 at 3:35 P.M. with the Director of Nursing (DON) revealed the facility currently had two RN's on staff. The facility did not admit residents that required RN coverage and a RN (director of nursing and assistant director of nursing) were on call 24 hours a day, seven days a week. The DON confirmed the facility did not staff an RN seven days per week for eight consecutive hours. Review of the facility policy titled Staffing and Scheduling, dated 06/08/23, revealed the facility would follow the Centers for Medicare and Medicaid Services (CMS) staffing requirements. This deficiency represents non-compliance investigated under Complaint Number OH00145194, OH00144880 and OH00138034.

Based on medical record review, staff interview, and incident report review the facility failed to ensure Resident #80's safety while using a mechanical lift to transfer the resident while providing care. This affected one (Resident #80) of the five residents reviewed for safe transfers. The facility census was 94. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE]. Diagnosis included altered mental status, dementia without behavioral disturbances, disorder of bone density and structure, osteoarthritis, and muscle wasting and atrophy. Review of Resident #80's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 experienced long and short-term memory problems as well as a severely impaired cognition for daily decision-making abilities. Resident #80 was noted to have difficulty focusing attention and noted to display an altered level of consciousness. No behaviors were noted during the assessment review. Resident #80 required extensive assistance from two staff members for bed mobility, dressing, toilet use, personal hygiene, and extensive assistance from one staff member for eating, and transfers were noted to have not occurred. Resident #80 was noted to have impairment to one upper and one lower extremity. Review of Resident #80's physician orders for November 2022 revealed, orders for staff to monitor Steri-strips to the left calf and to the left elbow until they fall off on their own. Review of the plan of care, dated 01/10/22 and revised on 05/03/22, revealed Resident #80 had a self-care deficit as evidenced by weakness related to disease process, cerebral vascular accident (CVA) with hemiparesis, Parkinson's, physical limitations, inability to ambulate, terminal prognosis. Interventions included to complete active range of motion (ROM) to upper extremities during activities of daily living (ADL), collaborate care with Hospice, and family and resident prefers bed baths and hair washed in bed, do not transfer with a mechanical lift per family request. Review of the plan of care dated 04/27/22 revealed Resident #80 was resistive/noncompliant with treatment/care, refusing geri-legs to protect skin to lower extremities related to a belief that the treatment was not needed/working. Interventions include to allow for flexibility in ADL, elicit family input for bed approaches, return later to attempt care again, and educate about risk of not complying with therapeutic regimen. Review of incident report dated 11/09/22 revealed, Resident #80 sustained a skin tear to the left calf while staff was giving her a shower. Staff went to lift her leg and her skin tore. When staff was putting the resident to bed with a Maxi (mechanical) lift, the resident grabbed the bar and refused to let go causing skin tear to left elbow. Action taken during investigation- Treatment completed for both areas, daughter notified and upset that mother sustained skin tears. Staff explained as we get older our skin gets thinner. Statements were obtained. Education was provided to staff on avoiding skin alterations. Conclusion- Resident #80 is an [AGE] year-old female with a diagnosis of cerebral vascular accident (CVA) disease, altered mental status (AMS), dementia, arthrodesis, of native arteries of right with ulceration of heel and mid foot. Polyosteoarthritis, neuropathy, and more. Resident #80's skin is thin and fragile; it tears very easily related to the aging process. The resident's daughter has requested not to use the Hoyer lift anymore and to complete bed baths for the resident and shampoo hair in bed. Skin tear was accident and defined not intentional. Review of the progress note dated 11/09/22 at 11:40 A.M. created by Licensed Practical Nurse (LPN) #201 revealed, while staff was giving Resident #80 a shower in the shower room, staff lifted her left leg causing a skin tear measuring 5.0 centimeters (cm) by 1.0 cm. When staff took the resident back to her room to put her back to bed using the mechanical lift, the resident refused to let go of the bar causing a skin tear measuring 2.0 cm by 1.0 cm. Both areas cleansed with wound cleanser and Steri-strips applied. The physician and family were notified. Review of the Braden Scale assessment completed for Resident #80 dated 10/08/22 revealed a score of 08 indicating the resident was at a very high risk of developing a skin injury, skin tear, or pressure wound. Review of Resident #80's Admission/Readmission screening dated 01/08/22 revealed the resident came from an acute care hospital, noted to understand, and follows instructions. The resident was noted with weakness, clear speech, and able to understand verbal commands, able to express self. The resident was noted to display an unsteady balance, with sitting, standing, and gait, noted to be pleasant and cooperative. The resident was noted to have right lower left round raised bruising areas and an open area to the right buttocks and the right heel. Resident #80 required assistance/potential to restore function for transferring from one position to another, transfer with mechanical lift. Interview on 11/30/22 at 3:00 P.M. with the Director of Nursing (DON) revealed Resident #80 was noted to have fragile skin due to the diagnoses of peripheral vascular disease and atherosclerosis of the arteries of the legs, causing issues with circulation. The incident that occurred where Resident #80 received a skin tear to the left calf and left elbow was an accident. Education was provided to staff regarding the proper procedure when transferring residents with a mechanical lift. Review of the facility policies revealed the facility did not provide a policy regarding the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00137500.

Based on medical record review, staff interviews, menu spread sheet review, and moist and minced food procedure review the facility failed to ensure Resident #87 received the correct food consistency during mealtime. This affected one (Resident #87) of the five residents reviewed for food texture. The facility census was 94. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbances, seizures, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, and cognitive communication deficit. Review of Resident #87's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a long- and short-term memory deficit and a severely impaired cognition for daily decision-making abilities. No behaviors were noted with this assessment review. Resident #87 required extensive assistance from two staff members for bed mobility, transfers, dressing, limited assistance from one staff member for eating, extensive assistance from one staff member for toilet use, and personal hygiene. Resident #87 was noted with impairment to one lower extremity and required the use of a wheelchair for mobility. Review of the care plan, dated 05/12/21 and revised on 07/09/21, revealed Resident #87 had a couple of natural teeth. Interventions include to report changes in chewing ability, and signs and symptoms of oral pain. Review of Resident #87's physician orders for November 2022 revealed the following diet order, No added salt diet, Minced and Moist textured food. Review of progress note date 11/19/22 at 1:36 P.M. created by Licensed Practical Nurse (LPN) #65 revealed, a nurse aide reported to this nurse during lunch the resident was eating her lunch and when the nurse aide walked by her room, she was noted to be having some trouble with her lunch. When the nurse aide approached the resident, she was noted to have her mouth open, and a French fry was sticking out of her mouth. She quickly did a finger sweep and obtained the food. When she looked at the tray, she had eaten a piece of cake and was eating French fries and discovered the resident had been given the wrong meal tray. The resident was on a puree diet and had a regular tray. LPN #65 went to assess the resident. Resident #87 was sitting upright in her bed with the head of bed elevated. Vital Signs- Temperature 97.6 degrees Fahrenheit, blood pressure - 126/68 milliliters of mercury (mmHg), respirations - 26 breaths per minute, and oxygen saturation was 97% on room air. Lungs sounds were diminished. The resident did not appear to be in any distress. Resident #87 was already eating the correct tray and was having no issues. Physician #243 was made aware. The resident's daughter was notified. Resident #87 was placed on alert charting and new orders were received to obtain vital signs every four hours for 24 hours. Interview on 11/29/22 at 1:48 P.M. with Dietary Manager #117 revealed each resident receiving a meal tray had a diet slip printed out in advance with menu items noted on it for that specific meal. Resident #87 was noted to receive a regular diet with minced and moist textured food. For the lunch meal on 11/19/22, Resident #87 should have received minced chicken with gravy on it and mashed potatoes instead of French fires. After lunch meal trays had been delivered, a staff member was walking by Resident #87 and noted she had a French fry sticking out of her mouth and intervened immediately by removing the French fry out of her mouth and requested a new meal tray with the appropriate textured food. After looking at the meal tray it was concluded that when staff members were passing out the lunch meal trays, one of the staff members gave Resident #87 the wrong meal tray. There were two residents in the same room that had the same first name and this caused the confusion. Interview on 11/29/22 at 2:30 P.M. with LPN #65 confirmed she was the nurse who was working on 11/19/22 when it was reported to her by a State tested Nursing Assistant (STNA) that Resident #87 had received the incorrect meal tray. Resident #87 was assessed with no concerns noted. Resident #87 had not choked on any of the food and was noted to be at baseline. Resident #87 normally does very well at mealtime. Staff will set up her meal tray and monitor throughout the meal to ensure she is eating. Most of the time Resident #87 does not require encouragement or cueing. Review of the menu spread sheet for 11/19/22 for lunch revealed the following food items and textures to be served to a resident receiving a regular textured diet, BBQ chicken on a bun, seasoned potato wedges, green bean, bread, and a honey bun cake. Residents who required to receive a Moist and Minced textured food diet were to receive, minced BBQ chicken, mashed potatoes, green bean, and honey bun cake. Review of the facility policy titled Minced and Moist Diet -MM 5, dated 07/21 revealed, The diet consists of food that are soft and moist with pieces no bigger than 4 millimeter (mm) by 15 mm with no thin liquid or dripping from the food. The foods are not sticky because this can cause the food to stick to the cheeks, teeth, roof of mouth, or in the throat. Guideline: Meat if finely minced to 4 mm lump size serving in non-pouring sauces or gravy. Vegetables are cooked and blenderized into 4 mm lump sizes, excess liquid is drained. Bread and rice are pureed. This deficiency represents non-compliance investigated under Complaint Number OH00137764.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive plan of care to address the behavioral issues of a resident. This affected one (Resident #56) of three residents identified with behavioral issues. The facility census was 83. Findings Include: Review of the medical record for Resident #56 revealed a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 11/24/21, revealed the resident had impaired cognition with continuous inattention, disorganized thinking, and trouble sleeping. Resident #56 had delusions and verbal behaviors directed towards others which interfered with care, social interactions, and significantly disrupted care and the living environment. The resident rejected care and required extensive assistance of two for activities of daily living, except for eating. Review of the admission nursing assessment dated [DATE] revealed Resident #56 had resistive behaviors, rejected care and anxiety. Review of the plan of care dated 01/22/22 revealed Resident #56 was at risk for behavior symptoms (no symptoms were listed) related to [CONDITION(S)] and delusions. The interventions included attempt [CONDITION(S)] drug reduction per physician orders, observe for mental status/behavior changes when new medication started or with changes in dosage, and psychiatric referral as needed. Review of the nurses notes from 01/21/22 to 03/02/22 revealed multiple incidents of resident having aggressive behavior and agitation. On 01/23/22 at 9:46 A.M. the resident was threatening to take her room mates cup from her hands and throw it down the hallway, then proceeded to go through the room mates personal belongings. The resident then entered the hallway dressed only in her bra. The nurse explained to resident she couldn't be showing her body like that and the resident put on a shirt. The ex husband and physician were notified. On 01/26/22 at 2:12 P.M. Resident #56 was yelling, cursing and tearing the electrical cords from the oxygen concentrator out of the wall. The nurse explained to the resident she could get electrocuted. The nurse turned the television on, and guided imagery was attempted. The resident was talking inappropriately about cursing and sex. The nurse attempted another redirection and was unsuccessful. The Unit Manager talked with the resident with no success, as she continued to hallucinate. The Nurse Practitioner (NP) was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/26/22 at 3:27 P.M. Resident #56 threatened the housekeeper telling her to leave the room that she does not work here. On 01/31/22 at 1:01 P.M. Resident #56 was screaming that the facility was lying to the kids out here and it was not right. The resident threw her lunch tray in the floor along with her drinks and refused to allow the staff to pick it up. An order was received for [MEDICATION(S)] five mg/ml give five mg IM one time dose now. On 02/02/22 at 11:00 A.M. Resident #56 was in her wheelchair in the hallway attempting to go in to another resident's room. When the therapist was trying to redirect the resident, she grabbed the therapist and started yelling and cursing. The resident threw her food at the staff and yelled at them. The NP was notified and requested a facetime call with the resident. Resident #56 refused, said she was only talking to the police. On 02/02/22 at 11:16 A.M. the nurse took the phone to Resident #56 as the NP was on the line. The resident grabbed the phone and twisted the right wrist of the nurse and refused to talk. The NP gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/22 at 11:44 A.M. Resident #56 was in the hallway yelling loudly that the staff was breaking the law and she was calling the police. The staff attempted redirection and the resident continued to yell. On 02/02/22 at 12:22 P.M. a note by social services stated the resident was yelling at staff, accusing them of hurting the children. Upon passing the residents room the social worker witnessed the resident arguing with nurse and rehab staff. There was a sliver of paper on the floor that the resident was attempting to pick up. The rehab staff picked the paper up for the resident and the resident yelled the rehab staff had hit her. The social worker was present for the interaction and the rehab staff did not touch the resident in any manner. The Unit Manager and Director of Nursing entered the room to provide skin care for the resident and she repeatedly refused. The social worker documented she had spoken to the NP about Resident #56's case and the NP suggested various behavior based facilities. All attempts to place the resident in a more appropriate facility have been made in her previous admission and while in the hospital the ex husband reported the hospital was attempting to place the resident at a facility in a near by cite. The social worker was unaware as to why the resident did not go to that facility. On 02/03/22 at 5:22 P.M. Resident #56 had been up all night yelling and cursing at the staff. The resident was going in to other residents rooms yelling and cursing. All attempts at redirection were unsuccessful. When the resident went in to her own room, she stripped all of her clothes off and would not shut the door or allow it to be shut. She continued to yell and curse to be left alone. The Certified Nursing Assistant (CNA) entered the residents room to gather garbage and Resident #56 hit the CNA on the arm, yelled and cursed at her. The resident was sitting naked in her wheelchair playing a game on her phone. At 6:10 A.M. Resident #56 put on a shirt but no bottoms. On 02/07/22 at 12:50 P.M. Resident #56 was having increased behaviors out in the hallway and attempting to go in to another residents room. When redirected she became very angry and threw her lunch tray with several cups of fluids. The staff asked why she did that and the resident yelled and cursed. The staff attempted to calm and redirect Resident #56 without success. An interview on 03/01/22 at 2:30 P.M. with the Unit Manager (UM)/Assistant Director of Nursing (ADON) confirmed Resident #56 had behavioral problems, could benefit from psychiatric services, and the plan of care was not comprehensive and complete. Review of facility policy titled Behavior Practice Guide dated 2015 revealed the facility did not implement the policy in regards to a comprehensive plan of care related to inappropriate abnormal behavior. This deficiency substantiates Complaint Number OH 369.

Based on interview, record review and facility policy review the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to attain her highest practicable mental and psychosocial well being. This affected one resident (Resident #56) of three reviewed for behavioral issues. The facility census was 83. Findings Include: Review of the medical record for Resident #56 revealed a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 11/24/21, revealed the resident had impaired cognition with continuous inattention, disorganized thinking, and trouble sleeping. Resident #56 had delusions and verbal behaviors directed towards others which interfered with care, social interactions and significantly disrupted care and the living environment. The resident rejected care and required extensive assistance of two for activities of daily living, except for eating. Review of the admission nursing assessment dated [DATE] revealed Resident #56 had resistive behaviors, rejected care and anxiety. Review of the plan of care dated 01/22/22 revealed Resident #56 was at risk for behavior symptoms (no symptoms were listed) related to [CONDITION(S)] and delusions. The interventions included attempt [CONDITION(S)] drug reduction per physician orders, observe for mental status/behavior changes when new medication started or with changes in dosage, and psychiatric referral as needed. Review of the nurses notes from 01/21/22 to 03/02/22 revealed multiple incidents of resident having aggressive behavior and agitation. On 01/23/22 at 9:46 A.M. the resident was threatening to take her room mates cup from her hands and throw it down the hallway, the proceeded to go through the room mates personal belongings. The resident then entered the hallway dressed only in her bra. The nurse explained to resident she couldn't be showing her body like that and the resident put on a shirt. The ex husband and physician were notified. On 01/26/22 at 2:12 P.M. Resident #56 was yelling, cursing and tearing the electrical cords from the oxygen concentrator out of the wall. The nurse explained to the resident she could get electrocuted. The nurse turned the television on, and guided imagery was attempted. The resident was talking inappropriately about cursing and sex. The nurse attempted another redirection and was unsuccessful. The Unit Manager talked with the resident with no success, as she continued to hallucinate. The Nurse Practitioner (NP) was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/26/22 at 3:27 P.M. Resident #56 threatened the housekeeper telling her to leave the room that she does not work here. On 01/31/22 at 1:01 P.M. Resident #56 was screaming that the facility was lying to the kids out here and it was not right. The resident threw her lunch tray in the floor along with her drinks and refused to allow the staff to pick it up. An order was received for [MEDICATION(S)] five mg/ml give five mg IM one time dose now. On 02/02/22 at 11:00 A.M. Resident #56 was in her wheelchair in the hallway attempting to go in to another residents room. When the therapist was trying to redirect the resident, she grabbed the therapist and started yelling and cursing. The resident threw her food at the staff and yelled at them. The NP was notified and requested a facetime call with the resident. Resident #56 refused, said she was only talking to the police. On 02/02/22 at 11:16 A.M. the nurse took the phone to Resident #56 as the NP was on the line. The resident grabbed the phone and twisted the right wrist of the nurse and refused to talk. The NP gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/22 at 11:44 A.M. Resident #56 was in the hallway yelling loudly that the staff was breaking the law and she was calling the police. The staff attempted redirection and the resident continued to yell. On 02/02/22 at 12:22 P.M. a note by social services stated the resident was yelling at staff, accusing them of hurting the children. Upon passing the residents room the social worker witnessed the resident arguing with nurse and rehab staff. There was a sliver of paper on the floor that the resident was attempting to pick up. The rehab staff picked the paper up for the resident and the resident yelled the rehab staff had hit her. The social worker was present for the interaction and the rehab staff did not touch the resident in any manner. The Unit Manager and Director of Nursing entered the room to provide skin care for the resident and she repeatedly refused. The social worker documented she had spoken to the NP about Resident #56 case and the NP suggested various behavior based facilities. All attempts to place the resident in a more appropriate facility have been made in her previous admission and while in the hospital the ex husband reported the hospital was attempting to place the resident at a facility in a near by city. The social worker was unaware as to why the resident did not go to that facility. On 02/03/22 at 5:22 P.M. Resident #56 had been up all night yelling and cursing at the staff. The resident was going in to other residents rooms yelling and cursing. All attempts at redirection were unsuccessful. When the resident went in to her own room, she stripped all of her clothes off and would not shut the door or allow it to be shut. She continued to yell and curse to be left alone. The Certified Nursing Assistant (CNA) entered the residents room to gather garbage and Resident #56 hit the CNA on the arm, yelled and cursed at her. The resident was sitting naked in her wheelchair playing a game on her phone. At 6:10 A.M. Resident #56 put on a shirt but no bottoms. On 02/07/22 at 12:50 P.M. Resident #56 was having increased behaviors out in the hallway and attempting to go in to another residents room. When redirected she became very angry and threw her lunch tray with several cups of fluids. The staff asked why she did that and the resident yelled and cursed. The staff attempted to calm and redirect Resident #56 without success. An interview on 03/01/22 at 1:00 P.M. with the Licensed Social Worker (LSW) revealed Resident #56 was a resident at the facility prior to this admission and was sent out to the hospital for medical reasons. While the resident was in the hospital, the hospital said they had tried to place her at a behavioral center. When the resident returned here to the facility the LSW also tried to find placement for the resident but was not successful. The LSW did not provide documentation of where or who she spoke to about treatment and placement. The LSW said the facility does not currently provide any psychiatric or psychosocial services. The LSW revealed the facility's Medical Director provides oversight of [CONDITION(S)] and psychoactive medications. An interview on 03/01/22 at 2:30 P.M. with the Unit Manager (UM)/Assistant Director of Nursing (ADON) #120 confirmed the facility does not provide psychiatric or psychosocial services, and that residents needing service would be sent to an inpatient facility. The UM/ADON confirmed Resident #56 had behavioral problems and could benefit from psychiatric or psychosocial services. Review of the facility policy titled Behavior Practice Guide 2015 indicated the facility staff would complete the MDS, social service assessment, and monitor for changes in status with the resident. If the resident exhibited changes or increased behavior the staff was to contact the physician for a mental health professional consult. There was not any evidence of a mental health professional referral or consult in the medical record for Resident #56. This deficiency substantiates Complaint Number OH 369.

Based on observation, record review, interview and review of the facility policy titled Restorative Nursing Guidelines the facility failed to ensure Resident #17 received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Actual Harm occurred when Resident #17, who was cognitively impaired and required extensive assistance/dependence on staff for activities of daily living was identified to have a decline in range of motion of her neck and left wrist with new onset contractures resulting in the resident's neck being bent to the left side with her head touching her shoulder and her left hand being in a bent downward position from her wrist. There was no evidence of a comprehensive and individualized range of motion program being implemented following therapy recommendations in June 2021 to prevent the declines and new onset contractures from occurring. This affected one resident (#17) of one resident reviewed for range of motion. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE]. The resident was admitted from the hospital after treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The MDS assessment revealed Resident #17 had impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional mobility. Notes indicated the resident previously lived in an apartment independently. The notes indicated the resident's left lower extremity range of motion was impaired but without contractures. The physical therapy discharge summary on 06/24/21 revealed the resident required substantial/maximal assistance with transfers from chair to bed, was dependent for toilet transfer and no longer allowed attempts at walking. The discharge summary indicated follow up care was to include a restorative range of motion program. However, there was no evidence a restorative range of motion program was implemented. Record review revealed the resident was provided with occupational therapy from 04/16/21 until 06/24/21. The goal was for the resident to increase ability to engage in self care. The notes indicated the resident's right upper extremity range of motion was within normal limits. The left upper extremity range of motion was impaired but no muscle contraction was detected. Review of the occupational therapy discharge summary, dated 06/24/21 revealed Resident #17 was demonstrating left neck flexion and at time of discharge had increased tightness of left upper extremity noted but the resident was unwilling to let the therapist position left upper extremity in any way. Recommendations included 24 hour care and assistance with all activities of daily living including self feeding. Chair with head/neck support recommended when out of bed to facilitate most appropriate positioning. There was no evidence any other treatment was recommended for the neck flexion or tightness in left upper extremity at the time of therapy discharge. Review of Resident #17's plan of care revealed the resident had an activity of daily living deficit as evidenced by muscle atrophy and weakness multiple sites related to recent [CONDITION(S)]. The care plan was initiated 04/16/21. The goal was to improve activity of daily living self performance. The only intervention included was physical therapy (which was discontinued 06/24/21). There was no evidence of any interventions in place after therapy was discontinued to improve or maintain the resident's range of motion. Review of the quarterly MDS 3.0 assessment, dated 07/23/21 revealed the resident was totally dependent upon two staff for transfers, required extensive assistance from staff with dressing, eating, and hygiene, and now had impairments in range of motion on both sides including the upper and lower extremities. Record review revealed no evidence any treatment related to range of motion was provided between 06/24/21 and 10/05/21 for the resident. On 10/05/21 an occupational therapy evaluation was completed. The evaluation revealed the reason for the referral was due to worsening of range of motion. The resident's left wrist was noted to be at a 100 degree position relative to left radius and ulna, with increased tightness so much so that changes in range of motion during flexion/extension were not measurable. The evaluation indicated the resident had functional limitations due to contractures. The evaluation also revealed decreased range of motion of the left upper extremity and neck limited participation in self care without pain as well as increased risk for skin breakdown. Occupational therapy was initiated to address contracture impairment. The notes indicated Resident #17 demonstrated poor supine positioning with her head laterally flexed and rotated to left. Left upper extremity at risk for worsening contracture. Therapy to trial orthotic devices to manage decreased range of motion and increased tightness. Resident to participate in manual therapy to manage decreased range of motion. On 10/18/21 at 12:06 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder). The resident's left hand was contracted downward at the wrist. Staff were observed feeding the resident her lunch with her head bent completely to the left side. On 10/18/21 at 2:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. On 10/19/21 at 7:48 A.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. Staff were observed feeding the resident her breakfast with her head bent completely to the left side. On 10/19/21 at 9:50 A.M. interview with Resident #17's brother revealed when the resident was in the hospital her head was not leaning to the left and now it was. The brother indicated he felt this had been a decline for the resident since her admission to the facility. The resident's brother revealed about a week ago staff had talked to him about the resident wearing a collar on her neck but he was not aware if this had been implemented. On 10/19/21 at 1:34 P.M. and 4:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. Resident #17 was not observed to be out of bed on 10/18/21 or 10/19/21. On 10/20/21 at 7:15 A.M. interview with Occupational Therapist (OT) #415 revealed he had provided occupational therapy for Resident #17 during the period of 04/16/21 to 06/24/21. OT #415 revealed the resident's left wrist was starting to contract during that time but that the resident would not allow him to work with her left arm. OT #415 also indicated the resident had some neck flexion starting at that time and she would allow him to provide range of motion for her neck but the neck had since worsened. OT #415 revealed he was not sure what had been done to prevent the resident's neck from further contracting after she was discontinued from therapy services on 06/24/21. OT #415 verified his discharge recommendations on 06/24/21 did not include any type of passive range of motion for her neck or left upper extremity. OT #415 verified both the resident's left wrist and neck had declined in range of motion. He stated since therapy restarted 10/05/21, she sometimes allowed him to provide range of motion and sometimes not. On 10/11/21 the resident allowed nine minutes of stretching of her neck. He stated her neck was at approximately 60 degrees laterally flexed and with range of motion he could get it to midline. The resident's left wrist was at approximately 90 degrees flexion and he could get it to about 30 degrees with range of motion now. OT #415 revealed he planned to attempt splinting for the resident's neck and wrist. On 10/20/21 at 8:40 A.M. observations of an occupational therapy session revealed Resident #17 was up in a chair with lateral neck support. The resident did allow intermittent stretching of her neck to almost midline. On 10/20/21 at 11:08 A.M. interview with MDS Coordinator #145 revealed when Resident #17 was first admitted she had limitations described as left sided weakness on one side. Then when she completed the quarterly MDS in July 2021, she noticed issues on the right side. MDS Coordinator #145 revealed she did not know what the issue was that prompted her to mark both sides as having limitations in range of motion as she made no notes. During the interview, MDS Coordinator #145 also confirmed there was no plan of care in place related to range of motion. She stated when range of motion was recommended by therapy, if it was done, it was documented by nursing assistant staff. MDS Coordinator #145 confirmed there was no evidence of any range of motion program being in place or provided for Resident #17 between 06/24/21 and 10/05/21. On 10/20/21 at 2:00 P.M. interview with Interim Director of Nursing #325 and Director of Rehab #125 confirmed there was no treatment provided for Resident #17 after her therapy was discontinued on 06/24/21. Review of the facility policy titled Restorative Nursing Guideline, dated 08/2019 revealed restorative nursing care included nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. Restorative nursing programs were individualized to specific patient needs and have many tangible positive effects including preventing further decline and reducing risk of complications related to immobility. Restorative nursing does not require a physician's order. Patients may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational, or speech rehabilitation program. Techniques include passive range of motion and active range of motion. Interventions were provided by nursing staff who have completed the appropriate competency evaluation.

Based on record review and interview the facility failed to adequately monitor and assess Resident #44 for adverse consequences following the initiation of the psychoactive medication, [MEDICATION(S)]. The facility also failed to provide an appropriate diagnosis for the use of the antipsychotic medication, [MEDICATION(S)] for Resident #46. Actual harm occurred on 07/23/21 when Resident #44 sustained a fall resulting in a fractured arm (humerus) related to possible side effects of the new [MEDICATION(S)] medication being prescribed for the resident without proper monitoring and notification of the physician of the presence of adverse side effects prior to the resident's fall/fracture. This affected one resident (#44) of three residents reviewed for falls and one resident (#46) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed the resident was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on and leave bathroom door ajar. Review of the physicians' orders for July 2021 revealed on 07/01/21 a new order was obtained for [MEDICATION(S)] 10 milligrams (mg), one tablet every night for [CONDITION(S)]. Review of the nursing progress note, dated 07/02/21 at 3:41 A.M. revealed the resident was documented to have had an adverse reaction to [MEDICATION(S)] as she had been excitable and yelling all night and had been attempting to wander into other resident's rooms. There was no evidence the physician was notified of the adverse reaction at that time. Review of the Treatment Administration Record (TAR) for 07/2021 revealed Resident #44 was documented to have received one [MEDICATION(S)] 10 mg tablet every night from 07/02/21 through 07/23/21. There was no evidence the resident was assessed/monitored for side effects/additional adverse consequences of the medication during this time period. Review of a nursing progress note, dated 07/23/21 at 2:30 A.M. revealed Resident #44 was heard yelling out and was found lying on the floor of her room complaining of pain to her left arm. The Nurse Practitioner (NP) was notified of the fall and gave orders for the resident to be sent to the hospital where she was diagnosed with a fractured humerus. The resident was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and limited assistance from one staff member for transfers. This resident was assessed to have suffered one fall without major injury since the prior assessment. Review of the facility list of resident falls from 10/01/20 through 10/18/21, provided by Registered Nurse (RN) #325, revealed Resident #44 was identified to have one fall during this time period, the fall on 07/23/21. On 10/20/21 at 10:30 A.M. interview with Interim Director of Nursing (IDON) #325 revealed she was not aware of any adverse side effects of the medication prior to the resident's fall/fracture on 07/23/21. IDON #325 verified the lack of evidence of monitoring of the medication between 07/02/21 and 07/23/21. IDON #325 started at the facility the beginning of July 2021. On 10/20/21 at 1:20 P.M. interview with Medical Director (MD) #675 verified he had ordered [MEDICATION(S)] for Resident #44 but could not recall being notified of any adverse side effects of the medication by facility staff. MD #675 revealed if he had been notified of adverse side effects of the [MEDICATION(S)] therapy, he would have placed the medication on hold until he could have reassessed Resident #44. Medication guidelines reveal [MEDICATION(S)] is designed for short term use only and commonly prescribed for anxiety related [CONDITION(S)] and other sleeping difficulties. The medication may cause some people, especially older persons, to become drowsy, lightheaded, dizzy, unsteady, or less alert than they are normally, which may lead to falls as seniors are more likely to be more sensitive to the drugs' effects than younger adults. The medication can cause confusion and memory problems that more than double the risk for falls and fractures in the elderly. The recommended dose of [MEDICATION(S)] in these patients is 5 milligrams once daily before bedtime. 2. Review of Resident #46's medical record revealed an original admitted [DATE] with diagnoses including Alzheimer's disease, chronic pain, nonthrombocytopenia purpura, anxiety, [CONDITION(S)] heart disease, cardiac pacemaker, [CONDITION(S)], diabetes mellitus type II, anorexia, dementia with behavioral disturbance, debility, dysphagia, cognitive communication deficit, depression, peripheral vascular disease, [CONDITION(S)], COVID-19, muscle wasting and atrophy, hypertension and [CONDITION(S)] flutter. Review of the resident's quarterly MDS 3.0 assessment, dated 08/31/21 revealed the resident had a BIMS score of 3, indicating severe cognitive impairments. Review of physician's orders revealed an order (dated 09/01/21) for [MEDICATION(S)] 1 mg by mouth daily at bedtime for dementia related to agitation/irritability. The resident also had an order (dated 09/02/21) for [MEDICATION(S)] 0.75 mg by mouth daily in the morning On 10/20/21 at 11:02 A.M. interview with the Director of Nursing verified the resident was currently receiving two doses of an antipsychotic medication, [MEDICATION(S)] for a diagnosis of dementia with behavioral disturbance. The Director of Nursing verified these were not appropriate medications for the resident's diagnoses. No additional information was provided during the survey to justify the use of the medication for Resident #46.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to provide a resident with the necessary assistance during personal care resulting in the resident rolling out of bed and falling to the floor. Actual Harm occurred to Resident #6 when the resident received assistance from one staff person instead of the necessary two staff resulting in an avoidable fall with injuries including an unspecified [MEDICAL CONDITION] end of right femur, unspecified [MEDICAL CONDITION] end of the right tibia, other [MEDICAL CONDITION] and lower end of the right fibula and non displaced [MEDICAL CONDITION] and second metatarsal bones of the right foot. This affected one (Resident #6) of three residents reviewed for falls. The facility census was 82. Findings include: Review of the medical record revealed Resident #6 was readmitted to the facility from an acute hospital stay on 01/10/2021 with [DIAGNOSES REDACTED]. Review of the medical record for Resident #6 revealed no formal fall risk assessment completed on admission or re-admission. Review of the quarterly Minimum Data Set (MDS) 3.0 completed on 11/06/20, revealed the resident was alert and oriented to person, place and time. She was identified as needing extensive assistance of two persons for bed mobility, dressing, toileting and personal hygiene. Review of the plan of care dated 12/03/20 revealed Resident #6 was at risk for falls due to [MEDICAL CONDITIONS], weakness, pain, potential medication side effects and a history of falls. Interventions included to place the resident in a bariatric wide bed in a low position, encourage to transfer and change positions slowly, have commonly used articles within easy reach, reinforce need to call for assistance and the resident was redirected to not transfer herself out of bed and to always use the call button if needed help. The plan of care also revealed Resident #6 had a self-care deficit as evidenced by physical limitations, weakness, [MEDICAL CONDITION], chronic knee pain/arthritis and [MEDICAL CONDITION]. Interventions included two-person maximum assistance with daily hygiene, dressing, toileting and turning from side to side in bed. Staff to assist resident with bed bath as needed. Review of the facility fall investigation revealed on 01/07/21 at 4:20 P.M. the State tested Nursing Assistant (STNA) was providing incontinence care to the resident when the resident moved her leg over and she fell out of the bed onto the floor. The resident was in the prone position with her upper body lying on the over bed table bar. The STNA reported she was providing care to the resident by herself. The facility investigation conclusion stated it was determined the STNA did not have access to the computer and Kardex. The STNA was unable to validate how many staff were needed to assist the resident with bed mobility. Review of the nurse's note dated 01/07/21 at 4:20 P.M. revealed the nurse was called to Resident #6's room and upon entering observed the resident on the floor lying on her stomach. Resident #6 complained of pain to bilateral legs but more pain in the right leg. Deformity of the joints was difficult to assess due to [MEDICAL CONDITION] and legs were typically externally rotated. The staff was assisting Resident #6 with incontinence care and the resident moved her leg over to help with positioning prior to the staff being in position. At 11:25 P.M. the nurse called the hospital for an update, and the resident was being admitted . Review of the hospital discharge summary dated 01/10/21 indicated the resident presented to the emergency department on 01/07/21 from a fall out of bed during care. The x-rays in the emergency department demonstrated the right femur, tibias, fibula, and metatarsal fractures. The Orthopedic surgeon was consulted, and the resident was admitted to the trauma service for pain control and plans for fixation with surgery. However, upon further evaluation orthopedic surgery decided to non-operatively manage the fractures in a long leg splint. Outpatient follow up in six weeks. Interview with the Director of Nursing (DON) on 03/09/21 at 2:05 P.M. verified the resident fell off her bed while one STNA was providing incontinence care resulting in the resident having multiple fractures of her right leg. The DON verified the STNA did not follow the plan of care which stated the resident required two-person assistance for bed mobility and personal hygiene. The DON stated the facility initiated a plan of correction which included: a.) An Interdisciplinary team meeting b.) Education provided to all staff on bed mobility/assistance c.) Audit of all care plans to ensure the assistance required was correct and on the Kardex d.) Audit the documentation in point of care matched the care plan. e.) New agency staff sign an acknowledgment form indicating ability to sign in to Point Click f.) Care and a supervisor signs the acknowledgment as a witness. g.) The fall and plan of correction was reviewed at the monthly quality assurance performance improvement meeting along with the audits. The deficient practice was corrected on 01/27/21 when the facility implemented the following corrective actions: · Resident #6 was sent to the local emergency department on 01/07/21 · On 01/08/21 through 01/27/21 the facility nurse managers provided education to nine Registered Nurses, 29 Licensed Practical Nurses, and 61 STNA's that included checking the kiosk/Kardex for assistance needed to safely position the resident while in bed, roll the resident towards you, not away from you, and the nurse must complete the Patient Transfer Worksheet on admission and use this to initiate the Activities of Daily Living (ADL) care plan. The STNA's were to check the Kardex before providing care to the resident, and all staff were to follow the directions on the Kardex. If agency staff does not have the ability to log in to the kiosk/Kardex -refer them to Human Resources. If Human Resources not in the facility, call the Administrator. · On 01/08/21 the facility nurse managers reviewed all like resident's plan of care and Kardex to ensure correct amount of assistance required for bed mobility as indicated on ADL assessment was noted correctly on the Kardex. · On 01/11/21 the facility nurse managers started an audit of documentation in point of care to compare what was charted against what was care planned. · On 01/08/21 and ongoing, all agency staff were witnessed by a nurse supervisor signing in to Point Click Care and how to navigate to the Kardex for information related to assistance needed for ADL's. · The fall investigation and plan of correction would be discussed at the next monthly quality assurance performance improvement meeting. This deficiency substantiates Complaint Number OH 581

Based on observation, interview and record review, the facility failed to ensure interventions were implemented to prevent accidents and injury to two residents (Residents #56 and #99). This affected two of four residents reviewed for injuries. Actual Harm occurred to Resident #99 when a state tested nursing assistant (STNA) failed to ensure two staff provided personal care and Resident #99 slid to the floor during care resulting in fractures to both lower extremities. Findings Include: 1. Review of the medical record for the Resident #99 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/25/19, revealed the resident had intact cognition. Resident #99 was identified to require extensive assistance of two staff members for bed mobility, transfer, dressing and personal hygiene. The plan of care for Resident #99 dated 05/07/19 revealed she had an activity of daily living self-care deficit and required two-person assistance with toileting, bed mobility, dressing, bathing; one person assistance with oral care and grooming, set up tray for eating. The care plan indicated Resident #99 was at risk for falls due to a history of falls, impaired balance/poor coordination, and potential medication side effects. Identified interventions included to encourage Resident #99 to transfer and change positions slowly and have commonly used articles within easy reach. A review of the nurses notes dated [DATE] at 12:02 P.M. by Registered Nurse (RN) #171 indicated Resident #99 was witnessed rolling out of bed onto the floor by STNA #124. The nursing note indicated Resident #99 complained of right knee pain, the physician was notified and an order for [REDACTED].#99 continued to complain of severe right knee pain as well as increased anxiety was noted. The Nurse Practitioner was present in the building, assessed Resident #99 and ordered her to be sent to local hspital for further evaluation. On [DATE] at 11:10 P.M. the nursing note indicated Resident #99 returned to the facility with [DIAGNOSES REDACTED]. Review of the fall investigation for Resident #99 dated 02/05/20 included a statement by STNA # 124 which stated around 8:45 A.M. on [DATE] Resident #99 had put on her call light and stated she needed changed. STNA #124 documented her partner was giving a shower to another resident, and she was the STNA making rounds. STNA #124 reported she asked Resident #99 if she could wash her up while already in the room providing care and Resident #99 agreed. STNA #124 reported Resident #99 requested her hair be washed while getting morning care and STNA #124 reported she washed her hair. STNA #124 indicated she was finishing washing, drying and applying lotion to Resident #99 legs, she noticed Resident #99 had another bowel movement. STNA #124 reported she cleaned the front of her and rolled her toward the window side of the room to clean her bottom. STNA #124 indicated she then rolled Resident #99 to the other side and when she started to put a new brief under her, Resident #99's legs started to slide off the bed. STNA #124 reported she attempted to catch her legs with her left hand, but by that time her whole body was rolling off the bed. STNA #124 indicated as Resident #99 was rolling off the bed, her body turned, and her feet touched the ground first. STNA #124 stated Resident #99 was in a sitting position on the floor leaning next to the dresser. STNA #124 reported she made sure Resident #99 was okay and left the room to get help. STNA #124 reported the nurse, another STNA and the unit manager came to Resident #99's room. STNA #124 indicated after Resident #99 was assessed they returned her to bed using a hoyer lift. A statement by Registered Nurse (RN) #171 dated 02/05/20 indicated when she entered the room Resident #99 was noted next to the window leaning over the nightstand with both legs bent towards the left. Resident #99 complained of pain to the right knee when trying to move. No concerns with range of motion were identified. Resident #99 was returned to bed, however, she became more anxious when her husband talked about the incident. Resident #99 was noted to start mouth breathing and her oxygen saturation dropped to 47%. Resident #99's oxygen mask was applied, and oxygen saturation returned to 99% in less than two minutes. Unit Manager (UM) #146 statement dated 02/05/20 indicated when she first saw Resident #99, she was sitting up against the wall with legs slightly bent in front of her. Her vital signs were stable and she asked Resident #99 if she felt she could get in bed and Resident #99 said yes. UM #146 indicated Resident #99 was alert and kept saying she just wanted to get back to bed. Oxygen was applied while Resident #99 was seated on the floor. The physician was notified of the incident, Resident #99 did not want to go to the hospital at that time, and x-rays were ordered. A review of STNA #124 personnel file and the accident report indicated she was suspended on [DATE] pending investigation of the accident. During an interview on 02/20/20 at 11:00 A.M. with the Director of Nursing (DON) and Administrator #178, the DON stated Resident #99 was rolled onto her side for care when she began to roll out of bed. The DON stated STNA #124 immediately called for help and the nurse on duty came and immediately checked the resident. The DON stated UM #146 also came to evaluate Resident #99 and the resident was assisted back to bed. The physician was notified and orders received for an x-ray of the right knee. The DON and Administrator #178 confirmed Resident #99 was identified as requiring two person assist for personal hygiene and mobility and the Kardex indicated Resident #99 was to have two person assistance with care. The DON confirmed STNA #124 provided care without assistance for Resident #99. The DON reported Resident #99 was sent out to local hospital later on [DATE] due to respiratory problems and the in-facility x-ray had not been obtained before transfer to the hospital. The DON stated when she returned to the facility, they had identified Resident #99 had fractured both lower femurs. The DON stated Resident #99 returned to the facility that same day with immobilizer's to the lower extremities, an order for [REDACTED]. Review of facility policy titled Falls Practice Guide, dated 12/2011, revealed the facility would assess residents upon admission, develop and implement ongoing fall strategies. 2. A review of the medical record for the Resident #56 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 12/31/19 and significant change assessment completed on 01/22/20 indicated Resident #56 had impaired cognition. Resident #56 required extensive assistance of two persons for bed mobility, transfers, ambulation. The admission nursing assessment dated [DATE] indicated Resident #56 was at risk for falls. A review of the plan of care dated 10/01/19 revealed Resident #56 was at risk for falls due to medications, weakness, history of falls and poor safely awareness. The care plan dated 10/01/19 indicated to coordinate care with hospice, have commonly used articles within easy reach. On 10/24/19 an intervention of non-skid socks when in bed was added. On 12/2019 the care plan was updated to include to offer toileting before meals and at bedtime, encourage resident to sit in front of nurses station when up in chair to be in staff view, encourage/assist resident to lay in bed when tired and bed in low position was noted. On 01/2020 additional interventions included administer medication per physician's orders [REDACTED]. On 02/2020 additional interventions included encourage/assist resident to scoot himself back in wheelchair, ensure resident is positioned in center of bed while in bed, assist to stand/walk short distances with two person assist when restless. On 02/03/20 after a fall from bed, which did not result in an injury, the intervention of a scoop/perimeter mattress was added to the care plan. The treatment administration record, STNA documentation nor the Kardex identified Resident #56 was to have a scoop/perimeter mattress to the bed. Review of the nurses notes dated 02/02/20 at 12:30 A.M. indicated Resident #56 had slid out of bed and was found on the floor with no injuries noted. The physician and family were notified. The nursing note indicated all previous fall interventions were noted to be in place. A review of an Interdisciplinary Team meeting note dated 02/03/20 at 10:04 A.M. indicated the fall on 02/02/20 was reviewed and a new intervention of a scoop/perimeter mattress was initiated. All parties agreed with applying the scoop/perimeter mattress to Resident #56 bed. The nursing noted dated 02/07/20 at 9:47 A.M. indicated Resident #56's roommate notified staff that Resident #56 had fallen. Resident #56 was found lying on the floor beside the bed without his pants on. Resident #56 was assessed and noted to have busted his right upper lip and bleeding was noted to this area. Resident #56 right eye was noted to have immediate swelling and discoloration, a quarter size knot was noted to the right elbow and immediate bruising noted to the top of the left hand. Resident #56 was assisted back to bed and the physician was contacted. The physician indicated to notify Resident #56 family and inquire if they wished to be transferred to the emergency room for evaluation. The family requested the facility to continue monitoring Resident #56 at this time. On 02/07/20 at 11:03 A.M. Resident #56's family requested to have him sent to the emergency room for evaluation of the laceration to his lip. An observation of Resident #56's bed on 02/20/20 at 11:30 A.M. revealed no scoop/perimeter mattress on the bed and the bed was made. Resident #56 was sitting in a tilt in space chair in the hall near the nurses station. Non slip foot covering was noted on Resident #56. During an interview on 02/20/20 at 12:36 P.M., the DON reported Resident #56 had experienced multiple falls and upon each fall, the interdisciplinary team (IDT) would meet and decide if interventions were appropriate or what additional interventions may help prevent further falls. The DON confirmed that on 02/03/20 the IDT team met and determined the addition of a scoop/perimeter mattress intervention would be initiated to prevent further falls from bed. During observation of Resident #56's room, the DON confirmed no scoop/perimeter mattress to Resident #56 bed. Interview 02/20/20 between 10:20 A.M. to 2:20 P.M. with Registered Nurse (RN) #231 and STNAs #117 and #128 reported they had cared for Resident #56 and did not recall a scoop/perimeter mattress on Resident #56's bed. Review of facility policy titled Falls Practice Guide, dated 12/2011, revealed the facility did not follow the policy in regards to fall interventions. This deficiency substantiates Complaint Number OH 208, OH 094.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to ensure Resident #68's insulin was administered as ordered which resulted in a significant medication error for the resident. Actual Harm occurred on 07/31/19 when Registered Nurse (RN) #341 administered 20 units of [MEDICATION NAME]to Resident #68 without a physician order resulting in the resident exhibiting [DIAGNOSES REDACTED] with a low blood sugar of 47. Resident #68 required hospitalization and medical intervention. This affected one resident (#68) of three residents reviewed for medication administration. The facility identified 25 residents who received insulin. Findings Include: Record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the plan of care, dated 08/17/18 revealed Resident #68 had an endocrine system related focus due to insulin dependent diabetes mellitus. The goal was identified for Resident #68 to minimize or be free of complications related to the disease process with interventions including administer medication per physician order, obtain glucometer readings and report abnormalities as ordered, obtain laboratory results as ordered and notify physician of results, provide diet per physician orders, report symptoms of [MEDICAL CONDITION] (excessive thirst/urination, hunger weakness, nausea, [MEDICATION NAME] breath) and report symptoms of [DIAGNOSES REDACTED] (weakness, pallor, diaphoresis, vision changes, change in consciousness). The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19 revealed Resident #68 had intact cognition. The MDS identified Resident #68 had received insulin injections daily. Review of Resident #68's physician's orders for 07/2019 revealed an order to check the resident's blood sugar two times daily and if under 60 or over 300, to contact the physician. The physician orders also indicated from 07/09/19 through 07/26/19 Resident #68 was to receive 12 units [MEDICATION NAME] daily. On 07/27/19, the physician ordered to increase the [MEDICATION NAME] to 14 units daily. On 07/31/19 at 4:00 P.M., Resident #68's blood sugar was documented as 492 (elevated). There was no documentation the physician was notified at that time or any documentation related to insulin administration at that time. Review of the nursing progress note, dated 07/26/19 at 5:36 P.M. revealed the physician was notified of an elevated blood sugar of 478 and an order was obtained to increase the resident's [MEDICATION NAME] to 14 units in the morning and give a one time dose of two units. The next nursing progress note related to the resident's blood sugar was on 08/01/19 at 2:35 [NAME]M. which indicated the nurse was in Resident #68's room and noticed she was very pale and soaked in sweat. The nurse assessed the resident and checked her blood sugar at that time which was 46 (low). The nurse then attempted to assist the resident to drink juice, however the resident was unable. The physician was notified and an ordered was received to transport Resident #68 to the emergency room . Record review revealed the resident was hospitalized from [DATE] through 08/09/19. Review of a Self Reported Incident (SRI), tracking number 2 initiated on 08/02/19, finalized on 08/09/19 and completed by the Director of Nursing (DON) revealed an incident was reported to the State Agency that RN #341 reported she had administered insulin to Resident #68 from another resident's insulin vial. The date of discovery of the incident was noted on the SRI to be 08/01/19. Review of the SRI revealed the facility substantiated an incident of misappropriation of medication as it was determined RN #341 administered insulin to Resident #68 from another resident's (unknown resident) insulin vial. A statement completed by Licensed Practical Nurse (LPN) #283 during the facility investigation of SRI 2, dated 08/01/19 revealed on 07/31/19 Resident #68's blood sugar was checked around 4:45 P.M. and it was 492. LPN #283 reported the physician's orders for Resident #68 indicated to call the physician if the resident's blood sugar was over 300. LPN #283 reported she attempted to notifify Physician (Dr) #364 of elevated blood sugar by telephone and left a voice message. LPN #283 stated she did not administer insulin to Resident #68 at that time as there was no physician order for [REDACTED]. A statement completed by RN #341 on 08/01/19 revealed she she came to work at 6:00 P.M. on 07/31/19 and Resident #68's blood sugar was elevated in the 400's. RN #341 reported she attempted to contact Dr #364 multiple times with no answer. RN #341 documented Resident #68 blood sugar was 497 and then climbed to 509. RN #341 indicated at this time, she decided to administer insulin, [MEDICATION NAME] 20 units. The statement by RN #341 revealed Resident #68 was not well, did not have an insulin order and that was what he (Dr #364) gives so the nurse administered what she thought Dr #364 would give. RN #341 reported Resident #68's blood sugar was 214 between 12:10 [NAME]M. and 12:15 [NAME]M. RN #341 reported she informed Licensed Practical Nurse (LPN) #313 and Dr #364 she administered the insulin, however did not notify the family the insulin was administered. A statement completed by LPN #313 on 08/02/19 revealed when she arrived to work on 07/31/19 (11:00 P.M.), RN #341 reported Resident #68's blood sugar was 498 at 4:00 P.M. RN #341 reported Resident #68's blood sugar was 509 at 11:00 P.M. and she administered 20 units of [MEDICATION NAME]and informed Dr #364. LPN #313 indicated she then contacted Dr #364 regarding the insulin administration and received a new insulin orders for Resident #68 and to monitor blood sugars every hour. LPN #313 indicated she did not record Resident #68 blood sugar results. LPN #313 indicated she found the resident soaking wet and shaking with a blood sugar of 47. LPN #313 reported she attempted to have Resident #68 drink orange juice, however was unable to swallow. LPN #313 reported she called Dr #364 who instructed the nurse to start intravenous fluid administration, however when DR #364 was informed there was no RN present in the building (to initiate the IV fluids), he instructed LPN #313 to send the resident to the local emergency room for treatment. A statement completed by Dr #364 dated 08/02/19 revealed on rare occasions he would order 20 units of insulin, however this was common only for residents receiving high insulin routinely. Dr #364 reported Resident #68 was prone to dropping and he would not have ordered this dosage. Dr #364 stated he ordered hourly and as needed glucose monitoring after being notified of the insulin administered by RN #341. Dr #364 reported he was notified Resident #68's blood sugar was 60, she was awake and able to drink. Dr #364 reported he was then notified of the resident's blood sugar continuing to drop and gave an order to start an IV and have local emergency medical service (EMS) staff start IV since an RN was not working that night. Dr #364 reported LPN #313 returned a call that EMS was not available to start the IV and the resident's blood sugar continued to drop. Dr #364 indicated he then ordered Resident #68 to be transported to the local emergency room for treatment. An incident report completed on 08/01/19 at 10:00 P.M. by LPN #313 indicated Resident #68 was administered insulin without an order and was sent to local emergency room per physician order on 08/01/19 at 2:35 [NAME]M. Resident #68's daughter was notified on transfer on 08/01/19 at 2:30 [NAME]M. During an interview on 08/23/19 at 9:20 [NAME]M. with the Administrator and DON, the DON reported staff and Dr #364 reported the above incident to her on 08/01/19 and an investigation was initiated. The Administrator reported RN #341 was placed on leave during the investigation and was terminated on 08/09/19 due to a critical Type A violation for failure to comply with all health and safety rules, including unsafe conduct or unsafe acts that jeopardize the health and safety of self or others or result in serious injury. The Administrator provided documentation the facility had also contacted the Board of Nursing in regards to the incident on 08/18/19. On 08/23/19 at 11:20 [NAME]M. during an interview with Dr #364 revealed he cared for Resident #68 and remembered the incident on 07/31/19 when RN #341 administered 20 units of insulin without a physician order. Dr #364 reported Resident #68 had multiple health concerns and was on a small dosage of insulin and he would have never ordered 20 units of insulin coverage. Dr #364 recalled he was notified of the increased finger stick by LPN #283 and did not have a message from RN #341. Dr #364 reported the facility did not have any standing orders regarding insulin administration for [MEDICAL CONDITION], that the physician was to be contacted for specific orders for individual residents. Dr #364 stated this was not an acceptable practice at the facility and he spoke with the DON on 08/01/19 and a thorough investigation was completed which included RN #341 being terminated, the Board of Nursing notification, and ongoing facility interventions to ensure this did not happen again. Review of facility policy titled [MEDICAL CONDITION]: Treatment, dated 12/2009 revealed to notify the physician of clinical condition, including vital signs and blood glucose level, do not leave resident unattended, verify physician's order, administer insulin as ordered, and monitor blood glucose every 15 minutes or per physician order until results within normal limits. Review of the facility policy titled Medication Administration, dated 03/2010 indicated medications would be administered according to physician order. Review of the facility's corrective action plan revealed the following actions were implemented resulting in the deficiency being corrected as of 08/09/19: a. On 08/01/19 Resident #68 was transported to the emergency room for treatment of [REDACTED]. b. On 08/01/19 the Administrator and DON implemented a facility identification and improvement plan related to Resident #68 being administered insulin for [MEDICAL CONDITION] without a physician order. The information contained documentation of the incident completed by RN #341, LPN #283, LPN #313 and Dr #364. c. On 08/01/19 RN #341 was placed on a leave of absence. The employee was terminated on 08/09/19. b. On 08/05/19 documentation was provided by the facility that all diabetic residents were audited to ensure insulin orders were current and being followed by nursing staff. c. On 08/06/19 the facility completed an audit on all residents with rehospitalization over the past 12 months to ensure they were not related to [DIAGNOSES REDACTED]. d. On 08/06/19 all medication carts (4 carts) were audited to ensure all insulin was properly labeled with resident name and date opened. e. From 08/01/19 to 08/08/19 the facility completed inservice education for all licensed nurses addressing diabetic mellitus protocol, misappropriation (of medications), physician orders, medication administration, and med pass. This inservice was also added to the nurse orientation packet. f. On 08/07/19, an Adhoc Quality Assurance (QA) meeting was held with the medical director in attendance to address the insulin administration without a physician order. A second Adhoc QA meeting was held on 08/23/19 which identified no further concerns and identified this incident with Resident #68 was believed to be isolated incident and not a systemic problem g. The facility implemented a plan for ongoing audits/monitoring for blood sugar outside parameters and physician notification of all residents which was completed for 14 days from 08/10/19 to 08/23/19. This deficiency substantiates Control Number OH 541.

Based on record review and interview the facility failed to ensure Resident #93, who required extensive assistance from two staff for bed mobility, was provided adequate assistance during incontinence care resulting in a fall out of bed. Actual harm occurred when the resident sustained [REDACTED].#131 was providing incontinence care unassisted. This affected one resident (Resident #93) of four residents reviewed for falls. Findings include: Record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #93 was assessed to be alert to person, place, and time during the assessment dated [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/15/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was alert and oriented. Review of the MDS 3.0 assessments, dated 12/15/17 and 03/17/18 revealed the resident required extensive assistance from two staff for bed mobility. Review of nursing progress notes, dated 03/19/18, revealed Resident #93 was being provided with incontinence care by one facility staff member, STNA #131. While providing incontinence care, STNA #131 rolled Resident #93 to her left side to place a new adult undergarment under her. Resident #93 then fell out of the bed onto the floor, hitting her head on the metal trash can beside the bed. Per the note, the resident stated she fell out of bed because she did not have anything to hold on to. Resident #93 was documented as having pain in her left hip and leg on assessment, and also noted to have a laceration to her forehead as a result of the fall. Resident #93 was subsequently sent to the emergency room for evaluation and treatment. Per nursing notes, the resident was admitted to the hospital with [REDACTED]. Review of the hospital discharge summary revealed Resident #93 was admitted with [DIAGNOSES REDACTED]. Resident #93 returned to the facility on [DATE]. Review of the facility investigation with the Administrator revealed a statement was obtained from STNA #131 on 03/20/18 by the facility, which stated she turned Resident #93 away from her during care, which resulted in the resident falling from the bed and hitting her head on the trash can. On 04/18/18 at 1:10 P.M., interview with Resident #93 revealed on 03/19/18 she was being cleaned up by one of the STNA staff after she had been incontinent. The resident stated STNA #131 was standing on the right side of her bed near the window, and had rolled her away from her to where she was lying on her left side facing the doorway. The resident stated the STNA let her go at some point, and she continued to roll off of her bed and onto the floor nearest to the doorway. The resident confirmed that she received a laceration to her forehead and a fracture to her left hip as a result of the fall to the floor. The resident stated that ever since then, there have always been two staff members cleaning her up and changing her. The resident also stated that none of the bed rails were in the raised position at the time of the care being provided. On 04/19/18 at 3:26 P.M., interview with Registered Nurse Unit Manager #167 revealed STNA #131 was providing care to Resident #93 on 03/19/18. She verified the STNA had turned the resident away from her during incontinence care that day, causing the resident to fall out of bed and onto the floor. She verified that the resident received a laceration to her head, and when sent to the hospital, was diagnosed with [REDACTED]. During the onsite survey, attempts to reach STNA #131 were unsuccessful. Review of the facility investigation of the above incident revealed on 03/19/18, an investigation was initiated in regards to Resident #93 falling from her bed and being sent to the hospital on that date. The investigation revealed Resident #93 was in bed with the call light on when STNA #131 went into the room to provide incontinence care. The STNA rolled the resident onto her side and the resident rolled out of bed. The resident was sent to the emergency room and diagnosed with [REDACTED].#93 required a two-person maximum assist for activities of daily living and incontinence care. STNA #131 was interviewed on 03/20/18 by the Director of Nursing and revealed she was providing care to Resident #93 alone when the resident fell out of bed. On 04/20/18 at 1:59 P.M., interview with Licensed Practical Nurse (LPN) #215 revealed on 03/19/18, she was called to Resident #93's room by an STNA. When she got to the room, she discovered STNA #131 was in the room standing between the window and the resident's bed. LPN #215 stated Resident #93 was bleeding from her forehead, and STNA #131 was holding both of the resident's lower legs. She stated the resident was facing towards the door to the room, and was hanging from the bed on her left side. LPN #215 stated that she immediately assessed the resident who was complaining of pain to her forehead, and to her left hip. The LPN stated STNA #131 was alone in the room at the time of the incident from what she witnessed when she walked into the room. LPN #215 stated Resident #93 required extensive, two-person assist for bed mobility, transfers, and incontinence care. Review of the Facility Incontinence Policy, with a revision date of 08/2014 revealed during the procedure staff were to assist the resident to a side-lying position by turning towards the caregiver and assure the resident was positioned in the center of the bed before moving to the opposite side of the bed to provide care.

Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, review of the Social Networking facility policy, the facility failed to ensure staff did not violate residents rights to privacy and confidentially. This resulted in Immediate Jeopardy and psychosocial harm for one Resident (#1) when State tested Nurse Aide (STNA) #10 engaged in an act meant to humiliate and ridicule the resident by taking a photograph of Resident #1 without permission and not in accordance with facility policy. STNA #10 defaced the photograph of Resident #1 by adding drawings of male genitalia, female breasts and a beard and posted it on the social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame. The facility also failed to ensure staff did not violate a residents right to privacy that was not Immediate Jeopardy when STNA #10 took a photograph of cognitively impaired Resident #62 without the resident's knowledge or permission and posted this photograph on the same social media website. This affected two (Residents #1 and #62) of four residents reviewed for abuse. The facility identified 14 Residents who were cognitively impaired and lived on the same unit as Residents #1 and #62. The facility census was 99. On 03/08/18 at 11:53 A.M., the Administrator, Director of Nursing (DON), and Corporate Quality Assurance Nurse (CQAN) #26 were notified that Immediate Jeopardy began on 12/13/17 at approximately 12:45 P.M. when STNA #10 took a photograph of Resident #1 lying in bed and altered it by drawing male genitalia by the resident's mouth, giving the resident a beard and adding female breasts that protruded down to the resident's waist. STNA #10 posted the altered photograph on a social media website identified as Snap Chat. The embarrassing ridiculing photograph potentially could have been viewed by others in the community on Snap Chat and was viewed by two people not employed by the facility. The Immediate Jeopardy was removed on 03/09/18 when the facility implemented the following corrective actions: · On 12/13/18 at approximately 1:45 P.M., the Administrator initiated an internal investigation involving the photo taken of Resident #1 and altered by STNA #10. At approximately 4:00 P.M., STNA #10 was suspended pending the outcome of the investigation. · On 12/13/17, the Interdisciplinary team (IDT) consisting of the Administrator, DON, Unit Managers (UM) #81, #82 and #83, Social Service Director (SSD) #44, Activities Director (AD) #9, and Director of Rehabilitation (DOR) #27 began reviews Monday through Friday of all current residents in the morning interdisciplinary team meeting that convenes approximately from 9:30 A.M. to 10:30 A.M., for any changes in condition, behavioral and/or mood symptoms related to abuse with follow up to the attending physician within the business hours. This will continue indefinitely. · On 12/15/17 at 9:15 A.M., the Administrator educated department managers including Activities Director (AD) #9, Registered Dietitian (RD) #41, Food Service Director (FSD) #51, Environmental Services Supervisor (ESS) #28, Interim Director of Nursing (IDON), Admissions Director (AD) #8, Social Services (SS) #44, Medical Records (MR) #60, Business Office Administrator (BOA) #7, Payroll Clerk (PC) #121, Director of Rehabilitation (DOR) #27, Human Resources Director (HRD) #55 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. · On 12/15/17 at 9:30 A.M., the facility Quality Assessment and Assurance (QAA) committee met to review and resolve the incident related to a photograph taken by STNA #10 of Resident #1 and sent to others. · On 12/15/17 at 2:17 P.M., Resident #1's attending physician and family were notified of the incident by the IDON. · On 12/15/17 at approximately 3:15 P.M., HRD #55 completed notification to the Ohio Department of Health (ODH) Nurse Aide Registry of the incident with Resident #1 involving STNA #10. · On 12/15/17 at 5:36 P.M., SS #44 completed a psychosocial evaluation of Resident #1 which showed no negative effects from the incident. · On 12/18/17 at approximately 8:00 A.M. through 12/28/17 at approximately 5:00 P.M., Department Managers, AD #9, RD #41, FSD #51, ESS #28, IDON, AD #8, SS #44, MR #60, BOA #7, PC #121, DOR #27, HRD #55 began educating all staff Including STNA #101 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. All staff were in-serviced with the exception of STNA #33, #58, #94, #100, #131, and #135. · On 12/18/17 at approximately 10:00 A.M., through 12/21/17 at approximately 4:00 P.M., Facility Management including the Administrator, IDON, UMs #81, #82 and #83, SS #44, Admissions Director #8, ESS #28, HRD #55, BOA #7, Scheduler #50, AD #9, Minimum Data Set (MDS) Coordinator #42 and Administrative Assistant (AA) #121 interviewed all alert and oriented residents, a total of 77, to inquire if they had knowledge of their picture being taken. No negative responses were obtained. · On 12/18/17, at approximately 4:45 P.M., STNA #10 was terminated from the facility for taking a picture of a resident and posting it on social media and sharing it with other individuals. · On 12/19/17 from approximately 8:00 A.M. to 5:00 P.M., Licensed Practical Nurse (LPN) #50 completed random staff interviews with eight staff members, STNAs #35, #91, #98, #130, #223, Registered Nurses (RN) #75, #80 and LPN #103 for any knowledge that staff may have regarding pictures being taken of residents for purposes other than their medical records. No negative responses were obtained. · On 01/05/18, the DON began interviewing one resident on each hallway to inquire if any staff had taken a photo of them other than for the medical record. These interviews continued weekly for four weeks. No negative responses were reported. · On 01/05/18, the DON began interviewing four staff members each week to inquire if they were aware of any staff member taking a picture of a resident. These interviews continued weekly for four weeks. No negative responses were reported · On 03/08/18 at approximately 2:15 P.M., the Administrator initiated an investigation regarding Resident #62. · On 03/08/18 at 1:45 P.M., the Quality Assurance Consultant (QAC) #26 educated the Administrator on the Facility Abuse, Neglect, Exploitation, Misappropriation Requirements of Participation and the Incident Prevent Process Flowchart. · On 03/09/18 at approximately 11:00 A.M., the facility's QAPI Committee met to review the Abatement plan with the Medical Director and Committee members. · On 03/09/18 at 2:45 P.M., all six additional employees (STNA #33, #58, #94, #100, #131, and #135) identified as not to have received the above training, had been educated by QAC #26 on the facility cell phone guidelines and reporting guidelines from the Prevent Practice Guide. Newly hired employees will continue to be educated upon hire on the facility cell phone guidelines and Reporting guidelines from the Prevent Practice Guide in New Hire General Orientation by the Human Resource Director. · On 03/09/18 beginning at 2:21 P.M., and concluding at 4:20 P.M., the DON, UM #81, #82, #83 , MDS Coordinator #42, and LPN #50 reviewed nursing notes from 12/12/17 to present of all cognitively impaired residents including Resident #1 and Resident #62 (defined as patients with a BIMS score of 13 or lower on the most current MDS) currently residing in the facility, to determine if there were any indications of psychosocial distress, mood/behavioral distress and/or signs of abuse and results were documented on the QAPI Audit tool. No negative responses were obtained. · Effective 03/10/18, the DON and/or Unit Managers will continue to review progress notes daily of cognitively impaired as well as alert and oriented residents for any changes in condition, behavioral and/or mood symptoms that may be an indication of abuse times 14 days and then Monday through Friday thereafter. Any indications of abuse will be reported immediately to the Administrator for further follow up. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and was sometimes able to understand others and could sometimes make herself understood. The resident required extensive assistance of one person for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use and personal hygiene. The resident utilized a walker and wheelchair to aid in mobility. The resident was occasionally incontinent of bladder and was always continent of bowel. Review of a facility email dated 12/13/17 at 1:14 P.M., revealed Teacher #222, from a local career center, reported to HRD #55 a photo was attached to the email that had a modification on it for Resident #1. The email revealed a student at the school informed Teacher #222 the photo was sent by STNA #10 who was an employee of the facility. The student showed it to Teacher #222 and, due to the inappropriateness of the modifications, she thought that it should be brought to the facility's attention. Review of facility SRI # 3 dated 12/15/17 at 1:16 P.M., revealed the facility filed a report for neglect/mistreatment which was unsubstantiated for Resident #1. The facility reported STNA #10 took a photo of Resident #1, modified it, and sent to two students from a career center, through Snap Chat. This was brought to the attention of the facility on 12/13/17. Review of STNA #10's personnel file revealed an employee warning notice signed 12/18/17 which documented the employee admitted to taking and posting the photo of Resident #1 on social media. STNA #10 verified in the documentation the photo was shared with other individuals. The form was dated 12/15/17 and signed by STNA #10 on 12/18/17. STNA #10 was discharged from employment. Interview with HRD #55 on 03/08/18 at 9:09 A.M., revealed Teacher #222 notified him via email on the morning of 12/13/17. Teacher #222 notified him a student reported that STNA #10 posted a photo of Resident #1 on social media with an obscene drawing. The teacher emailed the photo to the facility. Observation of the photo on 03/08/18 at 11:35 A.M., on a computer provided by the Administrator, revealed a photograph of Resident #1 lying in bed with her eyes open. Resident #1 was altered by a drawing of male genitalia by Resident #1's mouth, giving the resident a beard and female breasts that protruded down to the resident's waistline. The Administrator verified the alterations to the photograph including drawing of male genitalia by Resident #1's mouth, a beard and female breasts that protruded down to the resident's waistline during the time of the observation. Interview with Teacher #222 on 03/08/18 at 1:15 P.M. revealed that a student at her career center reported to her on 12/13/17 a photo that was taken of Resident #1. She stated she called the facility and spoke to HRD #55 to report it. Teacher #222 stated she sent him a copy of the photo through email. Teacher #222 stated a facility employee did not report the photo to her, it was a student who was not associated with the nursing facility. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., revealed she verified that she did take the photo of Resident #1 and altered it. STNA #10 stated that STNA #101 must have reported her since she only sent the photo to her. When asked if anyone else could have seen the photo of Resident #1, she stated only if STNA #101 took a screen shot of the picture and saved it to her camera roll. 2. Record review revealed Resident #62 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident was rarely understood and required extensive assistance for bed mobility, transfers, locomotion on unit, dressing, eating, and toilet use. Resident #62 required total dependence for bathing and personal hygiene and utilized a wheelchair to aid in mobility. She was frequently incontinent of bladder and always incontinent of bowel. Interview with the Administrator on 03/08/18 at 2:25 P.M., revealed an investigator from the abuse, neglect, and misappropriation department notified him on 01/09/17 that STNA #10 had also posted a photo of Resident #62 on social media in addition to Resident #1's photo. Interview with HRD #55 on 03/09/18 at 1:15 P.M. revealed he interviewed STNA #101 on 12/15/17 and asked her if she worked on 12/12/17 to which she stated yes. He asked her if she knew of anyone sending or taking pictures and she replied that she had heard there was a snapchat thing the day before. She stated that STNA #10 had taken a picture of her and another resident without her knowledge. HRD #55 asked who knew about it and she stated a few other aides and a night shift nurse. STNA #101 said that STNA #10 had posted it on her story on snapchat and it was up for 24 hours and any of STNA #10's friends could have seen it. HRD #55 verified he interviewed STNA #101 and did not seek clarification on who the resident was on STNA #10's SnapChat as he just figured it was Resident #1. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., verified that she also took a photo of Resident #62 with STNA #101 and posted it to her story on SnapChat. STNA #10 verified the photo was able to be viewed by all her friends for a 24 hour period. STNA #10 stated that Residents #1 and #62 was not aware she was photographing them. Interview on 03/09/18 at 3:20 P.M., with the Administrator verified the photograph of Resident #1, taken and altered by STNA #10 and subsequently posted on snapchat, violated the residents privacy. The Administrator also verified the photo STNA #10 took of Resident #62 and posted to snapchat, violated the resident's privacy as well. Review of the facility Policy titled Standards and Guidelines for Personal Use of Social Media and Social Networking Technology dated 01/01/12 revealed employees must not use social networking communication or personal electronic devices to disclose information about patients or families. Content should not include personal insults, or comments considered obscene, profane, or harassing to patients or their families. Review of the facility policy titled Professional Appearance and Dress Code Guidelines for Employees dated 06/01/16 revealed employees should not have any type of cell phone, pager, or other personal media on their person in work areas unless required for job duties. Personal media included, ear pieces, cameras, MP3 players, and devices used for texting.

Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, review of the Social Networking facility policy and the Abuse, Neglect, Exploitation & Misappropriation of Resident facility policy, the facility failed to ensure a cognitively impaired resident was free from mental and emotional abuse by a facility staff member. This resulted in Immediate Jeopardy and psychosocial harm for one Resident (#1) when State tested Nurse Aide (STNA) #10 engaged in an act meant to humiliate and ridicule the resident by taking a photograph of Resident #1 without permission and not in accordance with facility policy. STNA #10 defaced the photograph of Resident #1 by adding drawings of male genitalia, female breasts and a beard and posted it on the social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame. The facility also failed to prevent mental and emotional abuse that was not Immediate Jeopardy when STNA #10 took a photograph of cognitively impaired Resident #62 without the resident's knowledge or permission and posted this photograph on the same social media website. This affected two (Residents #1 and #62) of four residents reviewed for abuse. The facility identified 14 Residents who were cognitively impaired and lived on the same unit as Residents #1 and #62. The facility census was 99. On 03/08/18 at 11:53 A.M., the Administrator, Director of Nursing (DON), and Corporate Quality Assurance Nurse (CQAN) #26 were notified that Immediate Jeopardy began on 12/13/17 at approximately 12:45 P.M. when STNA #10 took a photograph of Resident #1 lying in bed and altered it by drawing male genitalia by the resident's mouth, giving the resident a beard and adding female breasts that protruded down to the resident's waist. STNA #10 posted the altered photograph on a social media website identified as Snap Chat. The embarrassing ridiculing photograph potentially could have been viewed by others in the community on Snap Chat and was viewed by two people not employed by the facility. The Immediate Jeopardy was removed on 03/09/18 when the facility implemented the following corrective actions: · On 12/13/18 at approximately 1:45 P.M., the Administrator initiated an internal investigation involving the photo taken of Resident #1 and altered by STNA #10. At approximately 4:00 P.M., STNA #10 was suspended pending the outcome of the investigation. · On 12/13/17, the Interdisciplinary team (IDT) consisting of the Administrator, DON, Unit Managers (UM) #81, #82 and #83, Social Service Director (SSD) #44, Activities Director (AD) #9, and Director of Rehabilitation (DOR) #27 began reviews Monday through Friday of all current residents in the morning interdisciplinary team meeting that convenes approximately from 9:30 A.M. to 10:30 A.M., for any changes in condition, behavioral and/or mood symptoms related to abuse with follow up to the attending physician within the business hours. This will continue indefinitely. · On 12/15/17 at 9:15 A.M., the Administrator educated department managers including Activities Director (AD) #9, Registered Dietitian (RD) #41, Food Service Director (FSD) #51, Environmental Services Supervisor (ESS) #28, Interim Director of Nursing (IDON), Admissions Director (AD) #8, Social Services (SS) #44, Medical Records (MR) #60, Business Office Administrator (BOA) #7, Payroll Clerk (PC) #121, Director of Rehabilitation (DOR) #27, Human Resources Director (HRD) #55 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. · On 12/15/17 at 9:30 A.M., the facility Quality Assessment and Assurance (QAA) committee met to review and resolve the incident related to a photograph taken by STNA #10 of Resident #1 and sent to others. · On 12/15/17 at 2:17 P.M., Resident #1's attending physician and family were notified of the incident by the IDON. · On 12/15/17 at approximately 3:15 P.M., HRD #55 completed notification to the Ohio Department of Health (ODH) Nurse Aide Registry of the incident with Resident #1 involving STNA #10. · On 12/15/17 at 5:36 P.M., SS #44 completed a psychosocial evaluation of Resident #1 which showed no negative effects from the incident. · On 12/18/17 at approximately 8:00 A.M. through 12/28/17 at approximately 5:00 P.M., Department Managers, AD #9, RD #41, FSD #51, ESS #28, IDON, AD #8, SS #44, MR #60, BOA #7, PC #121, DOR #27, HRD #55 began educating all staff Including STNA #101 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. All staff were in-serviced with the exception of STNA #33, #58, #94, #100, #131, #135, · On 12/18/17 at approximately 10:00 A.M., through 12/21/17 at approximately 4:00 P.M., Facility Management including the Administrator, IDON, UMs #81, #82 and #83, SS #44, Admissions Director #8, ESS #28, HRD #55, BOA #7, Scheduler #50, AD #9, Minimum Data Set (MDS) Coordinator #42 and Administrative Assistant (AA) #121 interviewed all alert and oriented residents, a total of 77, to inquire if they had knowledge of their picture being taken. No negative responses were obtained. · On 12/18/17, at approximately 4:45 P.M., STNA #10 was terminated from the facility for taking a picture of a resident and posting it on social media and sharing it with other individuals. · On 12/19/17 from approximately 8:00 A.M. to 5:00 P.M., Licensed Practical Nurse (LPN) #50 completed random staff interviews with eight staff members, STNAs #35, #91, #98, #130, #223, Registered Nurses (RN) #75, #80 and LPN #103 for any knowledge that staff may have regarding pictures being taken of residents for purposes other than their medical records. No negative responses were obtained. · On 01/05/18, the DON began interviewing one resident on each hallway to inquire if any staff had taken a photo of them other than for the medical record. These interviews continued weekly for four weeks. No negative responses were reported. · On 01/05/18, the DON began interviewing four staff members each week to inquire if they were aware of any staff member taking a picture of a resident. These interviews continued weekly for four weeks. No negative responses were reported · On 03/08/18 at approximately 2:15 P.M., the Administrator initiated an investigation regarding Resident #62. · On 03/08/18 at 1:45 P.M., the Quality Assurance Consultant (QAC) #26 educated the Administrator on the Facility Abuse, Neglect, Exploitation, Misappropriation Requirements of Participation and the Incident Prevent Process Flowchart. · On 03/09/18 at approximately 11:00 A.M., the facility's QAPI Committee met to review the Abatement plan with the Medical Director and Committee members. · On 03/09/18 at 2:45 P.M., all six additional employees (STNA #33, #58, #94, #100, #131, #135) identified as not to have received the above training, had been educated by QAC #26 on the facility cell phone guidelines and reporting guidelines from the Prevent Practice Guide. Newly hired employees will continue to be educated upon hire on the facility cell phone guidelines and Reporting guidelines from the Prevent Practice Guide in New Hire General Orientation by the Human Resource Director. · On 03/09/18 beginning at 2:21 P.M., and concluding at 4:20 P.M., the DON, UM #81, #82, #83 , MDS Coordinator #42, and LPN #50 reviewed nursing notes from 12/12/17 to present of all cognitively impaired residents including Resident #1 and Resident #62 (defined as patients with a BIMS score of 13 or lower on the most current MDS) currently residing in the facility, to determine if there were any indications of psychosocial distress, mood/behavioral distress and/or signs of abuse and results were documented on the QAPI Audit tool. No negative responses were obtained. · Effective 03/10/18, the DON and/or Unit Managers will continue to review progress notes daily of cognitively impaired as well as alert and oriented residents for any changes in condition, behavioral and/or mood symptoms that may be an indication of abuse times 14 days and then Monday through Friday thereafter. Any indications of abuse will be reported immediately to the Administrator for further follow up. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: 1. Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and was sometimes able to understand others and could sometimes make herself understood. The resident required extensive assistance of one person for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use and personal hygiene. The resident utilized a walker and wheelchair to aid in mobility. The resident was occasionally incontinent of bladder and was always continent of bowel. Review of a facility email dated 12/13/17 at 1:14 P.M., revealed Teacher #222, from a local career center, reported to HRD #55 a photo was attached to the email that had a modification on it for Resident #1. The email revealed a student at the school informed Teacher #222 the photo was sent by STNA #10 who was an employee of the facility. The student showed it to Teacher #222 and, due to the inappropriateness of the modifications, she thought that it should be brought to the facility's attention. Review of facility SRI # 3 dated 12/15/17 at 1:16 P.M., revealed the facility filed a report for neglect/mistreatment which was unsubstantiated for Resident #1. The facility reported STNA #10 took a photo of Resident #1, modified it, and sent to two students from a career center, through Snap Chat. This was brought to the attention of the facility on 12/13/17. Review of STNA #10's personnel file revealed an employee warning notice signed 12/18/17 which documented the employee admitted to taking and posting the photo of Resident #1 on social media. STNA #10 verified in the documentation the photo was shared with other individuals. The form was dated 12/15/17 and signed by STNA #10 on 12/18/17. STNA #10 was discharged from employment. Interview with HRD #55 on 03/08/18 at 9:09 A.M., revealed Teacher #222 notified him via email on the morning of 12/13/17. Teacher #222 notified him a student reported that STNA #10 posted a photo of Resident #1 on social media with an obscene drawing. The teacher emailed the photo to the facility. Observation of the photo on 03/08/18 at 11:35 A.M., on a computer provided by the Administrator, revealed a photograph of Resident #1 lying in bed with her eyes open. Resident #1 was altered by a drawing of male genitalia by Resident #1's mouth, giving the resident a beard and female breasts that protruded down to the resident's waistline. The Administrator verified the alterations to the photograph including drawing of male genitalia by Resident #1's mouth, a beard and female breasts that protruded down to the resident's waistline during the time of the observation. Interview with Teacher #222 on 03/08/18 at 1:15 P.M. revealed that a student at her career center reported to her on 12/13/17 a photo that was taken of Resident #1. She stated she called the facility and spoke to HRD #55 to report it. Teacher #222 stated she sent him a copy of the photo through email. Teacher #222 stated a facility employee did not report the photo to her, it was a student who was not associated with the nursing facility. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., revealed she verified that she did take the photo of Resident #1 and altered it. STNA #10 stated that STNA #101 must have reported her since she only sent the photo to her. When asked if anyone else could have seen the photo of Resident #1, she stated only if STNA #101 took a screen shot of the picture and saved it to her camera roll. Interview on 03/09/18 at 3:20 P.M. with the Administrator verified his witness statement documented that on 12/13/17, a photo of Resident #1 had been taken by STNA #10 and altered. The document revealed the photo was taken while the Resident was lying in bed. The photo was partially altered with drawn in male genitalia pointing to her face, with scrub under her chin, and what looks to be breasts drawn on her over clothes. There was also what appeared to be a hand drawn hat and then some items above her head circled. The Administrator also verified that STNA #10 did not follow the facility's abuse and social media policy when she took a picture of Resident #1, altered it and posted it to social media. 2. Record review revealed Resident #62 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident was rarely understood and required extensive assistance for bed mobility, transfers, locomotion on unit, dressing, eating, and toilet use. Resident #62 required total dependence for bathing and personal hygiene and utilized a wheelchair to aid in mobility. She was frequently incontinent of bladder and always incontinent of bowel. Interview with the Administrator on 03/08/18 at 2:25 P.M., revealed an investigator from the abuse, neglect, and misappropriation department notified him on 01/09/17 that STNA #10 had also posted a photo of Resident #62 on social media in addition to Resident #1's photo. Interview with HRD #55 on 03/09/18 at 1:15 P.M. revealed he interviewed STNA #101 on 12/15/17and asked her if she worked on 12/12/17 to which she stated yes. He asked her if she knew of anyone sending or taking pictures and she replied that she had heard there was a snapchat thing the day before. She stated that STNA #10 had taken a picture of her and another resident without her knowledge. HRD #55 asked who knew about it and she stated a few other aides and a night shift nurse. STNA #101 said that STNA #10 had posted it on her story on snapchat and it was up for 24 hours and any of STNA #10's friends could have seen it. HRD #55 verified he interviewed STNA #101 and did not seek clarification on who the resident was on STNA #10's SnapChat as he just figured it was Resident #1. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., verified that she also took a photo of Resident #62 with STNA #101 and posted it to her story on SnapChat. STNA #10 verified the photo was able to be viewed by all her friends for a 24 hour period. STNA #10 stated that Residents #1 and #62 was not aware she was photographing them. Review of the facility Policy titled Standards and Guidelines for Personal Use of Social Media and Social Networking Technology dated 01/01/12 revealed employees must not use social networking communication or personal electronic devices to disclose information about patients or families. Content should not include personal insults, or comments considered obscene, profane, or harassing to patients or their families. Review of the facility policy titled Professional Appearance and Dress Code Guidelines for Employees dated 06/01/16 revealed employees should not have any type of cell phone, pager, or other personal media on their person in work areas unless required for job duties. Personal media included, ear pieces, cameras, MP3 players, and devices used for texting. Review of the facility policy titled Abuse Neglect, Exploitation, Mistreatment, and Misappropriation Prevention dated 11/03/16 revealed allegations of abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than two hours after the allegation was made if it involved abuse. It should be reported to the Administrator of the facility and to other officials including the state agency. Patients have the right to be free from abuse that may occur from unauthorized taking of pictures or recordings that are demeaning or humiliating. Once reported the center conducts a timely, thorough, and objective investigation of any allegations of abuse. This deficiency substantiates complaint number OH 458.

Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, review of the Social Networking facility policy and the Abuse, Neglect, Exploitation & Misappropriation of Resident facility policy, the facility failed to implement policies prohibiting resident abuse and the inappropriate use of cellular phones to ensure residents were free from mental and emotional abuse by a facility staff member. This resulted in Immediate Jeopardy and psychosocial harm for one Resident (#1) when State tested Nurse Aide (STNA) #10 engaged in an act meant to humiliate and ridicule the resident by taking a photograph of Resident #1 without permission and not in accordance with facility policy. STNA #10 defaced the photograph of Resident #1 by adding drawings of male genitalia, female breasts and a beard and posted it on the social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame. The facility also failed to implement policies prohibiting resident abuse and the inappropriate use of cellular phones to prevent mental and emotional abuse that was not Immediate Jeopardy when STNA #10 took a photograph of cognitively impaired Resident #62 without the resident's knowledge or permission and posted this photograph on the same social media website. The facility failed to report allegations of abuse to the state agency in the required time frame and failed to thoroughly investigate the allegations of abuse. This affected two (Residents #1 and #62) of four residents reviewed for abuse. The facility identified 14 Residents who were cognitively impaired and lived on the same unit as Residents #1 and #62. The facility census was 99. On 03/08/18 at 11:53 A.M., the Administrator, Director of Nursing (DON), and Corporate Quality Assurance Nurse (CQAN) #26 were notified that Immediate Jeopardy began on 12/13/17 at approximately 12:45 P.M. when STNA #10 took a photograph of Resident #1 lying in bed and altered it by drawing male genitalia by the resident's mouth, giving the resident a beard and adding female breasts that protruded down to the resident's waist. STNA #10 posted the altered photograph on a social media website identified as Snap Chat. The embarrassing ridiculing photograph potentially could have been viewed by others in the community on Snap Chat and was viewed by two people not employed by the facility. The Immediate Jeopardy was removed on 03/09/18 when the facility implemented the following corrective actions: · On 12/13/18 at approximately 1:45 P.M., the Administrator initiated an internal investigation involving the photo taken of Resident #1 and altered by STNA #10. At approximately 4:00 P.M., STNA #10 was suspended pending the outcome of the investigation. · On 12/13/17, the Interdisciplinary team (IDT) consisting of the Administrator, DON, Unit Managers (UM) #81, #82 and #83, Social Service Director (SSD) #44, Activities Director (AD) #9, and Director of Rehabilitation (DOR) #27 began reviews Monday through Friday of all current residents in the morning interdisciplinary team meeting that convenes approximately from 9:30 A.M. to 10:30 A.M., for any changes in condition, behavioral and/or mood symptoms related to abuse with follow up to the attending physician within the business hours. This will continue indefinitely. · On 12/15/17 at 9:15 A.M., the Administrator educated department managers including Activities Director (AD) #9, Registered Dietitian (RD) #41, Food Service Director (FSD) #51, Environmental Services Supervisor (ESS) #28, Interim Director of Nursing (IDON), Admissions Director (AD) #8, Social Services (SS) #44, Medical Records (MR) #60, Business Office Administrator (BOA) #7, Payroll Clerk (PC) #121, Director of Rehabilitation (DOR) #27, Human Resources Director (HRD) #55 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. · On 12/15/17 at 9:30 A.M., the facility Quality Assessment and Assurance (QAA) committee met to review and resolve the incident related to a photograph taken by STNA #10 of Resident #1 and sent to others. · On 12/15/17 at 2:17 P.M., Resident #1's attending physician and family were notified of the incident by the IDON. · On 12/15/17 at approximately 3:15 P.M., HRD (I added HRD back in if this is okay. It was missing) #55 completed notification to the Ohio Department of Health (ODH) Nurse Aide Registry of the incident with Resident #1 involving STNA #10. · On 12/15/17 at 5:36 P.M., SS #44 completed a psychosocial evaluation of Resident #1 which showed no negative effects from the incident. · On 12/18/17 at approximately 8:00 A.M. through 12/28/17 at approximately 5:00 P.M., Department Managers, AD #9, RD #41, FSD #51, ESS #28, IDON, AD #8, SS #44, MR #60, BOA #7, PC #121, DOR #27, HRD #55 began educating all staff Including STNA #101 on the facility cell phone guidelines, abuse policy and abuse reporting guidelines from the Prevent Practice Guide. All staff were in-serviced with the exception of STNA #33, #58, #94, #100, #131, and #135. · On 12/18/17 at approximately 10:00 A.M., through 12/21/17 at approximately 4:00 P.M., Facility Management including the Administrator, IDON, UMs #81, #82 and #83, SS #44, Admissions Director #8, ESS #28, HRD #55, BOA #7, Scheduler #50, AD #9, Minimum Data Set (MDS) Coordinator #42 and Administrative Assistant (AA) #121 interviewed all alert and oriented residents, a total of 77, to inquire if they had knowledge of their picture being taken. No negative responses were obtained. · On 12/18/17, at approximately 4:45 P.M., STNA #10 was terminated from the facility for taking a picture of a resident and posting it on social media and sharing it with other individuals. · On 12/19/17 from approximately 8:00 A.M. to 5:00 P.M., Licensed Practical Nurse (LPN) #50 completed random staff interviews with eight staff members, STNAs #35, #91, #98, #130, #223, Registered Nurses (RN) #75, #80 and LPN #103 for any knowledge that staff may have regarding pictures being taken of residents for purposes other than their medical records. No negative responses were obtained. · On 01/05/18, the DON began interviewing one resident on each hallway to inquire if any staff had taken a photo of them other than for the medical record. These interviews continued weekly for four weeks. No negative responses were reported. · On 01/05/18, the DON began interviewing four staff members each week to inquire if they were aware of any staff member taking a picture of a resident. These interviews continued weekly for four weeks. No negative responses were reported · On 03/08/18 at approximately 2:15 P.M., the Administrator initiated an investigation regarding Resident #62. · On 03/08/18 at 1:45 P.M., the Quality Assurance Consultant (QAC) #26 educated the Administrator on the Facility Abuse, Neglect, Exploitation, Misappropriation Requirements of Participation and the Incident Prevent Process Flowchart. · On 03/09/18 at approximately 11:00 A.M., the facility's QAPI Committee met to review the Abatement plan with the Medical Director and Committee members. · On 03/09/18 at 2:45 P.M., all six additional employees (STNA #33, #58, #94, #100, #131, and #135) identified as not to have received the above training, had been educated by QAC #26 on the facility cell phone guidelines and reporting guidelines from the Prevent Practice Guide. Newly hired employees will continue to be educated upon hire on the facility cell phone guidelines and Reporting guidelines from the Prevent Practice Guide in New Hire General Orientation by the Human Resource Director. · On 03/09/18 beginning at 2:21 P.M., and concluding at 4:20 P.M., the DON, UM #81, #82, #83 , MDS Coordinator #42, and LPN #50 reviewed nursing notes from 12/12/17 to present of all cognitively impaired residents including Resident #1 and Resident #62 (defined as patients with a BIMS score of 13 or lower on the most current MDS) currently residing in the facility, to determine if there were any indications of psychosocial distress, mood/behavioral distress and/or signs of abuse and results were documented on the QAPI Audit tool. No negative responses were obtained. · Effective 03/10/18, the DON and/or Unit Managers will continue to review progress notes daily of cognitively impaired as well as alert and oriented residents for any changes in condition, behavioral and/or mood symptoms that may be an indication of abuse times 14 days and then Monday through Friday thereafter. Any indications of abuse will be reported immediately to the Administrator for further follow up. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and was sometimes able to understand others and could sometimes make herself understood. The resident required extensive assistance of one person for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use and personal hygiene. The resident utilized a walker and wheelchair to aid in mobility. The resident was occasionally incontinent of bladder and was always continent of bowel. Review of a facility email dated 12/13/17 at 1:14 P.M., revealed Teacher #222, from a local career center, reported to HRD #55 a photo was attached to the email that had a modification on it for Resident #1. The email revealed a student at the school informed Teacher #222 the photo was sent by STNA #10 who was an employee of the facility. The student showed it to Teacher #222 and, due to the inappropriateness of the modifications, she thought that it should be brought to the facility's attention. Review of facility SRI # 3 dated 12/15/17 at 1:16 P.M., revealed the facility filed a report for neglect/mistreatment which was unsubstantiated for Resident #1. The facility reported STNA #10 took a photo of Resident #1, modified it, and sent to two students from a career center, through Snap Chat. This was brought to the attention of the facility on 12/13/17. Review of STNA #10's personnel file revealed an employee warning notice signed 12/18/17 which documented the employee admitted to taking and posting the photo of Resident #1 on social media. STNA #10 verified in the documentation the photo was shared with other individuals. The form was dated 12/15/17 and signed by STNA #10 on 12/18/17. STNA #10 was discharged from employment. Interview with HRD #55 on 03/08/18 at 9:09 A.M., revealed Teacher #222 notified him via email on the morning of 12/13/17. Teacher #222 notified him a student reported that STNA #10 posted a photo of Resident #1 on social media with an obscene drawing. The teacher emailed the photo to the facility. Observation of the photo on 03/08/18 at 11:35 A.M., on a computer provided by the Administrator, revealed a photograph of Resident #1 lying in bed with her eyes open. Resident #1 was altered by a drawing of male genitalia by Resident #1's mouth, giving the resident a beard and female breasts that protruded down to the resident's waistline. The Administrator verified the alterations to the photograph including drawing of male genitalia by Resident #1's mouth, a beard and female breasts that protruded down to the resident's waistline during the time of the observation. Interview on 03/08/18 at 12:05 P.M. with the Administrator verified that he did not timely report the allegation of abuse to the State agency on 12/13/17 when it was first reported to him and that he was waiting on further information from his legal department before he reported it to the Ohio Department of Health. Interview with Teacher #222 on 03/08/18 at 1:15 P.M. revealed that a student at her career center reported to her on 12/13/17 a photo that was taken of Resident #1. She stated she called the facility and spoke to HRD #55 to report it. Teacher #222 stated she sent him a copy of the photo through email. Teacher #222 stated a facility employee did not report the photo to her, it was a student who was not associated with the nursing facility. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., revealed she verified that she did take the photo of Resident #1 and altered it. STNA #10 stated that STNA #101 must have reported her since she only sent the photo to her. When asked if anyone else could have seen the photo of Resident #1, she stated only if STNA #101 took a screen shot of the picture and saved it to her camera roll. Interview on 03/09/18 at 3:20 P.M. with the Administrator verified his witness statement documented that on 12/13/17, a photo of Resident #1 had been taken by STNA #10 and altered. The document revealed the photo was taken while the Resident was lying in bed. The photo was partially altered with drawn in male genitalia pointing to her face, with scrub under her chin, and what looks to be breasts drawn on her over clothes. There was also what appeared to be a hand drawn hat and then some items above her head circled. The Administrator also verified that STNA #10 did not follow the facility's abuse and social media policy when she took a picture of Resident #1, altered it and posted it to social media. 2. Record review revealed Resident #62 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident was rarely understood and required extensive assistance for bed mobility, transfers, locomotion on unit, dressing, eating, and toilet use. Resident #62 required total dependence for bathing and personal hygiene and utilized a wheelchair to aid in mobility. She was frequently incontinent of bladder and always incontinent of bowel. Interview with the Administrator on 03/08/18 at 2:25 P.M., revealed an investigator from the abuse, neglect, and misappropriation department notified him on 01/09/17 that STNA #10 had also posted a photo of Resident #62 on social media in addition to Resident #1's photo. The Administrator verified that he did not complete another SRI submission for Resident #62. He stated he just added an addendum to the previous SRI for Resident #1 on 12/15/17. The Administrator also verified that he did not do any further investigation of this incident except that he interviewed STNA #101. Interview with HRD #55 on 03/09/18 at 1:15 P.M. revealed he interviewed STNA #101 on 12/15/17and asked her if she worked on 12/12/17 to which she stated yes. He asked her if she knew of anyone sending or taking pictures and she replied that she had heard there was a snapchat thing the day before. She stated that STNA #10 had taken a picture of her and another resident without her knowledge. HRD #55 asked who knew about it and she stated a few other aides and a night shift nurse. STNA #101 said that STNA #10 had posted it on her story on snapchat and it was up for 24 hours and any of STNA #10's friends could have seen it. HRD #55 verified he interviewed STNA #101 and did not seek clarification on who the resident was on STNA #10's SnapChat as he just figured it was Resident #1. Telephone interview with STNA #10 on 03/09/18 at 2:57 P.M., verified that she also took a photo of Resident #62 with STNA #101 and posted it to her story on SnapChat. STNA #10 verified the photo was able to be viewed by all her friends for a 24 hour period. STNA #10 stated that Residents #1 and #62 was not aware she was photographing them. Review of the facility Policy titled Standards and Guidelines for Personal Use of Social Media and Social Networking Technology dated 01/01/12 revealed employees must not use social networking communication or personal electronic devices to disclose information about patients or families. Content should not include personal insults, or comments considered obscene, profane, or harassing to patients or their families. Review of the facility policy titled Professional Appearance and Dress Code Guidelines for Employees dated 06/01/16 revealed employees should not have any type of cell phone, pager, or other personal media on their person in work areas unless required for job duties. Personal media included, ear pieces, cameras, MP3 players, and devices used for texting. Review of the facility policy titled Abuse Neglect, Exploitation, Mistreatment, and Misappropriation Prevention dated 11/03/16 revealed allegations of abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than two hours after the allegation was made if it involved abuse. It should be reported to the Administrator of the facility and to other officials including the state agency. Patients have the right to be free from abuse that may occur from unauthorized taking of pictures or recordings that are demeaning or humiliating. Once reported the center conducts a timely, thorough, and objective investigation of any allegations of abuse. This deficiency substantiates complaint number OH 458.