Every finding on record at Scioto Pointe

Based on record review, interview, and facility policy review, the facility failed to report potential abuse incidents to the state agency. This affected four residents (#55, #53, #75 and #90) of four reviewed for abuse. The facility census was 95. Findings Include: Review of Resident #55's medical record revealed an original admission date of 04/18/24 and a reentry date of 06/25/25. Diagnoses included disorganized schizophrenia, schizoaffective disorder, bipolar type, intermittent explosive disorder, adjustment disorder with anxiety, nightmare disorder, drug-induced subacute dyskinesia, nicotine dependence, hypertension, type II diabetes mellitus with autonomic neuropathy, chronic obstructive pulmonary disease, chronic kidney disease, anemia, gastroesophageal reflux disease, benign prostatic hyperplasia, lumbar degenerative disc disease, and muscle weakness.Review of Resident #55's annual comprehensive Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented clear speech, the ability to make needs understood, and the ability to understand others.Review of Resident #55's comprehensive care plan revealed impaired psychosocial well-being related to interpersonal conflict. The care plan identified that verbal confrontations could escalate into physical confrontations and potentially result in injury to Resident #55 or others. Interventions included monitoring mood and behavior, identifying triggers and unmet needs, approaching Resident #55 calmly, providing reassurance, verbally redirecting Resident #55, avoiding confrontation, offering preferred activities, and obtaining psychiatric services as needed.Review of the facility's incident/accident report dated 04/27/26 revealed Resident #55 became agitated near the outside smoking-patio door at approximately 9:12 P.M. The report documented Resident #55 struck Activities Aide (AA) #320 multiple times, struck the window near the smoking-patio door, and moved around the nurses' station. No apparent injury was documented.Review of the facility's general investigation dated 04/27/26 revealed Resident #55 became agitated while waiting for a smoke break and began striking AA #320. The investigation documented AA #320 placed both arms around Resident #55 to prevent additional strikes. Resident #55 and AA #320 subsequently fell to the floor.Review of AA #320's written statement dated 04/27/26 at 9:12 P.M. revealed Resident #55 ran toward the smoking-patio door, pushed another resident, and moved toward the other resident again. AA #320 documented Resident #55 struck AA #320 multiple times with a closed fist. AA #320 documented hugging Resident #55 while holding Resident #55's arms and calling for staff assistance. AA #320 documented Resident #55 continued struggling, and both individuals fell to the floor.Review of two residents' (#43 and #16) witness statements dated 04/28/26 untimed revealed both witnesses observed Resident #55 strike AA #320. Both witnesses stated AA #320 held Resident #55 to prevent additional strikes and denied observing AA #320 strike Resident #55.Further review of the investigation documentation did not identify which care-planned interventions were attempted before AA #320 placed both arms around Resident #55. The documentation did not establish whether verbal redirection, reassurance, removal of the triggering stimulus, increased personal space, or assistance from additional staff was attempted before physical contact occurred.Further review of the investigation documentation revealed the Administrator's signature line was blank. The documentation did not establish that the Administrator reviewed or approved the investigative conclusion. Resident #55's record did not contain evidence that a Self Reported Incident (SRI) was submitted related to the physical contact between AA #320 and Resident #55.During an interview on 08/05/26 at 8:20 A.M., Resident #55 denied current concerns regarding staff treatment.During an interview on 08/05/26 at 11:25 A.M., the Administrator and Director of Nursing (DON) confirmed the former Administrator determined the incident did not require submission of a Self Reported Incident because Resident #55 did not sustain an identified injury or actual physical harm. The DON stated the investigation was completed within several hours. The DON stated AA #320 was permitted to return to work the following day and clocked in at approximately 2:00 P.M.The DON stated the facility interviewed residents identified as direct witnesses but did not interview a broader sample of residents who routinely interacted with or received assistance from AA #320. The DON stated the facility served a population with psychiatric, behavioral, and cognitive needs and did not routinely interview every resident because resident accounts could be inaccurate or inconsistent.During a follow-up interview on 08/05/26 at 12:03 P.M., the DON confirmed Resident #55 subsequently reported that AA #320 put both hands-on Resident #55. The DON stated the facility did not reopen, expand, or supplement the investigation because the original investigation was considered complete. The DON confirmed no additional resident interviews were conducted, and no SRI was submitted following Resident #55's allegation.2. Review of Resident #53's medical record revealed Resident #53 had the diagnoses of type II Diabetes, paranoid schizophrenia, chronic kidney disease, alcohol dependence with alcohol induced dementia, and obsessive compulsive behavior.Review of Resident #53's annual comprehensive MDS assessment, with an ARD of 02/10/26, revealed a BIMS score of 15, indicating intact cognition. Review of the facility's incident documentation dated 04/02/26 revealed Resident #53 and Resident #55 were involved in a physical altercation in the hallway at approximately 6:30 P.M. while waiting for a smoke break.Review of Resident #55's statement dated 04/02/26 untimed revealed Resident #53 was yelling and appeared to be approaching Resident #55. Resident #55 stated he pushed Resident #53 to the floor.Review of Resident #53's statement dated 04/02/26 untimed revealed Resident #55 was speaking about him under Resident #55's breath. Resident #53 stated he asked Resident #55 to stop, approached Resident #55, and was pushed to the floor.Review of the facility investigation revealed staff-witness statements dated 04/02/26 untimed revealed Licensed Practical Nurse (LPN) # 212 and Certified Nursing Assistant (CNA) #111 observed Residents #53 and #55 arguing before Resident #55 pushed Resident #53 to the floor. Staff intervened and separated both residents. Post-incident assessments did not identify an injury to either resident.Review of the investigation documentation revealed the event was identified as a physical altercation and reviewed internally. Resident #53's record did not contain evidence that the facility submitted an SRI related to the confirmed resident-to-resident physical contact.During an interview on 08/05/26 at 11:25 A.M., the Administrator and DON confirmed the facility did not submit an SRI related to the incident involving Residents #53 and #55. The Administrator and DON stated the former Administrator determined the incident was not reportable because neither resident sustained an identified injury or actual physical harm.3. Review of Resident #75's medical record revealed Resident #75 was diagnosed with type II diabetes, hypertensive heart disease, schizoaffective disorder bipolar type, dementia with agitation and pseudobulbar affect. Review of Resident #75's quarterly MDS assessment, with an ARD of 05/01/26, revealed a BIMS score of 14, indicating intact cognition. A subsequent quarterly MDS assessment, with an ARD of 07/16/26, revealed a BIMS score of 15, also indicating intact cognition. Closed record review for Resident #90 revealed Resident #90 was diagnosed with type II diabetes, Alzheimer's disease, dementia, anxiety Post Traumatic Stress Disorder (PTSD) and cognitive communication deficit. Review of Resident #90's MDS entry tracking record dated 03/07/26 revealed the MDS was completed as an entry tracking record. The MDS was not a comprehensive or quarterly assessment and did not contain a completed BIMS or staff assessment of cognitive status. Therefore, Resident #90's cognitive status at the time of the 03/12/26 incident could not be determined from the MDS entry tracking record.Review of the facility's incident documentation dated 03/12/26 revealed Resident #75 was involved in a physical altercation with Resident #90 in the dining room at approximately 9:00 P.M.Review of the facility's investigation revealed Residents #75 and Resident #90 began arguing after Resident #90 approached Resident #75 and used inappropriate language. The investigation documented Resident #75 grabbed and pulled Resident #90's hair.Review of Resident #75's statement dated 03/13/26 untimed revealed Resident #90 yelled at Resident #75 and accused Resident #75 of talking about Resident #90. Resident #75 stated Resident #90 moved close to Resident #75, and Resident #75 grabbed Resident #90 by the hair to keep Resident #90 away.Review of Resident #90's statement dated 03/13/26 untimed revealed Resident #75 began talking about Resident #90, which resulted in an argument. Resident #90 stated Resident #75 then pulled her hair.Review of a nursing assistant's witness statement dated 03/13/26 untimed revealed the nursing assistant heard Residents #75 and Resident #90 arguing and observed Resident #75 holding the end of Resident #90's hair. The nursing assistant directed Resident #75 to release Resident #90's hair, and Resident #75 complied. Staff separated both residents and redirected both residents to their rooms.Review of the investigation documentation revealed the event was identified as a physical altercation and reviewed internally. Resident #75 and Resident #90's record did not contain evidence that the facility submitted an SRI related to the incident. During an interview on 08/05/26 at 11:25 A.M., the Administrator and DON confirmed the facility did not submit an SRI related to the physical altercation involving Resident #75 and Resident #90. The Administrator and DON stated the former Administrator determined the event was not reportable because no injury or actual physical harm was identified.Review of the facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures, revised April 2021, revealed the Administrator was responsible for the overall coordination and implementation of the facility's policies and procedures related to abuse, neglect, exploitation, and misappropriation of resident property.The policy required processes for preventing abuse, identifying possible violations, protecting residents during investigations, investigating allegations, reporting allegations, responding to investigation findings, providing staff training, and coordinating identified concerns with the Quality Assurance and Performance Improvement committee.Further review of the policy revealed the Administrator could delegate components of the abuse-prevention process to other facility personnel but retained overall responsibility for coordination and implementation. The policy required identified deficiencies in processes that could lead to abuse, neglect, or exploitation to be addressed through the Quality Assurance and Performance Improvement committee.This deficiency represents non-compliance investigated under Complaint Number 3124543 and 3070583

Based on record review and interview the facility failed to follow through with the guardianship process. This affected one resident, (Resident #97) of three residents reviewed for advanced directives. The facility census was 95. Findings include:Review of the medical record for Resident #97 revealed an admission date of 11/25/15 with diagnoses of cardiac arrest, dementia, metabolic encephalopathy, opioid dependence, delirium due to known physiological condition, major depressive disorder, generalized anxiety disorder, paranoid schizophrenia and delusional disorder.Review of the care plan dated 1/31/18 revealed the resident exhibits cognitive impairments related to dementia, paranoid schizophrenia, delusional disorder, short term memory problems, impaired decision making ability and behavioral disturbance. Interventions include reorienting the resident to the facility, monitoring for cognitive changes, repeating communication using more than one method, and providing orientation and cueing during hands on care.Review of the statement of expert evaluation dated 10/29/25 for Resident #97 revealed the evaluation was completed for a guardianship application. The resident was deemed mentally impaired with a diagnosis of schizophrenia with severe dementia. During the evaluation the physician found the resident to lack capacity, reasoning, appreciation, rational thinking, insight and judgement. The physician noted the resident is not able to manage medications or activities of daily living. The physician also noted the resident is not capable of caring for activities of daily living or making decisions regarding medical treatment, living arrangement, finances, property and diet.Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #97 exhibited a short term memory problem and was severely impaired with cognitive skills for daily decision making.Review of the physician visit dated 7/17/26 revealed Resident #97 has severe cognitive deficits and was noted to have severe cognitive impairment, dementia and psychosis with delusions and paranoia. Advance care planning notes show the resident does not have capacity to make medical decisions.Review of the hospital record dated 7/28/26 revealed the physician noted it was evident the resident lacks the capacity to make a medical decision and was confused about details of medical history.Interview on 08/04/26 at 3:10 P.M. with Social Services Designee (SSD) #340 confirmed she had an expert evaluation completed at the request of the resident's daughter for guardianship. SSD #340 reported no additional action was taken after the evaluation was completed on 10/29/25. SSD #340 reported the guardianship process is lengthy and can take up to a year for finalization. SSD #340 confirmed Resident #97 lacked capacity and was appropriate for guardianship application Interview on 08/04/26 at 3:30 P.M. with the administrator confirmed Resident #97 does not have a guardian and the facility had not made progress in obtaining guardianship. The administrator confirmed Resident #97 exhibited severe cognitive impairment and lacks capacity to make decisions.Interview on 08/05/26 at 12:06 P.M. with Licensed Practical Nurse (LPN) #137 confirmed Resident #97 was severely cognitively impaired and the nurse felt the resident should have had a guardian since change in condition on 05/24/25. LPN #137 denied knowledge of the facility's progress on the guardianship application.Interview on 08/05/26 at 12:13 P.M. with Certified Nursing Assistant (CNA) #334 and CNA #115 revealed both staff confirmed Resident #97 lacks the ability to make safe choices.This deficiency represents non-compliance investigated under Complaint Number 3123445.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure staff to resident physical contact was appropriate. This affected one resident (#55) of one resident reviewed for staff-to-resident abuse. The facility census was 95. Findings include: Review of Resident #55's medical record revealed an original admission date of 04/18/24 and a reentry date of 06/25/25. Diagnoses included disorganized schizophrenia, schizoaffective disorder, bipolar type, intermittent explosive disorder, adjustment disorder with anxiety, nightmare disorder, drug-induced subacute dyskinesia, nicotine dependence, hypertension, type 2 diabetes mellitus with autonomic neuropathy, chronic obstructive pulmonary disease, chronic kidney disease, anemia, gastroesophageal reflux disease, benign prostatic hyperplasia, lumbar degenerative disc disease, and muscle weakness.Review of Resident #55's annual comprehensive Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented clear speech, the ability to make needs understood, and the ability to understand others. The MDS documented no signs of delirium, hallucinations, delusions, physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, rejection of care, or wandering during the assessment look-back period.Review of Resident #55's comprehensive care plan revealed impaired psychosocial well-being related to interpersonal conflict. The care plan identified that conflicts and verbal confrontations could escalate into physical confrontations and potentially result in injury to Resident #55 or others.Further review of Resident #55's comprehensive care plan revealed staff were directed to monitor mood and behavior, identify potential triggers or unmet needs, approach Resident #55 calmly, provide reassurance, use verbal redirection, allow Resident #55 to express concerns, provide structure, offer preferred activities, avoid confrontation, notify the physician of significant behavioral changes, and obtain psychiatric services as needed.The comprehensive care plan did not identify an intervention directing staff to place both arms around Resident #55 or physically hold Resident #55 during a behavioral escalation.Review of the facility's incident/accident report dated 04/27/26 revealed an incident occurred near the outside smoking-patio door at approximately 9:12 P.M. The report documented Resident #55 became agitated, struck AA #320 multiple times, struck the window near the smoking-patio door, and moved around the nurses' station. No apparent injury was documented following the incident.Review of the facility's general investigation dated 04/27/26 revealed Resident #55 became agitated while waiting for a smoke break and began striking AA #320. The investigation documented AA #320 placed both arms around Resident #55 to prevent additional strikes. Resident #55 and AA #320 subsequently fell to the floor.Review of AA #320's written statement dated 04/27/26 at 9:12 P.M. revealed Resident #55 ran toward the smoking-patio door, pushed another resident, and moved toward the other resident again. AA #320 documented Resident #55 struck AA #320 multiple times with a closed fist.AA #320 documented hugging Resident #55 while holding Resident #55's arms and calling for staff assistance. AA #320 further documented Resident #55 continued struggling, after which Resident #55 and AA #320 fell to the floor.Review of a resident-witness statement dated 04/28/26 revealed the witness observed Resident #55 strike AA #320 in the chest and face. The witness stated AA #320 held Resident #55 to prevent additional strikes. The witness denied observing AA #320 strike Resident #55 or otherwise act physically aggressive toward Resident #55.Review of a second resident-witness statement dated 04/28/26 revealed Resident #55 was observed striking the window near the smoking-patio door and nudging another resident. The witness documented AA #320 intervened between the residents, Resident #55 struck AA #320, and Resident #55 and AA #320 fell to the floor. The witness denied observing AA #320 strike Resident #55.Review of the investigation documentation revealed AA #320 and two residents identified as direct witnesses were interviewed. The investigation documentation did not contain evidence that AA #320's training or competency related to behavioral de-escalation, physical intervention, or abuse prevention was reviewed.Further review of the investigation documentation did not identify which of Resident #55's care-planned behavioral interventions were attempted before AA #320 placed both arms around Resident #55. The documentation did not establish whether verbal redirection, reassurance, removal of the triggering stimulus, increased personal space, or assistance from additional staff was attempted before the physical intervention.Review of the investigation documentation revealed the Administrator's signature line was blank. The documentation did not establish that the Administrator reviewed or approved the facility's determination that AA #320's physical intervention was appropriate and consistent with facility expectations.Observation of Resident #55 on 08/05/26 at 8:20 A.M. revealed Resident #55 was present in the assigned room. Resident #55's hair, clothing, and overall appearance appeared within normal limits. No visible injury or signs of immediate physical or emotional distress were observed.During an interview on 08/05/26 at 8:20 A.M., Resident #55 denied current concerns regarding staff treatment.During an interview on 08/05/26 at 11:25 A.M., the Administrator and Director of Nursing (DON) confirmed the facility completed an internal investigation related to the incident involving Resident #55 and AA #320. The Administrator and DON stated the former Administrator determined the incident did not require submission of a Self Reported Incident because no identified injury or actual physical harm occurred.During a follow-up interview on 08/05/26 at 12:03 P.M., the DON confirmed Resident #55 subsequently reported that AA #320 put both hands on Resident #55.The DON stated the facility did not reopen, expand, or supplement the investigation following Resident #55's statement because the original investigation was considered complete. The DON confirmed no additional resident interviews were conducted following Resident #55's allegation.The Administrator and DON did not identify documentation establishing that AA #320 was trained, authorized, or determined competent to use the physical intervention described in the investigation. The Administrator and DON also did not identify documentation establishing that AA #320's actions were consistent with Resident #55's individualized care-planned interventions.Review of the facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures, revised April 2021, revealed the Administrator was responsible for the overall coordination and implementation of the facility's policies and procedures related to abuse, neglect, exploitation, and misappropriation of resident property.The policy required processes for preventing abuse, identifying possible violations, protecting residents during investigations, investigating allegations, reporting allegations, responding to investigation findings, providing staff training, and coordinating identified concerns with the Quality Assurance and Performance Improvement committee.Further review of the policy revealed the Administrator could delegate components of the abuse-prevention process to other facility personnel but retained overall responsibility for coordination and implementation. The policy required identified deficiencies in processes that could lead to abuse, neglect, or exploitation to be addressed through the Quality Assurance and Performance Improvement committee. This deficiency represents non-compliance investigated under Complaint Numbers 3124543, 3122803, and 3123445.

Based on observation, interviews and facility policy review, the facility failed to maintain an environment free from pests. This affected five (Residents # 77, # 82, # 83, # 89 and # 90) of 22 residents residing on the 400 hall. The facility census was 96.Findings include:Observation of resident rooms on 06/10/26 from 9:00 A.M. to 10:00 A.M. revealed live cockroaches in Residents # 77, # 82, # 83, # 89 and # 90's bathrooms. Interviews during room observations on 06/10/26 from 9:00 A.M. to 10:00 A.M. with Maintenance Director # 423 and Housekeeping Director # 515 confirmed live cockroaches in the residents' rooms.Review of pest control service reports for May 2026 to June 2026 revealed no resident rooms on the 400 hall were treated for cockroaches. Review of facility policy titled Pest Control last revised May 2008 revealed the facility shall maintain an effective pest control program and the facility shall maintains an ongoing pest control program to continuously eliminate any insects and rodents. This deficiency represents non-compliance investigated under Complaint Number 3039203 and 3013766.

Based on record review, interviews and facility policy review, the facility failed to ensure visitation rights for Resident #33 were honored. This affected one of three residents reviewed for visitations. The facility census was 96.Findings include: Review of Resident #33's record revealed an admission date of 04/28/20 with diagnoses that included but were not limited to schizoaffective disorder, cerebral infarction and Parkinson's disease Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12. The resident was assessed to require supervision assistance from staff with toileting, transfers and personal hygiene. Review of Progress notes revealed an activity preference note dated 03/26/26 stating resident enjoys visits form her family and going on outside family visits. Interview with Resident #33 on 06/10/26 at 2:30 P.M. revealed she enjoyed it when her sister visited and wanted her to visit. Interview on 06/10/26 at 2:50 P.M. with the Administrator revealed she banned SR # 33's sister from visiting in March 2026 after an incident involving the family member and staff despite any formal or legal documents to prevent the family member from visiting. Administrator also confirmed Resident #33 still desired to visit with her sister and no accommodations had been made. Review of the facility policy titled Visitation dated November 2025 revealed residents are permitted to have visitors of their choice at the time of their choosing and the facility provides access for individuals visiting with the consent of the resident. This deficiency represents non-compliance investigated under Complaint Number 3039203 and 3013766.

Based on interview, review of infection control log, review of personnel files, review of tuberculosis (TB) risk assessment and review of facility policy the facility failed to ensure comprehensive surveillance of facility infections and failed to ensure staff had completed initial and annual TB screening. This affected 12 of 12 residents (#6, #18, #20, #24, #27, #37, #38, #44, #48, #54, #61, #96) reviewed on the infection control log for the months of February 2026 and March 2026. This had the potential to affect 95 residents of 95 residents residing in the facility.Findings include:1.Review of the infection control log for January 2026, February 2026, and March 2026 revealed it did not contain sufficient information. The log indicated the resident name, the room number, the date, the type of infection, the antibiotic, and whether or not the infection was facility acquired. The log did not indicate the type of bacteria, whether symptoms were present, or whether or not infections met McGeer's Criteria. Additionally, it was unclear if the date was the onset of the infection or the day the antibiotics were started. a. Resident #48 who admitted on [DATE], was given ciprofloxacin for a respiratory infection.b. Resident #24 who admitted on [DATE], was given Keflex for post-surgery.c. Resident #96 who admitted on [DATE], was given Macrobid for a UTId. Resident #27 who admitted on [DATE], was given azithromycin for respiratory infection.e. Resident #18 who admitted on [DATE], was given amoxicillin for a tooth infection.f. Resident #44 who admitted on [DATE] was given doxycycline for skin infection.g. Resident #61 who admitted on [DATE] was given ciprofloxacin for pneumonia.2.Review of the infection control log for March 2026 revealed the facility tracked the residents who received antibiotics during the month. It included the residents name, room number, date, type of infection, antibiotic, nosocomial, and community acquired. McGeer's criteria was not included, but was provided separately by the facility for some residents. However, review of the McGreer's form revealed it did not match current McGeer's Criteria. The following residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGeer's criteria infections:a. Resident #48 who admitted on [DATE], was given augmentin for an unknown infection.b. Resident #20 who admitted on [DATE], was given ceftriaxone for pneumonia.c. Resident #37 who admitted on [DATE], was given Keflex for post-surgery.d. Resident #38 who admitted on [DATE], was given vancomycin for sepsis.e.Resident #6 who admitted on [DATE], was on Keflex for a wound infection.f. Resident #54 who admitted on [DATE], was on keflex for a UTI.Interview on 04/02/26 at 9:28 A.M. and 11:17 A.M. with Charge Nurse #39 revealed the Director of Nursing (DON) was the infection preventionist and he was unavailable at the time of the survey. However, she verified the infection control log did not track the bacteria, symptoms, or whether or not McGeer's criteria was met. Charge Nurse #39 was unsure what the date indicated on the log would mean.Review of the policy 'Infection Prevention and Control Program' revised December 2025 revealed surveillance data is used to measure the effectiveness of the infection prevention and control program. Outcome surveillance collects data that indicates the presence of infections, communicable diseases, and antibiotic usage among residents. Data that can be used includes monitoring residents with signs of infection, laboratory cultures or diagnostic test results, antibiotic orders, medication regimen review reports, documentation from the clinical record of residents with suspicion of an infection, and the infection status on transfer and discharge summaries for new or readmitted residents. The data collection instruments were chosen or created by the infection preventionist and approved by the infection prevention and control committee and the medical director.3.Review of the personnel file for Certified Nurse Aide (CNA) #88 revealed a hire date of 06/23/25. There was no evidence an initial two-step Mantoux was completed.Review of the personnel file for Housekeeper #91 revealed a hire date of 02/26/25. There was no evidence of annual TB screening.Review of the personnel file for Housekeeper #98 revealed a hire date of 04/24/25. There was no evidence of annual TB screening.Review of the personnel file for CNA #38 revealed a hire date of 07/22/25. There was no evidence of annual TB screening.Review of the personnel file for Licensed Practical Nurse (LPN) #21 revealed a hire date of 09/26/17. There was no evidence of annual TB screening.Review of the personnel file for Housekeeper #112 revealed a hire date of 08/26/16. There was no evidence of annual TB screening.Interview on 04/02/26 at 3:15 P.M. with the Administrator revealed the Director of Nursing (DON) was responsible for maintaining evidence of staff initial and annual tuberculosis screening. The DON was unavailable and they were unable to find this evidence.Review of facility policy 'Tuberculosis Infection Control Program' dated August 2019, revealed the facility was to screen and surveil residents and employees for latent tuberculosis infection and active TB as appropriate for the current risk classification.Review of the 'TB risk assessment worksheet' revealed the facility screened healthcare workers including nurses, contract staff, and janitorial staff. They performed a baseline two-step test for healthcare workers and tested annually. These records were to be maintained by human resources.

Based on observation, interviews, and review of facility policy, the facility failed to ensure the common areas, resident rooms, and kitchen were free from pests. This had the potential to affect all 95 residents residing in the facility. Facility census was 95. 1.Observation on 03/30/26 at 10:10 A.M. of live cockroaches in Resident #24's room. Upon opening the bathroom door observation of live cockroaches on toilet seat. Interview on 03/30/26 at 10:10 A.M. with Resident #24 revealed she sees them all the time, she has seen them on her bed and crawling from under her bed. Observation on 03/30/26 at 10:45 A.M. of live cockroaches in Resident #12's room. Upon entering resident #12's room a live cockroach was observed crawling across the floor. Interview on 03/30/26 at 10:45 A.M. with Resident #12 revealed he sees them all the time. He stated they spray and try to get rid of them. Interview on 03/30/26 at 10:46 A.M. with LPN #102 verified the live cockroaches and stated the facility has had an ongoing issue but it is difficult to get rid of them. Interview on 03/30/26 at 11:00 A.M. with CNA #69 revealed several of the residents have cockroaches in the rooms, but due to the cleanliness and behaviors of the residents it is hard to get rid of them. Review of pest control invoices from August 2024 through March 2026 revealed on 05/06/25 activity was noticed of German cockroaches inside the kitchen area; on 08/20/25 minimal signs of cockroach activity inside the break room, sink areas, inside of water, cooler areas, and behind fridge inside of break room areas; on 01/22/26 Maintenance Supervisor # 89 mentioned the hallways and kitchen are seeing heavier activity of roaches; on 02/23/26 roaches still present, waiting on a quote for roaches treatment to be approved; and on 03/24/26 service technician was given a list of units to perform a gel baiting treatment for roaches. Interview on 04/01/26 at 9:13 A.M. with Maintenance Supervisor #89 verified there has been cockroach issues and they have monthly pest control completed. They had an estimate completed for around $15,000, but it is difficult to get all residents off one hall at a time out of their rooms due to the behaviors, but they are waiting for it to be approved. Review of facility policy titled Pest Control dated May 2008 revealed this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. 2. Observation on 03/30/26 at 6:37 A.M. during the initial tour of the kitchen revealed a light brown, six-legged insect consistent in appearance with a cockroach crawling on the wall to the right of the walk-in fridge. The insect crawled out of sight before it could be verified by staff. No other observations of insects or other pests through the end of the tour around 7:10 A.M. Interview on 04/01/26 at 11:10 A.M. with Cooks #44, #71, and #109 confirmed they have occasionally seen roaches or other insects (flies, gnats, etc.) in the kitchen and attributed it to a hazard of working in a commercial kitchen. Cooks #44, #71, and #109 denied evidence of infestations in the kitchen. Observation on 04/01/26 at 11:36 A.M. during lunch preparation in the kitchen revealed a light brown six-legged insect consistent with a cockroach on the shelf directly below the cutting surface of the steam table. Activities Director and Dietary Manager (AD/DM) #50 was alerted to the presence of the insect. AD/DM #50 put on a glove and used a disposable towel to dispose of the insect in the trash, then used sanitizer to clean the area. AD/DM #50 stated she believed it was a roach and has seen one or two in the kitchen from time to time. AD/DM #50 denied current infestation. 3. Observation on 03/31/26 at 10:02 A.M. revealed one six-legged insect outside Resident #66's room, with no staff nearby to verify the observation. The appearance of the insect was consistent with that of a cockroach. Further observation at this time revealed the insect went under the door into the resident's room while the resident was sleeping. Interview on 03/31/26 at 5:15 P.M. with the administrator revealed the facility has switched pest control companies several times during his time at the facility, and they are working towards improving the pest situation in the facility. Further interview with the administrator revealed he could not speak to specific interventions for addressing cockroaches in the facility. Observation on 04/01/26 at 7:56 A.M. revealed one dead insect was on the floor in Resident #70's bathroom directly in front of the toilet, the appearance of the insect was consistent with a cockroach and resembled a larger version of the same type of insect observed outside of Resident #66's room on the day prior. This observation was verified by Licensed Practical Nurse (LPN) #102 at the time of observation. Interview on 04/01/26 at 10:54 A.M. with LPN #102 revealed they have seen bugs similar to the one observed earlier in Resident #70's room for at least the last couple of months. Further interview revealed this issue had started to improve for some time after cleaning and extermination companies came out, but this has since worsened again. Further interview with LPN #102 revealed that residents in the facility are sometimes hiding foods in their rooms, often with open containers which they think may relate to the insect presence throughout the building. This deficiency represent noncompliance investigated under Complaint Number 2787253.

Based on observation, interview and review of facility policy the facility failed to maintain a clean, sanitary and pest free living environment for the residents. This affected six residents (Resident #9, #12, #18, #22, #24, and #84) of 95 residents reviewed for environment. The facility census was 95. Findings include:Findings include:Observation 03/30/26 at 9:16 A.M. of Resident #22's room revealed several holes on the top of the mattress and one bigger hole on the side of the mattress facing the doorway. The bathroom vanity was observed with rotted wood at the bottom. Observation on 03/30/26 at 10:10 A.M. of Resident #18's room revealed the floor was very dirty, his bed frame was coated with dust and food particles and the shower doors in the bathroom were removed from the tracks and sitting inside the shower.Observation on 03/30/26 at 10:53 A.M. of Resident #84's room revealed dried feces on the floor and bed and the shower doors in the bathroom were removed from the tracks and sitting inside the shower.Observation on 03/30/26 at 12:06 P.M. of Resident #24's room revealed the bed frame was dirty with food stains.Coackroaches were observed coming from her toilet after the bathroom door was opened and observed crawling across the floor. They resident stated the cockroaches are everywhere and it had started to piss her off because the facility should be doing something about the cockroaches.Observation on 03/30/26 at 12:28 P.M. of Resident #12's room revealed the bed frame was dirty with food stains and dust and the window sill was damaged with wood exposed.Interview on 03/30/26 at 2:16 P.M. with Resident #9's representative revealed the facility was not clean and had issues with cockroach infestation.Interview on 04/01/26 at 9:15 A.M. with Maintenance Supervisor #89 and Housekeeping Supervisor #52 verified the environmental and housekeeping issues.Review of facility policy titled Homelike Environment dated February 2021, revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment .This deficiency represents non-compliance investigated under Complaint Number 2787253.

Based on observations, interviews with nursing staff, and review of the facility provided glucometer policy, the facility failed to ensure glucometers (blood sugar measuring devices) were properly calibrated with control solutions that were not expired on two separate resident halls (200 and 400 halls) of the facility. This had the potential to affect 10 residents (#23, #60, #90, #2, #71, #41, #32, #24, #39, and #26) on the two affected halls out of a total of 18 facility identified residents that require blood sugar checks. The facility census was 95.Findings include: Based on observations, interviews with nursing staff, and review of the facility provided glucometer policy, the facility failed to ensure glucometers (blood sugar measuring devices) were properly calibrated with control solutions that were not expired on two separate resident halls of the facility. This had the potential to affect 10 residents (#23, #60, #90, #2, #71, #41, #32, #24, #39, and #26) on the two affected halls out of a total of 18 facility identified residents that require blood sugar checks. The facility census was 95.Observation on [DATE] at 12:04 P.M. of the medication cart for the 400 hall revealed a box of Assure Prism branded glucometer control solutions kept in the medication cart had an expiration date of [DATE]. This was the only box of glucometer control solutions observed in the same drawer of the medication cart that held the glucometer, lancets, and other blood glucose monitoring supplies. Interview on [DATE] at 12:05 P.M. with Registered Nurse (RN) #15 verified that the glucose control solutions were expired and should not be used for testing the glucometer. Further interview with RN #15 at this time revealed quality control (QC) measures of the glucometer with the control solutions happens every night shift and the control solutions should be checked to make sure they are not expired before use. Observation on [DATE] at 12:33 P.M. of the medication cart for the 200 hall revealed two bottles of Assure Prism branded glucometer control solutions that were expired. These solutions were kept in the medication cart directly next to the glucometer, lancets, and other glucose monitoring supplies, and they were the only quality control solutions in this drawer of the medication cart. The green bottle of control solution was labeled with an expiration date of [DATE], and the blue bottle of control solution was labeled with an expiration date of [DATE]. Interview on [DATE] at 12:35 P.M. with RN #115 confirmed that both bottles of control solutions for the glucometer held in the medication cart for the 200 hall were expired. Further interview with RN #115 revealed night shift nursing staff has the responsibility of using the control solutions to test the glucometers in the facility. Review of the facility provided policy for the glucometers used in the facility, titled Assure Prism Multi Blood Glucose Monitoring System revealed the expiration dates printed on the bottles of Assure Prism Glucose Control Solutions should be checked prior to using the control solution to test the glucometer. Further review of this policy revealed bottles of control solution that are past their printed expiration date should be discarded.

Based on interview, medical record review, review of facility infection control log, review of facility policy, and review of National Healthcare Safety Network (NHSN)'s report, the facility failed to ensure antibiotic stewardship was followed. This affected one resident (#84) of one resident reviewed for urinary tract infection (UTI) and 12 of 12 residents (#6, #18, #20, #24, #27, #37, #38, #44, #48, #54, #61, #96) reviewed on the infection control log for the months of February 2026 and March 2026. The facility census was 95.Findings include: 1.Review of the infection control log for February 2026 revealed the facility tracked the residents who received antibiotics during the month. It included the residents name, room number, date, type of infection, antibiotic, nosocomial, and community acquired. McGeer's criteria was not included, but was provided separately by the facility for some residents. However, review of the these forms revealed it did not match current McGeer's Criteria. The following residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGeer's criteria for infections: a. Resident #48 who admitted on [DATE], was given ciprofloxacin for a respiratory infection. Review of Resident #48's 'minimum criteria for initiating antibiotics for skin and soft tissue infection' dated 02/05/26 revealed the resident had a productive cough and a respiratory rate above 25 breaths per minute. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for an upper respiratory infection. The facility form did not have the correct parameters for beginning an antibiotic. b. Resident #24 who admitted on [DATE], was given Keflex for post-surgery. The facility was unable to provide McGeer's criteria for Resident #24 for February 2026. c. Resident #96 who admitted on [DATE], was given Macrobid for a UTI Review of Resident #96's 'minimum criteria for initiating antibiotics for a UTI' revealed the resident had urgency and frequency. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for a urinary system infection. The facility form did not have the correct parameters for beginning an antibiotic. d. Resident #27 who admitted on [DATE], was given azithromycin for respiratory infection. Review of Resident #27's 'minimum criteria for initiating antibiotics for a lower respiratory tract infection' revealed the resident had a productive cough. Someone had marked that the resident met criteria for antibiotic use, however, the resident did not meet the criteria outlined on the form. e. Resident #18 who admitted on [DATE], was given amoxicillin for a tooth infection. The facility was unable to provide McGeer's criteria for Resident #18 for February 2026. f. Resident #44 who admitted on [DATE] was given doxycycline for skin infection. Review of Resident #44 'minimum criteria for initiating antibiotics for skin and soft tissue infection' dated 02/26/26 revealed the resident had redness and tenderness. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for a skin infection. The facility form did not have the correct parameters for beginning an antibiotic. g. Resident #61 who admitted on [DATE] was given ciprofloxacin for pneumonia. Review of Resident #61's 'minimum criteria for initiating antibiotics for a lower respiratory tract infection' revealed the resident had a productive cough and a new infiltrate on a chest x-ray thought to represent pneumonia. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for a respiratory infection. The facility form did not have the correct parameters for beginning an antibiotic. 2.Review of the infection control log for March 2026 revealed the facility tracked the residents who received antibiotics during the month. It included the residents name, room number, date, type of infection, antibiotic, nosocomial, and community acquired. McGeer's criteria was not included, but was provided separately by the facility for some residents. However, review of the McGreer's form revealed it did not match current McGeer's Criteria. The following residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGeer's criteria infections: a. Resident #48 who admitted on [DATE], was given augmentin for an unknown infection. The facility was unable to provide McGeer's criteria for Resident #48 for March 2026. b. Resident #20 who admitted on [DATE], was given ceftriaxone for pneumonia. Review of Resident #20's 'minimum criteria for initiating antibiotics for a lower respiratory tract infection' revealed the resident had a productive cough and a new infiltrate on a chest x-ray thought to represent pneumonia. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for a respiratory infection. The facility form did not have the correct parameters for beginning an antibiotic. c. Resident #37 who admitted on [DATE], was given Keflex for post-surgery. The facility was unable to provide McGeer's criteria for Resident #37 for March 2026. d. Resident #38 who admitted on [DATE], was given vancomycin for sepsis. The facility was unable to provide McGeer's criteria for Resident #37 for March 2026. e.Resident #6 who admitted on [DATE], was on Keflex for a wound infection. The facility was unable to provide McGeer's criteria for Resident #6 for March 2026. f. Resident #54 who admitted on [DATE], was on keflex for a UTI. Review of Resident #54's 'minimum criteria for initiating antibiotics for a UTI' revealed the resident had superapubic pain and urinary incontinence. It was indicated this was sufficient and the resident met criteria for antibiotic use. The form indicated it referenced McGeer's definitions of infection. Review of National Healthcare Safety Network (NHSN)'s report 'Centers for Disease Control (CDC)/NHSN Surveillance Definitions for Types of Infection' dated January 2026, revealed this was not sufficient to begin an antibiotic for a urinary system infection. The form did not have the correct parameters for beginning an antibiotic. Interview on 04/02/26 at 9:28 A.M., 11:17 A.M. and 1:32 P.M. with Charge Nurse #39 revealed the Director of Nursing (DON) was the infection control designee and was unavailable. She revealed the facility should be using McGreer's to determine antibiotic use. However, she verified the form they were using to determine if antibiotic criteria was met did not match the McGeer's criteria. She was unsure where the form came from. She was unable to provide additional information on the missing McGreer's assessments. Charge Nurse #39 additionally verified some residents on antibiotics did not even meet the criteria on the from. Review of the policy 'antibiotic stewardship' dated 11/05/20, revealed residents must meet the minimal criteria for initiation of antibiotics in long term care to be placed on antibiotics. 3.Review of the medical record for Resident #84 revealed an admission date of 09/06/24 with diagnosis including adult failure to thrive, schizoaffective disorder, narcolepsy without cataplexy, and other drug induced secondary parkinsonism. Review of the physician's orders revealed an order for Bactrim DS (antibiotic) 800/160 (mg) twice daily for 10 days dated 01/04/26. Review of the medical record revealed progress notes dated 12/29/25 revealed Resident #84 with signs and symptoms of agitation, excited, seeking, and pacing the hallway. The psych NP was notified and an order for urinalysis was ordered. Further review of the progress notes revealed no urinary symptoms. Review of Resident #84's urinalysis 12/31/25 revealed positive for Escherichia coli (bacteria). Review of the facility McGeer's Criteria form dated 06/15/12 revealed resident must have at least three of the following signs and systems: fever or chills, new or increased burning pain on urination, frequency or urgency, may be new or increased incontinence, new flank or suprapubic pain or tenderness, change in character of urine, and worsening of mental or functional status. Interview on 04/02/26 at 1:35 P.M. with RN #39 verified Resident #84 did not meet McGeer's criteria for antibiotic treatment for a urinary tract infection. Review of facility policy titled Antibiotic Stewardship Policy, dated 11/05/20 revealed residents must meet the minimal criteria for initiation of antibiotics in long term care for residents to be placed on an antibiotic.

Based on interview and medical record review the facility failed to ensure Resident #6's Minimum Data Set (MDS) 3.0 assessment accurately reflected their wound status. This affected one resident (#6) of one resident reviewed for skin conditions. The facility census was 95. Review of Resident #6's medical record revealed an admission date of 12/06/24 with diagnoses including adult failure to thrive, unspecified open wound of the right lower leg, unspecified dementia, type two diabetes mellitus, schizoaffective disorder, unspecified psychosis, antisocial personality disorder, delusional disorder, and conduct disorder. Review of Resident #6's comprehensive Minimum Data Set (MDS) 3.0 assessments dated 08/12/25, 11/03/25, and 02/03/26 revealed the resident had intact cognition. No skin issues were marked in the MDS assessment.Review of Resident #6's wound assessment dated [DATE] revealed the resident had cellulitis to her right leg that had been present since 12/08/24.Interview on 04/02/26 at 12:45 P.M. with Registered Nurse (RN) #40 verified Resident #6's chronic wound had not been marked on her MDS assessments and should have been.

Based on observation, interview, medical record review, review of activity documentation, and review of facility policy, the facility failed to complete activities according to preference for Resident #18. This affected one (Resident #18) of one residents resident reviewed for activities. The facility census was 95. Findings include:Findings include:Review of the medical record for Resident #18 revealed an admission date of 03/21/24 with diagnosis including dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizoaffective disorder, bipolar type, high risk sexual behavior, obsessive compulsive personality disorder, and auditory hallucinations. Review of the care plan for Resident #18 dated 03/28/24 revealed resident presents with altered mood state which may adversely affect participation in activities of interest related to confusion, auditory hallucinations, and schizoaffective disorder-bipolar type. Interventions included: diversional activities that stimulate pleasant memories such as reminiscing about life accomplishments, diversional activities that stimulate pleasant memories such as group sing along, 1:1 visits as needed, small activities outside of room as needed, and encourage resident to come outside of room to participate in activities of interest. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 and Resident #18 prefered to do things with a group of people.Review of the medial record for Resident #18 of an activities assessments dated 12/08/25, and 02/23/26 revealed the resident's favorite activities included: rummy, basketball, music, walking, calling family and family visits. Resident #18 attended group activities three times a week chat session, bingo, watching tv, cards, movies, patio time, smoking, and church service. Resident #18 was actively involved in these activities.Review of the daily activity documentation for Resident #18 for December 2025 revealed he did not attend bingo, cards/games, music listening or music programs or party/social hour.Review of the daily activity documentation for Resident #18 for January 2026 revealed he did not attend bingo, cards/games, music listening or music programs or party/social hour.Review of the daily activity documentation for Resident #18 for February 2026 revealed he attended bingo twice, cards/games was crossed out and fun foods was put in place and he did not attend music listening or music programs or party/social hour.Review of the daily activity documentation for Resident #18 for March 2026 revealed he did not attend bingo, he attended cards/games once, and he did not attend music programs or party/social hour.On 03/31/26 at 10:00 A.M. interview with Resident #18 revealed he doesn't do much related to activities. The resident's room did not have items indicative of self-driven activities. On 04/01/26 ay 8:30 A.M. Resident #18 was observed, in bed, with his eyes closed.Interview on 04/01/2026 at 9:06 A.M. with Activities #59 revealed activities complete activity documentation in a book that is kept on the hall. The facility had 1:1 activities for some people, it depended on their preferences and the day due to the behaviors. Interview on 04/01/26 at 1:02 P.M. with Activity Director #50 revealed resident preferences were based off interviews with the resident or family members. She completes an assessment and, in that assessment, the resident preferences are indicated. Activity Director #50 could not verify the resident received activities per resident preference. Interview on 04/01/26 at 1:15 P.M. with MDS #53 revealed she completed the activity care plan based on the activity director's progress note/assessment. MDS #53 verified the care plan did not indicate resident preferred activities.Review of the facility policy titled Activities and Social Services, revised December 2006 revealed residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. When the care planning team develops the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care.

Based on record review, interview and review of facility policy the facility failed to ensure nutritional recommendations were addressed and meal intakes were adequately monitored. This affected one resident (#88) of three residents reviewed for nutrition. The facility census was 95.Findings include:Review of the medical record for Resident #88 revealed an admission date of 03/17/21 with diagnoses including metabolic encephalopathy, unspecified dementia, severe, with other behavioral disturbance, extrapyramidal and movement disorder, paranoid schizophrenia, schizoaffective disorder, dysphagia, muscle wasting and atrophy, and vitamin D deficiency. Review of the care plan dated initiated 03/29/21 revealed altered nutritional status as evidenced by obesity, history of dysphagia, paranoid schizophrenia, gastroesophageal reflux disease, depression, recent and history of weight loss, recent and history of poor intake, history of weight fluctuations and mechanically altered diet. Interventions included monitor and record oral intake at meals and report weight loss/gain of 5% or more to medical director (MD) and registered dietician licensed dietician (RDLD).Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed moderate cognitive impairment and indicated weight loss, not on a prescribed weight loss regimen, receiving a mechanically altered diet and not on a therapeutic diet.Review of weights for Resident #88 revealed on 09/04/25 a weight of 193 pounds (lbs.) and on 03/02/26 a weight of 163.8 lbs. which indicates a 15.13% weight loss.Review of the resident's meal percentages for October 2025 revealed no documented meal percentage intakes for 10/02/25 and 10/05/25 for dinner and 10/08/25, 10/11/25, 10/12/25, 10/14/25, 10/15/25, 10/19/25,10/21/25, 10/22/25, 10/23/25, 10/24/25, 10/27/25, 10/28/25,10/29/25, and10/31/25 for breakfast, lunch and dinner. Review of the resident's meal percentages for November 2025 revealed no documented meal percentage intakes for 11/1/25, 11/02/25, 11/04/25, 11/05/25, 11/06/25, 11/07/25, 11/12/25, 11/14/25, 11/16/25, 11/18/25, 11/19/25, 11/20/25, 11/22/25, 11/23/25, 11/26/25, 11/27/25, and 11/30/25 for breakfast, lunch and dinner. Review of the Dietician # 105's significant weight change report dated 02/18/26 revealed Resident #88 may benefit from Remeron (anti-depressant also used for an appetite stimulant). The Nurse Practitioner reviewed on 02/23/26 but there was no order for the recommendation.Review of Resident #88's physicians orders revealed an order dated 03/23/26 for Remeron 7.5 mg (milligrams).Interview on 04/02/26 at 1:50 P.M. with Dietician #105 revealed she reviews meal intakes and if observed missing meal percentages she notifies the administrator. Dietary recommendations are made by the situation. If there is a medication recommendation such as Remeron she notifies the NP (nurse practitioner). Dietician #105 stated the facility does not have nutrition at risk meetings. Dietician #105 verified that the NP was notified. and no follow up was completed and the Remeron was not ordered until 03/23/26. Review of facility policy titled Food and Nutrition Services, dated October 2017 revealed nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems.

Based on resident record reviews and staff interviews, the facility failed to ensure Residents #5 and #13's falls were accurately documented in the medical record and failed to ensure Resident #6's wound notes were accurate, and treatment documentation was complete. This affected three residents of 24 residents reviewed for accuracy of medical records and documentation. The facility census was 95.Findings include:1. Review of Resident #5's medical record revealed an admission date of 05/22/17. She had diagnoses that included undifferentiated schizophrenia, vascular dementia with behaviors, and history of cerebral infarction. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment completed on 03/17/26 revealed Resident #5 was cognitively intact and displayed no signs or symptoms of depression, delirium, psychosis, or rejection of care during the review period. Further review of the MDS assessment revealed Resident #5 was independent moving from a sitting to standing position and required supervision or touching assistance with transfers from a chair or bed to a chair. Resident #5 was independently mobile with the use of a manual wheelchair. Review of the facility's fall log revealed Resident #5 had a fall with a major injury on 01/17/26 and a fall with a minor injury on 01/24/26. Review of nursing progress notes of the fall on 01/17/26 revealed Resident #5's roommate alerted staff on 01/17/26 around 11:00 P.M. that Resident #5 had fallen and was on the floor. Resident #5 stated she had fallen when she got up to use the restroom and fell. Resident #5 stated she had pain in her left arm and wrist. Resident #5 was assessed by the nurse and noted some redness to the left wrist but no other apparent injury. Following the assessment, Resident #5 was returned to her bed and was started on 15-minute neurological checks. The facility's on-call physician was notified, and new orders were given for an x-ray of the left arm and wrist. Results of the x-ray returned on 01/18/26 around 12:36 P.M. and a moderately displaced transverse fracture of the left distal radial metaphysis. Resident #5 was then sent to the emergency room and returned to the facility same day with a splint on her left wrist. Review of the nursing progress notes for the fall on 01/24/26 revealed Resident #5 fell around 10:30 P.M. in her room when attempting to transfer from her wheelchair to her bed and had a laceration to the left side of her head. The nurse assessed Resident #5 and called the on-call physician who wrote orders for the wound to be cleaned. Resident #5 was returned to her bed, re-educated to turn on her light if she gets up in the dark or to press her call light for assistance. Review of the incident/accident report for the fall on 01/17/26 revealed the location of injury diagram did not indicate the pain and redness Resident #5 felt in her left arm and wrist. Review of the incident/accident report for the fall on 01/24/26 revealed the location of injury diagram did not indicate the laceration to Resident #'5 left temporal area. 2. Review of Resident #13's medical record revealed an admission date of 09/03/25. He had diagnoses that included bipolar disorder, chronic obstructive pulmonary disorder, and mild cognitive impairment. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment completed on 02/23/26 revealed Resident #13 had severe cognitive impairment and displayed no signs or symptoms of depression, delirium, psychosis, or rejection of care during the review period. Further review of the MDS assessment revealed Resident #13 was dependent on staff for all cares including dressing, bathing, and personal hygiene. Resident #13 was dependent on staff for all positioning, transfers, and mobility in his manual wheelchair. Review of the facility's fall log revealed Resident #13 had a fall with a minor injury on 02/22/26. Review of the nursing progress notes revealed no notes on 02/22/26 describing Resident #13's fall. The next nursing progress note was time stamped for 02/24/26 at 11:24 A.M., which stated that a new intervention was put in place for Resident #13 to be within sight of staff when out of bed as tolerated following his fall on 02/22/26. Interview on 04/02/26 at 10:14 A.M. with MDS Nurse #40 confirmed that the incident/accident report for Resident #5's falls on 01/17/26 and 01/24/26 should have indicated the injuries from the falls. MDS Nurse #40 also confirmed that there should have been a nursing progress note describing Resident #13's fall on 02/22/26. 2. Review of Resident #6's medical record revealed an admission date of 12/06/24 with diagnoses including adult failure to thrive, unspecified open wound of the right lower leg, unspecified dementia, schizoaffective disorder, unspecified psychosis, antisocial personality disorder, delusional disorder, and conduct disorder. Review of Resident #6's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #6's progress note dated 01/27/26 revealed she graduated from hospice. Review of Resident #6's skin progress notes dated 01/29/26, 02/05/26, 02/12/26, 02/19/26, 02/26/26, 03/05/26, and 03/12/26, revealed it was indicated the resident was on hospice. Review of Resident #6's physician order from 01/29/26 to 02/05/26 revealed an order to cleanse the right back calf and open area on right ankle with acetic acid 0.25%, pat dry and apply triad-soaked gauze to the wound bed. The whole area was to be covered with super absorbent dressing and wrapped with kerlix gauze twice. Review of Resident #6's physician order from 02/05/26 to 02/26/26 revealed an order to cleanse the open area to the back of the right calf and open area on the right ankle with 0.25% Dakin's, pat dry, then apply triad-soaked gauze to the wound bed. The whole area was to be covered with super absorbent dressing and wrapped with Kerlix twice a day. Review of Resident #6's February Medication Administration Record (MAR) revealed wound treatment was not done in the morning on 02/01/26, 02/03/26, 02/05/26, 02/09/26, 02/10/26, 02/23/26 and 02/26/26. Review of Resident #6's physician order dated 03/02/26 revealed an order to cleanse the open area to the back of the right calf and open area on the right ankle with 0.25% Dakin's, pat dry, then apply triad-soaked gauze to the wound bed. The whole area was to be covered with super absorbent dressing and wrapped with kerlix gauze twice. Review of Resident #6's March MAR revealed wound treatment was not done on 03/15/26, 03/16/26, and 03/17/26. Interview on 04/02/26 at 2:00 P.M. with Charge Nurse #70 verified Resident #6 was no longer on hospice and her notes should not indicate that she was. Additionally, she reported that Resident #6 received her dressing changes as ordered, however, they had a nurse who forgot to document the treatments she completed.

Based on medical record review, review of hospital documents, observation, Local Health Department (LHD) interview, staff interview, and review of facility policy, the facility failed to have an effective water management and legionella prevention plan and further failed to implement recommended legionella mitigation strategies to prevent the potential spread of Legionella pneumonia. This had the potential to affect all 94 residents residing in the facility. The facility census was 94. Findings include:Review of the medical record for Resident #88 (SR) revealed an admission date of 09/23/21. Diagnoses included cerebral infarct (stroke), diabetes, hemiplegia and hemiparesis, anxiety, cardiac arrhythmia, dysphagia, and weakness. Further review of the medical record revealed the resident was treated for pneumonia at the facility and sent to the hospital on [DATE] for further evaluation and treatment.Review of the hospital lab results, dated 10/03/25, revealed Resident #88 tested positive from a urinalysis test for legionella (bacteria that can cause a severe form of pneumonia). Further review of a hospital note dated 10/14/25 revealed Resident #88 was admitted with altered mental status and found to have acute respiratory failure and sepsis secondary to Legionella pneumonia. The note stated septic shock developed after admission and the hospital stay had been complicated with a diagnosis of atrial fibrillation (a-fib) with rapid ventricular response (RVR) and continued diuresis (increase production and excretion of urine) for pulmonary edema. Review of the facility policy and procedure titled, Reducing Legionella Risk and Transmission, dated June 2017, revealed legionella could cause pneumonia. It was the policy to reduce the risk of growth and spread of legionella through assessment identification, prevention, monitoring, reporting, investigating, and controlling infections and communicable diseases. The policy stated the facility should analyze and assess areas of risk with considerations of water temperatures, stagnation, no usage of disinfectants and conditions for bacteria spread. Prevention and monitoring mechanisms could include periodic disinfectants through usage of chemicals and consider testing residents for legionella when they develop pneumonia. If an infection was confirmed, the facility should complete an investigation including auditing and identification of the potential origin for the legionella. The facility should consider restricting water in the facility or other immediate control measures. Review of the Legionella Risk Assessment, dated November 2017, revealed the document was completed to reduce the growth and spread of legionella. The action plan included the weekly flushing of all faucets not in frequent use, all eye wash stations, all shower heads, and all bathtub faucets; all hot water tanks should be flushed bi-monthly; and the ice machine filter should be changed every six months. The risk assessment tool included no ranges or instructions of what to do if the measures were out of appropriate ranges. Review of the facility's Water Management Plan, undated, revealed a diagram of the water system. It stated, The diagram below shows which types of monitoring could occur at different locations within the facility water system to reduce spread of legionella. The diagram included upon entrance to the facility from [NAME] Avenue, a visual inspection and disinfectant levels should be completed; the ice machine in the dining room should have visual inspections; the water heaters for the resident rooms, the water heater for the kitchen, laundry and mechanical rooms, sinks and showers for the resident rooms and kitchen and laundry appliances should have temperature checks completed and sinks and showers should have disinfectant levels checked. Review of electronic mail (e-mail) communication between the facility Assistant Administrator (AA) #200 and the LHD revealed the facility notified the LHD on 10/06/25 of a resident with a positive legionella result. From 10/06/25 to 10/07/25, the e-mails discussed testing samples of the facility water sources. On 10/08/25, the LHD asked if facility had initiated water restrictions and asked, If yes, what specifically are you doing? The facility had no evidence this was responded to via e-mail. On 10/10/25, the LHD informed the facility they would be onsite for a consultation, stating the first priority was to protect current residents by restricting water usage or installing point of use filters. Interview on 10/14/25 at 2:20 P.M. with AA #200 revealed facility had a resident (#88) test positive for legionella while at the hospital. She reported the positive case was reported to both the LHD and the state health department (SHD). AA #200 stated the facility collected 13 samples from different areas of the facility and sent them to the lab for legionella testing. Interview on 10/14/25 at 3:00 P.M. with the Administrator revealed the facility completed flushes, monitored water temperatures, and changed the ice machine filter as outlined in the risk assessment, but they did not do chemical testing as the facility utilized city water. He also reported the facility had no bathtubs and no eye wash stations. Interview on 10/14/25 at 3:25 P.M. with the Administrator, AA #200 and the Director of Nursing (DON) revealed their contacts at the LHD requested they do a two-month look back for positive cases of pneumonia, test those residents for legionella, and send them their plan and auditing materials. The Administrator stated the facility had a good water management plan that was used by several other facilities. They reported they did everything they could think of and were waiting for final lab results. They acknowledged the emails on 10/08/25 and 10/10/25 with the LHD mentioned restricting water usage and using point of contact filters and verified neither of the recommended mitigation strategies were implemented. Interview on 10/14/25 at 3:40 P.M. with Maintenance Director (MD) #300 revealed he completed water temperature checks weekly and stated he attempted to keep the temperature between 110- and 120-degrees F. He also reported flushing the plumbing fixtures and the water heaters and conducted chlorine testing at the entry point of the building. He reported he was looking for chlorine levels between 0.5 parts per million (ppm) and 1.0 ppm and confirmed a few had been outside those levels at the beginning of the year. He reported the facility had no documentation of what steps were taken to address this but stated he called the city water department and retested after about one to two weeks. MD #300 had no evidence of any retesting being completed. MD #300 verified the facility did not restrict water usage in the facility following Resident #88's positive legionella test result and he was unaware of any plans to use filtration devices. Interview on 10/15/25 at 10:47 A.M. with LHD Staff (LHDS) #500 revealed they had spoken with facility staff and reviewed their overall water management plan. LHDS #500 stated if a facility had one positive legionella case, they should take water samples for testing. While waiting for the water testing results, the facility should restrict water usage for the water sources the affected resident had access to. LHDS #500 stated the facility should close the shower area and bathroom the affected resident had access to, especially if there was a roommate involved, or place filters on the water spickets. LHDS #500 stated the facility's legionella prevention plan was not thorough and did not include basic items such as visual inspections, chemical testing, taking temperatures and doing routine testing. They revealed they had planned to meet with facility later in the week and would be working with facility to improve their plan. LHDS #500 stated they recommended the facility work with a consultant. Observation on 10/15/25 at 10:55 A.M. of Resident #88's room confirmed the resident had a roommate who used the same bathroom, which was still in full use, without the installation of any filters. Concurrent interview with Certified Nurse Aide (CNA) #75 verified Resident #88 had a roommate and the bathroom remained operational, without the use of any filters. Additionally, CNA #75 confirmed the shower room used by Resident #88 was still in full use, without the use of filters on the water faucets. Continued observation of the shower room revealed the shower room floor was wet, as if a shower had recently been completed. No filters were observed on the shower faucet. Further observation revealed the shower room sink had an eye wash device on the faucet, with no filters observed. Observation on 10/15/25 at 11:47 A.M. revealed MD #300 completed a chlorine test of a water sample from the staff bathroom. MD #300 stated he was looking for a result of 0.5 ppm to 1.0 ppm. The result was 0.23 ppm. MD #300 stated he completed a test earlier to make sure it was in normal range and the chlorine level result at that time was 0.46 ppm. MD #300 redid the testing, shook the solution more vigorously, and confirmed the result was in the normal range. MD #300 stated there was an issue with the testing system as it did not instruct on a standard amount of time or how long to shake the solution prior to reading the result. Further interview with MD #300 verified the shower room had a functional eye wash station, although the facility stopped using them and used water bottles instead. Interview on 10/15/25 at 2:00 P.M. with the Administrator confirmed the facility's water management plan could have been more robust to address the legionella concerns. This deficiency represents non-compliance investigated under Complaint Number 2638537.

Based on observation and interviews, the facility failed to ensure sufficient support personnel to carry out the functions of the food and nutrition services. This had the potential to affect all 96 residents residing in the facility. Findings Include: On 06/30/25 observations during the breakfast meal on the 100 hallway revealed the resident's breakfast was served in disposable Styrofoam takeout containers and disposable Styrofoam cups. On 06/30/25 at 12:06 P.M., observation of the lunch meal in the dining room revealed the resident's drinks were served in Styrofoam cups. On 06/30/25 at 12:19 P.M., interview with the Dietary Manager (DM) #111 revealed when the dietary department was short staffed disposable containers and cups are used due to the cooks inability to assist with washing dishes. DM #111 verified the facility did not have sufficient staff for the food and nutrition services. On 06/30/25 at 12:21 P.M., observation of the lunch meal on the 400 hallway revealed the residents were served fluids in Styrofoam cups. On 06/30/25 at 12:23 P.M., an interview with Resident #20 revealed the dietary department always serves on disposable products. She said she prefers to eat/drink from dishes. She stated once in a while they may get a plate. On 07/02/25 during the lunch meal revealed the facility served drinks in Styrofoam cups. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation and interview, the facility failed to ensure an adequate supply of dishes to serve the residents of the facility. This had the potential to affect all 96 residents residing in the facility. Findings Include: On 06/30/25 observations during the breakfast meal on the 100 hallway revealed the resident's breakfast was served in disposable Styrofoam takeout containers and disposable Styrofoam cups. On 06/30/25 at 12:06 P.M., observation of the lunch meal in the dining room revealed the resident's drinks were served in Styrofoam cups. On 06/30/25 at 12:19 P.M., interview with the Dietary Manager (DM) #111 verified the facility does not have enough dishes to serve the residents and Styrofoam disposable containers/cups are utilized. On 06/30/25 at 12:21 P.M., observation of the lunch meal on the 400 hallway revealed the residents were served fluids in Styrofoam cups. On 06/30/25 at 12:23 P.M., an interview with Resident #20 revealed the dietary department always serves on disposable products. She said she prefers to eat/drink from dishes. She stated once in a while they may get a plate. On 07/02/25 during the lunch meal revealed the facility served drinks in Styrofoam cups. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation and staff interview the facility failed to provide a safe, sanitary and comfortable environment for resident in the resident rooms, hallways and bathrooms. This had the potential to affect all 96 residents residing in the facility. Findings include: 1. Review of the Resident Council Minutes from 04/22/25 revealed the residents requested more deep cleaning in their rooms. Also, Resident #32 had requested repairs to bed, blinds and her sink and toilet leaked. 2. Review of the Resident Council Minutes from 05/27/25 revealed Resident #82 reported a hole under her sink in the bathroom and Resident #32 reported again her sink and toilet were leaking leaking as well as Resident #7's sink was leaking. 3. Review of the Resident Council Minutes form 06/24/25 revealed Resident #82 again reported a hole under her bathroom sink. 4. On 06/30/25 at 10:53 A.M., observation of Resident #89's room revealed multiple areas of dry wall patches on the bathroom door and the room door handle was loose making the door difficult to close. 5. On 06/30/25 at 11:30 A.M., observation of the drain covers located on the 200 and 400 hallways revealed the covers were not secured to the floor posing an accident hazard. 6. On 07/01/25 at 10:54 A.M., observation of Resident #23's room revealed the wall on the left side of the bed had a large section of the paint missing with dry wall mud in the corner of the wall. 7. On 07/02/25 at 8:30 A.M., observations of the four resident hallways revealed all the doors had a black substance on them, and resident floors as well as the hallways had a build up of a black substance. On 07/01/25 at 09:50 A.M., interview with Registered Nurse (RN) #110 she knew the building needed repairs and deep cleaned. She verified the resident's were voicing concerns during resident council for maintenance concerns and they were not being addressed. The RN verified the wall behind Resident #23's bed should be repaired with a material that cannot be picked and in fact the facility had a smooth board they would place behind the bed for those residents that pick. On 07/02/25 at 11:23 A.M. interview with the Maintenance Director #187 revealed he had been off the past 10 days with COVID but was back to work as of 07/02/25. The Maintenance Director revealed he had gone and fixed the leaking sinks. This deficiency represents non-compliance investigated under Master Complaint Number OH00167030, Complaint Number OH00166963 and OH00165161.

Based on record review, observation, policy review, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity when indwelling urinary catheter collection bags were not covered when the residents were in bed and left visible from the hallway. Additionally, the facility also failed to ensure residents received non-disposable dishes during scheduled meals. This affected one resident (#31) of one resident reviewed for indwelling urinary catheters and one resident (#20) of five residents interviewed during the lunch meal. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 07/19/16 with the latest readmission of 05/10/25 with the diagnoses including but not limited to Parkinson's disease with dyskinesia, polyneuropathies, constipation, obstructive and reflux uropathy, hypertension, chronic kidney disease, chronic pain syndrome, hydrocele, psychotic disorder, restless leg syndrome, mood disorder, tachycardia, psychosis, developmental disability, gout, anemia, mood disorder, benign prostatic hyperplasia (BPH), intermittent explosive disorder, hallucinations, bladder neck obstruction, asthma, paranoid schizophrenia and borderline personality disorder. Review of the plan of care, not dated revealed the resident had a potential for alteration in urinary elimination related to obstructive uropathy, and potential inability to communicate needs, due to cognitive impairments with short term memory loss, impaired mobility, indwelling urinary catheter usage, history of BPH with obstruction, hydrocele, chronic kidney disease and recent urinary tract infection (UTI). Interventions included change indwelling urinary catheter as a whole unit every month as scheduled with prescribed size and balloon order on file and change as a unit routine or as needed, provide catheter care every shift and as needed, empty indwelling urinary catheter collection bag every shift and as needed, follow up with urology appointments as scheduled, indwelling urinary catheter irrigation of catheter as per most current physician order on file, 1500 milliliter (ml) fluid restriction non-compliance, monitor all labs as per current and routine physician orders on file, resident will allow indwelling urinary catheter collection bag cover to remain in place with the catheter itself and not remove the collection bag from the cover for it nor leave it in his room, staff to continue to monitor and remind him as appropriate, administer routine medications as per current physician order, keep call light within reach, remind resident to call for assistance. note any changes in amount, frequency, color or odor of urine, report any abnormalities to registered staff and treat UTI per physician order. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident had an indwelling urinary catheter and was occasionally incontinent of bowel. Review of the resident's monthly physician orders for July 2025 identified orders dated 05/14/19 indwelling urinary catheter care every shift and as needed, 05/12/21 empty indwelling urinary catheter collection bag every shift and as needed, 03/19/24 change indwelling urinary catheter with a 14 FR, 16 FR or 18 FR [NAME] catheter with a 10 ml balloon on the fourth of each month as a whole unit, and as needed, 07/30/21 Acetic Acid Solution 0.25 % use 50 ml via irrigation every shift and 05/24/24 enhanced barrier precautions (EBP) contact precautions due to indwelling urinary catheter every shift. On 07/02/25 at 7:49 A.M., observation of the resident's indwelling urinary catheter collection bag revealed the collection bag was lying on the floor with light yellow urine visible from the hallway. Interview with Registered Nurse (RN) #165 at the time of the observation verified the resident's indwelling urinary catheter collection bag was lying on the floor and was not contained in a privacy covering leaving the urine being visible from the hallway. The facility Administrator provided the urinary catheter or urinary tract infection critical element pathway through the Department of Health and Human Resources center for Medicare and Medicaid Services. 2. Review of the medical record for Resident #20 revealed an initial admission date of 01/25/17 with the latest readmission of 04/03/17 with the diagnosis including but not limited to chronic obstructive pulmonary disease, vascular dementia with behavioral disturbances, sever morbid obesity, diabetes mellitus, obstructive sleep apnea, hypertension, insomnia, psychosis, paranoid schizophrenia, anxiety disorder, bipolar disorder, narcolepsy and schizoaffective disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. On 06/30/25 observations during the breakfast meal on the 100 hallway revealed the resident's breakfast was served in disposable Styrofoam takeout containers and disposable Styrofoam cups. On 06/30/25 at 12:06 P.M., observation of the lunch meal in the dining room revealed the resident's drinks were served in Styrofoam cups. On 06/30/25 at 12:19 P.M., interview with the Dietary Manager (DM) #111 revealed when the dietary department was short staffed disposable containers and cups are used due to the cooks inability to assist with washing dishes. DM #111 verified the facility does not have enough dishes to serve the residents and Styrofoam disposable containers/cups are utilized. On 06/30/25 at 12:21 P.M., observation of the lunch meal on the 400 hallway revealed the residents were served fluids in Styrofoam cups. On 06/30/25 at 12:23 P.M., an interview with Resident #20 revealed the dietary department always serves on disposable products. She said she prefers to eat/drink from dishes. She stated once in a while they may get a plate. On 07/02/25 during the lunch meal revealed the facility served drinks in Styrofoam cups. Review of the facility policy titled, :Dignity, dated 02/21 revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well being level of satisfaction with life and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights, for example residents are provided with a dignified dining experience. This deficiency represents non-compliance investigated under Complaint Number OH00165161 and OH00167030.

Based on record review and interview, the facility failed to develop a comprehensive plan of care in the area of elopement risk and activities of daily living (ADL). This affected two residents (#48 and #98) of 15 sampled residents. The facility census was 96. Findings Include: 1. Review of the closed medical record for Resident #98 revealed an initial admission date of 06/18/24 with the latest readmission of 04/25/25 with the diagnoses including but not limited to chronic obstructive pulmonary disease, heart failure, diabetes mellitus, asthma, senile degeneration of brain, acute respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic pain, bipolar disorder, chronic pain syndrome, pure hypercholesterolemia, disorganized schizophrenia, morbid obesity, osteoarthritis, psychosis, hypertension, mood disorder, gastro-esophageal reflux disease, other symbolic dysfunction, depressive episodes and epilepsy. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident was dependent on staff for toileting, bathing and dressing, personal hygiene. Review of the resident's plan of care revealed no comprehensive care plan addressing the resident's ADL needs. On 07/02/25 at 12:55 P.M., interview with DON and Registered Nurse (RN) #110 verified the resident had no plan of care addressing the resident ADL status. 2. Review of the medical record for Resident #48 revealed an initial admission date of 07/14/22 with the latest readmission date of 07/26/24 with the diagnoses including but not limited to diabetes mellitus, hypercholesterolemia, psychophysiological insomnia, urethral stricture, constipation, disorganized schizophrenia, benign neoplasm of rib, sternum and clavicle, major depressive disorder, neuromuscular dysfunction of bladder, psychosis, anemia, schizophrenia, retention of urine and blindness one eye. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The assessment indicated the resident had no wandering. Review of the resident's elopement risk assessment dated [DATE] revealed the resident was at risk for elopement, however not at risk to elope at this time and placement on the elopement risk protocol was not indicated. The assessment indicated the elopement risk assessment was to be conducted on admission, within 30 days of admission, quarterly and any significant change affecting the assessment. Review of the plan of care revealed no care plan addressing the resident's elopement risk, despite the resident being identified as being at high risk for elopement by the facility. On 07/02/25 at 12:55 P.M., interview with DON and Registered Nurse (RN) #110 verified the resident had no plan of care addressing the resident elopement risk. This deficiency represents non-compliance investigated under Complaint Number OH00165161.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of guidance from the Centers for Disease Control (CDC) and Prevention website related to preparing for Coronavirus Disease 2019 (COVID-19) and responding to COVID-19 for nursing homes and health care facilities, surveyor observations, medical record reviews, staff interviews, review of the facility census sheet which included a detailed record of the residents COVID-19 status and location in the building, review of the testing timeline and resident testing log, and review of the facility's policy for communicable disease outbreaks, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 including: ensuring residents were cohorted correctly in accordance with CDC Guidelines; ensuring the facility's outbreak policy included a plan to cohort COVID-19 positive residents; and ensuring appropriate Personal Protective Equipment (PPE) was used with residents infected with COVID-19. This resulted in Immediate Jeopardy for 16 residents (#05, #07, #12, #17, #21, #23, #27, #38, #40, #53, #55, #58, #59, #72, #75 and #80) who were negative for COVID-19 and remained in the same room with a resident who was positive for COVID-19. Subsequent testing concluded five (#12, #17, #40, #55 and #80) of the 16 residents tested positive, who were previously negative, and the remaining 11 residents (#05, #07, #21, #23, #27, #38, #53, #58, #59, #72, and #75) who tested negative, continued to remain in rooms with residents who tested positive for COVID-19. The facility census was 88. On 12/01/20 at 1:58 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/21/20 when the facility failed to move residents in accordance with the latest CDC guidelines dated 06/25/20, after receiving results for COVID-19 initial outbreak testing. Residents Polymerase Chain Reaction (PCR) tests started to arrive the morning of 11/21/20, after being tested on [DATE]. Two confirmed residents who were positive were moved to the COVID-19 unit immediately. The facility conducted contact tracing based on the two positive tests received and conducted Rapid Point-of-Care (POC) tests for all known contacts. This resulted in eight additional residents who tested positive for COVID-19. At that time, the facility decided to test all residents on 11/21/20. There was a total of 32 positive residents at the end of the day on 11/21/20. All rooms with positive cases were placed on droplet precautions. However, roommates of those who tested positive, were presumed positive and continued to remain in the same room with the positive resident. The Immediate Jeopardy was removed on 12/03/20 at 7:30 P.M. when the facility made room changes based on the residents' COVID-19 status, updated the facility practice pertaining to PPE when caring for quarantined residents, and began developing a COVID-19 policy specifically for cohorting residents, and implemented the following corrective actions: · On 12/01/20, immediately after facility notification, the Administrator scheduled a virtual meeting for 4:30 P.M. with the DON, two members of their legal team, and the owner of the facility. The team discussed the ability to cohort residents based on their COVID-19 positivity status. The team also discussed the plan for staff in-servicing and policy for cohorting residents. · On 12/02/20, 32 residents met the CDC criteria to discontinue transmission-based precautions after being quarantined for 10 days. · On 12/02/20 at 9:00 A.M., the aforementioned team met via virtual conference and discussed the cohorting plan and room moves needed. They also discussed possible transfer of residents to sister facilities. · On 12/02/20, all positive residents on the fourth hallway were moved to their original rooms and rooms on the fourth hallway were deep cleaned in preparation for the necessary room changes. · On 12/02/20, the Administrator prepared a floor plan with projected room moves. The Administrator and legal counsel prepared an in-service for all staff related to infection control and the proper utilization of PPE. The Administrator and legal counsel worked on a formal policy for cohorting residents. · On 12/02/20, the Administrator was in contact with the Local Health Department to strategize effective outcomes on room changes and cohorting. The strategy identified was to cohort residents together based on COVID-19 status (Positive-Recovered, Positive-Active, Negative-Exposed and Negative-No exposure). · On 12/03/20 at 7:30 P.M., all resident room changes were made to ensure no residents who were negative for COVID-19 shared a room with a resident who was positive for COVID-19. All staff members were educated on infection control including the proper use of PPE during interactions with COVID-19 positive residents. · On 12/03/20, the Administrator scheduled an appointment with Infection Control Assessment and Response (ICAR) for 12/10/20 at 8:30 A.M. · On 12/03/20, the facility in-serviced all staff from 9:00 A.M. to 6:00 P.M., regarding appropriate PPE use when providing care to residents with COVID-19 including PPE such as N95's, face shield/eye protection, isolation gowns, and gloves. The training indicated all PPE was required during all interactions with COVID-19 positive residents, including during meal assistance and revealed proper PPE doffing strategies as well as appropriate hand hygiene. · Interview with the Administrator on 12/14/20 at 1:11 P.M., stated all staff were scheduled to be trained 12/17/20, on the facility's new cohorting policy. He revealed appropriate PPE use and cohorting of residents were going to be monitored three times daily for four weeks. He also indicated the Quality Assurance and Performance Improvement (QAPI) committee met on 12/10/20 and will be on a weekly basis (12/16/20, 12/23/20 and 12/30/30) to discuss monitoring and any revisions and/or corrective actions that would be warranted related to PPE use and cohorting of residents. · Interviews on 12/07/20 from 10:09 A.M. to 10:42 A.M. with State tested Nurse Aides (STNA's) #379, #430 and #801, Registered Nurses (RN's) #414 and #802, and Licensed Practical Nurse (LPN) #323 confirmed they were all in-serviced on the appropriate use of PPE to wear when providing care to COVID-19 positive residents including doffing strategies and appropriate hand hygiene. No concerns were identified, and staff were knowledgeable regarding the in-service provided by the facility. · Observations on 12/07/20 from 10:09 A.M. to 10:42 A.M., revealed there was no cohorting of positive and negative residents together in the same rooms. All positive residents were now cohorted with other positive residents or remained in the room by themselves. Negative residents were also only cohorted with other residents who were negative for COVID-19. · Review of a facility policy titled, COVID-19 Residents: Screening and Management, effective 12/07/20, revealed residents with a positive COVID-19 test should be placed in transmission-based precautions and ideally on a (separate unit/wing) OR (building) for residents with COVID-19 (COVID Unit). The policy indicated the facility would not cohort residents who were positive and negative for COVID-19. Although the Immediate Jeopardy was removed on 12/03/20 at 7:30 P.M., the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Review of the document titled, Testing Timeline, dated 11/30/20, revealed the facility map was color coded and COVID-19 positive residents were distributed throughout each of the four halls of the facility; however, hallway four was a dedicated COVID-19 positive wing. Further review of the document revealed five residents who were negative for COVID-19, had tested positive after being cohorted with a resident who had previously tested positive for COVID-19. On 11/24/20, Resident #80 tested positive for COVID-19. Her roommate received positive COVID-19 results on 11/22/20. On 11/24/20, Resident #40 tested positive for COVID-19. His roommate received a positive COVID-19 result on 11/22/20. On 11/24/20, Resident #17 tested positive for COVID-19. Her roommate tested positive on 11/21/20. On 11/27/20, Resident #12 tested positive for COVID-19. Her roommate received a positive COVID-19 test on 11/22/20. On 11/27/20, Resident #55 tested positive for COVID-19. Her roommate received a positive COVID-19 result on 11/24/20. Review of the Resident Testing Log and facility census with room numbers dated 11/30/20, revealed 11 residents who tested negative for COVID-19, were cohorted with residents who tested positive for COVID-19. Residents #05, #07, #23, #27, and #38 were cohorted with residents who tested positive for COVID-19 on 11/21/20. Residents #59 and #75 were cohorted with residents who tested positive for COVID-19 on 11/24/20. Residents #21, #53, #58, and #72 were cohorted with residents who tested positive for COVID-19 on 11/27/20. Review of Resident #80's medical record revealed she was admitted to the facility 06/17/20. [DIAGNOSES REDACTED]. Review of Resident #40's medical record revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #12's medical record revealed she was admitted to the facility 04/07/17. [DIAGNOSES REDACTED]. Review of Resident #17's medical record revealed she was admitted to the facility 09/20/19. [DIAGNOSES REDACTED]. Review of Resident #55's medical record revealed she was admitted to the facility 06/12/19. [DIAGNOSES REDACTED]. Review of Resident #05's medical record revealed she was admitted to the facility 08/22/13. [DIAGNOSES REDACTED]. Review of Resident #07's medical record revealed she was admitted to the facility 08/04/20. [DIAGNOSES REDACTED]. Review of Resident #21's medical record revealed he was admitted to the facility 06/13/19. [DIAGNOSES REDACTED]. Review of Resident #23's medical record revealed he was admitted to the facility 08/01/16. [DIAGNOSES REDACTED]. Review of Resident #27's medical record revealed she was admitted to the facility 12/05/18. [DIAGNOSES REDACTED]. Review of Resident #38's medical record revealed he was admitted to the facility 08/30/13. [DIAGNOSES REDACTED]. Review of Resident #53's medical record revealed he was admitted to the facility 07/22/19. [DIAGNOSES REDACTED]. Review of Resident #58's medical record revealed he was admitted to the facility 11/21/17. [DIAGNOSES REDACTED]. Review of Resident #59's medical record revealed she was admitted to the facility 02/04/14. [DIAGNOSES REDACTED]. Review of Resident #72's medical record revealed she was admitted to the facility 05/01/19. [DIAGNOSES REDACTED]. Review of Resident #75's medical record revealed he was admitted to the facility 10/13/18. [DIAGNOSES REDACTED]. Interview on 11/30/20 at 11:18 A.M. with the Administrator and DON revealed positive resident PCR tests started to arrive the morning of 11/21/20, after being tested [DATE]. Two confirmed positive residents were moved to the COVID-19 unit immediately. The facility conducted contact tracing based on the two positive tests received and conducted Rapid POC tests for all known contacts. There were eight additional residents who tested positive for COVID-19. At that time, the facility decided to test all residents on 11/21/20. There was a total of 32 positive residents at the end of the day on 11/21/20. All rooms with positive cases were placed on droplet precautions. Roommates of those who tested positive, were presumed positive. The Administrator stated he spoke with Medical Director #503 and they decided to shelter in place, and not separate residents who were negative and positive for COVID-19. He stated they came to this conclusion as the best plan of action because their facility population was behavioral, and they did not want to risk both physical and verbal altercations. The Administrator and DON confirmed five residents had contracted COVID-19 after continuing to share a room with a resident who had tested positive for COVID-19. The Administrator confirmed there were 11 residents who were negative for COVID-19 and who continued to share a room with a resident who had previously tested positive for COVID-19. Interview on 11/30/20 at 11:59 A.M. with the Administrator revealed there was not designated staff for residents who were positive for COVID-19. He stated nursing staff cohorted care duties and would also provide care to all negative residents first, then all positive residents to mitigate spread. He also indicated there was no attempt to make any room changes regarding the cohorting of positive and negative residents. Interview and observations on 11/30/20 at 12:09 P.M. revealed Receptionist #500 did not have the lower strap of her N95 around her head and it was hanging off the bottom of the mask. There was not a seal around her mouth and nose. She confirmed she should have had the strap around her head to create a seal. Observation and subsequent interview on 11/30/20 at 12:20 P.M. revealed STNA #501 was feeding Resident #32 without a gown or gloves on. STNA #501 confirmed Resident #32 was positive for COVID-19. She stated she did not know she had to wear a gown and gloves because all the residents on the hall were positive for COVID-19 and she planned on washing her hands before providing care to the next resident. STNA #501 followed the surveyor out of the room and did not sanitize her hands. She then put on her gown and gloves on without appropriate hand hygiene being competed. Interview on 11/30/20 at 12:36 P.M. with the Administrator, confirmed if staff entered a room with a resident who had COVID-19, they needed to don gloves and a gown in addition to their N95 mask and eye protection. During a phone interview on 11/30/20 at 3:34 P.M., the Administrator stated all residents who were positive with COVID-19 were asymptomatic. There had been no hospitalization s or deaths related to COVID-19. During a phone interview on 12/02/20 at 2:51 P.M. with Local Health Department Staff (LHDS) #504, revealed their initial contact with the facility was 11/22/20. LHDS #504 stated they went from one to 32 residents who were positive for COVID-19 that day. LHDS #504 stated she provided the facility guidelines based on the CDC's recommendations. She stated she was aware the facility planned to shelter in place, and that she neither condoned or disproved as her role was to only to provide guidance. Phone interview on 12/02/20 at 3:19 P.M. with the Administrator, revealed all staff would be educated by 12/03/20 at 6:00 P.M. All necessary room changes would be made 12/03/20 to ensure no residents negative for COVID-19 would be cohorted with a resident who was positive for COVID-19. He stated the fourth hallway was the wing of the facility that had no residents who were positive for COVID-19 and was going to be the reverse isolation wing for residents who were negative for COVID-19 and had not been exposed. The Administrator also stated he was working with his corporate team to develop a formal cohorting policy. Review of a facility provided floor plan dated 12/02/20 with projected room moves revealed no residents who were COVID-19 negative would share a room with a resident who was COVID-19 positive. Review of a color-coded floor plan and daily census sheet dated 12/04/20 which designated residents with and without COVID-19 as well as exposure and recovery, revealed no residents who were COVID-19 negative shared a room with a resident who was COVID-19 positive. Phone interview on 12/05/20 at 9:02 A.M. with the Administrator revealed all room changes and staff education was completed on 12/03/20 at 7:30 P.M. He stated no residents who were negative for COVID-19 shared a room with a resident who was positive for COVID-19. He stated the fourth hallway was a reverse isolation unit for residents who were negative for COVID-19 and had not been exposed. Review of the undated facility policy titled, Outbreak of Communicable Diseases, revealed outbreaks of communicable diseases within the facility would be promptly identified and appropriately handled. Further review of the policy lacked evidence the facility had a plan to manage a surge of positive COVID-19 cases in the facility. Review of the CDC website COVID-19 guidelines titled, Use of Testing to Inform the Response to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed if testing capacity allows use of facility wide testing following identification of newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or healthcare personal could be particularly important. Facility wide testing can help identify a symptomatic or pre-symptomatic resident with COVID-19 to guide movement into COVID-19 designated spaces. Review of the CDC website COVID-19 guidelines titled, Infection Control for Nursing Homes( https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) dated 06/25/20, revealed the facility should have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive) and have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the CDC website COVID-19 guidelines titled, Responding to COVID-19, dated 04/30/20, revealed responding to residents newly infected with [DIAGNOSES REDACTED]-CoV-2 includes ensuring the resident was isolated and cared for using all recommended COVID-19 PPE. The resident should be placed in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. This deficiency substantiates Complaint Number OH 7545 and is an example of continued noncompliance from the 10/07/20 survey.

Based on observation, resident and staff interviews, review of medical records, review of a personnel record, review of a facility Self-Reported Incident (SRI), and review of the facility's abuse policy and procedures, the facility staff failed to implement their abuse policy and procedures by not ensuring residents were free from physical abuse, failing to immediately report witnessing alleged incidents of abuse and protecting the residents, not completing a thorough investigation into the allegations and providing corrective action after an observed alleged incidents of staff to resident physical abuse during the provision of care. This resulted in Immediate Jeopardy for one resident (#66) when she was observed by three staff witnesses (Receptionist #05, Licensed Practical Nurses (LPN) #35 and #48) being dragged across the floor of her room and thrown into bed by State tested Nurse Aide (STNA) #69 after the resident had defecated on the floor. Additionally, a second resident (#2) was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. Consequently, all four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for his assigned residents. This affected two of two residents (#66 and #02) reviewed for abuse and placed 12 additional residents (#03, #10, #14, #17, #20, #21, #23, #36, #41, #51, #52, #91) at risk for the likelihood of serious harm or injury who were assigned STNA #69 as their care giver. On 10/31/18 at 2:20 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/05/18 at 7:35 P.M. when three staff members (Receptionist #05, LPNs #35 and #48) witnessed Resident #66 being dragged across the floor of her room and thrown into bed by STNA #69 after the resident had defecated on the floor. Additionally, on 10/05/18 at approximately 8:00 P.M., Resident #02 was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. All four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for residents for more than three hours after the initial witnessed incident of abuse. STNA #69 was eventually removed from her assignment and suspended on 10/05/18 at 11:00 P.M. pending an investigation; however, STNA #69 returned to work on 10/18/18 at 10:26 P.M. The Immediate Jeopardy was removed on 11/01/18 when the facility implemented the following corrective actions: · On 10/31/18 at 1:54 P.M., STNA #69 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 10/31/18, Resident #66 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #30 and there were no negative findings. · On 10/31/18, all eleven non-verbal and cognitively impaired residents had head-to-toe assessments completed by LPN #29, LPN #30 and Registered Nurse (RN) #44. There were no negative findings. · On 10/31/18, 24 alert and oriented residents were interviewed and asked if they felt safe in the facility and if they had any issues or concerns with staff. All 24 residents responded they felt safe in the facility and had no concerns regarding staff. The interviews were completed by LPN #30, LPN #39, RN #44 and Assistant Director of Nursing (ADON) #12. · On 10/31/18, the Administrator, DON, ADON #12, and RN #29 began mandatory staff in-servicing on abuse with the facility's 104 employees. The content of the education included the Abuse Policy, the definition of abuse, what to do if any staff suspect any type of abuse, reporting immediately to the Administrator, DON, or ADON, the alleged perpetrator needs to be removed immediately from the building pending investigation, a full head-to-toe assessment was to be completed by two nurses on separate occasions within 30 minutes of the reported allegation, the charge nurse was to collect statements from all involved parties in the facility at that time, including staff and residents if applicable, and staff to refer to the Abuse binder or Employee Handbook for further guidance on abuse. A plan for the remaining 12 staff to be educated prior to the start of their next shift was developed. · On 11/01/18, the Administrator and DON provided disciplinary action to the four witnesses (LPN #35, LPN #48, Receptionist #05 and STNA #72) of the two incidents of abuse on 10/05/18, for not following the facility's policy and procedures on abuse and/or abuse education. · On 11/01/18, the Administrator and DON initiated an abuse committee to meet one to two times per week for three months, then monthly. The committee will consist of interdisciplinary team members including social services, kitchen, human resources and an STNA. The first committee meeting will be held on 11/06/18. · On 11/01/18, interviews with STNA #64, STNA #66, LPN #28, LPN #25, LPN #32, Housekeeper #98, and Housekeeper #01 from 9:35 A.M. to 12:26 P.M. revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 11/01/18, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Medical record review for Resident #66 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/15/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills, required the limited assistance of one staff with transfers and the extensive physical assistance of one staff for ambulation. Review of the care plan, dated 02/02/18, revealed the resident had an unsteady gait, wandered around the facility with no purpose, had chronic back pain due to multiple car accidents, and had behaviors that were not easily altered including resistance with care. Review of the nursing head-to-toe assessment, dated 10/05/18 (with no time noted), revealed Resident #66 had no injuries, vital signs were stable and the resident was not observed with signs and symptoms of pain. The nursing note, dated 10/06/18, revealed the resident had no distress. There were no additional nursing skin assessments. Medical record review for Resident #04, who was Resident #66's roommate, revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/19/18, revealed the resident's cognition was intact. Medical record review for Resident #02 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/17/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills. The resident was totally dependent on two staff for transfers and did not ambulate. Review of the care plan, dated 06/25/18, revealed the resident had poor safety awareness and was resistive/combative with care at times. Review of the nursing head-to-toe assessment, dated 10/05/18 at 10:00 P.M., revealed the resident had no injuries, vital signs were stable and the resident did not exhibit signs and symptoms of pain. There were no additional nursing skin assessments. Review of a facility SRI dated 10/06/18 at 3:00 P.M. revealed it was created for two physical abuse allegations. Under the Summary of Incident section documentation revealed around the 7:00 P.M. hour, a first incident was witnessed by three staff including LPN #35, LPN #48 and Receptionist #05 who observed from the parking lot at dusk, STNA #69 (alleged perpetrator) in Resident #66's room with the lights on. The three facility staff alleged they observed STNA #69 dragging Resident #66 by the arm and throwing her on the bed near the window. STNA #69 reported Resident #66 was covered in feces and she was preparing the resident for incontinence care on her bed. The second incident involved STNA #72 who reported she witnessed STNA #66 'slap/hit' Resident #02's hands up to eight times during a stand-up lift transfer because the resident refused to let go of the sheets/clothing. STNA #69 denied abusing Residents #66 and #02 in both incidents. The nurse conducted head-to-toe assessments for both Residents #66 and #02, which indicated no evidence of bruising, redness or symptoms of abuse. Both residents were not interviewed due to extreme cognitive deficits. The four staff who witnessed the incidents were contacted by phone and interviewed by the Administrator. The conclusion revealed the incident with Resident #66 was witnessed from 15 to 20 feet away outside and the staff felt STNA #69 was too rough with the aforementioned residents. The facility conclusion documented the information was based on second hand information, the staff statements were subjective without an objective basis and subsequently the abuse was unsubstantiated. Review of the witness statements within the facility's abuse investigation revealed the following: Review of LPN #48's statement, dated 10/05/18, revealed she observed from the parking lot, STNA #69 drag Resident #66 by the arm and flung her on the bed. Within the same hour, STNA #72 reported STNA #69 was slapping Resident #02 roughly on his hands. Review of STNA #72's statement, dated 10/05/18, revealed she was in Resident #02's room assisting STNA #69 with a stand-up lift transfer when STNA #69 started hitting him on his hands about eight times telling the resident to let go of his clothing. STNA #72 stated she reported the concern to LPN #48. Review of LPN #35's statement, dated 10/06/18, revealed around 7:35 P.M. on 10/05/18, she was outside by her car and she observed a light in Resident #66's room and STNA #69 was dragging Resident #66 very hard into the room by her arm, tossed her into the bed and walked out of the room. Review of Receptionist #05's statement, dated 10/11/18, revealed LPN #48 and #35 were helping her put some bags in her van when she observed STNA #69 pulling Resident #66's arm 'really roughly' and slammed her onto the bed. STNA #69 left the room and shut the door. Resident #66 appeared very upset and kept rubbing her eyes and face and may have been crying. Review of the employee file for STNA #69 revealed a hire date of 04/25/18 and did not have any disciplinary action noted. Interview on 10/29/18 at 2:50 P.M. with STNA #72 revealed she was not aware of the incident involving Resident #66 on 10/05/18 at 7:35 P.M. and verified she assisted STNA #69 in providing the incontinence care after the incident. During the incontinence care, Resident #66 did not appear abused/upset in any way. The STNA stated soon after (unable to provide a time frame) providing incontinence care to Resident #66, she observed and immediately reported an allegation of abuse to LPN #48. The STNA stated she was assisting STNA #69 with a stand-up lift transfer for Resident #02, who was grabbing at his clothing instead of putting his hands on the stand-up lift. STNA #69 hit his hands about eight times. After the incident, STNA #69 came back looking mad and stated to her why did you tell on me. Before she left the building, she was cursing loudly in the hallway where residents could hear. STNA #72 stated she did not understand why STNA #69 returned to work after being so rough with Resident #02. Interview on 10/29/18 at 3:05 P.M. with Receptionist #05 revealed she was in the parking lot getting ready to leave after her shift on 10/05/18 around 7:30 P.M. She said she observed STNA #69 pulling Resident #66's arm and tossed her into the bed in a rough way. The resident did not understand and appeared upset and kept rubbing her eyes and face. She said she could not tell if the resident was crying. She verified she did not go back into the building to report and protect the resident. She stated she felt STNA #69's actions were abusive. Interview on 10/29/18 at 3:20 P.M. with STNA #69 revealed she typically worked the evening/night shifts and she denied abusing or rough handling of any resident. The STNA explained Resident #66 was defecating/urinating in the hallway on second hall and had feces all over her. She said she was holding the resident's arm trying to remove the poop. She stated STNA #72 assisted in providing incontinence care to the resident, who was upset. After the incontinence care was provided to Resident #66, STNA #72 and herself then went to assist Resident #02 in a stand-up lift transfer. Resident #02 did not want to let go of the lift bars and she told the resident to come on and open your hands. Observation of Resident #02 on 10/29/18 at 3:41 P.M. revealed he was clean with no evidence of bruising or redness to the skin. He did not appear fearful of the staff at any time. Interview on 10/30/18 at 6:50 A.M. with LPN #48 revealed she had worked with STNA #69 for a long time on night shift and said the STNA could be harsh and curse at the nursing staff where the residents could hear at times. On 10/05/18 around 7:30 P.M., LPN #48 stated it was getting dark outside and she was in the parking lot and could see inside Resident #66's room and the lights were turned on in the room. She observed STNA #69 dragging the resident's arm from the bedroom door to the second bed and flung her on the bed. LPN #48 stated she felt STNA #69 was abusive and said she observed the resident wiping her face/eyes. LPN #48 verified she did not go back into the facility to protect the residents from STNA #69 at this time. LPN #48 stated she reported the abuse allegation to the DON around 8:20 P.M. by phone who told her to get a statement from STNA #69. STNA #69 was in the second hallway (same hallway as both residents involved) writing her statement and left the building around 11:00 P.M. She did not understand why STNA #69 was not terminated. Interview on 10/30/18 at 9:40 A.M. with LPN #35 revealed she observed Resident #66 from the parking lot around 7:35 P.M. and verified she did not come back into the facility after the incident because she was off duty. LPN #35 observed the resident holding the door frame of her bedroom and STNA #69 dragging her with both arms to the bed, threw her hard on the bed and then she walked out of the room. LPN #35 stated it looked like abuse and observed the resident rubbing her eyes, like she was crying. LPN #35 stated Resident #66 followed directions when staff talked nice to her. STNA #69 cursed a lot at staff, which residents could hear at times. She did not understand why STNA #69 was not terminated. Observation of Resident #66 on 10/30/18 at 11:22 A.M. revealed she followed staff cues at times during an exercise program. The resident was smiling and did not appear fearful of the staff at any time. There was no evidence of bruising or redness to the skin. On 10/30/18 at 2:55 P.M., the Administrator provided STNA #69's time card for 10/05/18 which showed she was paid from on 10/05/18 from 6:24 P.M. to 6:00 A.M. and did not indicate the time she actually exited the facility. The Administrator stated he was notified of the abuse allegations around 11:00 P.M. on 10/05/18, at the time STNA #69 exited the facility. Interview on 10/31/18 at 11:00 A.M. with Resident #04 revealed she was in bed about three weeks ago in the evening and had feces on her water pitcher from her roommate, Resident #66. At that time, she observed an STNA grab her roommate's arm, pulled her to the bed and swung her into the bed in a rough way. The STNAs came in and cleaned her roommate up and replaced her water pitcher. She could not remember the names of STNAs who provided the care to her roommate. Interview on 10/31/18 at 11:45 A.M. with the Administrator and DON, the DON verified only one SRI was reported to the state agency because both incidents were reported at 10:39 P.M. on 10/05/18 when STNA #69 contacted him and was upset the staff were accusing her of being abusive to the residents. The DON verified the witnesses to the two allegations did not contact him prior to 10:30 P.M. The Administrator stated the 10/05/18 incident was his first SRI related to an abuse allegation. The Administrator felt there was no objective evidence to substantiate abuse and the allegations were unsubstantiated. The Administrator verified the four witnesses, Receptionist #05, LPN #35 and #48, and Resident #4, observed STNA #69 physically abuse Resident #66. The Administrator verified he was not notified of the two abuse allegations until 10/05/18 at 11:00 P.M. The Administrator and DON verified there were no residents interviewed as part of the facility's abuse investigation and STNA #69 was not removed from her assignment immediately and continued to work until 11:00 P.M. on 10/05/18. The Administrator verified he did not identify the fact the staff did not report timely of the abuse allegation and did not identify the staff did not remove STNA #69 from her work duties and protect the residents timely and in accordance with facility policy. The Administrator verified STNA #69 returned to work providing direct care to the residents on 10/18/18 and did not receive further training or disciplinary action. Review of the facility's policy on abuse prevention, last revised on 07/2005, revealed residents were to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. The residents were to be protected from harm through frequent supervision by staff. If the alleged abuser was an employee, the employee shall be removed from the facility and suspended pending the results of the facility's investigation. The suspension shall be documented in the employee personnel file and shall remain in effect until the investigation is completed. The investigation of the incident included an interview with the resident's roommate and review of all circumstances surrounding the incident. If the investigation revealed findings of abuse, such finding would be reported to the state abuse registry and the employee would be terminated. This deficiency substantiates Control Number OH 685.

Based on observation, resident and staff interviews, review of medical records, review of personnel records, review of a facility Self-Reported Incident (SRI), and review of the facility's abuse policy and procedures, the facility staff failed to thoroughly investigate alleged violations of physical abuse, protect residents from further abuse while the investigation was in progress and take appropriate corrective action as a result of the investigation, after alleged incidents of staff to resident physical abuse were observed during the provision of care. This resulted in Immediate Jeopardy for one resident (#66) when she was observed by three staff witnesses (Receptionist #05, Licensed Practical Nurses (LPN) #35 and #48) being dragged across the floor of her room and thrown into bed by State tested Nurse Aide (STNA) #69 after the resident had defecated on the floor. Additionally, a second resident (#2) was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. Consequently, all four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for his assigned residents. The Administrator was not notified of the alleged abuse violations until 10/05/18 at 11:00 P.M. The Administrator and DON verified there were no residents interviewed for this abuse investigation and STNA #69 was not removed from her assignment immediately and continued to work until 11:00 P.M. on 10/05/18. This affected two of two residents (#66 and #02) reviewed for abuse and placed 12 additional residents (#03, #10, #14, #17, #20, #21, #23, #36, #41, #51, #52, #91) at risk for the likelihood of serious harm or injury who were assigned STNA #69 as their care giver. On 10/31/18 at 2:20 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/05/18 at 7:35 P.M. when three staff members (Receptionist #05, LPNs #35 and #48) witnessed Resident #66 being dragged across the floor of her room and thrown into bed by STNA #69 after the resident had defecated on the floor. Additionally, on 10/05/18 at approximately 8:00 P.M., Resident #02 was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. All four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for residents for more than three hours after the initial witnessed incident of abuse. The Administrator verified he was not notified of the two abuse allegations until 10/05/18 at 11:00 P.M. The Administrator and DON verified there were no residents interviewed for this abuse investigation and STNA #69 was not removed from her assignment immediately and continued to work until 11:00 P.M. on 10/05/18. The Administrator verified he did not identify the issue that staff did not report the abuse allegation timely and did not identify the issue that staff did not immediately remove STNA #69 from her work duties and protect the residents timely. The Administrator verified STNA #69 returned to work on 10/18/18 at 10:26 P.M. and did not receive further training or disciplinary action. The Immediate Jeopardy was removed on 11/01/18 when the facility implemented the following corrective actions: · On 10/31/18 at 1:54 P.M., STNA #69 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 10/31/18, Resident #66 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #30 and there were no negative findings. · On 10/31/18, all eleven non-verbal and cognitively impaired residents had head-to-toe assessments completed by LPN #29, LPN #30 and Registered Nurse (RN) #44. There were no negative findings. · On 10/31/18, 24 alert and oriented residents were interviewed and asked if they felt safe in the facility and if they had any issues or concerns with staff. All 24 residents responded they felt safe in the facility and had no concerns regarding staff. The interviews were completed by LPN #30, LPN #39, RN #44 and Assistant Director of Nursing (ADON) #12. · On 10/31/18, the Administrator, DON, ADON #12, and RN #29 began mandatory staff in-servicing on abuse with the facility's 104 employees. The content of the education included the Abuse Policy, the definition of abuse, what to do if any staff suspect any type of abuse, reporting immediately to the Administrator, DON, or ADON, the alleged perpetrator needs to be removed immediately from the building pending investigation, a full head-to-toe assessment was to be completed by two nurses on separate occasions within 30 minutes of the reported allegation, the charge nurse was to collect statements from all involved parties in the facility at that time, including staff and residents if applicable, and staff to refer to the Abuse binder or Employee Handbook for further guidance on abuse. A plan for the remaining 12 staff to be educated prior to the start of their next shift was developed. · On 11/01/18, the Administrator and DON provided disciplinary action to the four witnesses (LPN #35, LPN #48, Receptionist #05 and STNA #72) of the two incidents of abuse on 10/05/18, for not following the facility's policy and procedures on abuse and/or abuse education. · On 11/01/18, the Administrator and DON initiated an abuse committee to meet one to two times per week for three months, then monthly. The committee will consist of interdisciplinary team members including social services, kitchen, human resources and an STNA. The first committee meeting will be held on 11/06/18. · On 11/01/18, interviews with STNA #64, STNA #66, LPN #28, LPN #25, LPN #32, Housekeeper #98, and Housekeeper #01 from 9:35 A.M. to 12:26 P.M. revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 11/01/18, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Medical record review for Resident #66 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/15/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills, required the limited assistance of one staff with transfers and the extensive physical assistance of one staff for ambulation. Review of the care plan, dated 02/02/18, revealed the resident had an unsteady gait, wandered around the facility with no purpose, had chronic back pain due to multiple car accidents, and had behaviors that were not easily altered including resistance with care. Review of the nursing head-to-toe assessment, dated 10/05/18 (with no time noted), revealed Resident #66 had no injuries, vital signs were stable and the resident was not observed with signs and symptoms of pain. The nursing note, dated 10/06/18, revealed the resident had no distress. There were no additional nursing skin assessments. Medical record review for Resident #04, who was Resident #66's roommate, revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/19/18, revealed the resident's cognition was intact. Medical record review for Resident #02 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/17/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills. The resident was totally dependent on two staff for transfers and did not ambulate. Review of the care plan, dated 06/25/18, revealed the resident had poor safety awareness and was resistive/combative with care at times. Review of the nursing head-to-toe assessment, dated 10/05/18 at 10:00 P.M., revealed the resident had no injuries, vital signs were stable and the resident did not exhibit signs and symptoms of pain. There were no additional nursing skin assessments. Review of a facility SRI dated 10/06/18 at 3:00 P.M. revealed it was created for two physical abuse allegations. Under the Summary of Incident section documentation revealed around the 7:00 P.M. hour, a first incident was witnessed by three staff including LPN #35, LPN #48 and Receptionist #05 who observed from the parking lot at dusk, STNA #69 (alleged perpetrator) in Resident #66's room with the lights on. The three facility staff alleged they observed STNA #69 dragging Resident #66 by the arm and throwing her on the bed near the window. STNA #69 reported Resident #66 was covered in feces and she was preparing the resident for incontinence care on her bed. The second incident involved STNA #72 who reported she witnessed STNA #66 'slap/hit' Resident #02's hands up to eight times during a stand-up lift transfer because the resident refused to let go of the sheets/clothing. STNA #69 denied abusing Residents #66 and #02 in both incidents. The nurse conducted head-to-toe assessments for both Residents #66 and #02, which indicated no evidence of bruising, redness or symptoms of abuse. Both residents were not interviewed due to extreme cognitive deficits. The four staff who witnessed the incidents were contacted by phone and interviewed by the Administrator. The conclusion revealed the incident with Resident #66 was witnessed from 15 to 20 feet away outside and the staff felt STNA #69 was too rough with the aforementioned residents. The facility conclusion documented the information was based on second hand information, the staff statements were subjective without an objective basis and subsequently the abuse was unsubstantiated. Review of the witness statements within the facility's abuse investigation revealed the following: Review of LPN #48's statement, dated 10/05/18, revealed she observed from the parking lot, STNA #69 drag Resident #66 by the arm and flung her on the bed. Within the same hour, STNA #72 reported STNA #69 was slapping Resident #02 roughly on his hands. Review of STNA #72's statement, dated 10/05/18, revealed she was in Resident #02's room assisting STNA #69 with a stand-up lift transfer when STNA #69 started hitting him on his hands about eight times telling the resident to let go of his clothing. STNA #72 stated she reported the concern to LPN #48. Review of LPN #35's statement, dated 10/06/18, revealed around 7:35 P.M. on 10/05/18, she was outside by her car and she observed a light in Resident #66's room and STNA #69 was dragging Resident #66 very hard into the room by her arm, tossed her into the bed and walked out of the room. Review of Receptionist #05's statement, dated 10/11/18, revealed LPN #48 and #35 were helping her put some bags in her van when she observed STNA #69 pulling Resident #66's arm 'really roughly' and slammed her onto the bed. STNA #69 left the room and shut the door. Resident #66 appeared very upset and kept rubbing her eyes and face and may have been crying. Review of the employee file for STNA #69 revealed a hire date of 04/25/18 and did not have any disciplinary action noted. Interview on 10/29/18 at 2:50 P.M. with STNA #72 revealed she was not aware of the incident involving Resident #66 on 10/05/18 at 7:35 P.M. and verified she assisted STNA #69 in providing the incontinence care after the incident. During the incontinence care, Resident #66 did not appear abused/upset in any way. The STNA stated soon after (unable to provide a time frame) providing incontinence care to Resident #66, she observed and immediately reported an allegation of abuse to LPN #48. The STNA stated she was assisting STNA #69 with a stand-up lift transfer for Resident #02, who was grabbing at his clothing instead of putting his hands on the stand-up lift. STNA #69 hit his hands about eight times. After the incident, STNA #69 came back looking mad and stated to her why did you tell on me. Before she left the building, she was cursing loudly in the hallway where residents could hear. STNA #72 stated she did not understand why STNA #69 returned to work after being so rough with Resident #02. Interview on 10/29/18 at 3:05 P.M. with Receptionist #05 revealed she was in the parking lot getting ready to leave after her shift on 10/05/18 around 7:30 P.M. She said she observed STNA #69 pulling Resident #66's arm and tossed her into the bed in a rough way. The resident did not understand and appeared upset and kept rubbing her eyes and face. She said she could not tell if the resident was crying. She verified she did not go back into the building to report and protect the resident. She stated she felt STNA #69's actions were abusive. Interview on 10/29/18 at 3:20 P.M. with STNA #69 revealed she typically worked the evening/night shifts and she denied abusing or rough handling of any resident. The STNA explained Resident #66 was defecating/urinating in the hallway on second hall and had feces all over her. She said she was holding the resident's arm trying to remove the poop. She stated STNA #72 assisted in providing incontinence care to the resident, who was upset. After the incontinence care was provided to Resident #66, STNA #72 and herself then went to assist Resident #02 in a stand-up lift transfer. Resident #02 did not want to let go of the lift bars and she told the resident to come on and open your hands. Observation of Resident #02 on 10/29/18 at 3:41 P.M. revealed he was clean with no evidence of bruising or redness to the skin. He did not appear fearful of the staff at any time. Interview on 10/30/18 at 6:50 A.M. with LPN #48 revealed she had worked with STNA #69 for a long time on night shift and said the STNA could be harsh and curse at the nursing staff where the residents could hear at times. On 10/05/18 around 7:30 P.M., LPN #48 stated it was getting dark outside and she was in the parking lot and could see inside Resident #66's room and the lights were turned on in the room. She observed STNA #69 dragging the resident's arm from the bedroom door to the second bed and flung her on the bed. LPN #48 stated she felt STNA #69 was abusive and said she observed the resident wiping her face/eyes. LPN #48 verified she did not go back into the facility to protect the residents from STNA #69 at this time. LPN #48 stated she reported the abuse allegation to the DON around 8:20 P.M. by phone who told her to get a statement from STNA #69. STNA #69 was in the second hallway (same hallway as both residents involved) writing her statement and left the building around 11:00 P.M. She did not understand why STNA #69 was not terminated. Interview on 10/30/18 at 9:40 A.M. with LPN #35 revealed she observed Resident #66 from the parking lot around 7:35 P.M. and verified she did not come back into the facility after the incident because she was off duty. LPN #35 observed the resident holding the door frame of her bedroom and STNA #69 dragging her with both arms to the bed, threw her hard on the bed and then she walked out of the room. LPN #35 stated it looked like abuse and observed the resident rubbing her eyes, like she was crying. LPN #35 stated Resident #66 followed directions when staff talked nice to her. STNA #69 cursed a lot at staff, which residents could hear at times. She did not understand why STNA #69 was not terminated. Observation of Resident #66 on 10/30/18 at 11:22 A.M. revealed she followed staff cues at times during an exercise program. The resident was smiling and did not appear fearful of the staff at any time. There was no evidence of bruising or redness to the skin. On 10/30/18 at 2:55 P.M., the Administrator provided STNA #69's time card for 10/05/18 which showed she was paid from on 10/05/18 from 6:24 P.M. to 6:00 A.M. and did not indicate the time she actually exited the facility. The Administrator stated he was notified of the abuse allegations around 11:00 P.M. on 10/05/18, at the time STNA #69 exited the facility. Interview on 10/31/18 at 11:00 A.M. with Resident #04 revealed she was in bed about three weeks ago in the evening and had feces on her water pitcher from her roommate, Resident #66. At that time, she observed an STNA grab her roommate's arm, pulled her to the bed and swung her into the bed in a rough way. The STNAs came in and cleaned her roommate up and replaced her water pitcher. She could not remember the names of STNAs who provided the care to her roommate. Interview on 10/31/18 at 11:45 A.M. with the Administrator and DON, the DON verified only one SRI was reported to the state agency because both incidents were reported at 10:39 P.M. on 10/05/18 when STNA #69 contacted him and was upset the staff were accusing her of being abusive to the residents. The DON verified the witnesses to the two allegations did not contact him prior to 10:30 P.M. The Administrator stated the 10/05/18 incident was his first SRI related to an abuse allegation. The Administrator felt there was no objective evidence to substantiate abuse and the allegations were unsubstantiated. The Administrator verified the four witnesses, Receptionist #05, LPN #35 and #48, and Resident #4, observed STNA #69 physically abuse Resident #66. The Administrator verified he was not notified of the two abuse allegations until 10/05/18 at 11:00 P.M. The Administrator and DON verified there were no residents interviewed as part of the facility's abuse investigation and STNA #69 was not removed from her assignment immediately and continued to work until 11:00 P.M. on 10/05/18. The Administrator verified he did not identify the fact the staff did not report the allegation of abuse timely and did not identify the staff did not remove STNA #69 from her work duties and protect the residents timely and in accordance with facility policy. The Administrator verified STNA #69 returned to work on 10/18/18 and did not receive further training or disciplinary action. Review of the facility's policy on abuse prevention, last revised on 07/2005, revealed residents were to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. The residents were to be protected from harm through frequent supervision by staff. If the alleged abuser was an employee, the employee shall be removed from the facility and suspended pending the results of the facility's investigation. The suspension shall be documented in the employee personnel file and shall remain in effect until the investigation is completed. The individual conducting the investigation will, as a minimum, included to interview the resident's roommate, family members and visitors and interview other residents to whom the accused employee provided care or services. If the investigation revealed findings of abuse, such findings would be reported to the state abuse registry and the employee would be terminated. This deficiency substantiates Control Number OH 685.

Based on observation, resident and staff interviews, review of medical records, review of a personnel record, review of a facility Self-Reported Incident (SRI), and review of the facility's abuse policy and procedure, the facility failed to ensure residents were free from physical abuse by a staff member. This resulted in Immediate Jeopardy for one resident (#66) when she was observed by three staff witnesses (Receptionist #05, Licensed Practical Nurses (LPN) #35 and #48) being dragged across the floor of her room and thrown into bed by State tested Nurse Aide (STNA) #69 after the resident had defecated on the floor. Additionally, a second resident (#2) was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. Consequently, all four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for his assigned residents. This affected two of two residents (#66 and #02) reviewed for abuse and placed 12 additional residents (#03, #10, #14, #17, #20, #21, #23, #36, #41, #51, #52, #91) at risk for the likelihood of serious harm or injury who were assigned STNA #69 as their care giver. On 10/31/18 at 2:20 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/05/18 at 7:35 P.M. when three staff members (Receptionist #05, LPNs #35 and #48) witnessed Resident #66 being dragged across the floor of her room and thrown into bed by STNA #69 after the resident had defecated on the floor. Additionally, on 10/05/18 at approximately 8:00 P.M., Resident #02 was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. All four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for residents for more than three hours after the initial witnessed incident of abuse. STNA #69 was eventually removed from her assignment and suspended on 10/05/18 at 11:00 P.M. pending an investigation; however, STNA #69 returned to work on 10/18/18 at 10:26 P.M. The Immediate Jeopardy was removed on 11/01/18 when the facility implemented the following corrective actions: · On 10/31/18 at 1:54 P.M., STNA #69 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 10/31/18, Resident #66 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #30 and there were no negative findings. · On 10/31/18, all eleven non-verbal and cognitively impaired residents had head-to-toe assessments completed by LPN #29, LPN #30 and Registered Nurse (RN) #44. There were no negative findings. · On 10/31/18, 24 alert and oriented residents were interviewed and asked if they felt safe in the facility and if they had any issues or concerns with staff. All 24 residents responded they felt safe in the facility and had no concerns regarding staff. The interviews were completed by LPN #30, LPN #39, RN #44 and Assistant Director of Nursing (ADON) #12. · On 10/31/18, the Administrator, DON, ADON #12, and RN #29 began mandatory staff in-servicing on abuse with the facility's 104 employees. The content of the education included the Abuse Policy, the definition of abuse, what to do if any staff suspect any type of abuse, reporting immediately to the Administrator, DON, or ADON, the alleged perpetrator needs to be removed immediately from the building pending investigation, a full head-to-toe assessment was to be completed by two nurses on separate occasions within 30 minutes of the reported allegation, the charge nurse was to collect statements from all involved parties in the facility at that time, including staff and residents if applicable, and staff to refer to the Abuse binder or Employee Handbook for further guidance on abuse. A plan for the remaining 12 staff to be educated prior to the start of their next shift was developed. · On 11/01/18, the Administrator and DON provided disciplinary action to the four witnesses (LPN #35, LPN #48, Receptionist #05 and STNA #72) of the two incidents of abuse on 10/05/18, for not following the facility's policy and procedures on abuse and/or abuse education. · On 11/01/18, the Administrator and DON initiated an abuse committee to meet one to two times per week for three months, then monthly. The committee will consist of interdisciplinary team members including social services, kitchen, human resources and an STNA. The first committee meeting will be held on 11/06/18. · On 11/01/18, interviews with STNA #64, STNA #66, LPN #28, LPN #25, LPN #32, Housekeeper #98, and Housekeeper #01 from 9:35 A.M. to 12:26 P.M. revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 11/01/18, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Medical record review for Resident #66 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/15/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills, required the limited assistance of one staff with transfers and the extensive physical assistance of one staff for ambulation. Review of the care plan, dated 02/02/18, revealed the resident had an unsteady gait, wandered around the facility with no purpose, had chronic back pain due to multiple car accidents, and had behaviors that were not easily altered including resistance with care. Review of the nursing head-to-toe assessment, dated 10/05/18 (with no time noted), revealed Resident #66 had no injuries, vital signs were stable and the resident was not observed with signs and symptoms of pain. The nursing note, dated 10/06/18, revealed the resident had no distress. There were no additional nursing skin assessments. Medical record review for Resident #04, who was Resident #66's roommate, revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/19/18, revealed the resident's cognition was intact. Medical record review for Resident #02 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/17/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills. The resident was totally dependent on two staff for transfers and did not ambulate. Review of the care plan, dated 06/25/18, revealed the resident had poor safety awareness and was resistive/combative with care at times. Review of the nursing head-to-toe assessment, dated 10/05/18 at 10:00 P.M., revealed the resident had no injuries, vital signs were stable and the resident did not exhibit signs and symptoms of pain. There were no additional nursing skin assessments. Review of a facility SRI dated 10/06/18 at 3:00 P.M. revealed it was created for two physical abuse allegations. Under the Summary of Incident section documentation revealed around the 7:00 P.M. hour, a first incident was witnessed by three staff including LPN #35, LPN #48 and Receptionist #05 who observed from the parking lot at dusk, STNA #69 (alleged perpetrator) in Resident #66's room with the lights on. The three facility staff alleged they observed STNA #69 dragging Resident #66 by the arm and throwing her on the bed near the window. STNA #69 reported Resident #66 was covered in feces and she was preparing the resident for incontinence care on her bed. The second incident involved STNA #72 who reported she witnessed STNA #66 'slap/hit' Resident #02's hands up to eight times during a stand-up lift transfer because the resident refused to let go of the sheets/clothing. STNA #69 denied abusing Residents #66 and #02 in both incidents. The nurse conducted head-to-toe assessments for both Residents #66 and #02, which indicated no evidence of bruising, redness or symptoms of abuse. Both residents were not interviewed due to extreme cognitive deficits. The four staff who witnessed the incidents were contacted by phone and interviewed by the Administrator. The conclusion revealed the incident with Resident #66 was witnessed from 15 to 20 feet away outside and the staff felt STNA #69 was too rough with the aforementioned residents. The facility conclusion documented the information was based on second hand information, the staff statements were subjective without an objective basis and subsequently the abuse was unsubstantiated. Review of the witness statements within the facility's abuse investigation revealed the following: Review of LPN #48's statement, dated 10/05/18, revealed she observed from the parking lot, STNA #69 drag Resident #66 by the arm and flung her on the bed. Within the same hour, STNA #72 reported STNA #69 was slapping Resident #02 roughly on his hands. Review of STNA #72's statement, dated 10/05/18, revealed she was in Resident #02's room assisting STNA #69 with a stand-up lift transfer when STNA #69 started hitting him on his hands about eight times telling the resident to let go of his clothing. STNA #72 stated she reported the concern to LPN #48. Review of LPN #35's statement, dated 10/06/18, revealed around 7:35 P.M. on 10/05/18, she was outside by her car and she observed a light in Resident #66's room and STNA #69 was dragging Resident #66 very hard into the room by her arm, tossed her into the bed and walked out of the room. Review of Receptionist #05's statement, dated 10/11/18, revealed LPN #48 and #35 were helping her put some bags in her van when she observed STNA #69 pulling Resident #66's arm 'really roughly' and slammed her onto the bed. STNA #69 left the room and shut the door. Resident #66 appeared very upset and kept rubbing her eyes and face and may have been crying. Review of the employee file for STNA #69 revealed a hire date of 04/25/18 and did not have any disciplinary action noted. Interview on 10/29/18 at 2:50 P.M. with STNA #72 revealed she was not aware of the incident involving Resident #66 on 10/05/18 at 7:35 P.M. and verified she assisted STNA #69 in providing the incontinence care after the incident. During the incontinence care, Resident #66 did not appear abused/upset in any way. The STNA stated soon after (unable to provide a time frame) providing incontinence care to Resident #66, she observed and immediately reported an allegation of abuse to LPN #48. The STNA stated she was assisting STNA #69 with a stand-up lift transfer for Resident #02, who was grabbing at his clothing instead of putting his hands on the stand-up lift. STNA #69 hit his hands about eight times. After the incident, STNA #69 came back looking mad and stated to her why did you tell on me. Before she left the building, she was cursing loudly in the hallway where residents could hear. STNA #72 stated she did not understand why STNA #69 returned to work after being so rough with Resident #02. Interview on 10/29/18 at 3:05 P.M. with Receptionist #05 revealed she was in the parking lot getting ready to leave after her shift on 10/05/18 around 7:30 P.M. She said she observed STNA #69 pulling Resident #66's arm and tossed her into the bed in a rough way. The resident did not understand and appeared upset and kept rubbing her eyes and face. She said she could not tell if the resident was crying. She verified she did not go back into the building to report and protect the resident. She stated she felt STNA #69's actions were abusive. Interview on 10/29/18 at 3:20 P.M. with STNA #69 revealed she typically worked the evening/night shifts and she denied abusing or rough handling of any resident. The STNA explained Resident #66 was defecating/urinating in the hallway on second hall and had feces all over her. She said she was holding the resident's arm trying to remove the poop. She stated STNA #72 assisted in providing incontinence care to the resident, who was upset. After the incontinence care was provided to Resident #66, STNA #72 and herself then went to assist Resident #02 in a stand-up lift transfer. Resident #02 did not want to let go of the lift bars and she told the resident to come on and open your hands. Observation of Resident #02 on 10/29/18 at 3:41 P.M. revealed he was clean with no evidence of bruising or redness to the skin. He did not appear fearful of the staff at any time. Interview on 10/30/18 at 6:50 A.M. with LPN #48 revealed she had worked with STNA #69 for a long time on night shift and said the STNA could be harsh and curse at the nursing staff where the residents could hear at times. On 10/05/18 around 7:30 P.M., LPN #48 stated it was getting dark outside and she was in the parking lot and could see inside Resident #66's room and the lights were turned on in the room. She observed STNA #69 dragging the resident's arm from the bedroom door to the second bed and flung her on the bed. LPN #48 stated she felt STNA #69 was abusive and said she observed the resident wiping her face/eyes. LPN #48 verified she did not go back into the facility to protect the residents from STNA #69 at this time. LPN #48 stated she reported the abuse allegation to the DON around 8:20 P.M. by phone who told her to get a statement from STNA #69. STNA #69 was in the second hallway (same hallway as both residents involved) writing her statement and left the building around 11:00 P.M. She did not understand why STNA #69 was not terminated. Interview on 10/30/18 at 9:40 A.M. with LPN #35 revealed she observed Resident #66 from the parking lot around 7:35 P.M. and verified she did not come back into the facility after the incident because she was off duty. LPN #35 observed the resident holding the door frame of her bedroom and STNA #69 dragging her with both arms to the bed, threw her hard on the bed and then she walked out of the room. LPN #35 stated it looked like abuse and observed the resident rubbing her eyes, like she was crying. LPN #35 stated Resident #66 followed directions when staff talked nice to her. STNA #69 cursed a lot at staff, which residents could hear at times. She did not understand why STNA #69 was not terminated. Observation of Resident #66 on 10/30/18 at 11:22 A.M. revealed she followed staff cues at times during an exercise program. The resident was smiling and did not appear fearful of the staff at any time. There was no evidence of bruising or redness to the skin. On 10/30/18 at 2:55 P.M., the Administrator provided STNA #69's time card for 10/05/18 which showed she was paid from on 10/05/18 from 6:24 P.M. to 6:00 A.M. and did not indicate the time she actually exited the facility. The Administrator stated he was notified of the abuse allegations around 11:00 P.M. on 10/05/18, at the time STNA #69 exited the facility. Interview on 10/31/18 at 11:00 A.M. with Resident #04 revealed she was in bed about three weeks ago in the evening and had feces on her water pitcher from her roommate, Resident #66. At that time, she observed an STNA grab her roommate's arm, pulled her to the bed and swung her into the bed in a rough way. The STNAs came in and cleaned her roommate up and replaced her water pitcher. She could not remember the names of STNAs who provided the care to her roommate. Interview on 10/31/18 at 11:45 A.M. with the Administrator and DON, the DON verified only one SRI was reported to the state agency because both incidents were reported at 10:39 P.M. on 10/05/18 when STNA #69 contacted him and was upset the staff were accusing her of being abusive to the residents. The DON verified the witnesses to the two allegations did not contact him prior to 10:30 P.M. The Administrator stated the 10/05/18 incident was his first SRI related to an abuse allegation. The Administrator felt there was no objective evidence to substantiate abuse and the allegations were unsubstantiated. The Administrator felt the evening shift staff were upset because STNA #69 was not terminated and he was addressing this concern starting today. The Administrator verified he was not notified of the two abuse allegations until 10/05/18 at 11:00 P.M. Review of the facility's policy on abuse prevention, last revised on 07/2005, revealed residents were to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. The residents were to be protected from harm through frequent supervision by staff. If the alleged abuser was an employee, the employee shall be removed from the facility and suspended pending the results of the facility's investigation. The suspension shall be documented in the employee personnel file and shall remain in effect until the investigation is completed. This deficiency substantiates Control Number OH 685.

Based on observation, resident and staff interviews, review of medical records, review of a personnel record, review of a facility Self-Reported Incident (SRI), and review of the facility's abuse policy and procedure, the facility staff failed to immediately report to the Administrator witnessed incidents of staff to resident abuse during the provision of resident care. This resulted in Immediate Jeopardy for one resident (#66) when she was observed by three staff witnesses (Receptionist #05, Licensed Practical Nurses (LPN) #35 and #48) being dragged across the floor of her room and thrown into bed by State tested Nurse Aide (STNA) #69 after the resident had defecated on the floor. Additionally, a second resident (#2) was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. Consequently, all four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for his assigned residents. This affected two of two residents (#66 and #02) reviewed for abuse and placed 12 additional residents (#03, #10, #14, #17, #20, #21, #23, #36, #41, #51, #52, #91) at risk for the likelihood of serious harm or injury who were assigned STNA #69 as their care giver. On 10/31/18 at 2:20 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/05/18 at 7:35 P.M. when three staff members (Receptionist #05, LPNs #35 and #48) witnessed Resident #66 being dragged across the floor of her room and thrown into bed by STNA #69 after the resident had defecated on the floor. Additionally, on 10/05/18 at approximately 8:00 P.M., Resident #02 was witnessed by a fourth staff member (STNA #72) to have his hand slapped multiple times by the same STNA (#69) while attempting to get the resident to move his hand during a transfer utilizing a mechanical lift. All four staff witnesses failed to immediately report the observed incidents of resident abuse thus allowing STNA #69 to continue providing care for residents for more than three hours after the initial witnessed incident of abuse. STNA #69 was eventually removed from her assignment and suspended on 10/05/18 at 11:00 P.M. pending an investigation; however, STNA #69 returned to work on 10/18/18 at 10:26 P.M. The Immediate Jeopardy was removed on 11/01/18 when the facility implemented the following corrective actions: · On 10/31/18 at 1:54 P.M., STNA #69 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 10/31/18, Resident #66 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #30 and there were no negative findings. · On 10/31/18, all eleven non-verbal and cognitively impaired residents had head-to-toe assessments completed by LPN #29, LPN #30 and Registered Nurse (RN) #44. There were no negative findings. · On 10/31/18, 24 alert and oriented residents were interviewed and asked if they felt safe in the facility and if they had any issues or concerns with staff. All 24 residents responded they felt safe in the facility and had no concerns regarding staff. The interviews were completed by LPN #30, LPN #39, RN #44 and Assistant Director of Nursing (ADON) #12. · On 10/31/18, the Administrator, DON, ADON #12, and RN #29 began mandatory staff in-servicing on abuse with the facility's 104 employees. The content of the education included the Abuse Policy, the definition of abuse, what to do if any staff suspect any type of abuse, reporting immediately to the Administrator, DON, or ADON, the alleged perpetrator needs to be removed immediately from the building pending investigation, a full head-to-toe assessment was to be completed by two nurses on separate occasions within 30 minutes of the reported allegation, the charge nurse was to collect statements from all involved parties in the facility at that time, including staff and residents if applicable, and staff to refer to the Abuse binder or Employee Handbook for further guidance on abuse. A plan for the remaining 12 staff to be educated prior to the start of their next shift was developed. · On 11/01/18, the Administrator and DON provided disciplinary action to the four witnesses (LPN #35, LPN #48, Receptionist #05 and STNA #72) of the two incidents of abuse on 10/05/18, for not following the facility's policy and procedures on abuse and/or abuse education. · On 11/01/18, the Administrator and DON initiated an abuse committee to meet one to two times per week for three months, then monthly. The committee will consist of interdisciplinary team members including social services, kitchen, human resources and an STNA. The first committee meeting will be held on 11/06/18. · On 11/01/18, interviews with STNA #64, STNA #66, LPN #28, LPN #25, LPN #32, Housekeeper #98, and Housekeeper #01 from 9:35 A.M. to 12:26 P.M. revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 11/01/18, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Medical record review for Resident #66 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/15/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills, required the limited assistance of one staff with transfers and the extensive physical assistance of one staff for ambulation. Review of the care plan, dated 02/02/18, revealed the resident had an unsteady gait, wandered around the facility with no purpose, had chronic back pain due to multiple car accidents, and had behaviors that were not easily altered including resistance with care. Review of the nursing head-to-toe assessment, dated 10/05/18 (with no time noted), revealed Resident #66 had no injuries, vital signs were stable and the resident was not observed with signs and symptoms of pain. The nursing note, dated 10/06/18, revealed the resident had no distress. There were no additional nursing skin assessments. Medical record review for Resident #04, who was Resident #66's roommate, revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/19/18, revealed the resident's cognition was intact. Medical record review for Resident #02 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/17/18, revealed the resident had both short and long-term memory impairment and severely impaired decision-making skills. The resident was totally dependent on two staff for transfers and did not ambulate. Review of the care plan, dated 06/25/18, revealed the resident had poor safety awareness and was resistive/combative with care at times. Review of the nursing head-to-toe assessment, dated 10/05/18 at 10:00 P.M., revealed the resident had no injuries, vital signs were stable and the resident did not exhibit signs and symptoms of pain. There were no additional nursing skin assessments. Review of a facility SRI dated 10/06/18 at 3:00 P.M. revealed it was created for two physical abuse allegations. Under the Summary of Incident section documentation revealed around the 7:00 P.M. hour, a first incident was witnessed by three staff including LPN #35, LPN #48 and Receptionist #05 who observed from the parking lot at dusk, STNA #69 (alleged perpetrator) in Resident #66's room with the lights on. The three facility staff alleged they observed STNA #69 dragging Resident #66 by the arm and throwing her on the bed near the window. STNA #69 reported Resident #66 was covered in feces and she was preparing the resident for incontinence care on her bed. The second incident involved STNA #72 who reported she witnessed STNA #66 'slap/hit' Resident #02's hands up to eight times during a stand-up lift transfer because the resident refused to let go of the sheets/clothing. STNA #69 denied abusing Residents #66 and #02 in both incidents. The nurse conducted head-to-toe assessments for both Residents #66 and #02, which indicated no evidence of bruising, redness or symptoms of abuse. Both residents were not interviewed due to extreme cognitive deficits. The four staff who witnessed the incidents were contacted by phone and interviewed by the Administrator. The conclusion revealed the incident with Resident #66 was witnessed from 15 to 20 feet away outside and the staff felt STNA #69 was too rough with the aforementioned residents. The facility conclusion documented the information was based on second hand information, the staff statements were subjective without an objective basis and subsequently the abuse was unsubstantiated. Review of the witness statements within the facility's abuse investigation revealed the following: Review of LPN #48's statement, dated 10/05/18, revealed she observed from the parking lot, STNA #69 drag Resident #66 by the arm and flung her on the bed. Within the same hour, STNA #72 reported STNA #69 was slapping Resident #02 roughly on his hands. Review of STNA #72's statement, dated 10/05/18, revealed she was in Resident #02's room assisting STNA #69 with a stand-up lift transfer when STNA #69 started hitting him on his hands about eight times telling the resident to let go of his clothing. STNA #72 stated she reported the concern to LPN #48. Review of LPN #35's statement, dated 10/06/18, revealed around 7:35 P.M. on 10/05/18, she was outside by her car and she observed a light in Resident #66's room and STNA #69 was dragging Resident #66 very hard into the room by her arm, tossed her into the bed and walked out of the room. Review of Receptionist #05's statement, dated 10/11/18, revealed LPN #48 and #35 were helping her put some bags in her van when she observed STNA #69 pulling Resident #66's arm 'really roughly' and slammed her onto the bed. STNA #69 left the room and shut the door. Resident #66 appeared very upset and kept rubbing her eyes and face and may have been crying. Review of the employee file for LPN #48 revealed she was hired on 11/24/17 and signed on that date that she received the abuse policy that stated as an employee it was her responsibility to notify the DON/Administrator immediately of any abuse concerns. Review of Resident #05, LPN #35, LPN #48 and STNA #72's employee files revealed there were no disciplinary actions regarding reporting allegations of abuse. Review of the employee file for STNA #69 revealed a hire date of 04/25/18 and no documented evidence of any disciplinary action. Interview on 10/29/18 at 2:50 P.M. with STNA #72 revealed she was not aware of the incident involving Resident #66 on 10/05/18 at 7:35 P.M. and verified she assisted STNA #69 in providing the incontinence care after the incident. During the incontinence care, Resident #66 did not appear abused/upset in any way. The STNA stated soon after (unable to provide a time frame) providing incontinence care to Resident #66, she observed and immediately reported an allegation of abuse to LPN #48. The STNA stated she was assisting STNA #69 with a stand-up lift transfer for Resident #02, who was grabbing at his clothing instead of putting his hands on the stand-up lift. STNA #69 hit his hands about eight times. After the incident, STNA #69 came back looking mad and stated to her why did you tell on me. Before she left the building, she was cursing loudly in the hallway where residents could hear. STNA #72 stated she did not understand why STNA #69 returned to work after being so rough with Resident #02. Interview on 10/29/18 at 3:05 P.M. with Receptionist #05 revealed she was in the parking lot getting ready to leave after her shift on 10/05/18 around 7:30 P.M. She said she observed STNA #69 pulling Resident #66's arm and tossed her into the bed in a rough way. The resident did not understand and appeared upset and kept rubbing her eyes and face. She said she could not tell if the resident was crying. She verified she did not go back into the building to report and protect the resident. She stated she felt STNA #69's actions were abusive. Interview on 10/29/18 at 3:20 P.M. with STNA #69 revealed she typically worked the evening/night shifts and she denied abusing or rough handling of any resident. The STNA explained Resident #66 was defecating/urinating in the hallway on second hall and had feces all over her. She said she was holding the resident's arm trying to remove the poop. She stated STNA #72 assisted in providing incontinence care to the resident, who was upset. After the incontinence care was provided to Resident #66, STNA #72 and herself then went to assist Resident #02 in a stand-up lift transfer. Resident #02 did not want to let go of the lift bars and she told the resident to come on and open your hands. Observation of Resident #02 on 10/29/18 at 3:41 P.M. revealed he was clean with no evidence of bruising or redness to the skin. He did not appear fearful of the staff at any time. Interview on 10/30/18 at 6:50 A.M. with LPN #48 revealed she had worked with STNA #69 for a long time on night shift and said the STNA could be harsh and curse at the nursing staff where the residents could hear at times. On 10/05/18 around 7:30 P.M., LPN #48 stated it was getting dark outside and she was in the parking lot and could see inside Resident #66's room and the lights were turned on in the room. She observed STNA #69 dragging the resident's arm from the bedroom door to the second bed and flung her on the bed. LPN #48 stated she felt STNA #69 was abusive and said she observed the resident wiping her face/eyes. LPN #48 verified she did not go back into the facility to protect the residents from STNA #69 at this time. LPN #48 stated she reported the abuse allegation to the DON around 8:20 P.M. by phone who told her to get a statement from STNA #69. STNA #69 was in the second hallway (same hallway as both residents involved) writing her statement and left the building around 11:00 P.M. She did not understand why STNA #69 was not terminated. Interview on 10/30/18 at 9:40 A.M. with LPN #35 revealed she observed Resident #66 from the parking lot around 7:35 P.M. and verified she did not come back into the facility after the incident because she was off duty. LPN #35 observed the resident holding the door frame of her bedroom and STNA #69 dragging her with both arms to the bed, threw her hard on the bed and then she walked out of the room. LPN #35 stated it looked like abuse and observed the resident rubbing her eyes, like she was crying. LPN #35 stated Resident #66 followed directions when staff talked nice to her. STNA #69 cursed a lot at staff, which residents could hear at times. She did not understand why STNA #69 was not terminated. Observation of Resident #66 on 10/30/18 at 11:22 A.M. revealed she followed staff cues at times during an exercise program. The resident was smiling and did not appear fearful of the staff at any time. There was no evidence of bruising or redness to the skin. On 10/30/18 at 2:55 P.M., the Administrator provided STNA #69's time card for 10/05/18 which showed she was paid from on 10/05/18 from 6:24 P.M. to 6:00 A.M. and did not indicate the time she actually exited the facility. The Administrator stated he was notified of the abuse allegations around 11:00 P.M. on 10/05/18, at the time STNA #69 exited the facility. Interview on 10/31/18 at 11:00 A.M. with Resident #04 revealed she was in bed about three weeks ago in the evening and had feces on her water pitcher from her roommate, Resident #66. At that time, she observed an STNA grab her roommate's arm, pulled her to the bed and swung her into the bed in a rough way. The STNAs came in and cleaned her roommate up and replaced her water pitcher. She could not remember the names of STNAs who provided the care to her roommate. Interview on 10/31/18 at 11:45 A.M. with the Administrator and DON, the DON verified only one SRI was reported to the state agency because both incidents were reported at 10:39 P.M. on 10/05/18 when STNA #69 contacted him and was upset the staff were accusing her of being abusive to the residents. The DON verified the witnesses to the two allegations did not contact him prior to 10:30 P.M. The Administrator stated the 10/05/18 incident was his first SRI related to an abuse allegation. The Administrator felt there was no objective evidence to substantiate abuse and the allegations were unsubstantiated. The Administrator verified the four witnesses, Receptionist #05, LPN #35 and #48, and Resident #4, observed STNA #69 physically abuse Resident #66. The Administrator verified he was not notified of the two abuse allegations until 10/05/18 at 11:00 P.M. The Administrator and DON verified there were no residents interviewed as part of the facility's abuse investigation and STNA #69 was not removed from her assignment immediately and continued to work until 11:00 P.M. on 10/05/18. The Administrator verified he did not identify the fact the staff did not report timely of the abuse allegation and did not identify the staff did not remove STNA #69 from her work duties and protect the residents timely and in accordance with facility policy. The Administrator verified STNA #69 returned to work providing direct care to the residents on 10/18/18 and did not receive further training or disciplinary action. Review of the facility's policy on abuse prevention, last revised on 07/2005, revealed residents were to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. The residents were to be protected from harm through frequent supervision by staff. If the alleged abuser was an employee, the employee shall be removed from the facility and suspended pending the results of the facility's investigation. The suspension shall be documented in the employee personnel file and shall remain in effect until the investigation is completed. This deficiency substantiates Control Number OH 685.

Based on medical record review, observation, resident and staff interview, review of information from Medscape, and review of facility policy, the facility failed to ensure a resident's pain was adequately managed during a dressing change to the resident's pressure ulcer. This resulted in actual harm when nursing failed to ensure Resident #8 received an as needed (PRN) pain medication when the resident reported pain resulting in the resident having unrelieved severe pain. This affected one (#8) of three residents reviewed for pain management. The facility identified 38 residents on a pain management program. Findings include: Medical record review for Resident #8 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].) to administer one tablet every eight hours PRN for pain. Review of annual Minimum Data Set (MDS) assessment, dated 10/25/18, revealed the resident was cognitively impaired and she was a total dependent on staff for bed mobility and transfers. Review of pain management for the past five days revealed there were not any scheduled pain medications, but the resident received PRN pain medications. The resident revealed during the past five days she had pain that made it hard for her to sleep. The resident had one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Review of the resident's care plan for pain, dated 10/25/18, revealed there was potential for pain. Interventions included for pain assessments quarterly and PRN, administer pain medications per physician orders, give PRN pain medication for breakthrough pain, acknowledge presence of pain and discomfort and listen to the resident's concerns, and assess for verbal and nonverbal complaints of pain. Review of Resident #8's pain rating form, dated 11/01/18 at 2:15 P.M., revealed the resident said her pain was a ten out of ten (a scale indicating zero for no pain and ten being worse pain ever) and said it started during the dressing change to her left heel and described it as throbbing. Review of a progress note, dated 11/01/18 at 2:32 P.M., revealed Resident #8 took her medications. The resident had complaints of pain at a nine out of ten after the dressing change and [MEDICATION NAME] 50 mg. was given. The note revealed the resident was previously asked at 10:30 A.M. and the resident stated she didn't want pain medication prior to the dressing change. Observation of a dressing change to the unstageable pressure ulcer to the left heel of Resident #8 on 11/01/18 from 1:45 P.M. to 1:55 P.M. with Licensed Practical Nurse (LPN) #30 revealed when the nurse touched the left heel, the resident said, that hurts. The nurse asked the resident how she rates her pain and the resident replied 100 percent (%). The LPN replied she was going to get her some pain medication, but the LPN continued with the dressing change and applied normal saline to clean the wound and the resident was observed to wince. The LPN continued with applying 50% Hypochlorite solution and the resident said, oh 'expletive' that hurts. The nurse continued with the treatment and when she applied the [MEDICATION NAME] to the wound, the resident winced again and said, oh 'expletive' that hurts. During the observation, the surveyor asked if the resident had pain medication before the treatment and the LPN replied she wasn't the nurse for the resident but could find out. The LPN told the resident she was sorry it was painful, and she didn't get a pain medication for her. Interview with LPN #30 on 11/01/18 at 1:57 P.M. revealed she didn't ask the resident if she needed pain medication prior to the dressing change and stated the resident wasn't usually in this much pain with the dressing change. She said she was waiting on the surveyor to tell her to medicate for pain. She asked the surveyor what did you want me to do, stop in the middle of the treatment and medicate the resident for pain. She stated her normal process would be to check with the resident and see if they wanted something for pain before the treatment. Interview with LPN #32 on 11/01/18 at 1:59 P.M. revealed Resident #8 didn't ask for any pain medication, but then stated at 10:30 A.M. on 11/01/18 she asked if the resident needed anything for pain before her dressing change and the resident said no at the time. The LPN verified she did not ask the resident again prior to the dressing change. Subsequent interview with LPN #32 on 11/01/18 at 2:35 P.M. revealed she medicated the resident for pain at 2:15 P.M. Interview with Resident #8 on 11/01/18 at 2:06 P.M. revealed she was tearful and said the staff didn't ask her if she wanted pain medication before the dressing change and stated it makes her feel terrible. She rated her pain at a 10 out of 10 for pain during and after the dressing change. Review of information from Medscape revealed [MEDICATION NAME] is an opioid [MEDICATION NAME] that is indicated to treat moderate to severe pain. Further review revealed precise and systematic pain assessment is required to make the correct [DIAGNOSES REDACTED]. During a Pain Assessment, the resident's pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. Review of policy entitled Pain Assessment and Management, dated (MONTH) (YEAR), revealed the pain management program was based on facility-wide commitment to resident's comfort. Pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and was based on his or her clinical condition and established goals.

Based on closed medical record review, review of the Emergency Medical Services (EMS) report and interview with the paramedics who responded, review of the Preliminary Autopsy Report and staff from the Coroner's office, review of the facility's incident investigation, observation of video recordings, staff interviews, interview with the resident's guardian, interview with the Nurse Practitioner for the facility, interview with a family member, interview with the Medical Director and the office manager of the Medical Director, and review of facility policies and procedures, the facility failed to ensure one (#1) of eight residents were free from neglect when Resident #1 was heard by staff yelling for help and no staff went to assist the resident for 19 minutes. Consequently, State tested Nursing Assistant (STNA) #50 entered the resident's room and found Resident #1 sitting on the mat, on the floor, with his upper body leaning up against the bed, with part of his head and throat between the grab bar and mattress. At that time, the resident was unresponsive and had passed away. This resulted in Immediate Jeopardy and serious life threatening harm and subsequent death when Resident #1 was neglected for 19 minutes after he was heard yelling out for help and was found unresponsive and subsequently expired. On [DATE] at 1:29 P.M., the Licensed Nursing Home Administrator (LNHA), Licensed Practical Nurse (LPN) #38, the Assistant Director of Nursing (ADON), LPN #37, and the Owner (via speaker phone) were notified Immediate Jeopardy began on [DATE] at 11:54 A.M. when Resident #1 was heard by Dietary Manager (DM) #100 and Dietary Aide (DA) #91 yelling for help and immediately notified LPN #20 who neglected to check on the resident. No staff went to assist the resident for 19 minutes after he was heard yelling for help and subsequently died . The Immediate Jeopardy was removed on [DATE] when the facility established systems to ensure residents were not neglected and received appropriate services and care in a timely manner, and the facility implemented the following corrective actions: · On [DATE], the facility suspended LPN #20, pending an investigation who was identified on the video recording and had been informed Resident #1 was yelling for help and neglected to check on the resident. · On [DATE], the LNHA and/or designee(s) began educating/in-servicing the entire facility staff on the expectations of response time to resident requests for assistance. The in-service included if a resident was requesting help, to see what they need. The in-service revealed, under no circumstances were staff to walk past a room of a resident who was asking for help and not physically go in the room and see what the resident needed. By 4:15 P.M., three LPNs (#29, #37 and #58), eight STNAs (#9, #12, #44, #52, #72, #81, #83 and #91), DM #100, the ADON, Activities Director (AD) #4, Human Resource Director (HRD) #13, the Business Office Manager (BOM), Social Service Worker (SSW) #35, Physical Therapist Assistant (PTA) #89, the Maintenance Director and Maintenance Assistant Director #68 were educated/in-serviced. All remaining staff who were not in the building, would be educated/in-serviced via telephone and would not be permitted to work until they have received the education/in-service. · On [DATE], all residents at the facility will be assessed by the LNHA and/or her designee(s) for any potential negative outcomes as related to resident's requests for assistance and response time. These assessments will be completed before midnight on [DATE]. · On [DATE], call light audits for alternating hallways will be conducted by the LNHA and/or her designee(s) with any concerns being reported immediately to the Quality Assurance and Performance Improvement (QAPI) committee and directly resolved. Each audit will be a minimum of 30 minutes in length. The audits will be completed three times daily for five days per week, for two weeks, then twice daily for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing and randomly thereafter. · On [DATE], the LNHA and/or her designee(s) will begin to audit response times when requests for help, are issued from a room or area of the building. The audits will be conducted with an employee going in a room, or an area of the building and shouting for help. The response of the employees will be evaluated and timed. These audits will be conducted at varying times, on varied shifts, as follows: three times daily for five days per week for two weeks, then twice daily, for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing, and randomly thereafter. · Interviews on [DATE] between 4:17 P.M. and 4:35 P.M. with three LPNs (#29, #58 and #64) and four STNAs (52, #54, #81 and #83) confirmed they had all been educated and in-serviced regarding response times when resident's requested assistance or needed help. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. His functional status was noted as extensive one person assist for transfers and bed mobility, and extensive one person assist for all other activities of daily living. Review of Resident #1's care plan dated [DATE] revealed the resident was at risk for falls characterized by involuntary movements and [MEDICAL CONDITION] medication. The care plan revealed the resident often put himself on the floor and had impaired physical mobility in bed, related to cognitive impairment, activity intolerance, limited endurance, uncontrolled body movements, weakness, and anxiety. Interventions included to continue with therapy and reinforce the need to call for assistance. Review of the last nurse's progress note dated [DATE] at 9:29 A.M. revealed Resident #1 took his morning medications without issues and there were no signs or symptoms of distress noted. This was the last nurse's note in the resident's record. There was no change of condition or death documented in the medical record. Further review of Resident #1's medical record revealed a subpoena from the Franklin County Coroner's office dated [DATE] had been sent to the facility. The subpoena revealed the death of Resident #1 had come under the jurisdiction of the Office of the Coroner of Franklin County as a medico-legal investigation. A request for the death/incident of [DATE] for Resident #1 was requested by the end of the business day on [DATE]. There was no evidence in the record the report had been sent to the Coroner's office as of [DATE]. Review of the paramedic's report dated [DATE] revealed the paramedics were called on [DATE] at 3:15 P.M. and arrived at the facility at 3:17 P.M. for a possible dead on arrival incident. The report revealed Resident #1 was found unresponsive, lying in bed, covered up. The report further revealed rigor mortis (stiff body) had set in. The report revealed as the paramedics were leaving the facility, LPN #38 stopped them and asked about calling the Coroner. The paramedics told LPN #38 the facility or the police would do that, not the EMS. The report revealed the LPN stated it was an accidental death. The LPN was then asked if he suspected foul play and he stated no. The report revealed the paramedic offered to call the police and was told by the LPN he would handle it. Per the report, there was nothing seen that would have indicated this was an accidental death as the resident, upon arrival, was lying flat in bed. Review of the Preliminary Autopsy Report for Resident #1 dated [DATE] revealed there were no cutaneous or internal injuries of the neck and there was a slight pectus excavatum (concave chest), unremarkable heart, lungs, and liver. The report further revealed an unremarkable brain, and the final autopsy was pending toxicology, microscopy and medical review. Review of the facility's incident report with LPN #38 dated [DATE] and witness statements on [DATE] revealed Resident #1 was found by staff on the floor sitting on the mat with his upper body leaning against the grab bar and mattress and the resident was unresponsive with no vital signs. No external injury was noted. Resident #1's guardian, the LNHA, Medical Director and the resident's brother were notified. Review of the witness statements provided by LPN #38 revealed all employees who were working on [DATE] wrote statements, except there were no statements from STNA #50 and LPN #20 who were the first to respond to Resident #1's room. The LPN confirmed there were no statements from STNA #50 and LPN #20 in the incident report. He stated LPN #20 was too upset to write one. Review of DM #100's statement revealed she was going down the hall around noon on [DATE] when she heard Resident #1 yelling for help. The statement further revealed she told LPN #20 the resident was yelling for help. Interview with LPN #20 on [DATE] at 9:58 A.M. confirmed she was the nurse assigned to the care of Resident #1, the day of his death on [DATE]. She stated she first saw Resident #1 around 7:30 A.M., walking down the hall to the vending room, which was his normal routine. LPN #20 then stated she gave Resident #1 his medications around 9:30 A.M. and the resident had no complaints. She stated the resident's brother came to visit the resident around 10:00 A.M. LPN #20 stated around noon on [DATE], STNA #50 came out of Resident #1's room yelling she needed a nurse immediately. LPN #20 revealed she went to Resident #1's room and found the resident sitting on his bottom on the mat on the floor, with his upper body/back leaning against his bed. The LPN stated Resident #1's head and neck were stuck between the grab bar and mattress. She stated his face was extremely pale. She stated she immediately yelled for more help and when LPN #38 and Registered Nurse (RN) #23 came into Resident #1's room they moved his head from between the grab bar and mattress and laid him down flat on his back, on the mat. She stated RN #23 stated Resident #1 did not have a pulse. LPN #20 stated she was clueless as to what to do and no one seemed to know what they were doing. LPN #20 stated LPN #38 asked her to contact the resident's Power of Attorney (POA), who was the Guardian appointed by the courts, and to call the physician. She stated she contacted the physician, (she could not remember what time) who told her to call emergency services (911) so they could come and pronounce the resident as expired. The LPN stated the coroner came and got the resident around 6:30 P.M. LPN #20 stated she left the facility around 7:15 P.M. after her shift and confirmed she did not write a progress note or witness statement regarding the resident's incident/death. LPN #20 confirmed DM #100 told her Resident #1 was yelling for help on [DATE], however, stated it was around 10:00 A.M., and not noon. Interview with STNA #50 on [DATE] at 10:11 A.M. confirmed she was assigned to the care of Resident #1 on [DATE], the day of the resident's death. She stated she helped Resident #1 that morning wash up and dress for the day. She stated he had no complaints and was in no distress. STNA #50 stated Resident #1's brother came in the room around 10:00 A.M. to visit and left around 11:15 A.M. STNA #50 stated she went back to Resident #1's room at approximately 11:30 A.M. to get Resident #5 (Resident #1's roommate) and take him to the dining room. She stated she asked Resident #1 if he wanted to go to the dining room for lunch and he stated he did not. STNA #50 stated this was normal, as the resident would go to the dining room at times, and at others he preferred to eat in his room. She stated when she left the room with the resident's roommate, Resident #1 was lying on his back in his bed. STNA #50 stated when she brought Resident #5 back to the room around noon, she stepped around Resident #5's wheelchair and saw Resident #1's lower body was on the mat, on the floor, and he was leaning up against his bed. She stated his head was leaned back tilted to the left on the bed, and part of his head and throat were between the grab bar and mattress, with his throat against the grab bar. She stated the resident's eyes and mouth were open and he was very pale. She yelled his name and did not get a response. She stated she then ran to the door and yelled for LPN #20 she needed help. LPN #20 came into the room and she told me to get her more help. STNA #50 stated she ran to LPN #38's office and told him to come quick and stated she did not go back in the room as she was too upset. STNA #50 stated Resident #1 would sometimes use his grab bar on his bed to help him move and position himself in bed. Interview with LPN #38 on [DATE] at 10:22 A.M. revealed STNA #50 came to his office on [DATE] around noon and told him to come quick to Resident #1's room. The LPN stated when he got to the resident's room Resident #1 was sitting on the floor, on the mat, leaning against his bed. His head was tilted back on top of the mattress and his neck was up against the grab bar, however, was not wedged between the grab bar and mattress. LPN #38 stated RN #23 was in the room and assessed the resident for a pulse and he did not have one, nor were any vital signs present. LPN #38 stated he sent the ADON to find out the code status of Resident #1. He then stated he and RN #23 placed the resident flat on the mat, on his back, on the floor. LPN #38 stated he assessed for bruising and redness of the resident's neck and nothing was noted. LPN #38 then was told Resident #1 was a Do Not Resuscitate Comfort Care (DRNCC) and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was not done. The LPN stated he and RN #23 picked up Resident #1 off the floor and placed him in his bed. He then went to make sure calls were made to the guardian and he stated he called the LNHA. He stated the physician told him to call the paramedics. The resident's brother was also notified the resident had passed away. He stated the paramedics arrived at the facility around 3:00 P.M. LPN #38 stated the paramedics told him to call the Coroner. The Coroner was called and a female (did not know her name) came to the facility and examined Resident #1's body and took pictures and stated she would call someone to pick up the body. The LPN stated Resident #1 was removed from the facility by the Coroner around 6:30 P.M. Interview with the LNHA on [DATE] at 11:00 A.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she had the resident's bed removed from the room and placed in the back hallway so staff could do a reenactment of how the resident was found to ensure he was not stuck between the grab bar and mattress. Observation of Resident #1's bed at the time of the interview revealed there was no gap between the mattress and the grab bar, nor was it loose. Interview with DM #100 on [DATE] at 12:10 P.M. revealed she had been in the snack shack on [DATE] getting snacks for residents. She stated the snack shack was two doors up from Resident #1's room. She stated just before noon she left the snack shack as she had a dishwasher repairman waiting for her. She stated when she got closer to Resident #1's room she heard him yelling help me. She stated she did not go in the room and all she could see from the hallway was Resident #1's lower body which was sitting on the mat on the floor. She stated she saw his arms on the mat, however, did not see his head. She stated she told the resident she would get help and then told LPN #20 that Resident #1 was yelling for help and he was on the floor. Interview with Occupational Therapy Assistant (OTA) #110 on [DATE] at 1:18 P.M. revealed she had worked with Resident #1 in occupational therapy. She stated the resident did need help with bed mobility. OTA #110 stated some days the resident would be up walking and other days he would need his wheelchair. He had good days and bad days. She stated some days he could feed himself and other days when he had tremors, he would need help to eat. OTA #110 stated Resident #1 would not always use his grab bar to get out of bed. She stated the resident would sit on the side of the bed and slide himself onto the floor on his knees and use the bed to stand up. She stated he told her that he had to put himself on the floor and use the bed as leverage to get up. Interview with LPN #22 on [DATE] at 1:30 P.M. revealed she was being oriented on the floor with LPN #20 the day Resident #1 was found to have passed away in his room. She stated she was at the end of the hall doing blood sugar checks when she heard STNA #50 yell for a nurse. LPN #22 stated when she arrived to Resident #1's room LPN #20 was already in the room. She stated the resident was sitting on the floor with his back against the bed, he was gray and his eyes and mouth were open. LPN #22 stated it looked as though the resident's neck was resting on the grab bar and was in between the mattress. She stated she saw LPN #38 remove the resident's head from the grab bar to secure his neck in case it was broken. Interview on [DATE] at 2:25 PM with the facility's Nurse Practitioner (NP) #99 revealed she had been in the building on [DATE] making rounds, however had left around noon and was unaware of the incident/death with Resident #1. She further stated she did not see Resident #1 on [DATE]. Interview on [DATE] at 3:00 PM with Resident #1's POA revealed he was contacted by LPN #38 around 1:00 PM on [DATE] that the resident was found partially off the bed and his head and neck were between the grab bar and mattress and he had passed away. The POA further stated he was waiting for the final Autopsy report and death certificate. A release of information request by the Ohio Department of Health was made via fax to the Coroner's office for the final autopsy report and death certificate on [DATE] at 4:06 P.M. Interview with the ADON on [DATE] at 8:40 A.M. revealed she was walking down hall on [DATE] when STNA #50 said she needed help in Resident #1's room. The ADON stated when she got to the room the resident was sitting on the floor on his bottom, on the mat with his upper body leaning against the bed. She stated the resident was very pale in color, and his head was behind the grab bar on the mattress, and his arms were down at his side. She stated LPN #38 and RN #23 were already in the room attending to the resident and she left to get the resident's code status. She returned to the room and informed the staff not to perform CPR as the resident was a DNRCC. The ADON then stated she took STNA #50 away from the room because she was very upset and did not go back into the room. Interview with Resident #1's brother at 10:05 A.M. on [DATE] confirmed he came to visit his brother on [DATE] around 10:00 A.M., which he stated he did almost every day. He stated when he arrived to his brother's room he found him on the floor, which he stated he often would find him on the floor. He helped him up and sat him on the side of the bed. They visited and talked for a while. He stated he bought him a pop and ice tea and left around 11:30 A.M., and told him he would be back to visit the next day. He stated he was still sitting on the side of the bed when he left. He was fine and his normal self. He then stated around 2:00 P.M. someone from the facility (was not sure who it was) called him and told him his brother was found on the floor and had passed away. The brother stated he could not believe it and was in shock as he was just at the facility visiting him a few hours earlier. He stated he came to the facility and his brother was lying in bed. He stated he was very upset and did not notice if there was any visible injuries to his brother, as he was completely covered up. He stated he left around 3:00 P.M. Interview with the Medical Director at 1:10 P.M. on [DATE] revealed the facility called his office on [DATE] (was unsure of the time) and he was at a different nursing facility. He stated the facility (unaware of who called his office) told his Office Manager, Resident #1 was dead. He stated his Office Manager got a hold of him and told him Resident #1 was found with his head and neck wedged between the grab bar and mattress of his bed. He then stated he called the facility and spoke with LPN #38 who denied the resident was wedged in between the mattress and grab bar, however the resident was just leaning up against it. He stated he advised the facility to call emergency services so someone could pronounce him dead. He stated he was waiting on the final autopsy report and the death certificate. The Medical Director further stated his Office Manager was out of state for the week and unavailable for an interview at this time. Interview on [DATE] at 10:40 P.M. with the paramedic who came to the facility on [DATE] to assess Resident #1 stated he was met at the front desk by a female nurse (he did not know her name), who told him it was obvious the resident was dead and took him to his room. The paramedic stated when he arrived to Resident #1's room the resident was lying flat on the bed with a blanket covering his face. He then stated he slightly pulled the blanket back and immediately knew he was dead as rigor mortis had set in and that meant he had been dead for a while. At that time, the paramedic stated he didn't think anything about it, only that the resident must have died in his sleep, given his position in bed. He left the room and LPN #38 followed him out of the building and asked him if he knew if they should call the Coroner since it was an accidental death. The paramedic stated he asked the LPN if he suspected foul play and the LPN stated no, it was an accident. The paramedic stated he did not examine his neck/throat area as it was obvious he was dead and assumed he died in his sleep. The paramedic stated he was told the resident was found unresponsive in bed. He further stated if the resident died due to an accident, then someone had to have moved him. He stated he offered to call the Coroner or police for the LPN and the LPN declined and stated he would handle it. In a second interview, via telephone, with LPN #38 on [DATE] at 11:10 A.M., he confirmed he did ask the paramedic what he should do, if he should call the police or the Coroner. The paramedic told him he would call the Coroner, however the LPN stated he told the paramedic he would handle it. LPN #38 stated it was LPN #20 who called the Medical Director's office and spoke with the Office Manager on [DATE] regarding the incident with Resident #1. The LPN stated the Medical Director called the facility and asked him if the resident was wedged in between the grab bar and mattress and he told the Medical Director no, he was just resting up against the grab bar. The Medical Director was under the impression the death was an accident, however the LPN stated what he meant as an accident was that it was not expected. The Medical Director then advised him to call the Coroner's office as it was a Coroner's case. During a telephone interview with RN #23 on [DATE] at 11:20 A.M. she stated she was at the nurse's station charting on [DATE] when STNA #50 came running down the hall screaming they needed a nurse in Resident #1's room. The RN stated when she got to the room she saw the resident sitting on the floor on his mat, with his legs straight out in front of him and his arms were at his side, his upper body was up against the bed and his head/neck were hyperextended on the bed. RN #23 stated at first it looked like his head and throat were in between the grab bar and mattress and he had been strangled. The RN stated when she went to check for a pulse and respirations, she then noticed his head and shoulder was just leaning up against the grab bar. She stated the resident's eyes and mouth were open and stated she saw no redness or [MEDICAL CONDITION] to the resident's head/throat or shoulder area. She stated she moved the rest of his body to the floor with LPN #38 and then they placed him on the bed. Interview with the Pathologist from the Coroner's Office on [DATE] at 12:08 P.M. he stated a cause of death had not been determined for Resident #1. He stated his office had just received records from the facility that had been subpoenaed on [DATE] and they haven't been reviewed. The Pathologist stated a person could suffocate without leaving marks, however, the way it was reported by the facility of the position the resident was found, he did not think that was what caused his death. He stated his office was told the resident was found unresponsive, lying in bed flat on his back. He confirmed he was not aware the resident was found partially on the floor. He stated the microscopy results would show more and that was not back yet. On [DATE] at 12:46 P.M., the facility's video tape of [DATE] of Resident #1's hallway was viewed with two surveyors, the LNHA, the Maintenance Director, and LPN #38 present. The video began at 10:22 A.M. and revealed STNA #50, Resident #1's brother, Laundry Worker #60, and STNA #81 were in and out of the resident's room from 10:22 A.M. through 10:55 A.M. There were no more than 11 minutes where there was not a staff person or the resident's brother in the room. The video was stopped at 10:55 A.M., due to the facility being put on lockdown. Interview with the Medical Director's Office Manager on [DATE] at 1:55 P.M. revealed she received a phone call from a nurse (unsure of who or the time) of the facility that Resident #1 had been found unresponsive. She stated the nurse told her the resident's lower part of his body was on the floor and upper body on the bed. She denied the nurse stated the resident was wedged between the grab bar and mattress. She then stated she advised the facility to call 911 immediately. Interview with the Coroner's Investigator on [DATE] at 3:25 P.M. revealed LPN #38 called the coroner's office on [DATE] and stated they had a resident who was unresponsive and his head was wedged between the grab bar and mattress. The investigator stated she arrived at the facility at 4:48 P.M., and took several pictures of Resident #1. She stated the resident was lying flat on his back, in his bed and totally covered up with a sheet. She stated she removed the sheet and she saw no red marks on his neck or any visible signs of trauma. She stated she called for transport to transport the body to the Coroner's Office. The Investigator stated LPN #38 told her he was found in bed, flat on his back with the left side of his head and neck up against the grab bar. He told her they did move his head and neck away from the grab bar before she got there. She denied she was informed the resident was found with half of his body on the floor. She stated she measured the space between the grab bar and mattress and it was two inches. She then stated the facility's Medical Director told the Coroner he thought the resident had died of accidental asphyxiation. The investigator further stated the Coroner's office would not call the police until after the final autopsy, and then, only if foul play was suspected. Interview with LPN #42 on [DATE] at 6:32 P.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she only worked on the weekends. She stated LPN #20 did contact her the day of the resident's death. She stated LPN #20 was a fairly new nurse and was very upset and wanted to know what to do. LPN #42 stated LPN #20 told her Resident #1 was found with his head and neck between the grab bar and mattress, and he was dead. LPN #42 stated she told LPN #20 to document everything she saw and be thorough, that it was very important. During an interview with LPN #38 on [DATE] at 8:10 AM he denied telling the coroner investigator Resident #1 was found unresponsive in bed. He states he told her he was on the floor and he moved him in the bed so his brother could come and see him. Review of the General Incident Investigation report, undated, given to the surveyor on [DATE], which was sent to the Coroner's office, revealed general investigation forms were to be completed for an unexpected or unusual death. The report revealed it was to be completed and forwarded to the ADON/Unit Manager, Director of Nursing (DON) and then finally the Administrator within 48 hours of the incident. The report was not signed as being received by the ADON/Unit Manager, DON or the Administrator. The incident report further revealed Resident #1 was found on [DATE] at 12:15 P.M. by staff on the floor sitting on the mat, with his upper body leaning against the assist bar and mattress. Vital signs were unable to be obtained. The resident's guardian was notified at 12:30 P.M. and the physician was notified at 3:15 P.M. The person who signed the report was LPN #38. On [DATE], continuation of viewing of the facility's video of [DATE] began at 11:15 A.M. with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. The video was started at 10:55 A.M. and revealed from 10:55 A.M. to 11:20 A.M., STNA #50, and STNA #81 were in and out of the resident's room. There was no more than three minutes viewed where at least one of the STNAs were in the room. The last time STNA #50 was viewed in Resident #1's room was at 11:17 A.M. and she left the room at 11:20 A.M. with Resident #5 (Resident #1's roommate) pushing him in a wheelchair. The video revealed DM #100 and DA #91 was seen leaving the snack shack which was two doors up from Resident #1's room at 11:54 A.M. When DM #100 and DA #81 were in front of Resident #1's door, the DM looked in the resident's room and then continued down the hall and was seen stopped at LPN #20's medication cart, then the DM was out of view. LPN #20 was seen on the video at 12:04 P.M. walking down the hallway past Resident #1's room, and she did not go in or look in the room. She continued to the end of the hallway where she was seen on her personal cell phone laughing. The next time someone went in the room was at 12:13 P.M. when STNA #50 returned Resident #5 to the room. At 12:14 P.M., STNA #50 was seen running out of the room and then LPN #20 was seen running down the hall and entered Resident #1's room. On [DATE] at 12:05 P.M., DM #100 was shown the video and interviewed with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. She confirmed it was her on the video and she had been in the snack shack with DA #91 and walked out at 11:54 A.M. and headed down the hall. She further stated as she approached Resident #1's room she heard him yelling for help. She stated she did not go in the room, however could see from the hallway he was sitting on the mat with his legs out in front of him and his arms were at this side. She stated she asked him if he needed help and he stated yes. She then stated she told him she would tell LPN #20. She then stated she continued down the hall and stopped at LPN #20's cart and told her Resident #1 was yelling for help. She then went to her office. On [DATE] at 12:10 P.M., DA #91 was shown the video and Interviewed. He confirmed it was him on the video coming out of the snack shack with DM #100 at 11:54 A.M. The DA further confirmed as they approached Resident #1's room he heard him yelling for help. He further confirmed both him and DM #100 stopped at LPN #20's medication cart and told her he needed help. He then stated he continued to the DM's office with her. <br (TRUNCATED)

Based on closed medical record review, review of the Emergency Medical Services (EMS) report and interview with the paramedics who responded, review of the Preliminary Autopsy Report and staff from the Coroner's office, review of the facility's incident investigation, observation of video recordings, staff interviews, interview with the resident's guardian, interview with the Nurse Practitioner for the facility, interview with a family member, interview with the Medical Director and the office manager of the Medical Director, and review of facility policies and procedures, the facility failed to thoroughly investigate and report an incident of neglect when one (#1) of eight residents reviewed for neglect was heard by staff yelling for help and no staff went to assist the resident for 19 minutes. Consequently, State tested Nursing Assistant (STNA) #50 entered the resident's room and found Resident #1 sitting on the mat, on the floor, with his upper body leaning up against the bed, with part of his head and throat between the grab bar and mattress. At that time, the resident was unresponsive and had passed away. This resulted in Immediate Jeopardy and serious life threatening harm and subsequent death when Resident #1 was neglected for 19 minutes after he was heard yelling out for help and was found unresponsive and subsequently expired. On [DATE] at 1:29 P.M., the Licensed Nursing Home Administrator (LNHA), Licensed Practical Nurse (LPN) #38, the Assistant Director of Nursing (ADON), LPN #37, and the Owner (via speaker phone) were notified Immediate Jeopardy began on [DATE] at 11:54 A.M. when Resident #1 was heard by Dietary Manager (DM) #100 and Dietary Aide (DA) #91 yelling for help and immediately notified LPN #20 who neglected to check on the resident. No staff went to assist the resident for 19 minutes after he was heard yelling for help and subsequently died . The Immediate Jeopardy was removed on [DATE] when the facility established systems to ensure residents were not neglected and received appropriate services and care in a timely manner, and the facility implemented the following corrective actions: · On [DATE], the facility suspended LPN #20, pending an investigation who was identified on the video recording and had been informed Resident #1 was yelling for help and neglected to check on the resident. · On [DATE], the LNHA and/or designee(s) began educating/in-servicing the entire facility staff on the expectations of response time to resident requests for assistance. The in-service included if a resident was requesting help, to see what they need. The in-service revealed, under no circumstances were staff to walk past a room of a resident who was asking for help and not physically go in the room and see what the resident needed. By 4:15 P.M., three LPNs (#29, #37 and #58), eight STNAs (#9, #12, #44, #52, #72, #81, #83 and #91), DM #100, the ADON, Activities Director (AD) #4, Human Resource Director (HRD) #13, the Business Office Manager (BOM), Social Service Worker (SSW) #35, Physical Therapist Assistant (PTA) #89, the Maintenance Director and Maintenance Assistant Director #68 were educated/in-serviced. All remaining staff who were not in the building, would be educated/in-serviced via telephone and would not be permitted to work until they have received the education/in-service. · On [DATE], all residents at the facility will be assessed by the LNHA and/or her designee(s) for any potential negative outcomes as related to resident's requests for assistance and response time. These assessments will be completed before midnight on [DATE]. · On [DATE], call light audits for alternating hallways will be conducted by the LNHA and/or her designee(s) with any concerns being reported immediately to the Quality Assurance and Performance Improvement (QAPI) committee and directly resolved. Each audit will be a minimum of 30 minutes in length. The audits will be completed three times daily for five days per week, for two weeks, then twice daily for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing and randomly thereafter. · On [DATE], the LNHA and/or her designee(s) will begin to audit response times when requests for help, are issued from a room or area of the building. The audits will be conducted with an employee going in a room, or an area of the building and shouting for help. The response of the employees will be evaluated and timed. These audits will be conducted at varying times, on varied shifts, as follows: three times daily for five days per week for two weeks, then twice daily, for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing, and randomly thereafter. · Interviews on [DATE] between 4:17 P.M. and 4:35 P.M. with three LPNs (#29, #58 and #64) and four STNAs (52, #54, #81 and #83) confirmed they had all been educated and in-serviced regarding response times when resident's requested assistance or needed help. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. His functional status was noted as extensive one person assist for transfers and bed mobility, and extensive one person assist for all other activities of daily living. Review of Resident #1's care plan dated [DATE] revealed the resident was at risk for falls characterized by involuntary movements and [MEDICAL CONDITION] medication. The care plan revealed the resident often put himself on the floor and had impaired physical mobility in bed, related to cognitive impairment, activity intolerance, limited endurance, uncontrolled body movements, weakness, and anxiety. Interventions included to continue with therapy and reinforce the need to call for assistance. Review of the last nurse's progress note dated [DATE] at 9:29 A.M. revealed Resident #1 took his morning medications without issues and there were no signs or symptoms of distress noted. This was the last nurse's note in the resident's record. There was no change of condition or death documented in the medical record. Further review of Resident #1's medical record revealed a subpoena from the Franklin County Coroner's office dated [DATE] had been sent to the facility. The subpoena revealed the death of Resident #1 had come under the jurisdiction of the Office of the Coroner of Franklin County as a medico-legal investigation. A request for the death/incident of [DATE] for Resident #1 was requested by the end of the business day on [DATE]. There was no evidence in the record the report had been sent to the Coroner's office as of [DATE]. Review of the paramedic's report dated [DATE] revealed the paramedics were called on [DATE] at 3:15 P.M. and arrived at the facility at 3:17 P.M. for a possible dead on arrival incident. The report revealed Resident #1 was found unresponsive, lying in bed, covered up. The report further revealed rigor mortis (stiff body) had set in. The report revealed as the paramedics were leaving the facility, LPN #38 stopped them and asked about calling the Coroner. The paramedics told LPN #38 the facility or the police would do that, not the EMS. The report revealed the LPN stated it was an accidental death. The LPN was then asked if he suspected foul play and he stated no. The report revealed the paramedic offered to call the police and was told by the LPN he would handle it. Per the report, there was nothing seen that would have indicated this was an accidental death as the resident, upon arrival, was lying flat in bed. Review of the Preliminary Autopsy Report for Resident #1 dated [DATE] revealed there were no cutaneous or internal injuries of the neck and there was a slight pectus excavatum (concave chest), unremarkable heart, lungs, and liver. The report further revealed an unremarkable brain, and the final autopsy was pending toxicology, microscopy and medical review. Review of the facility's incident report with LPN #38 dated [DATE] and witness statements on [DATE] revealed Resident #1 was found by staff on the floor sitting on the mat with his upper body leaning against the grab bar and mattress and the resident was unresponsive with no vital signs. No external injury was noted. Resident #1's guardian, the LNHA, Medical Director and the resident's brother were notified. Review of the witness statements provided by LPN #38 revealed all employees who were working on [DATE] wrote statements, except there were no statements from STNA #50 and LPN #20 who were the first to respond to Resident #1's room. The LPN confirmed there were no statements from STNA #50 and LPN #20 in the incident report. He stated LPN #20 was too upset to write one. Review of DM #100's statement revealed she was going down the hall around noon on [DATE] when she heard Resident #1 yelling for help. The statement further revealed she told LPN #20 the resident was yelling for help. Interview with LPN #20 on [DATE] at 9:58 A.M. confirmed she was the nurse assigned to the care of Resident #1, the day of his death on [DATE]. She stated she first saw Resident #1 around 7:30 A.M., walking down the hall to the vending room, which was his normal routine. LPN #20 then stated she gave Resident #1 his medications around 9:30 A.M. and the resident had no complaints. She stated the resident's brother came to visit the resident around 10:00 A.M. LPN #20 stated around noon on [DATE], STNA #50 came out of Resident #1's room yelling she needed a nurse immediately. LPN #20 revealed she went to Resident #1's room and found the resident sitting on his bottom on the mat on the floor, with his upper body/back leaning against his bed. The LPN stated Resident #1's head and neck were stuck between the grab bar and mattress. She stated his face was extremely pale. She stated she immediately yelled for more help and when LPN #38 and Registered Nurse (RN) #23 came into Resident #1's room they moved his head from between the grab bar and mattress and laid him down flat on his back, on the mat. She stated RN #23 stated Resident #1 did not have a pulse. LPN #20 stated she was clueless as to what to do and no one seemed to know what they were doing. LPN #20 stated LPN #38 asked her to contact the resident's Power of Attorney (POA), who was the Guardian appointed by the courts, and to call the physician. She stated she contacted the physician, (she could not remember what time) who told her to call emergency services (911) so they could come and pronounce the resident as expired. The LPN stated the coroner came and got the resident around 6:30 P.M. LPN #20 stated she left the facility around 7:15 P.M. after her shift and confirmed she did not write a progress note or witness statement regarding the resident's incident/death. LPN #20 confirmed DM #100 told her Resident #1 was yelling for help on [DATE], however, stated it was around 10:00 A.M., and not noon. Interview with STNA #50 on [DATE] at 10:11 A.M. confirmed she was assigned to the care of Resident #1 on [DATE], the day of the resident's death. She stated she helped Resident #1 that morning wash up and dress for the day. She stated he had no complaints and was in no distress. STNA #50 stated Resident #1's brother came in the room around 10:00 A.M. to visit and left around 11:15 A.M. STNA #50 stated she went back to Resident #1's room at approximately 11:30 A.M. to get Resident #5 (Resident #1's roommate) and take him to the dining room. She stated she asked Resident #1 if he wanted to go to the dining room for lunch and he stated he did not. STNA #50 stated this was normal, as the resident would go to the dining room at times, and at others he preferred to eat in his room. She stated when she left the room with the resident's roommate, Resident #1 was lying on his back in his bed. STNA #50 stated when she brought Resident #5 back to the room around noon, she stepped around Resident #5's wheelchair and saw Resident #1's lower body was on the mat, on the floor, and he was leaning up against his bed. She stated his head was leaned back tilted to the left on the bed, and part of his head and throat were between the grab bar and mattress, with his throat against the grab bar. She stated the resident's eyes and mouth were open and he was very pale. She yelled his name and did not get a response. She stated she then ran to the door and yelled for LPN #20 she needed help. LPN #20 came into the room and she told me to get her more help. STNA #50 stated she ran to LPN #38's office and told him to come quick and stated she did not go back in the room as she was too upset. STNA #50 stated Resident #1 would sometimes use his grab bar on his bed to help him move and position himself in bed. Interview with LPN #38 on [DATE] at 10:22 A.M. revealed STNA #50 came to his office on [DATE] around noon and told him to come quick to Resident #1's room. The LPN stated when he got to the resident's room Resident #1 was sitting on the floor, on the mat, leaning against his bed. His head was tilted back on top of the mattress and his neck was up against the grab bar, however, was not wedged between the grab bar and mattress. LPN #38 stated RN #23 was in the room and assessed the resident for a pulse and he did not have one, nor were any vital signs present. LPN #38 stated he sent the ADON to find out the code status of Resident #1. He then stated he and RN #23 placed the resident flat on the mat, on his back, on the floor. LPN #38 stated he assessed for bruising and redness of the resident's neck and nothing was noted. LPN #38 then was told Resident #1 was a Do Not Resuscitate Comfort Care (DRNCC) and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was not done. The LPN stated he and RN #23 picked up Resident #1 off the floor and placed him in his bed. He then went to make sure calls were made to the guardian and he stated he called the LNHA. He stated the physician told him to call the paramedics. The resident's brother was also notified the resident had passed away. He stated the paramedics arrived at the facility around 3:00 P.M. LPN #38 stated the paramedics told him to call the Coroner. The Coroner was called and a female (did not know her name) came to the facility and examined Resident #1's body and took pictures and stated she would call someone to pick up the body. The LPN stated Resident #1 was removed from the facility by the Coroner around 6:30 P.M. Interview with the LNHA on [DATE] at 11:00 A.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she had the resident's bed removed from the room and placed in the back hallway so staff could do a reenactment of how the resident was found to ensure he was not stuck between the grab bar and mattress. Observation of Resident #1's bed at the time of the interview revealed there was no gap between the mattress and the grab bar, nor was it loose. Interview with DM #100 on [DATE] at 12:10 P.M. revealed she had been in the snack shack on [DATE] getting snacks for residents. She stated the snack shack was two doors up from Resident #1's room. She stated just before noon she left the snack shack as she had a dishwasher repairman waiting for her. She stated when she got closer to Resident #1's room she heard him yelling help me. She stated she did not go in the room and all she could see from the hallway was Resident #1's lower body which was sitting on the mat on the floor. She stated she saw his arms on the mat, however, did not see his head. She stated she told the resident she would get help and then told LPN #20 that Resident #1 was yelling for help and he was on the floor. Interview with Occupational Therapy Assistant (OTA) #110 on [DATE] at 1:18 P.M. revealed she had worked with Resident #1 in occupational therapy. She stated the resident did need help with bed mobility. OTA #110 stated some days the resident would be up walking and other days he would need his wheelchair. He had good days and bad days. She stated some days he could feed himself and other days when he had tremors, he would need help to eat. OTA #110 stated Resident #1 would not always use his grab bar to get out of bed. She stated the resident would sit on the side of the bed and slide himself onto the floor on his knees and use the bed to stand up. She stated he told her that he had to put himself on the floor and use the bed as leverage to get up. Interview with LPN #22 on [DATE] at 1:30 P.M. revealed she was being oriented on the floor with LPN #20 the day Resident #1 was found to have passed away in his room. She stated she was at the end of the hall doing blood sugar checks when she heard STNA #50 yell for a nurse. LPN #22 stated when she arrived to Resident #1's room LPN #20 was already in the room. She stated the resident was sitting on the floor with his back against the bed, he was gray and his eyes and mouth were open. LPN #22 stated it looked as though the resident's neck was resting on the grab bar and was in between the mattress. She stated she saw LPN #38 remove the resident's head from the grab bar to secure his neck in case it was broken. Interview on [DATE] at 2:25 PM with the facility's Nurse Practitioner (NP) #99 revealed she had been in the building on [DATE] making rounds, however had left around noon and was unaware of the incident/death with Resident #1. She further stated she did not see Resident #1 on [DATE]. Interview on [DATE] at 3:00 PM with Resident #1's POA revealed he was contacted by LPN #38 around 1:00 PM on [DATE] that the resident was found partially off the bed and his head and neck were between the grab bar and mattress and he had passed away. The POA further stated he was waiting for the final Autopsy report and death certificate. A release of information request by the Ohio Department of Health was made via fax to the Coroner's office for the final autopsy report and death certificate on [DATE] at 4:06 P.M. Interview with the ADON on [DATE] at 8:40 A.M. revealed she was walking down hall on [DATE] when STNA #50 said she needed help in Resident #1's room. The ADON stated when she got to the room the resident was sitting on the floor on his bottom, on the mat with his upper body leaning against the bed. She stated the resident was very pale in color, and his head was behind the grab bar on the mattress, and his arms were down at his side. She stated LPN #38 and RN #23 were already in the room attending to the resident and she left to get the resident's code status. She returned to the room and informed the staff not to perform CPR as the resident was a DNRCC. The ADON then stated she took STNA #50 away from the room because she was very upset and did not go back into the room. Interview with Resident #1's brother at 10:05 A.M. on [DATE] confirmed he came to visit his brother on [DATE] around 10:00 A.M., which he stated he did almost every day. He stated when he arrived to his brother's room he found him on the floor, which he stated he often would find him on the floor. He helped him up and sat him on the side of the bed. They visited and talked for a while. He stated he bought him a pop and ice tea and left around 11:30 A.M., and told him he would be back to visit the next day. He stated he was still sitting on the side of the bed when he left. He was fine and his normal self. He then stated around 2:00 P.M. someone from the facility (was not sure who it was) called him and told him his brother was found on the floor and had passed away. The brother stated he could not believe it and was in shock as he was just at the facility visiting him a few hours earlier. He stated he came to the facility and his brother was lying in bed. He stated he was very upset and did not notice if there was any visible injuries to his brother, as he was completely covered up. He stated he left around 3:00 P.M. Interview with the Medical Director at 1:10 P.M. on [DATE] revealed the facility called his office on [DATE] (was unsure of the time) and he was at a different nursing facility. He stated the facility (unaware of who called his office) told his Office Manager, Resident #1 was dead. He stated his Office Manager got a hold of him and told him Resident #1 was found with his head and neck wedged between the grab bar and mattress of his bed. He then stated he called the facility and spoke with LPN #38 who denied the resident was wedged in between the mattress and grab bar, however the resident was just leaning up against it. He stated he advised the facility to call emergency services so someone could pronounce him dead. He stated he was waiting on the final autopsy report and the death certificate. The Medical Director further stated his Office Manager was out of state for the week and unavailable for an interview at this time. Interview on [DATE] at 10:40 P.M. with the paramedic who came to the facility on [DATE] to assess Resident #1 stated he was met at the front desk by a female nurse (he did not know her name), who told him it was obvious the resident was dead and took him to his room. The paramedic stated when he arrived to Resident #1's room the resident was lying flat on the bed with a blanket covering his face. He then stated he slightly pulled the blanket back and immediately knew he was dead as rigor mortis had set in and that meant he had been dead for a while. At that time, the paramedic stated he didn't think anything about it, only that the resident must have died in his sleep, given his position in bed. He left the room and LPN #38 followed him out of the building and asked him if he knew if they should call the Coroner since it was an accidental death. The paramedic stated he asked the LPN if he suspected foul play and the LPN stated no, it was an accident. The paramedic stated he did not examine his neck/throat area as it was obvious he was dead and assumed he died in his sleep. The paramedic stated he was told the resident was found unresponsive in bed. He further stated if the resident died due to an accident, then someone had to have moved him. He stated he offered to call the Coroner or police for the LPN and the LPN declined and stated he would handle it. In a second interview, via telephone, with LPN #38 on [DATE] at 11:10 A.M., he confirmed he did ask the paramedic what he should do, if he should call the police or the Coroner. The paramedic told him he would call the Coroner, however the LPN stated he told the paramedic he would handle it. LPN #38 stated it was LPN #20 who called the Medical Director's office and spoke with the Office Manager on [DATE] regarding the incident with Resident #1. The LPN stated the Medical Director called the facility and asked him if the resident was wedged in between the grab bar and mattress and he told the Medical Director no, he was just resting up against the grab bar. The Medical Director was under the impression the death was an accident, however the LPN stated what he meant as an accident was that it was not expected. The Medical Director then advised him to call the Coroner's office as it was a Coroner's case. During a telephone interview with RN #23 on [DATE] at 11:20 A.M. she stated she was at the nurse's station charting on [DATE] when STNA #50 came running down the hall screaming they needed a nurse in Resident #1's room. The RN stated when she got to the room she saw the resident sitting on the floor on his mat, with his legs straight out in front of him and his arms were at his side, his upper body was up against the bed and his head/neck were hyperextended on the bed. RN #23 stated at first it looked like his head and throat were in between the grab bar and mattress and he had been strangled. The RN stated when she went to check for a pulse and respirations, she then noticed his head and shoulder was just leaning up against the grab bar. She stated the resident's eyes and mouth were open and stated she saw no redness or [MEDICAL CONDITION] to the resident's head/throat or shoulder area. She stated she moved the rest of his body to the floor with LPN #38 and then they placed him on the bed. Interview with the Pathologist from the Coroner's Office on [DATE] at 12:08 P.M. he stated a cause of death had not been determined for Resident #1. He stated his office had just received records from the facility that had been subpoenaed on [DATE] and they haven't been reviewed. The Pathologist stated a person could suffocate without leaving marks, however, the way it was reported by the facility of the position the resident was found, he did not think that was what caused his death. He stated his office was told the resident was found unresponsive, lying in bed flat on his back. He confirmed he was not aware the resident was found partially on the floor. He stated the microscopy results would show more and that was not back yet. On [DATE] at 12:46 P.M., the facility's video tape of [DATE] of Resident #1's hallway was viewed with two surveyors, the LNHA, the Maintenance Director, and LPN #38 present. The video began at 10:22 A.M. and revealed STNA #50, Resident #1's brother, Laundry Worker #60, and STNA #81 were in and out of the resident's room from 10:22 A.M. through 10:55 A.M. There were no more than 11 minutes where there was not a staff person or the resident's brother in the room. The video was stopped at 10:55 A.M., due to the facility being put on lockdown. Interview with the Medical Director's Office Manager on [DATE] at 1:55 P.M. revealed she received a phone call from a nurse (unsure of who or the time) of the facility that Resident #1 had been found unresponsive. She stated the nurse told her the resident's lower part of his body was on the floor and upper body on the bed. She denied the nurse stated the resident was wedged between the grab bar and mattress. She then stated she advised the facility to call 911 immediately. Interview with the Coroner's Investigator on [DATE] at 3:25 P.M. revealed LPN #38 called the coroner's office on [DATE] and stated they had a resident who was unresponsive and his head was wedged between the grab bar and mattress. The investigator stated she arrived at the facility at 4:48 P.M., and took several pictures of Resident #1. She stated the resident was lying flat on his back, in his bed and totally covered up with a sheet. She stated she removed the sheet and she saw no red marks on his neck or any visible signs of trauma. She stated she called for transport to transport the body to the Coroner's Office. The Investigator stated LPN #38 told her he was found in bed, flat on his back with the left side of his head and neck up against the grab bar. He told her they did move his head and neck away from the grab bar before she got there. She denied she was informed the resident was found with half of his body on the floor. She stated she measured the space between the grab bar and mattress and it was two inches. She then stated the facility's Medical Director told the Coroner he thought the resident had died of accidental asphyxiation. The investigator further stated the Coroner's office would not call the police until after the final autopsy, and then, only if foul play was suspected. Interview with LPN #42 on [DATE] at 6:32 P.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she only worked on the weekends. She stated LPN #20 did contact her the day of the resident's death. She stated LPN #20 was a fairly new nurse and was very upset and wanted to know what to do. LPN #42 stated LPN #20 told her Resident #1 was found with his head and neck between the grab bar and mattress, and he was dead. LPN #42 stated she told LPN #20 to document everything she saw and be thorough, that it was very important. During an interview with LPN #38 on [DATE] at 8:10 AM he denied telling the coroner investigator Resident #1 was found unresponsive in bed. He states he told her he was on the floor and he moved him in the bed so his brother could come and see him. Review of the General Incident Investigation report, undated, given to the surveyor on [DATE], which was sent to the Coroner's office, revealed general investigation forms were to be completed for an unexpected or unusual death. The report revealed it was to be completed and forwarded to the ADON/Unit Manager, Director of Nursing (DON) and then finally the Administrator within 48 hours of the incident. The report was not signed as being received by the ADON/Unit Manager, DON or the Administrator. The incident report further revealed Resident #1 was found on [DATE] at 12:15 P.M. by staff on the floor sitting on the mat, with his upper body leaning against the assist bar and mattress. Vital signs were unable to be obtained. The resident's guardian was notified at 12:30 P.M. and the physician was notified at 3:15 P.M. The person who signed the report was LPN #38. On [DATE], continuation of viewing of the facility's video of [DATE] began at 11:15 A.M. with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. The video was started at 10:55 A.M. and revealed from 10:55 A.M. to 11:20 A.M., STNA #50, and STNA #81 were in and out of the resident's room. There was no more than three minutes viewed where at least one of the STNAs were in the room. The last time STNA #50 was viewed in Resident #1's room was at 11:17 A.M. and she left the room at 11:20 A.M. with Resident #5 (Resident #1's roommate) pushing him in a wheelchair. The video revealed DM #100 and DA #91 was seen leaving the snack shack which was two doors up from Resident #1's room at 11:54 A.M. When DM #100 and DA #81 were in front of Resident #1's door, the DM looked in the resident's room and then continued down the hall and was seen stopped at LPN #20's medication cart, then the DM was out of view. LPN #20 was seen on the video at 12:04 P.M. walking down the hallway past Resident #1's room, and she did not go in or look in the room. She continued to the end of the hallway where she was seen on her personal cell phone laughing. The next time someone went in the room was at 12:13 P.M. when STNA #50 returned Resident #5 to the room. At 12:14 P.M., STNA #50 was seen running out of the room and then LPN #20 was seen running down the hall and entered Resident #1's room. On [DATE] at 12:05 P.M., DM #100 was shown the video and interviewed with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. She confirmed it was her on the video and she had been in the snack shack with DA #91 and walked out at 11:54 A.M. and headed down the hall. She further stated as she approached Resident #1's room she heard him yelling for help. She stated she did not go in the room, however could see from the hallway he was sitting on the mat with his legs out in front of him and his arms were at this side. She stated she asked him if he needed help and he stated yes. She then stated she told him she would tell LPN #20. She then stated she continued down the hall and stopped at LPN #20's cart and told her Resident #1 was yelling for help. She then went to her office. On [DATE] at 12:10 P.M., DA #91 was shown the video and Interviewed. He confirmed it was him on the video coming out of the snack shack with DM #100 at 11:54 A.M. The DA further confirmed as they approached Resident #1's room he heard him yelling for help. He further confirmed both him and DM #100 stopped at LPN #20's medication cart and told her he needed help. He then stated he continu (TRUNCATED)

Based on closed medical record review, review of the Emergency Medical Services (EMS) report and interview with the paramedics who responded, review of the Preliminary Autopsy Report and staff from the Coroner's office, review of the facility's incident investigation, observation of video recordings, staff interviews, interview with the resident's guardian, interview with the Nurse Practitioner for the facility, interview with a family member, interview with the Medical Director and the office manager of the Medical Director, and review of facility policies and procedures, the facility failed to implement thier abuse policy when one (#1) of eight residents reviewed for neglect was heard by staff yelling for help and no staff went to assist the resident for 19 minutes. Consequently, State tested Nursing Assistant (STNA) #50 entered the resident's room and found Resident #1 sitting on the mat, on the floor, with his upper body leaning up against the bed, with part of his head and throat between the grab bar and mattress. At that time, the resident was unresponsive and had passed away. This resulted in Immediate Jeopardy and serious life threatening harm and subsequent death when Resident #1 was neglected for 19 minutes after he was heard yelling out for help and was found unresponsive and subsequently expired. On [DATE] at 1:29 P.M., the Licensed Nursing Home Administrator (LNHA), Licensed Practical Nurse (LPN) #38, the Assistant Director of Nursing (ADON), LPN #37, and the Owner (via speaker phone) were notified Immediate Jeopardy began on [DATE] at 11:54 A.M. when Resident #1 was heard by Dietary Manager (DM) #100 and Dietary Aide (DA) #91 yelling for help and immediately notified LPN #20 who neglected to check on the resident. No staff went to assist the resident for 19 minutes after he was heard yelling for help and subsequently died . The Immediate Jeopardy was removed on [DATE] when the facility established systems to ensure residents were not neglected and received appropriate services and care in a timely manner, and the facility implemented the following corrective actions: · On [DATE], the facility suspended LPN #20, pending an investigation who was identified on the video recording and had been informed Resident #1 was yelling for help and neglected to check on the resident. · On [DATE], the LNHA and/or designee(s) began educating/in-servicing the entire facility staff on the expectations of response time to resident requests for assistance. The in-service included if a resident was requesting help, to see what they need. The in-service revealed, under no circumstances were staff to walk past a room of a resident who was asking for help and not physically go in the room and see what the resident needed. By 4:15 P.M., three LPNs (#29, #37 and #58), eight STNAs (#9, #12, #44, #52, #72, #81, #83 and #91), DM #100, the ADON, Activities Director (AD) #4, Human Resource Director (HRD) #13, the Business Office Manager (BOM), Social Service Worker (SSW) #35, Physical Therapist Assistant (PTA) #89, the Maintenance Director and Maintenance Assistant Director #68 were educated/in-serviced. All remaining staff who were not in the building, would be educated/in-serviced via telephone and would not be permitted to work until they have received the education/in-service. · On [DATE], all residents at the facility will be assessed by the LNHA and/or her designee(s) for any potential negative outcomes as related to resident's requests for assistance and response time. These assessments will be completed before midnight on [DATE]. · On [DATE], call light audits for alternating hallways will be conducted by the LNHA and/or her designee(s) with any concerns being reported immediately to the Quality Assurance and Performance Improvement (QAPI) committee and directly resolved. Each audit will be a minimum of 30 minutes in length. The audits will be completed three times daily for five days per week, for two weeks, then twice daily for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing and randomly thereafter. · On [DATE], the LNHA and/or her designee(s) will begin to audit response times when requests for help, are issued from a room or area of the building. The audits will be conducted with an employee going in a room, or an area of the building and shouting for help. The response of the employees will be evaluated and timed. These audits will be conducted at varying times, on varied shifts, as follows: three times daily for five days per week for two weeks, then twice daily, for five days per week for two weeks, then once daily for five days per week for two weeks, and ongoing, and randomly thereafter. · Interviews on [DATE] between 4:17 P.M. and 4:35 P.M. with three LPNs (#29, #58 and #64) and four STNAs (52, #54, #81 and #83) confirmed they had all been educated and in-serviced regarding response times when resident's requested assistance or needed help. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. His functional status was noted as extensive one person assist for transfers and bed mobility, and extensive one person assist for all other activities of daily living. Review of Resident #1's care plan dated [DATE] revealed the resident was at risk for falls characterized by involuntary movements and [MEDICAL CONDITION] medication. The care plan revealed the resident often put himself on the floor and had impaired physical mobility in bed, related to cognitive impairment, activity intolerance, limited endurance, uncontrolled body movements, weakness, and anxiety. Interventions included to continue with therapy and reinforce the need to call for assistance. Review of the last nurse's progress note dated [DATE] at 9:29 A.M. revealed Resident #1 took his morning medications without issues and there were no signs or symptoms of distress noted. This was the last nurse's note in the resident's record. There was no change of condition or death documented in the medical record. Further review of Resident #1's medical record revealed a subpoena from the Franklin County Coroner's office dated [DATE] had been sent to the facility. The subpoena revealed the death of Resident #1 had come under the jurisdiction of the Office of the Coroner of Franklin County as a medico-legal investigation. A request for the death/incident of [DATE] for Resident #1 was requested by the end of the business day on [DATE]. There was no evidence in the record the report had been sent to the Coroner's office as of [DATE]. Review of the paramedic's report dated [DATE] revealed the paramedics were called on [DATE] at 3:15 P.M. and arrived at the facility at 3:17 P.M. for a possible dead on arrival incident. The report revealed Resident #1 was found unresponsive, lying in bed, covered up. The report further revealed rigor mortis (stiff body) had set in. The report revealed as the paramedics were leaving the facility, LPN #38 stopped them and asked about calling the Coroner. The paramedics told LPN #38 the facility or the police would do that, not the EMS. The report revealed the LPN stated it was an accidental death. The LPN was then asked if he suspected foul play and he stated no. The report revealed the paramedic offered to call the police and was told by the LPN he would handle it. Per the report, there was nothing seen that would have indicated this was an accidental death as the resident, upon arrival, was lying flat in bed. Review of the Preliminary Autopsy Report for Resident #1 dated [DATE] revealed there were no cutaneous or internal injuries of the neck and there was a slight pectus excavatum (concave chest), unremarkable heart, lungs, and liver. The report further revealed an unremarkable brain, and the final autopsy was pending toxicology, microscopy and medical review. Review of the facility's incident report with LPN #38 dated [DATE] and witness statements on [DATE] revealed Resident #1 was found by staff on the floor sitting on the mat with his upper body leaning against the grab bar and mattress and the resident was unresponsive with no vital signs. No external injury was noted. Resident #1's guardian, the LNHA, Medical Director and the resident's brother were notified. Review of the witness statements provided by LPN #38 revealed all employees who were working on [DATE] wrote statements, except there were no statements from STNA #50 and LPN #20 who were the first to respond to Resident #1's room. The LPN confirmed there were no statements from STNA #50 and LPN #20 in the incident report. He stated LPN #20 was too upset to write one. Review of DM #100's statement revealed she was going down the hall around noon on [DATE] when she heard Resident #1 yelling for help. The statement further revealed she told LPN #20 the resident was yelling for help. Interview with LPN #20 on [DATE] at 9:58 A.M. confirmed she was the nurse assigned to the care of Resident #1, the day of his death on [DATE]. She stated she first saw Resident #1 around 7:30 A.M., walking down the hall to the vending room, which was his normal routine. LPN #20 then stated she gave Resident #1 his medications around 9:30 A.M. and the resident had no complaints. She stated the resident's brother came to visit the resident around 10:00 A.M. LPN #20 stated around noon on [DATE], STNA #50 came out of Resident #1's room yelling she needed a nurse immediately. LPN #20 revealed she went to Resident #1's room and found the resident sitting on his bottom on the mat on the floor, with his upper body/back leaning against his bed. The LPN stated Resident #1's head and neck were stuck between the grab bar and mattress. She stated his face was extremely pale. She stated she immediately yelled for more help and when LPN #38 and Registered Nurse (RN) #23 came into Resident #1's room they moved his head from between the grab bar and mattress and laid him down flat on his back, on the mat. She stated RN #23 stated Resident #1 did not have a pulse. LPN #20 stated she was clueless as to what to do and no one seemed to know what they were doing. LPN #20 stated LPN #38 asked her to contact the resident's Power of Attorney (POA), who was the Guardian appointed by the courts, and to call the physician. She stated she contacted the physician, (she could not remember what time) who told her to call emergency services (911) so they could come and pronounce the resident as expired. The LPN stated the coroner came and got the resident around 6:30 P.M. LPN #20 stated she left the facility around 7:15 P.M. after her shift and confirmed she did not write a progress note or witness statement regarding the resident's incident/death. LPN #20 confirmed DM #100 told her Resident #1 was yelling for help on [DATE], however, stated it was around 10:00 A.M., and not noon. Interview with STNA #50 on [DATE] at 10:11 A.M. confirmed she was assigned to the care of Resident #1 on [DATE], the day of the resident's death. She stated she helped Resident #1 that morning wash up and dress for the day. She stated he had no complaints and was in no distress. STNA #50 stated Resident #1's brother came in the room around 10:00 A.M. to visit and left around 11:15 A.M. STNA #50 stated she went back to Resident #1's room at approximately 11:30 A.M. to get Resident #5 (Resident #1's roommate) and take him to the dining room. She stated she asked Resident #1 if he wanted to go to the dining room for lunch and he stated he did not. STNA #50 stated this was normal, as the resident would go to the dining room at times, and at others he preferred to eat in his room. She stated when she left the room with the resident's roommate, Resident #1 was lying on his back in his bed. STNA #50 stated when she brought Resident #5 back to the room around noon, she stepped around Resident #5's wheelchair and saw Resident #1's lower body was on the mat, on the floor, and he was leaning up against his bed. She stated his head was leaned back tilted to the left on the bed, and part of his head and throat were between the grab bar and mattress, with his throat against the grab bar. She stated the resident's eyes and mouth were open and he was very pale. She yelled his name and did not get a response. She stated she then ran to the door and yelled for LPN #20 she needed help. LPN #20 came into the room and she told me to get her more help. STNA #50 stated she ran to LPN #38's office and told him to come quick and stated she did not go back in the room as she was too upset. STNA #50 stated Resident #1 would sometimes use his grab bar on his bed to help him move and position himself in bed. Interview with LPN #38 on [DATE] at 10:22 A.M. revealed STNA #50 came to his office on [DATE] around noon and told him to come quick to Resident #1's room. The LPN stated when he got to the resident's room Resident #1 was sitting on the floor, on the mat, leaning against his bed. His head was tilted back on top of the mattress and his neck was up against the grab bar, however, was not wedged between the grab bar and mattress. LPN #38 stated RN #23 was in the room and assessed the resident for a pulse and he did not have one, nor were any vital signs present. LPN #38 stated he sent the ADON to find out the code status of Resident #1. He then stated he and RN #23 placed the resident flat on the mat, on his back, on the floor. LPN #38 stated he assessed for bruising and redness of the resident's neck and nothing was noted. LPN #38 then was told Resident #1 was a Do Not Resuscitate Comfort Care (DRNCC) and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was not done. The LPN stated he and RN #23 picked up Resident #1 off the floor and placed him in his bed. He then went to make sure calls were made to the guardian and he stated he called the LNHA. He stated the physician told him to call the paramedics. The resident's brother was also notified the resident had passed away. He stated the paramedics arrived at the facility around 3:00 P.M. LPN #38 stated the paramedics told him to call the Coroner. The Coroner was called and a female (did not know her name) came to the facility and examined Resident #1's body and took pictures and stated she would call someone to pick up the body. The LPN stated Resident #1 was removed from the facility by the Coroner around 6:30 P.M. Interview with the LNHA on [DATE] at 11:00 A.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she had the resident's bed removed from the room and placed in the back hallway so staff could do a reenactment of how the resident was found to ensure he was not stuck between the grab bar and mattress. Observation of Resident #1's bed at the time of the interview revealed there was no gap between the mattress and the grab bar, nor was it loose. Interview with DM #100 on [DATE] at 12:10 P.M. revealed she had been in the snack shack on [DATE] getting snacks for residents. She stated the snack shack was two doors up from Resident #1's room. She stated just before noon she left the snack shack as she had a dishwasher repairman waiting for her. She stated when she got closer to Resident #1's room she heard him yelling help me. She stated she did not go in the room and all she could see from the hallway was Resident #1's lower body which was sitting on the mat on the floor. She stated she saw his arms on the mat, however, did not see his head. She stated she told the resident she would get help and then told LPN #20 that Resident #1 was yelling for help and he was on the floor. Interview with Occupational Therapy Assistant (OTA) #110 on [DATE] at 1:18 P.M. revealed she had worked with Resident #1 in occupational therapy. She stated the resident did need help with bed mobility. OTA #110 stated some days the resident would be up walking and other days he would need his wheelchair. He had good days and bad days. She stated some days he could feed himself and other days when he had tremors, he would need help to eat. OTA #110 stated Resident #1 would not always use his grab bar to get out of bed. She stated the resident would sit on the side of the bed and slide himself onto the floor on his knees and use the bed to stand up. She stated he told her that he had to put himself on the floor and use the bed as leverage to get up. Interview with LPN #22 on [DATE] at 1:30 P.M. revealed she was being oriented on the floor with LPN #20 the day Resident #1 was found to have passed away in his room. She stated she was at the end of the hall doing blood sugar checks when she heard STNA #50 yell for a nurse. LPN #22 stated when she arrived to Resident #1's room LPN #20 was already in the room. She stated the resident was sitting on the floor with his back against the bed, he was gray and his eyes and mouth were open. LPN #22 stated it looked as though the resident's neck was resting on the grab bar and was in between the mattress. She stated she saw LPN #38 remove the resident's head from the grab bar to secure his neck in case it was broken. Interview on [DATE] at 2:25 PM with the facility's Nurse Practitioner (NP) #99 revealed she had been in the building on [DATE] making rounds, however had left around noon and was unaware of the incident/death with Resident #1. She further stated she did not see Resident #1 on [DATE]. Interview on [DATE] at 3:00 PM with Resident #1's POA revealed he was contacted by LPN #38 around 1:00 PM on [DATE] that the resident was found partially off the bed and his head and neck were between the grab bar and mattress and he had passed away. The POA further stated he was waiting for the final Autopsy report and death certificate. A release of information request by the Ohio Department of Health was made via fax to the Coroner's office for the final autopsy report and death certificate on [DATE] at 4:06 P.M. Interview with the ADON on [DATE] at 8:40 A.M. revealed she was walking down hall on [DATE] when STNA #50 said she needed help in Resident #1's room. The ADON stated when she got to the room the resident was sitting on the floor on his bottom, on the mat with his upper body leaning against the bed. She stated the resident was very pale in color, and his head was behind the grab bar on the mattress, and his arms were down at his side. She stated LPN #38 and RN #23 were already in the room attending to the resident and she left to get the resident's code status. She returned to the room and informed the staff not to perform CPR as the resident was a DNRCC. The ADON then stated she took STNA #50 away from the room because she was very upset and did not go back into the room. Interview with Resident #1's brother at 10:05 A.M. on [DATE] confirmed he came to visit his brother on [DATE] around 10:00 A.M., which he stated he did almost every day. He stated when he arrived to his brother's room he found him on the floor, which he stated he often would find him on the floor. He helped him up and sat him on the side of the bed. They visited and talked for a while. He stated he bought him a pop and ice tea and left around 11:30 A.M., and told him he would be back to visit the next day. He stated he was still sitting on the side of the bed when he left. He was fine and his normal self. He then stated around 2:00 P.M. someone from the facility (was not sure who it was) called him and told him his brother was found on the floor and had passed away. The brother stated he could not believe it and was in shock as he was just at the facility visiting him a few hours earlier. He stated he came to the facility and his brother was lying in bed. He stated he was very upset and did not notice if there was any visible injuries to his brother, as he was completely covered up. He stated he left around 3:00 P.M. Interview with the Medical Director at 1:10 P.M. on [DATE] revealed the facility called his office on [DATE] (was unsure of the time) and he was at a different nursing facility. He stated the facility (unaware of who called his office) told his Office Manager, Resident #1 was dead. He stated his Office Manager got a hold of him and told him Resident #1 was found with his head and neck wedged between the grab bar and mattress of his bed. He then stated he called the facility and spoke with LPN #38 who denied the resident was wedged in between the mattress and grab bar, however the resident was just leaning up against it. He stated he advised the facility to call emergency services so someone could pronounce him dead. He stated he was waiting on the final autopsy report and the death certificate. The Medical Director further stated his Office Manager was out of state for the week and unavailable for an interview at this time. Interview on [DATE] at 10:40 P.M. with the paramedic who came to the facility on [DATE] to assess Resident #1 stated he was met at the front desk by a female nurse (he did not know her name), who told him it was obvious the resident was dead and took him to his room. The paramedic stated when he arrived to Resident #1's room the resident was lying flat on the bed with a blanket covering his face. He then stated he slightly pulled the blanket back and immediately knew he was dead as rigor mortis had set in and that meant he had been dead for a while. At that time, the paramedic stated he didn't think anything about it, only that the resident must have died in his sleep, given his position in bed. He left the room and LPN #38 followed him out of the building and asked him if he knew if they should call the Coroner since it was an accidental death. The paramedic stated he asked the LPN if he suspected foul play and the LPN stated no, it was an accident. The paramedic stated he did not examine his neck/throat area as it was obvious he was dead and assumed he died in his sleep. The paramedic stated he was told the resident was found unresponsive in bed. He further stated if the resident died due to an accident, then someone had to have moved him. He stated he offered to call the Coroner or police for the LPN and the LPN declined and stated he would handle it. In a second interview, via telephone, with LPN #38 on [DATE] at 11:10 A.M., he confirmed he did ask the paramedic what he should do, if he should call the police or the Coroner. The paramedic told him he would call the Coroner, however the LPN stated he told the paramedic he would handle it. LPN #38 stated it was LPN #20 who called the Medical Director's office and spoke with the Office Manager on [DATE] regarding the incident with Resident #1. The LPN stated the Medical Director called the facility and asked him if the resident was wedged in between the grab bar and mattress and he told the Medical Director no, he was just resting up against the grab bar. The Medical Director was under the impression the death was an accident, however the LPN stated what he meant as an accident was that it was not expected. The Medical Director then advised him to call the Coroner's office as it was a Coroner's case. During a telephone interview with RN #23 on [DATE] at 11:20 A.M. she stated she was at the nurse's station charting on [DATE] when STNA #50 came running down the hall screaming they needed a nurse in Resident #1's room. The RN stated when she got to the room she saw the resident sitting on the floor on his mat, with his legs straight out in front of him and his arms were at his side, his upper body was up against the bed and his head/neck were hyperextended on the bed. RN #23 stated at first it looked like his head and throat were in between the grab bar and mattress and he had been strangled. The RN stated when she went to check for a pulse and respirations, she then noticed his head and shoulder was just leaning up against the grab bar. She stated the resident's eyes and mouth were open and stated she saw no redness or [MEDICAL CONDITION] to the resident's head/throat or shoulder area. She stated she moved the rest of his body to the floor with LPN #38 and then they placed him on the bed. Interview with the Pathologist from the Coroner's Office on [DATE] at 12:08 P.M. he stated a cause of death had not been determined for Resident #1. He stated his office had just received records from the facility that had been subpoenaed on [DATE] and they haven't been reviewed. The Pathologist stated a person could suffocate without leaving marks, however, the way it was reported by the facility of the position the resident was found, he did not think that was what caused his death. He stated his office was told the resident was found unresponsive, lying in bed flat on his back. He confirmed he was not aware the resident was found partially on the floor. He stated the microscopy results would show more and that was not back yet. On [DATE] at 12:46 P.M., the facility's video tape of [DATE] of Resident #1's hallway was viewed with two surveyors, the LNHA, the Maintenance Director, and LPN #38 present. The video began at 10:22 A.M. and revealed STNA #50, Resident #1's brother, Laundry Worker #60, and STNA #81 were in and out of the resident's room from 10:22 A.M. through 10:55 A.M. There were no more than 11 minutes where there was not a staff person or the resident's brother in the room. The video was stopped at 10:55 A.M., due to the facility being put on lockdown. Interview with the Medical Director's Office Manager on [DATE] at 1:55 P.M. revealed she received a phone call from a nurse (unsure of who or the time) of the facility that Resident #1 had been found unresponsive. She stated the nurse told her the resident's lower part of his body was on the floor and upper body on the bed. She denied the nurse stated the resident was wedged between the grab bar and mattress. She then stated she advised the facility to call 911 immediately. Interview with the Coroner's Investigator on [DATE] at 3:25 P.M. revealed LPN #38 called the coroner's office on [DATE] and stated they had a resident who was unresponsive and his head was wedged between the grab bar and mattress. The investigator stated she arrived at the facility at 4:48 P.M., and took several pictures of Resident #1. She stated the resident was lying flat on his back, in his bed and totally covered up with a sheet. She stated she removed the sheet and she saw no red marks on his neck or any visible signs of trauma. She stated she called for transport to transport the body to the Coroner's Office. The Investigator stated LPN #38 told her he was found in bed, flat on his back with the left side of his head and neck up against the grab bar. He told her they did move his head and neck away from the grab bar before she got there. She denied she was informed the resident was found with half of his body on the floor. She stated she measured the space between the grab bar and mattress and it was two inches. She then stated the facility's Medical Director told the Coroner he thought the resident had died of accidental asphyxiation. The investigator further stated the Coroner's office would not call the police until after the final autopsy, and then, only if foul play was suspected. Interview with LPN #42 on [DATE] at 6:32 P.M. revealed she was not at the facility on [DATE] when Resident #1 passed away. She stated she only worked on the weekends. She stated LPN #20 did contact her the day of the resident's death. She stated LPN #20 was a fairly new nurse and was very upset and wanted to know what to do. LPN #42 stated LPN #20 told her Resident #1 was found with his head and neck between the grab bar and mattress, and he was dead. LPN #42 stated she told LPN #20 to document everything she saw and be thorough, that it was very important. During an interview with LPN #38 on [DATE] at 8:10 AM he denied telling the coroner investigator Resident #1 was found unresponsive in bed. He states he told her he was on the floor and he moved him in the bed so his brother could come and see him. Review of the General Incident Investigation report, undated, given to the surveyor on [DATE], which was sent to the Coroner's office, revealed general investigation forms were to be completed for an unexpected or unusual death. The report revealed it was to be completed and forwarded to the ADON/Unit Manager, Director of Nursing (DON) and then finally the Administrator within 48 hours of the incident. The report was not signed as being received by the ADON/Unit Manager, DON or the Administrator. The incident report further revealed Resident #1 was found on [DATE] at 12:15 P.M. by staff on the floor sitting on the mat, with his upper body leaning against the assist bar and mattress. Vital signs were unable to be obtained. The resident's guardian was notified at 12:30 P.M. and the physician was notified at 3:15 P.M. The person who signed the report was LPN #38. On [DATE], continuation of viewing of the facility's video of [DATE] began at 11:15 A.M. with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. The video was started at 10:55 A.M. and revealed from 10:55 A.M. to 11:20 A.M., STNA #50, and STNA #81 were in and out of the resident's room. There was no more than three minutes viewed where at least one of the STNAs were in the room. The last time STNA #50 was viewed in Resident #1's room was at 11:17 A.M. and she left the room at 11:20 A.M. with Resident #5 (Resident #1's roommate) pushing him in a wheelchair. The video revealed DM #100 and DA #91 was seen leaving the snack shack which was two doors up from Resident #1's room at 11:54 A.M. When DM #100 and DA #81 were in front of Resident #1's door, the DM looked in the resident's room and then continued down the hall and was seen stopped at LPN #20's medication cart, then the DM was out of view. LPN #20 was seen on the video at 12:04 P.M. walking down the hallway past Resident #1's room, and she did not go in or look in the room. She continued to the end of the hallway where she was seen on her personal cell phone laughing. The next time someone went in the room was at 12:13 P.M. when STNA #50 returned Resident #5 to the room. At 12:14 P.M., STNA #50 was seen running out of the room and then LPN #20 was seen running down the hall and entered Resident #1's room. On [DATE] at 12:05 P.M., DM #100 was shown the video and interviewed with two surveyors, the LNHA, LPN #38 and Maintenance Assistant #68 present. She confirmed it was her on the video and she had been in the snack shack with DA #91 and walked out at 11:54 A.M. and headed down the hall. She further stated as she approached Resident #1's room she heard him yelling for help. She stated she did not go in the room, however could see from the hallway he was sitting on the mat with his legs out in front of him and his arms were at this side. She stated she asked him if he needed help and he stated yes. She then stated she told him she would tell LPN #20. She then stated she continued down the hall and stopped at LPN #20's cart and told her Resident #1 was yelling for help. She then went to her office. On [DATE] at 12:10 P.M., DA #91 was shown the video and Interviewed. He confirmed it was him on the video coming out of the snack shack with DM #100 at 11:54 A.M. The DA further confirmed as they approached Resident #1's room he heard him yelling for help. He further confirmed both him and DM #100 stopped at LPN #20's medication cart and told her he needed help. He then stated he continued to the DM's office wit (TRUNCATED)

Based on medical record review, staff and resident interviews, review of hospital emergency room documentation and surveyor observations, the facility failed to ensure staff provided adequate supervision to prevent a resident from eloping from the facility. This resulted in Immediate Jeopardy when one (#73) of three sampled residents exited the facility unsupervised through the opened front doors of the building and was missing for 29 hours. The resident was returned to the facility the following day without injury and placed on one-on-one staff supervision. The facility identified 10 of 84 residents at high risk for elopement. On 07/14/14 at 5:00 P.M., the Administrator was informed Immediate Jeopardy began on 07/11/14 at 9:26 A.M. when Resident #73, who was assessed at high risk for elopement and required additional supervision including frequent 15 minute checks, exited the facility unsupervised as an emergency medical team was transporting another resident out of the facility. Medical Records Staff #50 realized Resident #73 was missing an hour and 15 minutes later and notified the Director of Nursing (DON). Staff searched the adjacent neighborhood for the resident and distributed flyers with the missing resident ' s picture and information. Resident #73 ' s whereabouts was not discovered until 29 hours later on 07/12/14 at 2:51 P.M. by Therapy Staff #49 and #51 about four miles from the facility, near the downtown area, at a bus stop talking to a police officer. Resident #73 was easily redirected and returned to the facility where he was placed on one-on-one supervision. The Immediate Jeopardy was removed on 07/13/14 when the facility implemented the following corrective actions: ? On 07/11/14, the facility modified its frequent observation form to identify why the residents at high risk for elopement were on frequent every 15 minute observation checks and transferred the responsibility from the State tested Nurse Aides (STNAs) to the nurses. ? On 07/11/14, the Quality Assurance (QA) committee met and discussed the lack of adequate supervision to prevent an elopement; the Medical Director was updated. This issue was monitored through the QA program effective 07/11/14. ? On 07/11/14, the facility ' s elopement policy was updated to transfer the responsibility for the frequent 15 minute checks for high elopement risk residents to the nurses and was approved by the Medical Director. ? On 07/11/14, the facility began training all nursing staff regarding the new supervision requirements and the elopement risk assessment. All staff was trained prior to working their next shift. ? On 07/11/14, nursing staff completed elopement risk assessments for all current residents to include 10 residents identified at high risk for elopement and updated the care plans for all residents identified at risk for elopement as appropriate. ? On 07/11/14, the facility updated its " Elopement Risk Notebook " with the current care plans and pictures for the 10 residents (#7, #11, #18, #23, #26, #28, #54, #66, #73 and #79) assessed at high risk for elopement. ? On 07/11/14, yellow signs were placed on the front door that stated, "Visitors please take care that no residents exit the building along with you. If in doubt, please ask for more information at the nursing station immediately". ? On 07/11/14, red tape was placed on the floor at the nurses station desk and a sign posted to encourage staff, residents and visitors to refrain from standing in the receptionist ' s line of sight of the front exit door. ? On 07/12/14 at 7:30 P.M., Resident #73 returned to the facility from the hospital after evaluation and was placed on one-on-one supervision with documentation every 15 minutes. ? The facility planned to implement a wanderguard system for the residents assessed at high risk for elopement; planned installation date of 07/23/14. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not yet implemented the wanderguard security system and monitored for on-going compliance of corrective actions. Findings include: Review of the medical record of Resident #73 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated 05/14/14 revealed he was identified as independently mobile, he expressed a desire to leave the facility unattended and he was at risk for elopement and injury. The care planned interventions included to monitor the resident frequently which meant he was to be checked at least every 15 minutes. The STNAs were to document the checks on the facility ' s "15 minute Surveillance Program " . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition; he ambulated independently with a steady gait and required assistance with dressing, bathing and toileting. An elopement risk assessment dated [DATE] indicated Resident #73 was not at risk for elopement. Subsequent elopement risk assessments dated 06/03/14 and 06/13/14 indicated the resident was at high risk for elopement. The resident was being seen by a psychiatrist and was ordered psychoactive medications, Haldol 10 milligrams (mg) twice daily and Cimetidine 400 mg on 06/22/14 for behaviors. On 06/23/14, staff observed Resident #73 exit the facility through the front doors of the building. The resident was redirected back in the facility without incident. On 07/03/14, staff again observed Resident #73 exit the facility through the front doors of the building. The resident was again redirected back into the facility without incident. On 07/11/14, an elopement risk assessment was completed on the resident and he was again assessed at high risk for elopement. Nurse ' s notes dated 07/11/14 at 11:45 A.M. documented the nurse (unidentified)was made aware Resident #73's location was unknown. The notes further stated " Code E " for missing person was called and all rooms were checked. There was no evidence of 15 minute surveillance documentation of the resident for 07/11/14. Nurse ' s notes dated 07/12/14 at 4:00 P.M. documented Resident #73 returned to the facility at 3:00 P.M. ambulating independently with a steady gait; had no pain or discomfort, no signs of distress, and his vital signs were within normal limits. Review of hospital emergency room documentation dated 07/12/14 at 5:52 P.M. revealed Resident #73 had no acute abnormality. There was no indication the resident had pain and no injuries were noted. There were no new physician orders. Nurse ' s notes dated 07/12/14 at 7:30 P.M. documented the resident was placed on one-on-one staff supervision upon return from the hospital emergency room . During an interview on 07/14/14 at 1:30 P.M., the Administrator stated the facility was a secured building with security numerical key pads at every exit. He stated the receptionist at the front desk could release the front exit doors for visitors and residents. The Administrator stated Resident #73 was observed on the facility video tape to exit the opened front doors unsupervised on 07/11/14 at 9:26 A.M. when an emergency medical team was taking another resident out of the facility. On 07/11/14 at 10:45 A.M., Medical Records Staff #50 realized Resident #73 could not be found and notified the DON at that time. At 11:00 A.M., eleven facility department heads started searching the area neighborhood for the resident. At 12:15 P.M., the resident's physician, guardian and police were notified Resident #73 was missing. At 1:00 P.M., the local hospital and emergency psychiatric unit were notified of the missing resident. At 1:30 P.M., the facility department heads continued to search for the resident and distributed 450 flyers with the missing resident ' s picture and information. About 50 volunteers and staff searched for the resident. The information regarding the missing resident was aired on media sources. According to the Administrator, Resident #73 was well known around the city. The Administrator stated the resident was found by Therapy Staff #49 and #51 on 07/12/14 at 2:51 P.M. about four miles from the facility, near the downtown area, at a bus stop talking to a police officer and was easily redirected and returned to the facility. The resident was assessed with [REDACTED]. His vital signs and blood sugar were within normal limits. The Administrator stated Resident #73 was placed on one-on-one staff supervision at all times. The Administrator stated no other residents had eloped out the front door except for Resident #73 on 07/11/14 in the past six months. During an interview on 07/14/14 at 2:15 P.M., the DON provided nursing documentation of the 15 minute checks of Resident #73 prior to 07/11/14 and verified there was no evidence of documentation of frequent 15 minute checks for Resident #73 on 07/11/14. The DON also provided documentation of one-on-one staff supervision provided after Resident #73 returned to the facility on [DATE] at 7:30 P.M. Observations on 07/14/14 at various times including 2:20 P.M. and 7:05 P.M. and on 07/15/14 at 12:00 P.M. revealed no evidence of any resident with exit seeking behaviors. Resident #73 was observed with one-on-one staff supervision at all times during the observations. The facility was observed secured with security numerical key pads at each exit door. The alarms on the exits of the secured unit were tested on [DATE] at 3:00 P.M. and found to be working properly. A numeric code was required to stop the sounding alarm. During an interview on 07/14/14 at 2:30 P.M., Resident #73 stated when he left the faciity on [DATE] he was headed towards the "East side" of the city where his brother and sister lived. He stated he spent the night of 07/11/14 in a disabled vehicle by himself on the East side of the city. Resident #73 stated he was safe, was not afraid and no one bothered him while he was gone. He stated he ate and drank juice at a local charity mission. Interview with night shift Licensed Practical Nurses (LPN) #27 and #16 on 07/14/14 at 6:40 P.M. revealed they were both recently in-serviced on their responsibility to complete and document frequent 15 minute checks for any resident at high risk for elopement. They stated the STNA ' s were previously responsible for completing the 15 minute checks. The nurses stated they would be notified at the beginning of their shift of the residents requiring frequent checks. Both nurses denied knowledge of any resident eloping from the facility property other than Resident #73 on 07/11/14. LPN #16 was on duty when Resident #73 returned from the emergency roiagnom on [DATE] at 7:30 P.M. and verified one-on-one staff monitoring was in place for Resident #73 at all times. This certification deficiency substantiates Complaint Control Number OH 525.