Every finding on record at Springfield Masonic Community

Based on observation, staff interview, interview with dishwasher technician, and review of facility policy, the facility filed to ensure dishwashers reached proper sanitation levels and ensure dietary staff were knowledgeable on checking dishwasher sanitation. This had the potential to affect all 74 residents who receive food from the kitchen. The census was 74.Findings include:Review of dishwasher logs form December 2025, January 2026, and February 2026 revealed wash and rinse temperatures were documented. Wash temperature varied form 140 F to 174 F. Rinse temperatures varied form 120 F to 185 F. Sanitizer levels were not documented on any of the logs.Observation of the dishwasher on 03/02/26 at 8:55 A.M. revealed the wash temperature reached 140 degrees Fahrenheit (F) and the rinse temperature reached 115 F. There was a bottle of sodium hypochlorite (bleach) sanitizer on top of the machine with tube running from it into the machine.Interview with Assistant Director of Dining Services (ADDS) #699 on 03/02/26 at 8:857 A.M. revealed the dishwasher was high temperature sanitizing and the bottle of bleach sanitizer was a back-up if the temperature did not go high enough.Observation of Director of Food Clinical Nutrition Services (DFCNS) #644 on 03/02/26 at 9:05 A.M. revealed she ran a sanitizer test strip through the entire wash and rinse cycle. The test strip when checked did not register a sanitizer level.Observation of DFCNS #644 on 03/02/26 at 9:10 A.M. revealed they were re-checking the dishwasher sanitation after reading directions posted on wall by dishwasher revealed sanitizer still remained less than required. The level of bleach sanitizer checked below 50 parts per million (PPM).Interview and observation on 03/02/26 at 3:05 A.M. with Dishwasher Repair Technician (DRT) #807 revealed he was repairing the dishwasher. DRT #807 confirmed the dishwasher used bleach sanitizer and was not using high temperatures to sanitize. The dishwasher had been using bleach sanitizer for several months.Interview with DFCNS #644 on 03/02/26 at 3:10 P.M. confirmed the dishwasher had not been serviced or changed from a high temperature to a sanitizing machine since she had worked for the facility. DFCNS #644 had worked a the facility approximately seven months. DFCNS #644 confirmed dietary staff were completing dishwasher check logs with water temperature readings that the dishwasher was not currently capable of reaching. DFCNS #644 confirmed dietary staff should have been checking and recording bleach sanitizer levels.During an interview on 03/05/26 at 8:15 A.M., the Director of Nursing (DON) stated all residents of the facility receive food from the kitchen.Review of the facility's policy titled Cleaning Dishes/Dish Machine dated reviewed January 2026 revealed prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Staff to confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. For a high temperature dish machine, wash temperatures should be from 150 F to 165 F. Final rinse temperatures should be 180 F. For a low temperature sanitizing dish machine, wash temperature should be 120 F and bleach sanitizer check be 50 PPM.

Based on staff interview and observation, the facility failed to ensure the carpet was in safe and comfortable conditions for the residents. This had the potential to affect the 29 residents who resided on the fourth floor of Rickly Commons. The facility census was 74. Findings include: Observation and interview on 03/03/26 between about 2:45 P.M. and 3:00 P.M. revealed the carpet on the fourth floor of Rickly Commons (RC) had multiple tears in carpet seams. The hallway between rooms RC428 to RC415 and the hallway between rooms RC410 to RC402 had multiple tears in carpet seams. Tears in hallway carpet seams were observed outside doorways to rooms RC402, RC404, RC405, RC408, RC407, RC410, RC420, RC422, RC423, and RC424. Torn carpet seams had bunching of carpet material beneath the handrail by electrical panel, outside room RC416 (biohazard storage room), and outside room RC413. Registered Nurse (RN) #773 confirmed tears in carpet seams were between rooms RC428 to RC415 and the hallway between rooms RC410 to RC402 and outside of rooms RC402, RC404, RC405, RC408, RC407, RC410, RC420, RC422, RC423, and RC424.

Based on staff interview, review of medical records, and review of facility records, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident whose Medicare A benefits were ending. This affected one (Resident #24) of three residents reviewed for beneficiary notices. The facility census was 74.Findings include: Medical record review revealed Resident #24 was admitted [DATE]. Diagnoses included congestive heart failure. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review of the Notice of Medicare Non-Coverage revealed Medicare Part A Services ended on 12/15/25 for Resident #24. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted and Resident #24 remained in the facility. There was no documentation the facility provided the SNF ABN to Resident #24 and/or legal guardian. Interview with Social Services Director (SSD) #692 on 03/05/26 at 11:38 A.M. confirmed the facility did not provide the SNF ABN to Resident #24 and/or legal guardian when Medicare Part A Services ended on 12/15/25, did not exhaust benefit days, and remained in the facility.

Based on medical record review, observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility ailed to ensure therapy staff followed the physician orders for enhance barrier precautions (EBP) for residents who receive therapies while in the therapy room. This affected one resident (#45) and the facility identified eight residents who were on EBP and receiving therapy services. The facility census was 74. Findings include: Review of the medical record for Resident #45 revealed an admission date of 02/12/26. Diagnoses included sepsis, multiple myeloma, congestive heart failure, and other bacterial infections. The admission Minimum Data Set (MDS) assessment, dated 02/19/26, revealed Resident #45 was cognitively intact and required substantial/maximum staff assistance with transfers and bed mobility and was dependent upon staff for toilet hygiene and bathing. The physician order dated 02/23/26 revealed an order for EBP. Observation on 03/05/26 at 7:53 A.M. revealed Physical Therapy Assistant (PTA) #801 providing hands on assistance to Resident #45 with a transfer from his wheelchair to a set of steps in a common area on the unit. The observation revealed PTA #801 did not have on a gown or gloves. Interview on 03/05/26 at 7:55 A.M. with PTA #801 confirmed he provided Resident #45 with hands on assistance with transfer out of his wheelchair and continued to provide hands on assistance to Resident #45 for the steps. PTA #801 confirmed Resident #45 was on EBP because of a wound and he had not donned a gown or gloves when he provided hands on assistance with transfers. PTA #801 stated therapy staff do not wear gowns or gloves in the hallway or in the therapy room when they provided therapy services to residents under EBP. Interview on 03/05/26 at 7:58 A.M. with Occupational Therapy (OT) #802 stated therapy staff follow EBP when treating the residents in their rooms but stated EBP are not followed in the therapy gym when staff are providing hands on assistance. Interview on 03/05/26 at 8:01 A.M. with Director of Rehabilitation (DOR) #805 confirmed therapy staff do not follow EBP when providing treatment for residents with orders for EBP in the therapy gym. Review of the policy titled Enhanced Barrier Precautions revealed the facility is to implement EBP for the prevention of transmission of multi-drug resistant organisms (MRDOs). The policy stated EBP refers to an infection control intervention designed to reduce transmission of MRDOs that employs targeted gown and gloves use during high contact resident care activities. The policy stated EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assistance with transfers and mobility. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This deficiency represents non-compliance investigated under Complaint Number 2748252.

Based on review of medical records, observation, staff interview, laboratory services staff interview, and review of facility policy, the facility failed to residents were provided privacy during medical procedures. This affected #7 and #82 of residents observed dining in the memory care units. The facility census was 74.Findings include:1.Review of Resident #7's medical record revealed an admission date of 10/19/25. Diagnoses included Parkinson's disease, psychotic disturbance, bipolar disorder, and dementia.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment.Observation on 03/06/26 at 7:33 A.M. revealed Laboratory Technician (LT) #800 drawing blood from Resident #7's left arm while he was sitting at a table in the dining room. A female resident was sitting across the table from Resident #7. There were other residents sitting at a table behind Resident #7.Interview with LT #800 on 03/05/26 at 7:36 A.M. confirmed she had obtained a blood sample from Resident #7 was he was sitting at a table in the dining room. Interview with the Director of Nursing (DON) on 03/05/26 7:58 A.M. confirmed residents should not have blood samples drawn while in the dining room. The DON confirmed this violated their right to privacy.2. Review of Resident #82's medical record revealed an admission date of 01/29/24. Diagnoses included long term use of insulin, type two diabetes mellitus, cerebral infarction with residual effects, vascular dementia, and psychotic disturbances.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had severe cognitive impairment and received insulin injections.Observation on 03/05/26 at 7:41 A.M. revealed Resident #82 was given two insulin pen injections in the abdomen by Licensed Practical Nurse (LPN) #567 while she sitting at a dining room table. LPN #567 raised Resident #82's shirt and administered the insulin injections in the right lower abdomen. Other residents were sitting at the same dining room table and at various tables in the dining room.During and interview on 03/05/26 at 7:43 A.M., LPN #567 confirmed she had administered two insulin injections to Resident #82's right lower abdomen while she was sitting at the dining rooms table. LPN #567 confirmed insulin injections should not be given to residents while in the dining room.Interview with the Director of Nursing (DON) on 03/05/26 7:58 A.M. confirmed residents should not have insulin injections given while in the dining room. The DON confirmed this violated their right to privacy.Review of the facilities policy titled Injectable Medications dated 06/21/17 revealed staff will provide privacy to residents when administering injectable medications.

Based on observation, record review, policy review, and staff interview, facility failed to provide activities of interest and encourage participation to the residents. This affected three (#10, #34, and #78) of three residents reviewed for activities. The facility census was 74.Findings include1. Review of the medical record for Resident #78 revealed an admission date of 12/28/23. Diagnoses included Alzheimer's disease, epilepsy, diabetes, blindness in one eye, muscle weakness and cerebrovascular disease, vascular dementia, and history of traumatic brain injury. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had cognitive impairment and was dependent on staff for bed mobility and transfers.The undated care plan revealed Resident #78 was dependent on staff for meeting emotional, intellectual, physical and social needs with interventions to introduce the resident to other residents with similar backgrounds, invite residents to scheduled activities, and provide a program of activities that was of interest. The quarterly assessment dated [DATE] revealed Resident #78 liked visiting with staff about his time overseas, watching television in his room, pet visits and talking with other residents. The progress notes from 01/01/25 to 02/28/26 revealed on 01/07/26, activity staff went to the community center and got Resident #78 a cheeseburger and dessert. On 01/19/26, activity staff visited with the resident. Review of the activity participation documentation for January 2026 revealed Resident #78 was watching television in his room and on 12 occasions had staff room visits on 16 occasions. The activity participation documentation dated 02/2026 revealed Resident #78 was watching television in his room on 15 occasions and had staff room visits on 16 occasions. The participation documentation did not show where the resident was offered to talk with other residents and receive pet visits.Observations on 03/02/26 at 10:00 A.M., 11:27 A.M., 2:10 P.M., and 4:56 P.M. and on 03/03/26 at 8:25 A.M., 8:43 A.M., 12:40 P.M., and 3:40 P.M. revealed Resident #78 was sitting in his room. Resident was not observed to be out of his room at any time and no interactions with other residents was observed.Continuous observations on 03/04/26 from 8:35 A.M. to 10:10 A.M. revealed Resident #78 was sitting in his room with the television on. No staff entered his room to discuss mail, lunch choices, or the daily activities. Interview on 03/04/26 at 10:25 A.M. with Certified Nursing Aide (CNA) #710 revealed the residents did not participate in activities and acknowledged staff do not encourage residents to participate. The CNA acknowledged the facility should offer a variety of activities of interest and when asked about activities of interest, CNA declined to answer. The CNA confirmed most residents remain in their rooms all day. Interview on 03/04/26 at 10:40 A.M. with Activity Director (AD) #776 revealed activity staff provide one-on-one visits with every resident in the morning when they deliver mail and get food orders and they also inform every resident of the activities for each day. The AD was informed no activity staff was present in Resident #78's room to discuss any activities for the day. AD #776 verified Resident #78 should be provided activities of interest throughout the day. 2. Review of the medical record for Resident #10 revealed an admission date of 03/11/25. Diagnoses included respiratory failure with hypoxia, vascular dementia, muscle weakness dysphagia, psychotic disorder with delusions and epileptic disorder. Review of the care plan dated 08/27/25 revealed Resident #10 was dependent on staff for meeting emotional, intellectual, physical and social needs with interventions to introduce the resident to residents with similar backgrounds, invite residents to scheduled activities, music therapy to provide one session monthly, and provide a program of activities that was of interest. Review of the quarterly assessment dated [DATE] and 02/25/26 revealed Resident #10 enjoyed visits with staff and residents and was very social. He wound benefit from one to one visits as well as group activities and enjoyed the activity cart and enjoyed pet visits, watching television, happy hours on Fridays and other campus activities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition and required partial/moderate assistance for activities of daily living.Review of the progress notes from 01/01/26 to 03/04/26 revealed on 01/21/26 and 03/02/26, staff delivered the menu and on 03/03/26, staff visited and chatted with resident.Review of the activity participation documentation dated 01/2026 revealed Resident #10 was watching television in his room on 15 occasions and had staff room visits on 17 occasions. The activity participation documentation dated 02/2026 revealed Resident #10 was watching television in his room on 12 occasions had staff room visits on 13 occasions. The activity participation documentation did not show where the resident was offered group activities, the activity cart, pet visits, happy hours and other campus activities.Observations on 03/02/26 at 10:00 A.M., 11:27 A.M., 2:10 P.M., and 4:56 P.M. and on 03/03/26 at 8:25 A.M., 8:43 A.M., 12:40 P.M., and 3:40 P.M. revealed Resident #10O was found sleeping in his room with no stimulation beside the television being on in the room. The resident was not observed to be out of his room at any time and no interactions with other residents was observed. Continuous observations on 03/04/26 from 8:35 A.M. to 10:10 A.M. revealed Resident #10 was sitting in his room with the television on. No staff entered his room to discuss mail, lunch choices, or the daily activities. No activity staff were observed encouraging the resident to participate in activities. The activity staff was observed getting a lunch meal order for only one resident on the unit (not Resident #10) and informing only one resident (not Resident #10) about a craft activity going on in the afternoon. Interview on 03/04/26 at 10:25 A.M. with Certified Nursing Aide (CNA) #710 revealed the residents did not participate in activities and acknowledged staff do not encourage residents to participate. The CNA acknowledged the facility should offer a variety of activities of interest and when asked about activities of interest, CNA declined to answer. The CNA confirmed most residents remain in their rooms all day.Interview on 03/04/26 at 10:40 A.M. with Activity Director (AD) #776 revealed the activity staff pass out mail and take resident orders for the luncheon which was on the activity calendar. She reported the luncheon was when staff get carryout food from either the commons or take residents to a restaurant for lunch. She reported residents were required to have a regular diet to be able to participate in this. She reported activity staff provide one-on-one visits with every resident in the morning when they deliver mail and get food orders and they also inform every resident of the activities for each day. AD #776 verified Resident #10 should be provided activities of interest throughout the day.Review of the diet list audit revealed Resident #10 had an order for a regular diet and regular texture.3. Review of the medical record for Resident #34 revealed an admission date of 05/29/23. Diagnoses included hemiplegia and hemiparesis, heart disease vascular dementia, dysphagia, and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had severe cognitive impairment and was dependent on staff for bed mobility and transfers.Review of the care plan dated 06/01/23 revealed Resident #34 was dependent on staff for meeting emotional, intellectual, physical and social needs with interventions including to introduce the resident to residents with similar backgrounds, invite residents to scheduled activities, and provide a program of activities that was of interest. Review of the quarterly assessments dated 11/19/25 and 02/18/26 revealed Resident #34 enjoyed visits from family and staff and enjoyed music, ice cream, going outside on sunny days and enjoyed reading about history. Facility to continue to offer and encourage activities. Review of the activity participation documentation dated 01/2026 revealed resident was watching television in his room on six occasions had staff room visits on 14 occasions. The activity participation documentation dated 02/2026 revealed resident was watching television in his room on two occasions had staff room visits on 14 occasions. The activity participation documentation did not show where the resident was offered music, ice cream and events related to history. Observations on 03/02/26 at 10:00 A.M., 11:27 A.M., 2:10 P.M., and 4:56 P.M. and on 03/03/26 at 8:25 A.M., 8:43 A.M., 12:40 P.M., and 3:40 P.M. revealed Resident #34 was sitting in his room with no television or music playing. The resident was not observed to be out of his room at any time and no interactions with other residents was observed. Continuous observations on 03/04/26 from 8:35 A.M. to 10:10 A.M. revealed Resident #34 was sitting in his room. No staff entered his room to discuss mail and an activity staff member informed Resident #34 of a craft activity. The activity staff member did not offer to turn on the television or music for the resident. Interview on 03/04/26 at 10:25 A.M. with Certified Nursing Aide (CNA) #710 revealed the residents did not participate in activities and acknowledged staff do not encourage residents to participate. The CNA acknowledged the facility should offer a variety of activities of interest and when asked about activities of interest, CNA declined to answer. The CNA confirmed most residents remain in their rooms all day.Interview on 03/04/26 at 10:40 A.M. with Activity Director (AD) #776 revealed the activity staff provide one-on-one visits with every resident in the morning when they deliver mail and they inform every resident of the activities for each day. AD #776 verified Resident #34 should be provided activities of interest throughout the day.Review of the facility policy titled Activities in Skilled Nursing dated 03/08/23 revealed facility shall provide an ongoing structured activity program designed to meet the individualized interest and support the well-being of each resident in accordance with regulations. The facility shall provide activities that were person-centered and to enhance the quality of life. Facility shall document activity participation including refusals and shall provide group social activities, cognitive stimulation, physical wellness activities, creative and expressive programs, spiritual programs, and community involvement opportunities, and one to one activities.

Based on medical record review, staff interview, and policy review, the facility failed to accurately assess the resident's wound upon admission. This affected one (#100) out of three residents reviewed for pressure ulcers. The facility census was 74.Findings include:Review of the medical record for Resident #100 revealed an admission date of 02/20/26. Diagnoses included left hip fracture, diabetes mellitus, and Alzheimer's disease.Review of the hospital documentation dated 02/17/26 revealed Resident #100 had a unstageable pressure ulcer (slough and/or eschar, known but not stageable due to coverage of wound bed by slough and/or eschar) to coccyx which measured 1.5 centimeters (cm) in length, 2.0 cm in width, and 0.1 cm in depth and a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to right hip which measured 4.0 cm in length, 3.5 cm in width, and 0.1 cm in depth.Review of the admission assessment dated [DATE] revealed Resident #100 had severely impaired cognition and required staff assistance with activities of daily living. The Braden scale assessment dated [DATE] revealed Resident #100 was high risk for skin breakdown. Review of the skin observation evaluation dated 02/20/26 revealed the resident had several areas of skin breakdown and concerns. Resident #100 had a right hip pressure ulcer measuring 1.5 inches in length, 0.5 inches in width, and no depth; a surgical site to left hip; bruising to bilateral arms and legs; dry spots and scabbing to the right lower ankle on top; skin tear to left outer leg; and an area from moisture in the crack of the buttocks measuring 0.5 cm in length, 0.5 cm in width, and no depth. The evaluation did not contain documentation to support a description of the area to crack of the buttocks or if the area was pressure related injury. The physician orders dated 02/20/26 revealed an order to cleanse coccyx and right hip with normal saline and pat dry, apply collagen sheet to wound bed and cover with bordered foam dressing three times per week and as needed.The skin observation evaluation dated 02/25/26 stated Resident #100 had an unstageable pressure ulcer to the right hip measuring 2.5 cm in length, 2.0 cm in width, and 0.1 cm in depth and a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed) to coccyx which measured 1.0 cm in length, 0.5 cm in width, and 0.1 cm in depth. The evaluation indicated Wound Nurse Practitioner to evaluate and orders in place. The evaluation stated the Stage III pressure ulcer to the coccyx was present upon admission. The Wound Nurse Practitioner note stated 02/25/26 revealed he initial evaluation and Resident #100 was being seen for wound to coccyx and right hip. The note indicated Resident #100 had an unstageable pressure ulcer to right hip which measured 2.5 cm in length, 2.5 cm in width, and 0.1 cm in depth and a Stage III pressure ulcer to coccyx which measured 1.0 cm in length, 0.5 cm in width, and 0.1 cm in depth. The wounds were noted to be present upon admission.Interview on 03/04/26 at 12:20 P.M. with Assistant Director of Nursing (ADON) #539 confirmed Resident #100's skin observation evaluation on 02/20/26 did not contain documentation to support Resident #100 had a pressure ulcer to coccyx upon admission. ADON #539 confirmed the skin evaluation did not have a description for the area to the crack of the buttocks to indicate whether the area was opened, skin was blanchable, or any drainage was noted. ADON #539 stated Resident #100's Stage III pressure ulcer to the coccyx is the same area that was documented as an area from moisture in the crack of the buttocks on the 02/20/26 skin observation. Review of the policy titled Skin Care Management revised 04/20/24revealed a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the individual's clinical condition demonstrates that the pressure ulcer was unavoidable and a resident having pressure ulcer receives necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. The resident's skin evaluation and documentation included measurement and description of each chronic skin abnormality, current skin abnormality, and/or condition i.e. reddened areas, cuts, bruises, wounds, incisions, rashes, sutures, pressure ulcers, blisters, etc. The policy also stated if an ulcer has characteristics consistent with a pressure ulcer, but it is determined not to be one, document the clinical rationale which permits differentiating the ulcer type.

Based on observations, staff interviews, and policy review, the facility failed to ensure insulin vials/pen-injectors were dated after opened. This affected two of three medication carts reviewed for medication storage and the facility identified there were six medication carts. This affected two residents (#59 and #105) reviewed for medication storage. The facility census was 74.Findings include:Observation and interview on 03/04/26 at 9:20 A.M. of medication cart two on the 400 Hall revealed Resident #59's Lantus pen-injector (insulin) was opened and did not have a date to indicate when it was opened. Interview with Registered Nurse (RN) #643 confirmed the insulin was in the medication cart, was opened, and did not have a date indicating when it was opened. Observation and interview on 03/04/26 at 9:55 A.M. of medication cart two on 300 hall revealed Resident #105's Toujeo pen-injector (insulin) was opened and did not have a date to indicate when it was opened. Interview with RN #557 confirmed Resident #105's Toujeo was in the medication cart, was opened, and did not have a date to indicate when it was opened. Review of the facility policy titled Medication Administration revealed the staff are to ensure that the opened date was documented on insulin vial or pen.

Based on medical record review, staff interviews, and policy review, the facility failed to establish a communication system with hospice and ensure the hospice plan of care was readily available for staff to review. This affected one (Resident #78) of one resident reviewed for hospice services. The facility census was 74.Findings include:Review of the medical record for Resident #78 revealed an admission date of 12/28/23. Diagnoses included Alzheimer's disease, epilepsy, diabetes mellitus, cerebrovascular disease, and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had cognitive impairment and was dependent on staff for bed mobility and transfers.Review of the physician order dated 02/11/26 revealed Resident #78 was admitted to hospice on 02/11/26 for a diagnosis of cerebrovascular disease. Review of hospice communication binder on 03/04/26 revealed it only included the provider names for the hospice medical director, nurse and aide and the off hours contact information and during business hours contact information. The binder included a sign in sheet that included only the hospice Certified Nursing Aide (CNA). The dates included 02/12/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/20/26, 02/23/26, 02/24/26, 02/25/26, and 02/26/26 and had corresponding shower sheets on 02/12/26, 02/16/26, 02/19/26, 02/23/26, and 02/26/26. Observation, record review, and interview on 03/04/25 at 10:23 A.M. with Licensed Practical Nurse (LPN) #626 and Certified Nursing Aide (CNA) #710 revealed the hospice communication binder was found at the nursing station. Review of hospice communication binder on 03/04/26 revealed it only included the provider names for the hospice medical director, nurse and aide and the off hours contact information and during business hours contact information. The binder included a sign in sheet that included only the hospice CNA. The dates included 02/12/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/20/26, 02/23/26, 02/24/26, 02/25/26, and 02/26/26 and had corresponding shower sheets on 02/12/26, 02/16/26, 02/19/26, 02/23/26, and 02/26/26. LPN #626 and CNA #710 confirmed not much information was in the binder and hospice staff should be signing in and putting in notes when they visit. They also acknowledged it should have other hospice documents such as the care plan and orders. Interview on 03/04/26 from 12:04 P.M. to 1:13 P.M. with the Director of Nursing confirmed the hospice binder had limited information and nothing from the past week. The DON acknowledged it should contain additional information such as visit notes and the hospice care plan. The DON stated Resident #79 was enrolled for hospice now for three weeks. Review of the facility policy titled Hospice Services in a Skilled Nursing Facility dated 02/04/24 revealed the facility shall support residents who elect hospice and collaborate with the hospice provider to ensure coordinated compassionate care. The hospice shall maintain the hospice care plan and the facility shall maintain its own comprehensive care plan.

Based on staff interview, medical record review, observations, and policy review, the facility failed to ensure the the resident's call system was within the reach of the resident when lying in bed. The affected one (Resident #79) of 20 residents reviewed in the initial pool of the survey process. The facility had a census of 74 residents.Findings include: Review of the medical record for Resident #79 revealed an admission date of 10/03/24. Diagnoses included vascular dementia, metabolic encephalopathy, and cognitive communication deficit. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 had severe cognitive impairment. The care plan dated 01/12/26 revealed Resident #79 was dependent on staff for toileting and personal hygiene, and required substantial assistance from staff to reposition from lying to sitting on side of bed, reposition from sit to stand, and reposition from bed-to-chair transfer. Interventions included to ensure the resident's call light was within reach, encourage the resident to use it for assistance as needed, and the resident needs prompt response to all requests for assistance. Observation of Resident #79 on 03/02/26 at 11:03 A.M. revealed Resident #79 was lying in bed and was asking for ice cream. The call light was observed on the floor by the bed on the left hand side of where the resident was laying and was not within the resident's reach. Observation of Resident #79 on 03/02/26 at 11:53 A.M. revealed Resident #79 was lying in bed and a used lunch tray was sitting on an adjustable overbed table on the resident's right hand side. The call light was observed on the floor by the bed on the resident's left hand side. Observation of Resident #79 on 03/02/26 about 1:55 P.M. revealed Resident #79 was resting in bed and the call light was observed on the floor by the bed on the resident's left hand side. Observation and interview of Resident #79 on 03/02/26 about 3:09 P.M. revealed Resident #79 was awake lying in his bed and the call light was observed on the floor by the bed on the resident's left hand side. Registered Nurse (RN) #687 entered the room and asked the resident if they needed any care and services. RN #687 picked up the call light from the floor and placed it on the resident's bed with the resident's reach. RN #687 confirmed Resident #79's call light was on the floor by the bed and not within the reach of the resident. Review of the facility call light procedure dated 03/05/25 revealed call lights will be within reach of the resident when in resident room.

Based on resident interview and staff interview, the facility failed to ensure residents received delivered mail on Saturdays. The had the potential to affect all 74 residents residing in the facility. Findings include:Interview with Resident Council Members (#48, #59, #85, and #88) on 03/04/26 at 2:12 P.M. revealed they do not receive any mail on Saturdays. The residents stated the activity staff distribute mail at the facility.Interview with Director of Life Enrichment #776 one 03/04/26 2:28 P.M. revealed activity staff distribute mail at the facility. Mail received on the weekends gets distributed to residents on Monday.Interview with Business Office Manager #663 on 03/04/26 at 2:41 P.M. revealed mail was dropped off by post office staff in the mail room. Mail that is delivered on the weekends is distributed by activity staff on Monday. Resident do not receive any mail delivered on Saturday until the following Monday.

Based on medical record review and staff interviews, the facility failed to ensure a resident on dialysis was monitored for signs and symptoms of an infection or bleeding. This affected one (Resident #39) of one resident reviewed for dialysis. The facility identified one resident who resided in the facility and received dialysis services. The facility census was 73. Findings include: Review of the medical record for Resident #39 revealed she was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, type two diabetes mellitus, hypertensive heart disease with heart failure, and chronic kidney disease stage five. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/04/23, revealed Resident #39 had intact cognition. Review of the plan of care initiated on 01/12/21 revealed Resident #39 needed dialysis related to renal failure. Interventions included to encourage the resident to go to scheduled dialysis appointments, monitor for dry skin and apply lotion as needed, monitor labs and report to doctor as needed, monitor/document/report as needed any signs or symptoms of infection to access site, and monitor/document/report as needed for signs or symptoms of bleeding, hemorrhage, bacteremia, and septic shock. Review of the active physician orders, treatment administration record, and progress notes revealed there was no physician or any evidence nursing was routinely monitoring the access site for any issues related to bleeding or infection. Review of the Post Treatment form completed by the outside dialysis provider revealed Resident #39 had a central venous catheter located on the right. Interview on 02/09/23 at 12:44 P.M. with Licensed Practical Nurse (LPN) #108 revealed Resident #39 had an access site in her left arm, which became blocked. LPN #108 stated an access site was just placed in her right arm but the current access site was on the right side of her chest. LPN #108 reported she would see the access site on Resident #39's chest when she assisted the aides with care but expressed she had not documented when she saw the access site. LPN #108 confirmed there was no order in place to assess the current access site located on Resident #39's chest. Interview on 02/09/23 at 1:34 P.M. with the Director of Nursing (DON) confirmed there had not been an order to monitor the access site on Resident #39's chest that was currently being used during dialysis treatments.

Based on staff interview, review of the facility policy, and record review, the facility failed to ensure pre-admission screening and resident review (PASARR) were updated after changes in diagnosis. This affected two (Residents #20 and #32) of two residents reviewed for PASARR. The facility census was 73. Findings include 1. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included anxiety and psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Review of the PASARR dated 11/28/22 revealed Resident #20 had no mental health diagnoses. This PASARR was completed after a hospital admission. Interview on 02/07/23 at 4:20 P.M. with Administrator revealed the PASARR assessment was completed upon admission and should be updated after a significant change in condition. The Administrator confirmed the PASARR for Resident #20 did not include diagnosis of anxiety or psychotic disorder. The Administrator later revealed the social worker has been checking newly admitted residents to ensure accuracy of PASARR assessments from the hospital. The Administrator started the social worker began in 01/2021. Review of the facility policy titled PASARR Screen Policy, dated 03/17/15, revealed a PASARR would be completed to evaluate for serious mental illness upon admission and after a change in condition. 47058 2. Review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including dementia. Since admission, Resident #32 has been diagnosed with major depressive disorder, anxiety, and psychotic disorder with delusions due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's preadmission screening resident review (PASARR) dated 05/29/19 revealed Resident #32 had dementia no indications of serious mental illness. Further review of Resident #32's PASARR revealed Resident #32 did not have a significant change PASARR upon new diagnoses of serious mental illness. Interview on 02/07/23 at 3:42 P.M. with Administrator verified Resident #32 did not have a significant change PASARR when Resident #32 had new serious mental health illness diagnoses which included major depressive disorder, anxiety and psychotic disorder. Review of the facility's PASARR's policy date 03/17/15 revealed the facility coordinates assessments with the PASARR program to ensure individuals with a mental disorder receive care and services in the most integrated setting appropriate and resident reviews are to be completed when there is a significant change in condition.

Based on observation, staff and resident interview, review of facility policy, and medical record review, the facility failed to ensure residents who were dependent on staff for assistance with bathing and personal hygiene received adequate care and services. This affected one (Resident #23) of one resident reviewed for activities of daily living (ADL) care. The facility identified all 73 residents required assistance from staff for bathing. The facility census was 73. Findings include Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included osteoporosis, macular degeneration, low vision in right and left eye category two, and glaucoma. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively impaired and required extensive assistance of two staff members for personal hygiene and bathing. Resident #23's vision was severely impaired and did not wear corrective lenses. Review of the care plan dated 01/10/23 revealed Resident #23 had an ADL self-care deficit due to neck contracture with an intervention for ADL assistance from staff. Review of the bathing task revealed Resident #23 received a shower on 02/07/23. There was no mention if nail care was provided. Observation and interview on 02/06/23 at 2:40 P.M. with Resident #23 revealed she would like her nails trimmed. Resident #23's nails were broken, jagged and rough. Resident #23 stated she does not want them polished, just cut. Resident #23 stated she has not had her nails trimmed since admission and due to blindness cannot do them herself. Interview and observation on 02/08/23 at 1:17 P.M. with Resident #23 revealed her nails remained jagged and rough. Resident #23 said her nails were not trimmed when she received a shower yesterday (02/07/23). Resident #23's nails were dirty with a dark brown substance and several nails appeared jagged and broken and some were quite long. Interview on 02/08/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #141 revealed she was unaware of any concerns related to the resident's nails not being trimmed upon request. LPN #141 stated nails should be cleaned and offered to be cut when showers were provided. LPN #141 stated Resident #23 did not typically refuse care. LPN #141 confirmed Resident #23's nails were long and jagged. Interview on 02/09/23 at 10:50 A.M. with the Administrator revealed the facility does not have a policy related to providing ADL care for residents who were dependent on staff for assistance with ADL. The staff should follow the resident's care plan.

Based on record review and staff interview, the facility failed to develop care plans for a resident receiving wound care for Moisture Associated Skin Damage (MASD) and for the resident's Meibomian eye gland disease. This affected one (Resident #39) of twenty residents reviewed for the development and implementation of care plans. The facility census was 108. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the wound progress note, dated 02/20/20, revealed Wound Nurse Practitioner (NP) #4[AGE] documented Resident #39 had MASD bilateral buttocks. Review of the physician orders, dated 02/2020, revealed an order for [REDACTED]. Review of the resident's care plans revealed the resident did not have a care plan for MASD and antibiotic for the resident's Meibomian eye gland disease. Interview with the Director of Nursing (DON) on 02/27/20 at 10:37 A.M. verified Resident #39's care plan did not address the resident's MASD or Meibomian eye gland disease.

Based on medical record review and physician interview, the facility failed to ensure a medication was used for an appropriate diagnosis. This affected one (Resident's #39) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/19, revealed the resident had moderate cognitive impairment. Review of the physician orders, dated 02/2020, revealed an order for [REDACTED]. Interview with the Medical Director (MD) #550 on 02/27/20 at 8:52 A.M. revealed Resident #39 was ordered [MEDICATION NAME] (antibiotic) 50 milligram (mg.) once daily for Meibomian eye gland disease, not for antibiotic [MEDICATION NAME] for recurrent eye infections. MD #550 stated she contacted the resident's ophthalmologist and confirmed the antibiotic was prescribed for the resident's eye gland disease not for not for recurrent eye infections.

Based on medical record review and staff interview, the facility failed to accurately code Minimum Data Set (MDS) assessments for Resident #4. This affected one (#4) of 20 residents reviewed for accuracy of the MDS assessments. The facility census was 108. Findings include: Review of Resident #4's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessments, dated 02/12/19, 08/14/19, and 11/13/19, revealed Resident #4 was coded for daily restraint use per bed rails. However, there was no documentation of restraint use for those time periods in the resident's medical record. Interview with Registered Nurse (RN) #620 on 02/27/20 at 10:45 A.M. verified restraints were not used for Resident #4 during the look-back periods of the quarterly MDS assessments dated 02/12/19, 08/14/19, and 11/13/19. The RN verified the quarterly MDS assessments were coded incorrectly for restraint use on 02/12/19, 08/14/19, and 11/13/19.

Based on medical record review and staff interview, the facility failed to issue a bed hold notification, to the resident and/or representative. This affected four (#51, #57, #85, and #90) of five residents reviewed for hospitalization s. The facility census was 110. 1. Review of Resident #85's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On 12/03/18 at 1:42 P.M., the resident was transferred to the hospital for the evaluation of the resident's complaints of abdominal pain and tenderness on 12/05/18. The medical record was silent of verification, that a bed hold notification, was provided to Resident #85 and/or representative. Interview conducted on 01/08/19 at 4:12 P.M., the Administrator verified Resident #85 was transferred out of the facility on 12/03/18 and no notification of bed hold was provided in writing to the resident and/or representative. 2. Review of Resident #57's medical record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's medical record revealed he was hosptalized on [DATE] due to a change in condition and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #57 and /or their representative in writing. 3. Review of Resident #51's medical record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was hosptalized on [DATE] due to a complaint of right hip pain and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #51 and /or their representative in writing. 4. Review of Resident #90's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was noted to have been hosptalized on [DATE] due to complaint of hip pain and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #90 and /or their representative in writing.

Based on medical record review and staff interviews, the facility failed to issue written notice for transfer, to the resident and/or representative. This affected four (#51, #57, #85, and #90) of five residents reviewed for hospitalization s. The facility census was 110. 1. Review of Resident #85's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On 12/03/18 at 1:42 P.M., the resident was transferred to the hospital for the evaluation of the resident's complaints of abdominal pain and tenderness. The resident returned to the facility on [DATE]. The medical record was silent of verification, that a notification of transfer, was provided to Resident #85 and/or representative. Interview on 01/08/19 at 4:12 P.M., with the Administrator verified Resident #85 was transferred out of the facility on 12/03/18 and no written notification of transfer was provided in writing to the resident and/or representative. 2. Review of Resident #57's medical record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was noted to have be hosptalized on [DATE] due to a change in condition and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #57 and /or their representative in writing. 3. Review of Resident #51's medical record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was noted to have been hosptalized on [DATE] due to a complaint of right hip pain and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #51 and /or their representative in writing. 4. Review of Resident #90's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was hosptalized on [DATE] due to complaint of hip pain and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #90 and /or their representative in writing.

Based on record review and facility staff interview the facility failed to correctly code the minimum data set (MDS) assessment for one (#58) of one resident reviewed for hospice services. The facility census was 110. Findings include: Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident #58's most recent quarterly MDS assessment dated [DATE] revealed the resident did not have a condition or chronic disease the may result in a life expectancy of less that 6 months, however section O revealed the resident was receiving hospice services. Interview on 01/09/19 at 3:30 P.M., with MDS Registered Nurse (RN) #550 confirmed the MDS was coded incorrectly.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of a social media photograph, resident and family interviews, staff interviews, review of personnel files, review of the facility's Employee Handbook, and review of the facility's Social Media and Abuse policies and procedures, the facility failed to take actions to protect residents from mental and emotional abuse by timely identification of a perpetrator and failed to complete a thorough investigation of the allegation of abuse by interviewing the involved resident. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (#10) when Licensed Practical Nurse (LPN) #15 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate photograph of a large, undressed, open wound on the resident's left shoulder without permission from the resident and not in accordance with facility policy. This photograph was then posted on a social media website, Snap Chat, with derogatory comments added, and sent to staff member (MR#106), who worked in medical records, without the knowledge or permission of the resident. This affected one (#10) of three residents reviewed for abuse. On 01/26/17 at 4:50 P.M., the Administrator, Corporate Financial Officer #313 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 01/15/17 at approximately 1:40 P.M. when LPN #15 took a photograph with her personal cell phone of Resident #10's undressed, open shoulder wound without the resident's permission. LPN #15 proceeded to send the photograph to an employee who worked in Medical Records (MR #106) via the social media website identified as Snap Chat with a contemptuous comment noting I don't get paid enough for this (expletive). MR #106 responded to LPN #15 by asking who was in the picture. LPN #15 responded New guy we just got .wtf (what the expletive), thereby identifying the resident in the picture. The Immediate Jeopardy was removed on 01/26/17 at 11:59 P.M. when all staff was in-serviced regarding the identification of abuse, the abuse policy and social media procedures (which included privacy of resident information and photographs) and the facility implemented the following corrective actions: · On 01/16/17 at 8:00 A.M., the facility Administrator began an investigation of LPN #15 taking a photograph of Resident #10's wound. · On 01/16/17 at 9:30 A.M., LPN #15 was removed from patient care and placed on Administrative leave. · On 01/16/17 at 5:10 P.M., the facility reported the incident to the Ohio Department of Health. · On 01/17/17 LPN #15's employment with the facility was terminated. · On 01/25/17 at 5:15 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy and social media procedures per the facility's Employee Handbook. The re-education of staff included their responsibility to report any new allegations of abuse, which included social media posts, the facility's policy and procedure on abuse and social media usage with photographing/resident privacy. · On 01/25/17 at 5:45 P.M , the facility Administrator and Licensed Social Worker (LSW) #110 discussed the photograph and caption posted on social media with Resident #10. LSW #110 was to provide continued psychosocial follow up with the resident within 24 and 48 hours from that time. The resident stated he remembered a picture was taken. The Administrator informed the resident the picture was sent to someone via social media. The resident voiced understanding. · On 01/25/17 and 01/26/17, the Director of Nursing (DON) or designee interviewed 12 alert and oriented residents who were provided care by LPN #15. There were with no other reports of inappropriate photographs being taken. · On 01/26/17 at 10:52 A.M. Medical Director #200 was made aware of the incident on 01/15/17 of the photograph of Resident #10. · On 01/26/17 at 11:00 A.M., interviews were conducted with Housekeepers #109, #111 and #112, State tested Nurse Aides (STNA) #120, #121 and #122, LPN #125, and Registered Nurse (RN) #126. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. Additionally, they stated they had not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 01/26/17, review of Resident #65 and #105's medical records revealed no concerns with potential abuse or provisions of privacy. · On 01/26/17 at 11:55 A.M. interviews were conducted with Residents #52, #105, and #65, and the family members for Residents #44 and #83. All reported no abuse or unwanted photography in regards to their privacy. · · On 01/26/17, review of two additional facility SRIs revealed no concerns related to abuse, privacy or photographs. · On 01/26/17, the facility submitted an addendum statement to the 01/16/17 SRI submitted to the department of health reflecting the interview with Resident #10 and staff training in progress. · On 01/26/17 by 11:59 P.M., all staff, including the Administrator and DON, were re-educated prior to working, regarding the Abuse policy and Social Media procedure. The Administrator and DON were trained by Corporate Director of Clinical Services #314. 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 was in the process of implementing their corrective action plan, and monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was identified to have an open wound to the left shoulder measuring 24 centimeters (cm) by 17 cm by 3 cm in size. Review of the Minimum Data Set (MDS) assessment completed on 01/22/17 assessed the resident to have intact cognition. Review of the facility SRI, dated 01/16/17, and subsequent investigation, revealed on 01/15/17 at 5:00 P.M., MR #106 had forwarded a text message with a picture to LPN #107. The picture was of a resident's open shoulder wound with a caption that read I don't get paid enough for this s(expletive). The text written after the picture identified the resident to be New guy we just got. The investigation revealed on 01/15/17 at 5:32 P.M., LPN #107 contacted the DON via a telephone call to inform her of the picture, which appeared to have been posted on Snap Chat. The investigative statement written by the DON on 01/16/17 revealed she had forwarded the information onto the Administrator at 5:50 P.M. on 01/15/17. The DON then called LPN #107 on 01/15/17 at 6:05 P.M. to request a copy of the text and picture be sent to the DON's phone. The DON's statement indicated she had received a copy of the text message and picture at 6:20 P.M. The investigation does not indicate any attempts were made on the evening of 01/15/17 to contact MR #106 to identify the perpetrator who took the picture of Resident #10, nor was any investigation into the allegation of abuse initiated on 01/15/17. On 01/16/17 at 8:00 A.M., MR #106 provided a written statement in regards to receiving a picture of a resident's open wound via Snap Chat, with a text which contained a derogatory statement. MR #106's statement identified the resident in the picture as Resident #10. The investigation revealed LPN #15 had taken the photograph and sent it to MR #106 via the social web site Snap Chat. The investigation does not indicate Resident #10 was ever interviewed regarding staff taking his photograph during the investigation, or notified the photograph was posted on a social media web site. Upon investigation, LPN #15's employment with the facility was terminated. The facility investigation was completed on 01/17/17 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap Chat, dated 01/15/17 at 1:40 P.M. revealed a resident lying in bed with a very large, undressed, open wound to the left shoulder which extended over the top of the chest towards the resident's neck. The resident's head was turned away from the camera. The caption on the photograph stated, I don't get paid enough for this (expletive). Below the photograph and the caption was the comment New guy we just got .wtf (what the expletive). Review of the witness statement by LPN #15, dated 01/16/17 at 9:30 A.M., revealed she denied taking the photograph of Resident #10 and posting the photograph to Snap Chat. Observation of a text message dated 01/16/17 at 8:52 A.M. from LPN #15 to MR #106 revealed LPN #15 had stated Does anyone know about the picture I sent in? Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having his picture taken and posted to social media. During an interview on 01/25/17 at 10:00 A.M., the Administrator and DON stated when they received the initial copy of the photograph and text on 01/15/17, there was no information on the picture identifying the resident or the staff who took the photograph. The DON verified she viewed the photograph and social media posting on 01/15/17 at 5:32 P.M., but she made no attempt to identify the staff member who took the photograph until 01/16/17. As a result, LPN #15, who was identified as the staff who had taken the photograph, was allowed to continue work until 7:59 P.M. on 01/15/17. The Administrator stated LPN #15 did not return to work after 01/15/17 and was terminated after they were made aware of that issue. The Administrator verified Resident #10 was not interviewed or informed regarding a photograph of his shoulder wound being taken by staff and posted on Snap Chat. An interview on 01/25/17 at 10:30 A.M. revealed MR #106 verified she did not report the source of the Snap Chat photograph of Resident #10's wound until 01/16/17 at 8:00 A.M. when she met with the DON and Administrator. MR #106 stated she reported the photograph to LPN #107, who was the on call nurse, on 01/15/17 at 5:10 P.M. when she realized the photograph was of a new resident. An interview on 01/25/17 at 3:00 P.M. with LPN #107 revealed she received a call from MR #106 on 01/15/17 around 5:00 P.M. regarding a picture of a shoulder wound which was sent to her via Snap Chat. LPN #107 stated she reported this information to the DON immediately. The DON instructed her not to respond to MR #106. LPN #107 stated she did not know the source of the photograph but was aware of the newly admitted resident that had an open wound on his shoulder. During an interview on 01/25/17 at 3:30 P.M., Resident #10 revealed he was aware someone had taken a photograph of the wound on his shoulder. The resident stated he did not give permission for a photograph to be taken at any time. An additional interview on 01/26/17 at 11:45 A.M. revealed Resident #10 stated the nurse should not have posted the picture of his wound on social media. Resident #10 stated he was not upset but was trying to be forgiving regarding the incident with the photograph. Review of LPN #15's personnel file revealed a hire date of 11/14/11. LPN #15 signed acknowledgement she had received and reviewed the Employee Handbook on 05/15/12, which included the social media procedure. LPN #15 received a termination notice on 01/17/17 for violation of the social media procedure. Review of the facility policy titled Freedom of Abuse, Neglect and Exploitation, revised 10/31/16, revealed verbal abuse referred to any written language that willfully included disparaging and derogatory terms to describe a resident. The policy documents an employee who first identifies an alleged or suspected violation of abuse will immediately report to their immediate supervisor all facts which are known about the incident. The policy indicated the individual suspected of causing the violation will be immediately removed from the premises. The administrator shall coordinate the notification of the following (list of facility representatives) which may include, but is not limited to the resident's responsible party. The policy indicates the investigation should include a written statement from the resident as able. Review of the Employee Handbook, dated July 2012, revealed a procedure titled Social Media Procedure. This procedure defined social media as any web site or online medium that allows for communication to the public. The procedure revealed the staff may not disclose confidential information and may not disclose the name of or other information that would reasonably identify any current residents of the facility. They may not disclose information about or discuss in any way a current resident. The staff may not post any photograph or other visual recording of any present or past resident. The staff may not post material that was obscene, defamatory, or hateful concerning any person associated with the facility including residents. The procedure revealed anyone not authorized who posted information on behalf of the facility was subject to termination. This deficiency substantiates Master Complaint Control Number OH 100 and Complaint Control Number OH 029.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of a social media photograph, resident and family interviews, staff interviews, review of personnel files, review of the facility's Employee Handbook, and review of the facility's Social Media and Abuse policies and procedures, the facility failed to implement the facility policy to ensure a resident was free from mental and emotional abuse by a facility staff member during a treatment, take actions to protect residents following the incident by timely identifying the perpetrator and removing them from duty, and failed to complete a thorough investigation by interviewing the involved resident. This resulted in Immediate Jeopardy and potential for psychosocial harm for one resident (#10) when Licensed Practical Nurse (LPN) #15 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate photograph of a large, undressed, open wound on the resident's left shoulder without permission from the resident and not in accordance with facility policy. This photograph was then posted on a social media website, Snap Chat, with derogatory comments added, and sent to staff member (MR#106) who worked in medical records without the knowledge or permission of the resident. This affected one (#10) of three residents reviewed for abuse. On 01/26/17 at 4:50 P.M., the Administrator, Corporate Financial Officer #313 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 01/15/17 at approximately 1:40 P.M. when LPN #15 took a photograph with her personal cell phone of Resident #10's undressed, open shoulder wound without the resident's permission. LPN #15 proceeded to send the photograph to an employee who worked in Medical Records (MR #106) via the social media website identified as Snap Chat with a contemptuous comment noting I don't get paid enough for this (expletive). MR #106 responded to LPN #15 by asking who was in the picture. LPN #15 responded New guy we just got .wtf (what the expletive), thereby identifying the resident in the picture. The Immediate Jeopardy was removed on 01/26/17 at 11:59 P.M. when all staff was in-serviced regarding the identification of abuse, the abuse policy and social media procedures (which included privacy of resident information and photographs) and the facility implemented the following corrective actions: · On 01/16/17 at 8:00 A.M., the facility Administrator began an investigation into LPN #15 taking a photograph of Resident #10's wound. · On 01/16/17 at 9:30 A.M., LPN #15 was removed from patient care and placed on Administrative leave. · On 01/16/17 at 5:10 P.M., the facility reported the incident to the Ohio Department of Health. · On 01/17/17 LPN #15's employment with the facility was terminated. · On 01/25/17 at 5:15 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy and social media procedures per the facility's Employee Handbook. The re-education of staff included their responsibility to report any new allegations of abuse, which included social media posts, the facility's policy and procedure on abuse and social media usage with photographing/resident privacy. · On 01/25/17 at 5:45 P.M , the facility Administrator and Licensed Social Worker (LSW) #110 discussed the photograph and caption posted on social media with Resident #10. LSW #110 was to provide continued psychosocial follow up with the resident within 24 and 48 hours from that time. The resident stated he remembered a picture was taken. The Administrator informed the resident the picture was sent to someone via social media. The resident voiced understanding. · On 01/25/17 and 01/26/17, the Director of Nursing (DON) or designee interviewed 12 alert and oriented residents who were provided care by LPN #15. There were with no other reports of inappropriate photographs being taken. · On 01/26/17 at 10:52 A.M. the Medical Director #200 was made aware of the incident on 01/15/17 with the photograph of Resident #10. · On 01/26/17 at 11:00 A.M., interviews were conducted with Housekeepers #109, #111 and #112, State tested Nurse Aides (STNA) #120, #121 and #122, LPN #125, and Registered Nurse (RN) #126. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. Additionally, they stated they had not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 01/26/17, review of Resident #65 and #105's medical records revealed no concerns with potential abuse or provisions of privacy. · On 01/26/17 at 11:55 A.M. interviews were conducted with Residents #52, #105, and #65, and the family members for Residents #44 and #83. All reported no abuse or unwanted photography in regards to their privacy. · · On 01/26/17, review of two additional facility SRIs revealed no concerns related to abuse, privacy or photographs. · On 01/26/17, the facility submitted an addendum statement to the 01/16/17 SRI submitted to the department of health reflecting the interview with Resident #10 and staff training in progress. · On 01/26/17 by 11:59 P.M., all staff, including the Administrator and DON, were re-educated prior to working, regarding the Abuse policy and Social Media procedure. The Administrator and DON were trained by Corporate Director of Clinical Services #314. 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 was in the process of implementing their corrective action plan, and monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was identified to have an open wound to the left shoulder measuring 24 centimeters (cm) by 17 cm by 3 cm in size. Review of the Minimum Data Set (MDS) assessment completed on 01/22/17 assessed the resident to have intact cognition. Review of the facility SRI, dated 01/16/17, and subsequent investigation, revealed on 01/15/17 at 5:00 P.M., MR #106 had forwarded a text message with a picture to LPN #107. The picture was of a resident's open shoulder wound with a caption that read I don't get paid enough for this s(expletive). The text written after the picture identified the resident to be New guy we just got. The investigation revealed on 01/15/17 at 5:32 P.M., LPN #107 contacted the DON via a telephone call to inform her of the picture, which appeared to have been posted on Snap Chat. The investigative statement written by the DON on 01/16/17 revealed she had forwarded the information onto the Administrator at 5:50 P.M. on 01/15/17. The DON then called LPN #107 on 01/15/17 at 6:05 P.M. to request a copy of the text and picture be sent to the DON's phone. The DON's statement indicated she had received a copy of the text message and picture at 6:20 P.M. The investigation does not indicate any attempts were made on the evening of 01/15/17 to contact MR #106 to identify the perpetrator who took the picture of Resident #10, nor was any investigation into the allegation of abuse initiated on 01/15/17. On 01/16/17 at 8:00 A.M., MR #106 provided a written statement in regards to receiving a picture of a resident's open wound via Snap Chat, with a text which contained a derogatory statement. MR #106's statement identified the resident in the picture as Resident #10. The investigation revealed LPN #15 had taken the photograph and sent it to MR #106 via the social web site Snap Chat. The investigation does not indicate Resident #10 was ever interviewed regarding staff taking his photograph during the investigation, or notified the photograph was posted on a social media web site. Upon investigation, LPN #15's employment with the facility was terminated. The facility investigation was completed on 01/17/17 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap Chat, dated 01/15/17 at 1:40 P.M. revealed a resident lying in bed with a very large, undressed, open wound to the left shoulder which extended over the top of the chest towards the resident's neck. The resident's head was turned away from the camera. The caption on the photograph stated, I don't get paid enough for this (expletive). Below the photograph and the caption was the comment New guy we just got .wtf (what the expletive). Review of the witness statement by LPN #15, dated 01/16/17 at 9:30 A.M., revealed she denied taking the photograph of Resident #10 and posting the photograph to Snap Chat. Observation of a text message dated 01/16/17 at 8:52 A.M. from LPN #15 to MR #106 revealed LPN #15 had stated Does anyone know about the picture I sent in? Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having his picture taken and posted to social media. During an interview on 01/25/17 at 10:00 A.M., the Administrator and DON stated when they received the initial copy of the photograph and text on 01/15/17, there was no information on the picture identifying the resident or the staff who took the photograph. The DON verified she viewed the photograph and social media posting on 01/15/17 at 5:32 P.M., but she made no attempt to identify the staff member who took the photograph until 01/16/17. As a result, LPN #15, who was identified as the staff who had taken the photograph, was allowed to continue work until 7:59 P.M. on 01/15/17. The Administrator stated LPN #15 did not return to work after 01/15/17 and was terminated after they were made aware of that issue. The Administrator verified Resident #10 was not interviewed or informed regarding a photograph of his shoulder wound being taken by staff and posted on Snap Chat. An interview on 01/25/17 at 10:30 A.M. revealed MR #106 verified she did not report the source of the Snap Chat photograph of Resident #10's wound until 01/16/17 at 8:00 A.M. when she met with the DON and Administrator. MR #106 stated she reported the photograph to LPN #107, who was the on call nurse, on 01/15/17 at 5:10 P.M. when she realized the photograph was of a new resident. An interview on 01/25/17 at 3:00 P.M. with LPN #107 revealed she received a call from MR #106 on 01/15/17 around 5:00 P.M. regarding a picture of a shoulder wound which was sent to her via Snap Chat. LPN #107 stated she reported this information to the DON immediately. The DON instructed her not to respond to MR #106. LPN #107 stated she did not know the source of the photograph but was aware of the newly admitted resident that had an open wound on his shoulder. During an interview on 01/25/17 at 3:30 P.M., Resident #10 revealed he was aware someone had taken a photograph of the wound on his shoulder. The resident stated he did not give permission for a photograph to be taken at any time. An additional interview on 01/26/17 at 11:45 A.M. revealed Resident #10 stated the nurse should not have posted the picture of his wound on social media. Resident #10 stated he was not upset but was trying to be forgiving regarding the incident with the photograph. Review of LPN #15's personnel file revealed a hire date of 11/14/11. LPN #15 signed acknowledgement she had received and reviewed the Employee Handbook on 05/15/12, which included the social media procedure. LPN #15 received a termination notice on 01/17/17 for violation of the social media procedure. Review of the facility policy titled Freedom of Abuse, Neglect and Exploitation, revised 10/31/16, revealed verbal abuse referred to any written language that willfully included disparaging and derogatory terms to describe a resident. The policy documents an employee who first identifies an alleged or suspected violation of abuse will immediately report to their immediate supervisor all facts which are known about the incident. The policy indicated the individual suspected of causing the violation will be immediately removed from the premises. The administrator shall coordinate the notification of the following (list of facility representatives) which may include, but is not limited to the resident's responsible party. The policy indicates the investigation should include a written statement from the resident as able. Review of the Employee Handbook, dated July 2012, revealed a procedure titled Social Media Procedure. This procedure defined social media as any web site or online medium that allows for communication to the public. The procedure revealed the staff may not disclose confidential information and may not disclose the name of or other information that would reasonably identify any current residents of the facility. They may not disclose information about or discuss in any way a current resident. The staff may not post any photograph or other visual recording of any present or past resident. The staff may not post material that was obscene, defamatory, or hateful concerning any person associated with the facility including residents. The procedure revealed anyone not authorized who posted information on behalf of the facility was subject to termination. This deficiency substantiates Master Complaint Control Number OH 100 and Complaint Control Number OH 029.