Every finding on record at Three Rivers Healthcare Center

Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of abuse to the state agency. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 101 residents. Findings include: Review of the medical record for Resident #1 revealed an admission date of 11/14/20 with diagnoses including right sided hemiplegia and hemiparesis following cerebral infarction and hypertension.Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 07/10/25 revealed the was cognitively intact and required staff assistance with activities of daily living (ADLs.)Review of the skin assessments for Resident #1 dated 11/05/25 and 11/08/25 revealed there were no new areas of skin impairment noted.Review of the facility SRI for Resident #1 initiated 11/13/25 at 2:35 P.M. revealed the resident reported staff had been rough with her while providing care on 11/08/25 or 11/09/25. CNA #66 was suspended on 11/13/25 pending investigation. The facility was unable to determine if abuse had occurred as the evidence was inconclusive. The facility notified local police of the allegation and educated all staff on the abuse policy. Observation on 11/13/25 at 10:20 A.M. of Resident #1 revealed the resident had four discolored markings on her left forearm. Interview on 11/13/25 at 11:15 A.M. with Resident #1 confirmed the aides had been rough with her during a transfer from chair to bed on 11/08/25. Resident #1 confirmed staff had grabbed her by the left arm and that she had asked the Certified Nursing Assistant (CNA) assisting with the transfer to stop because it was hurt. Resident #1 confirmed she reported the incident to staff on 11/09/25. Interview on 11/13/25 at 1:47 P.M. with Licensed Practical Nurse LPN #3 confirmed on 11/08/25 Resident #1 complained of bruising to the left arm but was confused about how the bruises had occurred. LPN #3 confirmed she notified the on-call provider and obtained an order to collect a urine sample to rule out a urinary tract infection (UTI.) LPN #3 confirmed she then reported the conversation with Resident #1 to Registered Nurse (RN) #51 and CNA #66. During an interview on 11/13/25 at 2:05 P.M., CNA #66 denied having been rough with Resident #1 and thought the bruising on the resident's arms had been discovered in the shower room on the previous Wednesday. Interview on 11/13/25 at 2:26 P.M. with the Administrator confirmed the facility had not reported an allegation of abuse or mistreatment towards Resident #1 to the state agency. Interview on 11/17/25 at 10:24 A.M. with RN #51 confirmed he received a report on 11/09/25 from LPN#3 that there were markings on Resident #1's left forearm and the resident was confused about how they had occurred. RN #51 confirmed on 11/08/25 he notified the Administrator via telephone of Resident #1's concerns, but the Administrator had not directed the nurse to take any further action. Interview on 11/17/25 at 12:26 P.M. with CNA #35 confirmed Resident #1 notified her on 11/08/25 that CNA #66 had hurt her arm and described being pushed left and right. Resident #1 stated she CNA #66 she was hurting but the aide continued pushing her. CNA #35 confirmed she told LPN #3, LPN #79, and RN #51 of Resident #1's allegations against CNA #66. CNA #35 confirmed she then received a phone call from the Administrator regarding Resident #1's allegation. Interview on 11/17/25 at 11:28 A.M. with the Administrator confirmed he received a report from CNA#35 on 11/09/25 that Resident #1 had alleged CNA#66 was rough while providing care on 11/08/25. The Administrator confirmed RN #51 reported Resident #1's concerns regarding rough care to him on 11/09/25 at 3:00 P.M. The Administrator confirmed the facility did not report Resident #1's allegation of rough treatment on 11/08/25 to the state agency until 11/13/25 after discussion with the Surveyor. Interview on 11/17/25 at 3:03 P.M. with the Director of Nursing (DON) confirmed she was not aware of Resident 1's allegation until it was reported to facility administration by the Surveyor on 11/13/25 at 2:26 P.M. The DON confirmed allegations of abuse should be reported up to the Administrator following the chain of command. Review of the facility policy titled Ohio Abuse, Neglect and Misappropriation undated revealed the facility should investigate and report injuries of unknown origin which included injuries in which the source of the injury was not observed by any person and the source of the injury could not be explained by the resident. The facility should report alleged violations of mistreatment which did not result in serious bodily injury to the state agency no later than 24 hours. This deficiency represents noncompliance investigated under Complaint Number 2650862.

Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to initiate an investigation of an abuse allegation in a timely manner and failed to protect residents during an abuse investigation. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 101 residents. Findings include: Review of the medical record for Resident #1 revealed an admission date of 11/14/20 with diagnoses including right sided hemiplegia and hemiparesis following cerebral infarction and hypertension.Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 07/10/25 revealed the was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the skin assessments for Resident #1 dated 11/05/25 and 11/08/25 revealed there were no new areas of skin impairment noted.Review of the facility SRI for Resident #1 initiated 11/13/25 at 2:35 P.M. revealed the resident reported staff had been rough with her while providing care on 11/08/25 or 11/09/25. CNA #66 was suspended on 11/13/25 pending investigation. The facility was unable to determine if abuse had occurred as the evidence was inconclusive. The facility notified local police of the allegation and educated all staff on the abuse policy. Observation on 11/13/25 at 10:20 A.M. of Resident #1 revealed the resident had four discolored markings on her left forearm. Interview on 11/13/25 at 11:15 A.M. with Resident #1 confirmed the aides had been rough with her during a transfer from chair to bed on 11/08/25. Resident #1 confirmed staff had grabbed her by the left arm and that she had asked the Certified Nursing Assistant (CNA) assisting with the transfer to stop because it was hurt. Resident #1 confirmed she reported the incident to staff on 11/09/25. Interview on 11/13/25 at 1:47 P.M. with Licensed Practical Nurse LPN #3 confirmed on 11/08/25 Resident #1 complained of bruising to the left arm but was confused about how the bruises had occurred. LPN #3 confirmed she notified the on-call provider and obtained an order to collect a urine sample to rule out a urinary tract infection (UTI.) LPN #3 confirmed she then reported the conversation with Resident #1 to Registered Nurse (RN) #51 and CNA #66. During an interview on 11/13/25 at 2:05 P.M., CNA #66 denied having been rough with Resident #1 and thought the bruising on the resident's arms had been discovered in the shower room on the previous Wednesday. Interview on 11/13/25 at 2:26 P.M. with the Administrator confirmed the facility had not reported an allegation of abuse or mistreatment towards Resident #1 to the state agency, had not initiated an investigation of the abuse allegation, and had not taken steps to protect residents during the course of the investigation, such as suspending alleged perpetrators of abuse from working with residents. Interview on 11/17/25 at 10:24 A.M. with RN #51 confirmed he received a report on 11/09/25 from LPN#3 that there were markings on Resident #1's left forearm and the resident was confused about how they had occurred. RN #51 confirmed on 11/08/25 he notified the Administrator via telephone of Resident #1's concerns, but the Administrator had not directed the nurse to take any further action. Interview on 11/17/25 at 12:26 P.M. with CNA #35 confirmed Resident #1 notified her on 11/08/25 that CNA #66 had hurt her arm and described being pushed left and right. Resident #1 stated she CNA #66 she was hurting but the aide continued pushing her. CNA #35 confirmed she told LPN #3, LPN #79, and RN #51 of Resident #1's allegations against CNA #66. CNA #35 confirmed she then received a phone call from the Administrator regarding Resident #1's allegation. Interview on 11/17/25 at 11:28 A.M. with the Administrator confirmed he received a report from CNA#35 on 11/09/25 that Resident #1 had alleged CNA#66 was rough while providing care on 11/08/25. The Administrator confirmed RN #51 reported Resident #1's concerns regarding rough care to him on 11/09/25 at 3:00 P.M. The Administrator confirmed the facility did not report Resident #1's allegation of rough treatment on 11/08/25 to the state agency until 11/13/25 after discussion with the Surveyor. The Administrator confirmed CNA #66, the alleged perpetrator of abuse towards Resident #1 was not suspended pending investigation until after the survey was entered. Interview on 11/17/25 at 3:03 P.M. with the Director of Nursing (DON) confirmed she was not aware of Resident 1's allegation until it was reported to facility administration by the Surveyor on 11/13/25 at 2:26 P.M. The DON confirmed allegations of abuse should be reported up to the Administrator following the chain of command. Review of the facility policy titled Ohio Abuse, Neglect and Misappropriation undated revealed the facility should investigate and report injuries of unknown origin which included injuries in which the source of the injury was not observed by any person and the source of the injury could not be explained by the resident. The facility should report alleged violations of mistreatment which did not result in serious bodily injury to the state agency no later than 24 hours. The facility should investigate all allegations of abuse and should take measures to protect residents from harm during an investigation. This deficiency represents noncompliance investigated under Complaint Number 2650862.

Based on staff interview, review of Self-Reported Incidents (SRIs), and record review, the facility failed to report an allegation of resident to resident sexual abuse to the state surveying agency. This affected one (#500) of the six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors prior to 07/16/25. Review of Resident #500's progress note dated 09/02/24 at 6:07 A.M., revealed Resident #500 made frequent attempts at kissing, hugging and touching other male residents in the sitting area on 09/01/24 from the beginning of shift until Resident #500 went to bed. Each time, the residents were separated or redirected from the other resident who either attempted to hit her or shout at her. Review of Resident #500's psychiatry note dated 11/16/24, revealed Resident #500 was seen by Nurse Practitioner (NP) #900. Resident #500 was seen for a chronic psychiatric medication visit for dementia, depression, insomnia and inappropriate sexual behaviors. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Resident #500 was ordered to start Cimetidine 200 mgs by mouth daily. Review of Resident #500's physician order dated 11/25/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 milligrams (mgs) give one tablet by mouth a day for inappropriate sexual behaviors. The order was discontinued 12/04/25. Review of Resident #500's physician order dated 12/05/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth at bedtime for inappropriate sexual behaviors. The order was discontinued 04/14/25. Review of Resident #500's psychiatry notes dated 12/16/24 and 01/13/25, revealed Resident #500 was seen by NP #900. Resident #500 presented for medication management and discussion of symptoms of dementia, depression, insomnia and inappropriate sexual behaviors. Resident #500 was on Cimetidine 200 mgs daily for inappropriate sexual behaviors. Resident #500's inappropriate sexual behaviors were mentioned as a concern, and they were currently being treated with Cimetidine 200 mgs daily. However, no specific incidents or behaviors were discussed during the visit. The staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Review of Resident #500's progress note dated 01/09/25 at 7:09 A.M., revealed Resident #500 was noted in another resident's room undressing. Resident #500 was redirected by staff and Resident #500 displayed increased behaviors towards staff. The staff gave Resident #500 time to calm down and Resident #500 was redirected out of the room by staff. Review of Psychiatric NP #802's progress note dated 05/09/25 at 9:50 A.M., revealed Resident #500's Cimetidine was discontinued during the pharmacy meeting in April 2025. Resident #500 was recently found trying to kiss another female resident and was trying to put her arm around her in the lounge on the couch in a suggestive manner. Review of Resident #500's progress note dated 05/15/25 at 6:37 P.M., revealed Resident #500 was caught by the Certified Nursing Assistant (CNAs) in an empty room with another female resident and the CNAs had to pull the pants of the resident up. The resident was telling them to keep them down. Staff redirected them out of the room and separated the residents. Review of Resident #500's physician order dated 05/15/25, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth two times a day for sexually inappropriate behaviors. The order was discontinued 07/21/25. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed the Administrator was not aware of the incident on 05/15/25 where Resident #500 was found in an empty room with another female resident with her pants pulled down. The Administrator confirmed the facility did not complete an SRI or investigate the 05/15/25 incident per the abuse policy. Interview with Psychiatric NP #802 via telephone on 07/25/25 at 1:16 P.M., revealed she started working for her company in March 2025. Psychiatric NP #802 reported she saw Resident #500 on 04/07/25 and she documented that Resident #500's Cimetidine 200 mgs one time a day was effective for managing her sexually inappropriate behaviors. Psychiatric NP #802 reported Resident #500's Cimetidine 200 mgs was discontinued on 04/14/25 due to a gradual dose reduction. Psychiatric NP #802 stated she saw Resident #500 on 05/09/25 and it was reported to her by staff that Resident #500 recently tried to put her arm around and kiss another female resident. Psychiatric NP #802 stated that Resident #500's Cimetidine was ordered after Resident #500 was found in a room disrobing with another female resident on 05/15/25. Psychiatric NP #802 reported that Resident #500's Cimetidine was restarted on 05/15/25 and was increased from the previous dose of Cimetidine 200 mgs one time a day to Cimetidine 200 mgs two times per day because she did not feel that Cimetidine 200 one time a day was a therapeutic dose for hypersexual behaviors. Review of the facility's undated abuse, neglect and misappropriation policy, revealed the facility's intent was to prevent abuse, mistreatment or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse. In the event that a situation is identified as abuse, an investigation by executive leadership will immediately follow up. All alleged violations involving abuse are reported immediately but not later than two hours after the allegation is made. The self-report will be made by the executive director to the state survey agency and will be thoroughly investigated. This deficiency represents non-compliance investigated under Incident Number 2567007.

Based on staff interview, record review, and review of facility policy, the facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate sexual behaviors towards other residents. This affected one (#500) of six residents reviewed for care planning. The facility census was 106.Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors until 07/16/25. Review of Resident #500's progress note dated 09/02/24 at 6:07 A.M., revealed Resident #500 made frequent attempts at kissing, hugging and touching other male residents in the sitting area on 09/01/24 from the beginning of shift until Resident #500 went to bed. Each time, the residents were separated or redirected from the other resident who either attempted to hit her or shout at her. Review of Resident #500's psychiatry note dated 11/16/24, revealed Resident #500 was seen by Nurse Practitioner (NP) #900. Resident #500 was seen for a chronic psychiatric medication visit for dementia, depression, insomnia and inappropriate sexual behaviors. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Resident #500 was ordered to start Cimetidine 200 milligrams (mgs) by mouth daily. Review of Resident #500's physician order dated 11/25/24 revealed Resident #500 was ordered Cimetidine oral tablet 200 milligrams (mgs) give one tablet by mouth a day for inappropriate sexual behaviors. The order was discontinued 04/14/25. Review of Resident #500's psychiatry notes dated 12/16/24 and 01/13/25, revealed Resident #500 was seen by NP #900. Resident #500 presented for medication management and discussion of symptoms of dementia, depression, insomnia and inappropriate sexual behaviors. Resident #500 was on Cimetidine 200 mgs daily for inappropriate sexual behaviors. Resident #500's inappropriate sexual behaviors were mentioned as a concern, and they were currently being treated with Cimetidine 200 mgs daily. However, no specific incidents or behaviors were discussed during the visit. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Review of Resident #500's progress note dated 01/09/25 at 7:09 A.M., revealed Resident #500 was noted in another resident's room undressing. Resident #500 was redirected by staff and Resident #500 displayed increased behaviors towards staff. Staff gave Resident #500 time to calm down and Resident #500 was redirected out of the room by staff. Review of Psychiatric NP #802's progress note dated 05/09/25 at 9:50 A.M., revealed Resident #500's Cimetidine was discontinued during the pharmacy meeting in April 2025. Resident #500 was recently found trying to kiss another female resident and was trying to put her arm around her in the lounge on the couch in a suggestive manner. Review of Resident #500's progress note dated 05/15/25 at 6:37 P.M., revealed Resident #500 was caught by the Certified Nursing Assistant (CNAs) in an empty room with another female resident and the CNAs had to pull the other resident's pants up. Resident #500 was telling them to keep them down. The staff redirected them out of the room and separated the residents. Review of Resident #500's physician order dated 05/15/25, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth two times a day for sexually inappropriate behaviors. The order was discontinued 07/21/25. Review of Resident #500's telehealth visit dated 06/30/25 at 1:00 P.M., revealed NP #901 was called by the nurse stating that another resident was lying next to Resident #500 that evening. Both residents had clothing on and there was no inappropriate touching. Review of the police report dated 06/30/25 at 11:28 P.M., revealed the nursing staff found Resident #71 and Resident #500 in the same bed together. Resident #500 was fully clothed, but Resident #71 was in bed with his pants off. Review of Registered Nurse (RN) #207's witness statement dated 06/30/25, revealed Resident #500 and Resident #71 were lying in bed beside each other. Resident #500 was fully dressed, and Resident #71 had only his shirt on without pants. No one was seen touching the other. Review of Resident #500's progress note dated 07/01/25 at 2:16 A.M., revealed Resident #500 was in bed beside another resident (#71). The residents were immediately separated with no injuries. A head-to-toe assessment was completed. The family, Director of Nursing (DON), regional nurse, police and Administrator were notified. Review of Resident #500's progress note dated 07/01/25 at 12:36 P.M., revealed Resident #500's physician was notified of the incident. Review of the facility's SRI created on 07/01/25 for a sexual abuse allegation that was discovered on 06/30/25, revealed the staff noted Resident #500 and Resident #71 laying side by side in bed on 06/30/25. Resident #500 was fully dressed, and Resident #71 was without his pants and underwear. No touching was noted, and the residents were immediately separated. Head-to-toe skin assessments were completed on the residents without injuries noted. The SRI was unsubstantiated. Review of Resident #500's progress note dated 07/03/25 at 3:05 P.M., revealed Resident #500 was found in bed with another resident (#64) on 06/30/25 at 9:30 P.M. The staff observed Resident #500 in bed with a male resident fully clothed. Resident #500 had dementia and wandering behaviors with the belief that the male resident was her boyfriend. The residents were immediately separated, and no injuries were noted. Review of a police report dated 07/13/25 at 1:50 P.M., revealed a sexual contact was reported to the police when they responded to the facility on [DATE] at 9:00 A.M. The staff stated the two residents in the mental health wing were observed to be engaging in sexual contact on 07/13/25. The staff stated that both residents were diagnosed with dementia and both POAs were contacted and informed of the incident. The staff stated that Resident #500 was foundling Resident #64's genital area. This report was filed for reporting purposes only.Review of Resident #500's progress note dated 07/13/25 at 4:15 P.M., revealed an incident was reported to LPN #178 while doing her rounds that a staff entered another resident's room and noted a male resident was sitting in his chair while Resident #500 was massaging his genitals. The CNA instantly removed Resident #500 from the male resident's room and made LPN #178 aware. LPN #178 notified the unit manager. The CNA had recently witnessed Resident #500 in her room while picking up her lunch tray. Resident #500 was placed on one-on-one (1:1) observation until further notice and her daughter was made aware. Review of Resident #500's progress note dated 07/13/25 at 4:31 P.M., revealed the on call physician was made aware of the resident's behavior.Review of CNA #231's hand-written witness statement dated 07/13/25, revealed CNA #231 was going to check on Resident #64. When CNA #231 walked in the room, Resident #500 was being sexually inappropriate massaging Resident #64's private parts. CNA #231 separated them and informed the nurse of their behavior.Review of LPN #178's witness statement dated 07/13/25, revealed LPN #178 and another CNA were giving care to another resident. When LPN #178 and the CNA returned to the nurse's station, another CNA reported that she witnessed Resident #500 in Resident #64's room. Resident #64 was sitting in his chair with his pants down and Resident #500 was inappropriately massaging Resident #64's private area. The CNA immediately separated the residents and informed LPN #178 who informed the unit manager. LPN #178 placed Resident #500 on 1:1 observation and head-to-toe skin assessments were completed with no findings. The on-call physician was made aware. Review of Resident #500's progress note dated 07/14/25 at 9:32 A.M., revealed a report was given to the police regarding the sexual encounter between Resident #500 and Resident #64. Review of the facility's SRI created on 07/14/25 for a sexual abuse allegation that was discovered on 07/13/25, revealed Resident #64 and Resident #500 were found alone in Resident #64's room together. Resident #500 was fully dressed and Resident #64's pants and underwear were down. Resident #500 was noted touching Resident #64's groin area. The residents were separated, assessed, and interviewed. Resident #64 denied any penetration or injury. Resident #500 could not recall the incident and denied penetration or injury. Resident #500 was placed on 1:1 observation and all appropriate parties were notified. The police were contacted and found the residents were not in any immediate danger, and no legal action was required. The SRI was unsubstantiated. Interview with CNA #236 on 07/22/25 at 9:57 A.M., revealed she did not witness the incident between Resident #500 and Resident #64, but she was working on that date. CNA #236 reported Resident #500 was placed on 1:1 observation until she was discharged from the facility. CNA #236 stated she was not aware of Resident #500 or Resident #64 having sexually inappropriate behaviors prior to the incident. Interview with Registered Nurse (RN) #202 via telephone on 07/22/25 at 2:22 P.M., revealed RN #202 could not remember the dates of the incidents because it had been a while and she did not usually work on the memory care unit. RN #202 stated that Resident #500 would walk around and was clinging towards the male residents. RN #202 reported that Resident #500 would try to kiss, touch or hug male residents and CNAs would have to redirect her. RN #202 stated that management was informed of Resident #500's sexually inappropriate behaviors. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed the Administrator was not aware of Resident #500 attempting to kiss, hug and touch male residents on 09/01/25 or the incident on 05/15/25 where Resident #500 was found in an empty room with another female resident with her pants pulled down. The Administrator verified Resident #500 had inappropriate sexual behaviors directed towards other residents noted from September 2024. The Administrator verified the facility did not develop and implement a person centered care plan for Resident #500's sexually inappropriate behaviors until after the 07/13/25 incident. The Administrator confirmed Resident #500 had been prescribed Cimetidine for sexually inappropriate behaviors dating back to 11/25/24. Review of the facility's undated plan of care overview policy revealed the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.

Based on record review, staff interviews, Review of Self-Reported Incidents (SRI) and review of facility policy, the facility failed to investigate an allegation of resident to resident sexual abuse. This affected one (#500) of six residents reviewed for abuse. The facility census was 106.Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors prior to 07/16/25. Review of Resident #500's progress note dated 09/02/24 at 6:07 A.M., revealed Resident #500 made frequent attempts at kissing, hugging and touching other male residents in the sitting area on 09/01/24 from the beginning of shift until Resident #500 went to bed. Each time, the residents were separated or redirected from the other resident who either attempted to hit her or shout at her. Review of Resident #500's psychiatry note dated 11/16/24, revealed Resident #500 was seen by Nurse Practitioner (NP) #900. Resident #500 was seen for a chronic psychiatric medication visit for dementia, depression, insomnia and inappropriate sexual behaviors. The staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Resident #500 was ordered to start Cimetidine 200 mgs by mouth daily. Review of Resident #500's physician order dated 11/25/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 milligrams (mgs) give one tablet by mouth a day for inappropriate sexual behaviors. The order was discontinued 12/04/25. Review of Resident #500's physician order dated 12/05/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth at bedtime for inappropriate sexual behaviors. The order was discontinued 04/14/25. Review of Resident #500's psychiatry notes dated 12/16/24 and 01/13/25, revealed Resident #500 was seen by NP #900. Resident #500 presented for medication management and discussion of symptoms of dementia, depression, insomnia and inappropriate sexual behaviors. Resident #500 was on Cimetidine 200 mgs daily for inappropriate sexual behaviors. Resident #500's inappropriate sexual behaviors were mentioned as a concern, and they were currently being treated with Cimetidine 200 mgs daily. However, no specific incidents or behaviors were discussed during the visit. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Review of Resident #500's progress note dated 01/09/25 at 7:09 A.M., revealed Resident #500 was noted in another resident's room undressing. Resident #500 was redirected by staff and Resident #500 displayed increased behaviors towards staff. Staff gave Resident #500 time to calm down and Resident #500 was redirected out of the room by staff. Review of Psychiatric NP #802's progress note dated 05/09/25 at 9:50 A.M., revealed Resident #500's Cimetidine was discontinued during the pharmacy meeting in April 2025. Resident #500 was recently found trying to kiss another female resident and was trying to put her arm around her in the lounge on the couch in a suggestive manner. Review of Resident #500's progress note dated 05/15/25 at 6:37 P.M., revealed Resident #500 was caught by the Certified Nursing Assistant (CNAs) in an empty room with another female resident and the CNAs had to pull the pants of the resident up. The resident was telling them to keep them down. Staff redirected them out of the room and separated the residents. Review of Resident #500's physician order dated 05/15/25, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth two times a day for sexually inappropriate behaviors. The order was discontinued 07/21/25. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed the Administrator was not aware of the incident on 05/15/25 where Resident #500 was found in an empty room with another female resident with her pants pulled down. The Administrator confirmed the facility did not complete an SRI or investigate the 05/15/25 incident per the abuse policy. Interview with Psychiatric NP #802 via telephone on 07/25/25 at 1:16 P.M., revealed she started working for her company in March 2025. Psychiatric NP #802 reported she saw Resident #500 on 04/07/25 and she documented that Resident #500's Cimetidine 200 mgs one time a day was effective for managing her sexually inappropriate behaviors. Psychiatric NP #802 reported Resident #500's Cimetidine 200 mgs was discontinued on 04/14/25 due to a gradual dose reduction. Psychiatric NP #802 stated she saw Resident #500 on 05/09/25 and it was reported to her by staff that Resident #500 recently tried to put her arm around and kiss another female resident. Psychiatric NP #802 stated that Resident #500's Cimetidine was ordered after Resident #500 was found in a room disrobing with another female resident on 05/15/25. Psychiatric NP #802 reported that Resident #500's Cimetidine was restarted on 05/15/25 and was increased from the previous dose of Cimetidine 200 mgs one time a day to Cimetidine 200 mgs two times per day because she did not feel that Cimetidine 200 one time a day was a therapeutic dose for hypersexual behaviors. Review of the facility's undated abuse, neglect and misappropriation policy, revealed the facility's intent was to prevent abuse, mistreatment or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse. In the event that a situation is identified as abuse, an investigation by executive leadership will immediately follow up. All alleged violations involving abuse are reported immediately but not later than two hours after the allegation is made. The self-report will be made by the executive director to the state survey agency and will be thoroughly investigated. This deficiency represents non-compliance investigated under Incident Number 2567007.

Based on staff interview, record review and review of facility policy, the facility failed to ensure a resident and the resident's power of attorney (POA) received a discharge notice. This affected one (#500) of the three residents reviewed for discharges. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's chart from 03/11/24 to 07/19/25, revealed no documentation that Resident #500 or Resident #500's POA initiated Resident #500's discharge from the facility on 07/18/25. Further review of Resident #500's chart revealed Resident #500 did not have a discharge notice on file for her 07/18/25 discharge from the facility.Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors prior to 07/16/25 and no documented care plan for discharging the resident. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of a police report dated 07/13/25 at 1:50 P.M., revealed a sexual contact incident was reported to the police on 07/14/25 at 9:00 A.M. when they responded to the facility. The staff stated that two residents in the mental health wing were observed to be engaging in sexual contact on 07/13/25. The staff stated that both residents were diagnosed with dementia and both medical power of attorneys (POAs) were contacted and informed of the incident. The staff stated that Resident #500 was foundling Resident #64's genital area. This report was filed for reporting purposes only. Review of Resident #500's progress note dated 07/13/25 at 4:15 P.M., revealed an incident was reported to Licensed Practical Nurse (LPN) #178 while doing her rounds that a staff entered another resident's room and noted a male resident was sitting in his chair while Resident #500 was massaging his genitals. The CNA instantly removed Resident #500 from the male resident's room and made LPN #178 aware. LPN #178 notified the unit manager. The CNA had recently witnessed the resident in her room while picking up her lunch tray. Resident #500 was placed on one on one (1:1) observation until further notice and her daughter was made aware. Review of Resident #500's progress note dated 07/13/25 at 4:31 P.M., revealed the on call physician was made aware of the behavior.Review of Resident #500's progress note dated 07/14/25 at 9:32 A.M., revealed a report was given to the police regarding the sexual encounter between Resident #500 and a male resident. Review of Resident #500's physician order dated 07/14/25 and discontinued 07/21/25, revealed Resident #500 was to be on a 1:1 observation until further notice. Review of the facility's SRI for sexual abuse created on 07/14/25 for a sexual allegation that was discovered on 07/13/25, revealed Resident #64 and Resident #500 were found alone in Resident #64's room together. Resident #500 was fully dressed and Resident #64's pants and underwear were down. Resident #500 was noted touching Resident #64's groin area. The residents were separated, assessed, and interviewed. Resident #64 denied any penetration or injury. Resident #500 could not recall the incident and denied penetration or injury. Resident #500 was placed on a 1:1 observation and all appropriate parties were notified. The police were contacted and found the residents were not in any immediate danger, and no legal action was required. The SRI was unsubstantiated.Review of Resident #500's physician order dated 07/17/25, revealed Resident #500 may discharge to another skilled nursing facility on 07/18/25.Review of Resident #500's Discharge summary dated [DATE], revealed Resident #500 was on prophylactic antibiotics for urinary tract infection (UTI) prevention. Resident #500 resided on a secured dementia unit. Resident #500 discharged to another skilled nursing facility on 07/18/25. Review of Resident #500's progress note dated 07/18/25, revealed Resident #500 was discharged to another skilled nursing facility. A cab came for Resident #500 at about 3:30 P.M. The face sheet and medication lists were given. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed Resident #500 was placed on 1:1 observation due to her behaviors until she was discharged . The Administrator and RDCO #801 verified Resident #500 or Resident #500's POA was not given a discharge notice prior to her discharge from the facility on 07/18/25. The Administrator and RDCO #801 confirmed Resident #500 was discharged to a female dementia unit at another facility on 07/18/25. The Administrator and RDCO #801 were not aware of which staff member initiated or discussed Resident #500's discharge plans with Resident #500 or Resident #500's POA. The Administrator and RDCO #801 verified Resident #500 was discharged related to her inappropriate sexual behaviors. Interview with Social Services (SS) #247 on 07/22/25 at 3:58 P.M., revealed SS #247 was not aware of how Resident #500's discharge was initiated. SS #247 stated that he called Resident #500's daughter (POA) and stated the facility initiated two referrals to two different skilled nursing facilities. SS #247 reported Resident #500's daughter was on vacation at the time and stated she just stated she wanted to get back to her vacation. SS #247 was not aware of a discharge notice being given. Interview with Social Services Director (SSD) #241 on 07/22/25 at 4:10 P.M., revealed SSD #241 never discussed Resident #500's discharge with her POA and SS #247 arranged Resident #500's discharge. SSD #241 verified she was not involved in Resident #500's discharge from the facility.Review of email correspondence with the Administrator on 07/29/25 at 12:01 P.M., verified the receiving facility set up the transport by a cab for Resident #500. Review of email correspondence with the Administrator on 07/29/25 at 6:59 P.M., revealed the DON accompanied Resident #500 to ensure she was safe during transport to the receiving facility. Review of the facility's undated transfer and discharge policy revealed the facility will notify the resident and resident's representatives of the transfer or discharge and the reasons for the move in writing and in a language or manner they understand. The facility will send a copy of the notice to the Ombudsman. The facility will assist with transportation arrangements to the new facility.

Based on staff interview, review of Self-Reported Incidents (SRIs) and record review, the facility failed to implement their abuse policy for an allegation of resident to resident sexual abuse. This affected one (#500) of six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired.Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors prior to 07/16/25.Review of Resident #500's progress note dated 09/02/24 at 6:07 A.M., revealed Resident #500 made frequent attempts at kissing, hugging and touching other male residents in the sitting area on 09/01/25 from the beginning of shift until Resident #500 went to bed. Each time, the residents were separated or redirected from the other resident who either attempted to hit her or shout at her.Review of Resident #500's psychiatry note dated 11/16/24, revealed Resident #500 was seen by Nurse Practitioner (NP) #900. Resident #500 was seen for a chronic psychiatric medication visit for dementia, depression, insomnia and inappropriate sexual behaviors. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Resident #500 was ordered to start Cimetidine 200 mgs by mouth daily.Review of Resident #500's physician order dated 11/25/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 milligrams (mgs) give one tablet by mouth a day for inappropriate sexual behaviors. The order was discontinued on 04/14/25. Review of Resident #500's psychiatry notes dated 12/16/24 and 01/13/25, revealed Resident #500 was seen by NP #900. Resident #500 presented for medication management and discussion of symptoms of dementia, depression, insomnia and inappropriate sexual behaviors. Resident #500 was on Cimetidine 200 mgs daily for inappropriate sexual behaviors. Resident #500's inappropriate sexual behaviors were mentioned as a concern, and they were currently being treated with Cimetidine 200 mgs daily. However, no specific incidents or behaviors were discussed during the visit. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Review of Resident #500's progress note dated 01/09/25 at 7:09 A.M., revealed Resident #500 was noted in another resident's room undressing. Resident #500 was redirected by staff and Resident #500 displayed increased behaviors towards staff. The staff gave Resident #500 time to calm down and Resident #500 was redirected out of the room by staff. Review of Psychiatric NP #802's progress note dated 05/09/25 at 9:50 A.M., revealed Resident #500's Cimetidine was discontinued during the pharmacy meeting in April 2025. Resident #500 was recently found trying to kiss another female resident and was trying to put her arm around her in the lounge on the couch in a suggestive manner. Review of Resident #500's progress note dated 05/15/25 at 6:37 P.M., revealed Resident #500 was caught by the Certified Nursing Assistant (CNAs) in an empty room with another female resident and the CNAs had to pull the pants of the resident up. The resident was telling them to keep them down. Staff redirected them out of the room and separated the residents.Review of Resident #500's physician order dated 05/15/25, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth two times a day for sexually inappropriate behaviors. The order was discontinued 07/21/25. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed the Administrator was not aware of the incident on 05/15/25 where Resident #500 was found in an empty room with another female resident with her pants pulled down. The Administrator confirmed the facility did not implement their abuse policy when the two residents were observed in a room with the resident's pants pulled down. The Administrator verified the facility did not create an SRI or investigate the 05/15/25 incident per the abuse policy. Interview with Psychiatric NP #802 via telephone on 07/25/25 at 1:16 P.M., revealed she started working for her company in March 2025. Psychiatric NP #802 reported she saw Resident #500 on 04/07/25 and she documented that Resident #500's Cimetidine 200 mgs one time a day was effective for managing her sexually inappropriate behaviors. Psychiatric NP #802 reported Resident #500's Cimetidine 200 mgs was discontinued on 04/14/25 due to a gradual dose reduction. Psychiatric NP #802 stated she saw Resident #500 on 05/09/25 and it was reported to her by staff that Resident #500 recently tried to put her arm around and kiss another female resident. Psychiatric NP #802 stated that Resident #500's Cimetidine was ordered after Resident #500 was found in a room disrobing with another female resident on 05/15/25. Psychiatric NP #802 reported that Resident #500's Cimetidine was restarted on 05/15/25 and was increased from the previous dose of Cimetidine 200 mgs one time a day to Cimetidine 200 mgs two times per day because she did not feel that Cimetidine 200 one time a day was a therapeutic dose for hypersexual behaviors. Review of the facility's undated abuse, neglect and misappropriation policy revealed the facility's intent was to prevent abuse, mistreatment or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse. In the event that a situation is identified as abuse, an investigation by executive leadership will immediately follow up. All alleged violations involving abuse are reported immediately but not later than two hours after the allegation is made. The self-report will be made by the executive director to the state survey agency. This deficiency represents non-compliance investigated under Incident Number 2567007.

Based on record review, staff and resident interviews, review of Self-Reported Incident (SRI), review of facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (#64 and #500) of the six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. Review of Resident #500's behavior care plan dated 03/18/24 and revised on 07/16/25, revealed Resident #500 had a behavior problem related to Resident#500 being noted in bed unclothed with male residents at times, wandering into male resident rooms and exhibiting sexual behaviors. Interventions included encourage resident to participate in activities of choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to determine the underlying cause, resident had one on one supervision, communicate with the resident and resident representative regarding behaviors and treatment, encourage the resident to express feelings and encourage active support by family. Further review of Resident #500's care plan reviewed Resident #500 did not have a care plan for her sexual behaviors prior to 07/16/25. Review of Resident #500's progress note dated 09/02/24 at 6:07 A.M., revealed Resident #500 made frequent attempts at kissing, hugging and touching other male residents in the sitting area on 09/01/24 from the beginning of shift until Resident #500 went to bed. Each time, the residents were separated or redirected from the other resident who either attempted to hit her or shout at her. Review of Resident #500's psychiatry note dated 11/16/24, revealed Resident #500 was seen by Nurse Practitioner (NP) #900 for chronic psychiatric medication visit for dementia, depression, insomnia and inappropriate sexual behaviors. The staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset. Resident #500 was ordered to start Cimetidine 200 milligrams (mgs) by mouth daily for inappropriate sexual behaviors. Review of Resident #500's physician order dated 11/25/24, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth daily for inappropriate sexual behaviors. The order was discontinued 04/14/25. Review of Resident #500's psychiatry notes dated 12/16/24 and 01/13/25, revealed Resident #500 was seen by NP #900. Resident #500 presented for medication management and discussion of symptoms of dementia, depression, insomnia and inappropriate sexual behaviors. Resident #500 was on Cimetidine 200 mgs daily for inappropriate sexual behaviors. Resident #500's inappropriate sexual behaviors were mentioned as a concern, and they were currently being treated with Cimetidine 200 mgs daily. However, no specific incidents or behaviors were discussed during the visit. Staff reported inappropriate sexual behaviors with males and Resident #500 would try to kiss them or bring them to her. Resident #500 would not redirect easily and would become upset.Review of Resident #500's progress note dated 01/09/25 at 7:09 A.M., revealed Resident #500 was noted in another resident's room undressing. Resident #500 was redirected by staff and Resident #500 displayed increased behaviors towards staff. Staff gave Resident #500 time to calm down and Resident #500 was redirected out of the other resident's room by staff. Review of Psychiatric NP #802's progress note dated 05/09/25 at 9:50 A.M., revealed Resident #500's Cimetidine was discontinued during the pharmacy meeting in April 2025. Resident #500 was recently found trying to kiss another female resident and was trying to put her arm around her in the lounge on the couch in a suggestive manner. Review of Resident #500's progress note dated 05/15/25 at 6:37 P.M., revealed Resident #500 was caught by the Certified Nursing Assistant (CNAs) in an empty room with another female resident whose pants were down. The CNAs pulled the resident's pants up and Resident #500 was telling the CNAs to keep them down. The staff redirected the residents out of the room and separated the residents. Review of Resident #500's physician order dated 05/15/25, revealed Resident #500 was ordered Cimetidine oral tablet 200 mgs give one tablet by mouth two times a day for sexually inappropriate behaviors. Review of Resident #500's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired and Resident #500 required assistance or supervision with activities of daily living (ADLs). Review of the police report dated 06/30/25 at 11:28 P.M., revealed the nursing staff found Resident #71 and Resident #500 in the same bed together. Resident #500 was fully clothed, but Resident #71 was in the bed with his pants off.Review of Resident #500's telehealth visit dated 06/30/25 at 1:00 P.M., revealed NP #901 was called by the nurse on duty stating another resident (#71) was observed lying next to Resident #500 that evening. Both residents had clothing on and there was no inappropriate touching. Review of Registered Nurse (RN) #207's witness statement dated 06/30/25, revealed Resident #500 and Resident #71 were lying in bed beside each other. Resident #500 was fully dressed, and Resident #71 had a shirt on and without pants. No one was seen touching the other. Review of Resident #500's progress note dated 07/01/25 at 2:16 A.M., revealed Resident #500 was in the bed beside another resident (#71). The residents were immediately separated with no injuries. A head-to-toe assessment was completed. The family, Director of Nursing (DON), regional nurse, police and Administrator were notified. Review of Resident #500's progress note dated 07/01/25 at 12:36 P.M., revealed Resident #500's physician was notified of the incident. Review of the facility's SRI created on 07/01/25 for a sexual abuse allegation that was discovered on 06/30/25, revealed the staff noted Resident #500 and Resident #71 laying side by side in bed on 06/30/25. Resident #500 was fully dressed, and Resident #71 was without his pants and underwear. No touching was noted, and the residents were immediately separated. Head-to-toe skin assessments were completed on the residents without injuries noted. The SRI was unsubstantiated. Review of Resident #500's progress note dated 07/03/25 at 3:05 P.M., revealed Resident #500 was found in bed with another resident (#64) on 06/30/25 at 9:30 P.M. The staff observed Resident #500 in bed with a male resident fully clothed. Resident #500 had dementia and wandering behaviors with the belief that the male resident was her boyfriend. The residents were immediately separated, and no injuries were noted.Review of a police report dated 07/13/25 at 1:50 P.M., revealed a sexual contact was reported to the police when they responded to the facility on [DATE] at 9:00 A.M. The staff stated the two residents in the mental health wing were observed to be engaging in sexual contact on 07/13/25. The staff stated that both residents were diagnosed with dementia and both POAs were contacted and informed of the incident. The staff stated that Resident #500 was foundling Resident #64's genital area. This report was filed for reporting purposes only. Review of Resident #500's progress note dated 07/13/25 at 4:15 P.M., revealed an incident was reported to LPN #178 while doing her rounds that a staff entered another resident's room and noted a male resident was sitting in his chair while Resident #500 was massaging his genitals. The CNA instantly removed Resident #500 from the male resident's room and made LPN #178 aware. LPN #178 notified the unit manager. The CNA had recently witnessed Resident #500 in her room while picking up her lunch tray. Resident #500 was placed on one-on-one (1:1) observation until further notice and her daughter was made aware. Review of Resident #500's progress note dated 07/13/25 at 4:31 P.M., revealed the on-call physician was made aware of the behavior. Review of Resident #500's progress note dated 07/14/25 at 9:32 A.M., revealed a report was given to the police regarding the sexual encounter between Resident #500 and Resident #64. Review of Resident #500's physician order dated 07/14/25, revealed Resident #500 was to be on 1:1 observation until further notice. Review of the facility's SRI created on 07/14/25 for a sexual abuse allegation that was discovered on 07/13/25, revealed Resident #64 and Resident #500 were found alone in Resident #64's room together. Resident #500 was fully dressed and Resident #64's pants and underwear were down. Resident #500 was noted touching Resident #64's groin area. The residents were separated, assessed, and interviewed. Resident #64 denied any penetration or injury. Resident #500 could not recall the incident and denied penetration or injury. Resident #500 was placed on 1:1 observation and all appropriate parties were notified. The police were contacted and found the residents were not in any immediate danger, and no legal action was required. The SRI was unsubstantiated. Review of Resident #500's physician order dated 07/17/25 revealed Resident #500 may discharge to another skilled nursing facility on 07/18/25. Review of Resident #500's progress note dated 07/18/25, revealed Resident #500 was discharged to another skilled nursing facility. A cab came for Resident #500 at about 3:30 P.M. The face sheet and medication lists were given. Review of Resident #64's chart revealed Resident #64 admitted to the facility on [DATE] with chronic obstructive pulmonary disease, unspecified dementia unspecified severity with other behavioral disturbance, neurocognitive disorder with Lewy bodies, delirium due to known physiological condition, bell's palsy and paranoid schizophrenia. The resident was moderately cognitively impaired. Review of Resident #64's progress note dated 07/13/25 at 4:33 P.M., revealed LPN #178 was informed that another resident (#500) was in Resident #64's room. Resident #64 was sitting in his chair, and the other resident was massaging his genitals. The staff immediately removed the other resident from Resident #64's room and stayed with the other resident. The staff notified LPN #178 and LPN #178 notified the unit manager. The on-call physician was notified, and a head-to-toe assessment was completed with no findings. LPN #178 spoke with Resident #64's wife and made her aware of the incident.Review of CNA #231's hand-written witness statement dated 07/13/25, revealed CNA #231 was going to check on Resident #64. When CNA #231 walked in the room, Resident #500 was being sexually inappropriate massaging Resident #64's private parts. CNA #231 separated them and informed the nurse of their behavior. Review of LPN #178's witness statement dated 07/13/25, revealed LPN #178 and another CNA were giving care to another resident. When LPN #178 and the CNA returned to the nurse's station, another CNA reported that she witnessed Resident #500 in Resident #64's room. Resident #64 was sitting in his chair with his pants down and Resident #500 was inappropriately massaging Resident #64's private area. The CNA immediately separated the residents and informed LPN #178 who informed the unit manager. LPN #178 placed Resident #500 on 1:1 observation and head-to-toe skin assessments were completed with no findings. The on-call physician was made aware.Review of Resident #64's progress note dated 07/14/25 at 9:30 A.M., revealed a report was given to the police regarding the sexual encounter involving Resident #64 and the other female resident. Observation of Resident #64 on 07/22/25 at 9:53 A.M., revealed Resident #64 was sitting in his wheelchair in the common area. Resident #64 was clean and dressed appropriately. Interview with Resident #64 in his room on 07/22/25 at 9:53 A.M., revealed Resident #64 had not been sexually abused in the facility. Resident #64 denied having any sexual or intimate relationships in the facility. Interview with CNA #236 on 07/22/25 at 9:57 A.M., revealed she did not witness the incident between Resident #500 and Resident #64, but she was working on that date. CNA #236 reported Resident #500 was placed on 1:1 observation until she was discharged from the facility. CNA #236 stated she was not aware of Resident #500 or Resident #64 having sexually inappropriate behaviors prior to the incident. Interview with CNA #231 on 07/22/25 at 10:00 A.M., revealed CNA #231 was going to Resident #64's room to do a check and change on the date of the incident. CNA #231 stated Resident #64 was sitting in his wheelchair and Resident #500 was sitting in the recliner when she entered the room. CNA #231 reported Resident #64 had his penis out and Resident #500 was stroking Resident #64's erect penis. CNA #231 stated Resident #64's pants and brief were down to his thigh. CNA #231 reported she told the residents that they cannot be doing this and CNA #231 separated the residents by getting Resident #500 out of the chair, wiping Resident #500's hands and taking Resident #500 to the common area. CNA #231 stated she went back to Resident #64's room to assist him with pulling up his brief and pants after Resident #500 was removed from the room. CNA #231 asked Resident #64 if he wanted to stay in his room or go to the common area and Resident #64 stated he wanted to stay in his room. CNA #231 stated Resident #64 was upset with CNA #231 for stopping the incident and he stated, Don't talk to me anymore. CNA #231 also reported Resident #64 stated that he did not appreciate that because he was not finished. CNA #231 stated she reported the incident to LPN #178 after she removed Resident #500 from the situation but before returning to Resident #64's room to assist him with his pants. CNA #231 reported Resident #500 did not say anything about the incident, but she was hollering and screaming because she wanted to stay in Resident #64's room. CNA #231 reported that Resident #500 was placed on 1:1 observation and she continued to try to rub Resident #64's thigh after he decided to go back to the common area that day. CNA #231 stated that Resident #500 had a history of sexual behaviors and Resident #500 had been found in bed with other male residents in the past. Interview with LPN #178 on 07/22/25 at 10:19 A.M., revealed she was working on 07/13/25 when CNA #231 informed her that she was doing room checks and entered Resident #64's room and found him sitting in his wheelchair with his pants down and Resident #500 was massaging his penis. LPN #178 stated that CNA #231 separated the residents and Resident #500 was with CNA #231 when CNA #231 reported the incident to LPN #178. LPN #178 reported the incident occurred around 2:00 P.M. LPN #178 stated Resident #500 was upset that she was removed from the situation and Resident #64 was also upset that Resident #500 was removed from his room. LPN #178 reported that Resident #500 was placed on 1:1 observation, head-to-toe assessments were completed on Resident #500 and Resident #64 with no injuries noted and administrative staff were notified. LPN #178 stated she was not aware of Resident #500 or Resident #64 having any prior sexual behaviors. LPN #178 reported that the police were notified a skin sweep was completed on all the residents on the unit with no negative findings. Interview with Registered Nurse (RN) #202 via telephone on 07/22/25 at 2:22 P.M., revealed RN #202 could not remember the dates of the incident because it had been a while and she did not usually work on the memory care unit. RN #202 stated that Resident #500 would walk around and was clinging towards the male residents. RN #202 reported that Resident #500 would try to kiss, touch or hug male residents and CNAs would have to redirect her. RN #202 stated that management was informed of Resident #500's sexually inappropriate behaviors. Interview with the Administrator and Regional Director of Clinical Operations (RDCO) #801 on 07/22/25 at 2:28 P.M., revealed the Administrator was not aware of Resident #500 attempting to kiss, hug and touch male residents on 09/01/25 or the incident on 05/15/25 where Resident #500 was found in an empty room with another female resident with her pants pulled down. The Administrator confirmed the facility did not complete an SRI or investigate the 05/15/25 incident per the abuse policy. The Administrator stated an SRI was completed on 06/30/25 after staff found Resident #500 lying in bed with Resident #71 during rounds. Resident #71 was noted without any pants or brief on, and Resident #500 was fully clothed. The Administrator stated the staff separated the residents and Resident #500 was placed on 1:1 observation for three days after the incident. A medication review was also completed and Resident #500's room was moved to the opposite side of the unit. The Administrator stated the staff were educated on abuse. The Administrator stated Resident #500 was observed in Resident #64's room on 07/13/25. Resident #500 was fully clothed, and Resident 64 was sitting in his chair with his pants down. The Administrator reported staff witnessed Resident #500 touching Resident #64's penis with her hands. The Administrator stated the staff separated the residents and Resident #500 was placed on 1:1 observation. The Administrator reported Resident #500 and Resident #71 were both upset that they were separated but then did not recall the incident at a later time. The Administrator reported Resident #500 stayed on 1:1 observation until she was discharged to a female dementia unit. The Administrator stated that interviews of staff and residents and skin checks of residents were completed with no issues. The Administrator reported an SRI was filed on the 07/13/25 incident and laboratory tests (labs) were obtained on Resident #500 to rule out infection. The Administrator verified the facility did not care plan Resident #500 for sexually inappropriate behaviors until after the 07/13/25 incident. The Administrator confirmed Resident #500 had been prescribed Cimetidine for sexually inappropriate behaviors dating back to 11/25/24. Observation of Resident #71 on 07/22/25 at 3:53 P.M., revealed Resident #71 was sitting in a recliner in the common area. Resident #71's hand was on top of Resident #62's hand. Interview with Resident #71 on 07/22/25 at 3:53 P.M., revealed Resident #71 denied being sexually abused at the facility. Resident #71 denied having any intimate relationships at the facility. Interview with RDCO #801 and Divisional Director of Risk Management (DDRM) #803 on 07/23/25 at 12:02 P.M., revealed Resident #500 had made attempts at making contact with male residents on 09/01/24 but contact was never made. RDCO #801 stated Resident #500 had a urinary analysis pending on 09/01/24 and the facility thought that Resident #500's behaviors were from an infection on that date. RDCO #801 stated that a gradual dose reduction was completed on Resident #500's Cimetidine 200 mgs and the medication was discontinued on 04/14/25. RDCO #801 stated that Resident #500 was seen by Psychiatric NP #802 on 05/09/25 and it was reported that Resident #500 was trying to kiss another female resident, but no contact was made. RDCO #801 stated that Resident #500's was observed in a room with her pants down with another female resident on 05/15/25. RDCO #801 stated that no contact was made, and Resident #500 was ordered her Cimetidine 200 mgs two times a day for sexually inappropriate behaviors. RDCO #801 reported Resident #500 was found in bed with a male resident with his pants and brief off on 06/30/25 and the incident was reported to telehealth as sexually inappropriate behavior. RDCO #801 stated no contact was made between Resident #500 and Resident #71, but a medication review was completed and Resident #500's Lexapro was increased from 10 mgs to 15 mgs for anxiety and depression on 07/08/25. Interview with Psychiatric NP #802 via phone on 07/25/25 at 1:16 P.M., revealed she started working for the company in March 2025. Psychiatric NP #802 reported she saw Resident #500 on 04/07/25 and she documented that Resident #500's Cimetidine 200 mgs one time a day was effective for managing her sexually inappropriate behaviors. Psychiatric NP #802 reported Resident #500's Cimetidine 200 mgs was discontinued on 04/14/25 due to a gradual dose reduction. Psychiatric NP #802 stated she saw Resident #500 on 05/09/25 and it was reported to her by staff that Resident #500 recently tried to put her arm around and kiss another female resident. Psychiatric NP #802 stated that Resident #500's Cimetidine was ordered after Resident #500 was found in a room disrobing with another female resident on 05/15/25. Psychiatric NP #802 reported that Resident #500's Cimetidine was restarted on 05/15/25 and was increased from the previous dose of Cimetidine 200 mgs one time a day to Cimetidine 200 mgs two times per day because she did not feel that Cimetidine 200 one time a day was a therapeutic dose for hypersexual behaviors. Psychiatric NP #802 reported she saw Resident #500 on 06/13/25 and Resident #500 had no new inappropriate sexual behaviors. Psychiatric NP #802 reported she was notified that Resident #500 was found in bed with a male resident on 06/30/25 and her Lexapro was increased on 07/08/25 to decrease her hypersexual behaviors. Psychiatric NP #802 stated that she spoke with Resident #500's daughter in June 2025 and she stated that she had always had hypersexual behaviors prior to her dementia diagnosis. Review of the facility's undated abuse, neglect and misappropriation policy revealed the facility's intent was to prevent abuse, mistreatment or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse. In the event that a situation is identified as abuse, an investigation by executive leadership will immediately follow up. All alleged violations involving abuse are reported immediately but not later than two hours after the allegation is made. The self-report will be made by the executive director to the state survey agency. This deficiency represents non-compliance investigated under Incident Number 2567007 .

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored and served in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 of 111 residents. The facility identified three (Residents #37, #172, and #169) who did not receive food from the kitchen. The facility census was 111 residents. Findings include: 1. Observation on 02/03/25 at 9:15 A.M. of the facility's dry storage area revealed the following items: an opened undated bag of baking powder wrapped in plastic wrap, an opened bag of marshmallows wrapped in plastic wrap dated 08/20/23, an opened 12 quart plastic container of chocolate chips with an open date of 12/10/24 and discard date of 01/10/25, an opened undated bag of egg noodles wrapped in plastic wrap, a cardboard box containing a jug of oil stored directly on the floor, a box of bananas which were brown with several gnats flying around the immediate vicinity, an undated bag of cake mix wrapped in plastic wrap, a large bin of flour dated 03/26/24, four large plastic containers of cereal with open dates of 01/03/25 and discard dates of 01/10/25. Interview on 02/03/25 at 9:15 A.M. with Account Manager (AM) #410 confirmed the oil should not be stored directly on the floor. AM #410 stated the bananas were for the activity department and verified the gnats around them. AM #410 confirmed the marshmallows should have been discarded because they were outdate. AM #410 verified the baking powder, noodles, and cake mix should have been labeled and dated. AM #410 verified the chocolate chips, flour, and cereal were all outdated and should have been discarded by the dates on each product. 2. Observation on 02/03/25 at 9:20 A.M. revealed Dietary Aide (DA) #404 was using a black marker and writing the date 01/03/25 on four plastic bins containing dry cereal. Interview on 02/03/25 at 9:20 A.M. with DA #404 confirmed they wrote the date 01/03/25 on four plastic bins of dry cereal which had already been opened prior to the survey. Interview on 02/03/25 at 9:20 A.M. AM #410 confirmed the cereal had already been opened at an undetermined time prior to the survey observation and food items should be dated at the time of opening. 3. Observation on 02/03/25 at 9:21 A.M. revealed the following items were being stored in the facility's walk-in refrigerator: an undated, unlabeled pan of hotdogs loosely covered in plastic wrap, an undated, unlabeled pan of hamburgers loosely covered in plastic wrap, a brick of American cheese slices dated 01/10/25, an undated, unlabeled bag of parmesan cheese. Interview on 02/03/25 at 9:21 A.M. with AM #410 confirmed the hamburgers and hotdogs were not tightly sealed nor labeled, the American cheese slices were outdated, and the bag of parmesan cheese was not labeled. 4. Observation on 02/05/25 at 12:59 P.M. revealed staff loaded lunch trays onto cart which had a pink and sticky substance on the bottom of the cart. Interview on 02/05/25 at 12:59 P.M. with AM #410 confirmed there was a pink and sticky substance on the bottom of the cart, and the carts were supposed to be wiped down daily. 5. Observation on 02/05/25 at 1:05 P.M. during tray line revealed DA #407 reached for a hamburger bun from a bag of buns with a gloved hand. DA #407 then opened the door to the oven, retrieved a foil package, took a veggie burger out of the package, and placed the burger on a bun all while utilizing the same gloved hand. Interview on 02/05/25 at 1:06 P.M. with DA #407 confirmed he verified touched the burger with his gloved hand after touching oven handles. Observation on 02/05/25 at 1:06 P.M. revealed Director of Clinical Operations (DCO) #411 instructed DA #407 to remove the gloves and use serving utensils instead. 6. Observation on 02/05/25 at 1:19 P.M. during tray line revealed DA #407 retrieved a veggie burger from the oven and placed it on a bun using his bare ungloved hand. Interview on 02/05/25 at 1:19 P.M. with DA #407 confirmed he had handled the veggie burger with his bare hand. 7. Observation on 02/05/25 at 1:23 P.M. revealed another cart being utilized to load lunch trays during tray line had a sticky white substance in the bottom center. Interview on 02/05/25 at 1:23 P.M. with [NAME] #409 confirmed there was a white sticky substance on the bottom of the cart which was being utilized for clean lunch trays. 8. Observation on 02/05/25 at 3:45 P.M. revealed the refrigerator on the Applewood unit contained the following items: an opened carton of half and half with a use-by date of 01/13/25, three undated containers of orange juice, an opened unlabeled, undated bottle of pink lemonade, two bags of opened undated shredded cheese, multiple areas of a brown, sticky substance in the door of the refrigerator. Observation of the freezer compartment of the refrigerator on the Applewood unit revealed it contained three undated popsicles which appeared to be freezer-burnt. Interview on 02/05/25 at 3:45 P.M. with the Director of Nursing (DON) confirmed the half and half, the orange juice, the pink lemonade, the cheese, and the popsicles were not stored appropriately. The DON further confirmed there was a brown and sticky substance in the door of the refrigerator. 9. Observation on 02/05/25 at 3:50 P.M. revealed the refrigerator on the Elm unit contained the following items: six undated containers of orange juice, four undated containers of apple juice, and an opened and undated container of caramel syrup. Interview on 02/05/25 at 3:50 P.M. with the DON confirmed the juices and caramel syrup should have been dated. Review of the facility policy titled Food Storage: Cold Foods dated April 2018 revealed all foods would be stored six inches above the floor and all foods would be stored, wrapped, or in covered containers and labeled and dated. Review of the facility policy titled Environment dated September 2017 revealed all food service and preparation areas would be maintained in a clean and sanitary condition. This deficiency represents noncompliance investigated under Complaint Number OH00161232.

Based on medical record review, observation and staff interview, the facility failed to ensure resident dining choices were honored. This affected one (Resident #19) of nine residents observed in the main dining room. The facility census was 111 residents. Findings include: Review of medical record for Resident #19 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, hypertension, and depression. Review of physician's orders for Resident #19 revealed an order dated 03/24/24 for the resident to be on a consistent carbohydrate diet with regular texture and regular consistency. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 08/12/24 revealed the resident had intact cognition, had no swallowing issues and was on a therapeutic diet. Review of the facility lunch menu for 02/05/25 revealed the main entree was homestyle meatloaf with a catsup glaze. Review of the facility menu spreadsheet dated 02/05/25 for the lunch meal revealed residents on a consistent carbohydrate diet were to receive homestyle meatloaf with catsup glaze. Review of the lunch meal ticket for Resident #19 dated 02/05/25 revealed the resident was to receive a rotisserie chicken thigh as the entree. Observation on 02/05/25 at 1:05 P.M. in the facility dining room revealed Resident #19 appeared unhappy with the lunch served to her: a roasted chicken thigh, au gratin potatoes, spinach, a dinner roll, a pudding cup. Resident #19 told Dietary Aide (DA) #404 she was unhappy with the chicken and wanted the meatloaf. DA #404 told Resident #19 the consistent carbohydrate diet not allow for meatloaf. Resident #19 ate the pudding on her tray and said she would not eat anything else. DA #404 told Resident #19 she was not allowed to have meatloaf because she was on a consistent carbohydrate diet. Observation on 02/05/25 at 1:07 P.M. revealed Resident #19 wheeled herself toward exit and Licensed Practical Nurse (LPN #302) approached the resident and questioned why she was not eating. Resident #19 told LPN #302 she wanted to have meatloaf instead of chicken. LPN #302 told Resident #19 she was not allowed to have meatloaf because it was not on her diet. Resident #19 then left the dining room to return to her room. Observation on 02/05/25 at 1:10 P.M. revealed the Director of Nursing (DON) told LPN #302 after the resident had left the dining room, that residents have the right to choose menu items despite dietary restrictions. Interview on 02/05/25 at 2:13 P.M. with Resident #19 confirmed she wanted to have meatloaf like everyone else got for lunch. Resident #19 confirmed she had told kitchen staff on multiple occasions that she did not like chicken. Interview on 02/05/25 at 2:30 P.M with LPN #302 confirmed she was not overly familiar with Resident #19's diet but supported DA #404's statement that meatloaf was not on the resident's diet. LPN #302 confirmed residents had the right to self-determination and that all residents have the right to make choices. Interview on 02/05/25 at 3:03 P.M. with the DON confirmed the residents had the right to make their own choices and Resident #19 should have been able to substitute meatloaf for the chicken on her lunch tray. Interview with Director of Clinical Operation (DCO) # 422 on 02/05/25 at 3:15 P.M. confirmed DA #404 was mistaken, and meatloaf was permitted on the consistent-carbohydrate diet. Review of the facility policy titled Resident Rights undated revealed staff would respect resident choices.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff documented medication administration accurately in the electronic medical record. This affected one (Resident #99) of five residents reviewed for unnecessary medications. The facility census was 111 residents. Findings include: Review of the medical record of Resident #99 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic atrial fibrillation, chronic obstructive pulmonary disease, hypertension (HTN), and heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #99 dated 12/02/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #99 revealed an order dated 12/14/24 for metoprolol tartrate 25 mg give one half tablet by mouth two times per day for HTN and an order dated 01/22/25 to increase the metoprolol tartrate to 25 mg one tablet by mouth two times a day for HTN. Both metoprolol orders had parameters to hold the medication for a systolic blood pressure less than 110. Review of the Medication Administration Record (MAR) for Resident #99 dated January 2025 revealed metoprolol was documented as administered on the following dates and times when the resident's systolic BP was less than 110: on 01/01/25 at bedtime for a BP of 105/76, on 01/03/25 at bedtime for a BP of 100/74, on 01/06/25 at bedtime for a BP of 106/64. Review of a progress note for Resident #99 dated 01/03/25 timed at 9:18 P.M. revealed the metoprolol was held. Review of the physician's orders for Resident #99 revealed an order dated 12/17/24 for midodrine 5 mg one tablet three times a day for low blood pressure (BP) with parameters to hold the medication for a systolic BP greater than 110. Review of the MAR for Resident #99 dated January 2025 revealed midodrine was documented as administered on the following dates and times when the resident's systolic BP was greater than 110: on 01/02/25 in the afternoon for a BP of 121/77, on 01/03/25 in the afternoon for a BP of 119/68, on 01/04/25 in the morning for a BP of 127/78, on 01/04/25 in the afternoon for a BP of 127/78, on 01/04/25 in the evening for a BP of 122/70, on 01/05/25 in the morning for a BP of 128/78, on 01/05/25 in the afternoon for a BP of 122/73, on 01/05/25 in the evening for a BP of 127/25, on 01/08/25 in the afternoon for a BP of 119/77, on 01/09/25 in the afternoon for a BP of 124/66, on 01/09/25 in the evening for a BP of 127/75, on 01/10/25 in the evening for a BP of 120/80, on 01/14/25 in the afternoon for a BP of 148/85, on 01/18/25 in the afternoon for a BP of 135/89, on 01/18/25 in the evening for a BP of 129/78, on 01/20/25 in the afternoon for a BP of 136/75, on 01/22/25 in the evening for a BP of 157/98, on 01/26/25 in the morning for a BP of 132/67, on 01/30/25 in the afternoon for a BP of 125/79. Review of progress notes for Resident #99 dated 01/02/25 at 11:34 A.M., 01/09/25 at 11:31 A.M., and 01/20/25 at 12:15 P.M. revealed the resident's midodrine was held. Review of the MAR for Resident #99 dated January 2025 revealed on 01/04/25 and 01/26/25 in the morning the resident received both midodrine and metoprolol. Interview on 02/03/25 at 1:04 P.M. with Resident #99 confirmed the nurses had tried to give him midodrine at inappropriate times when his blood pressure was too high for midodrine to be administered. Interview on 02/06/25 at 1:24 P.M. with Regional Director of Clinical Operations (RDCO) #500 confirmed Resident #99's MAR revealed staff had documented administration of metoprolol and midodrine inappropriately and not in accordance with physician order parameters on multiple dates and times. RDCO #500 further confirmed staff documented administration of both midodrine and metoprolol at the same time on 01/04/25 and 01/26/25. Interviews on 02/06/25 at 2:52 P.M. with Licensed Practical Nurse (LPN) #244 and on 02/06/25 at 3:09 P.M. with Registered Nurse (RN) #401 confirmed they documented in error the administration of metoprolol and midodrine for Resident #99 on multiple dates in January 2025 outside of the physician-ordered parameters. LPN #244 and RN #401 further denied administration of both metoprolol and midodrine at the same time to Resident #99. Review of the facility policy titled Medication Administration undated, revealed medication should only be administered as prescribed by the provider, medications will be charted when given, medications that are refused or withheld will be documented, and documentation of medications will follow accepted standards of nursing practice.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, resident interview, staff interview, and review of the facility policy, the facility failed to properly transfer a resident using a mechanical lift (Hoyer) and the assistance of two staff per the resident's care plan. Actual harm occurred on 10/28/24 when Certified Nursing Assistant (CNA) #35 completed a hands-on pivot transfer of Resident #11 from the bed to the wheelchair without the assistance of additional staff or use of a gait belt. Resident #11 sustained a fall to the floor during the transfer which resulted in a left femur fracture. This affected one (Resident #11) of three residents reviewed for falls. The facility census was 115 residents. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including cerebral infarction, chronic respiratory failure, morbid obesity, cardiac murmur, and scoliosis. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 10/14/24 revealed the resident had mild cognitive deficits and required extensive assistance of staff with activities of daily living (ADLs). Review of the care plan for Resident #11 dated 04/09/24 revealed the resident had an ADL self-performance deficit and required staff assistance related to hemiplegia, chronic respiratory failure, obesity, spinal stenosis, multiple cardiac diagnoses, and overall medical condition. Interventions included the resident was totally dependent with transfers and required the assistance of two or more staff with transfer and the resident required the use of a mechanical lift (Hoyer) with two-person support. Review of a nursing note for Resident #11 dated 10/28/24 timed at 11:50 A.M. revealed CNA #35 notified Licensed Practical Nurse (LPN) #42 that Resident #11 was on the floor. LPN #42 assessed Resident #11 who complained of left leg pain which the resident rated as eight on a scale of 1 to 10 with 10 being the worst pain. LPN #42 notified Nurse Practitioner (NP) #41 who gave an order to send Resident #11 to the hospital via emergency medical services (EMS) for an evaluation. Review of a nursing note for Resident #11 dated 10/28/24 timed at 6:16 P.M. revealed the hospital reported to LPN #42 that Resident #11 had a fractured leg femur and would be sent back to facility on 10/28/24. Review of the Interdisciplinary Team (IDT) follow-up note for Resident #11 dated 10/29/24 revealed the resident had a fall with injury related to staff assisting the resident to the floor when the resident's legs became weak during transfer. Review of the results for the computed tomography (CT) scan of the left femur without contrast for Resident #11 dated 10/28/24 timed at 4:28 P.M. revealed the resident had a mildly displaced fracture of the distal femur. Review of a written statement per Resident #11dated 10/28/24 revealed the resident reported that on 10/28/24 a young girl came into her room, and she was no bigger than the resident and the girl tried to get the resident up into a chair, but the resident's legs gave out. Review of a written statement per CNA #35 dated 10/28/24 revealed Resident #11 was sitting on the edge of the bed with her legs off the side of the bed. CNA #35 attempted to do a pivot transfer of Resident #11 from the bed to the chair and during the transfer the resident's legs gave out. Further review of the statement revealed CNA #35 then placed her arms under the resident's arms and lowered the resident to the floor. Review of a written statement per LPN #42 dated 10/28/24 revealed the nurse was administering medications and conversing with Unit Manager (UM) #36 when CNA #35 alerted the nurses that Resident #11 was on the floor. When LPN #42 entered Resident #11's room, the resident was on the floor. CNA #35 stated she slid Resident #11 down her leg and lowered the resident to the floor because the resident's legs started getting weak. LPN #42 then assessed the resident and notified Nurse Practitioner (NP) #41. Review of an email sent from the Administrator to Regional Director of Clinical Operations (RDCO) #40 dated 10/28/24 timed at 4:57 P.M. revealed the Administrator was reaching out to inform that Resident #11 was improperly transferred by an aide on 10/28/24 which resulted in left leg pain and NP #41 requested that Resident #11 be sent out 911. From the hospital it was determined Resident #11's hip was fractured. The Administrator had completed the following: an in-service and a final write up (disciplinary action) for CNA #35, full house education started on transfers, root cause analysis, statements collected from staff, staff notified the Medical Director and NP #41, and the Administrator notified Resident #11's guardian of the incident. Interview on 12/04/24 at 4:01 P.M. with Resident #11 confirmed that when she was transferring with the assistance of one staff, her legs gave out, and she just fell . Resident #11 stated she did not fall out of the Hoyer lift, and that on 10/28/24, CNA #35 came in by herself and tried to transfer her to the wheelchair and she fell . Interview on 12/10/24 at 1:34 P.M. with CNA #35 confirmed she was not the aide assigned to Resident #11 on 10/28/24. CNA #35 stated another aide had asked her to get Resident #11 up in the wheelchair. CNA #35 stated she had seen other aides using a single-person pivot transfer for Resident #11 and she was unaware that Resident #11 was to be transferred by Hoyer lift with two staff assist. CNA #35 stated that while she was pivoting Resident #11 to the wheelchair the resident froze and would not move anymore. Resident #11 then stated her legs were going to go out, so the aide slowly lowered Resident #11 down to the ground and quickly hollered for UM #36 for assistance. UM #36 assessed Resident #11, and the resident started crying stating her leg hurt. CNA #35 stated she did not know Resident #11 was supposed to be transferred via the Hoyer (mechanical) lift, and the aide did not look at the Kardex (care plan) or ask anyone how the resident was supposed to be transferred. Interview on 12/10/24 at 4:08 P.M. with RDCO #40 confirmed Resident #11 should be transferred per two staff using a mechanical lift, and CNA #35 should have had another staff member assisting with the transfer. Review of the facility policy titled Plan of Care Overview dated 2017 revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff, and visitors. The deficiency was corrected on 11/27/24 when the facility implemented the following corrective actions: On 10/28/24, LPN #42 assessed Resident #11 with findings of left leg pain. On 10/28/24 at 11:50 A.M., LPN #22 notified NP #41 of Resident #11's leg pain and gave an order to send the resident to the hospital via nine-one-one (911) emergency transport. On 10/28/24 at 12:00 P.M., UM #26 notified the Administrator of Resident #11's fall. On 10/28/24 at 4:45 P.M., the hospital called and reported to facility nurse, LPN # 22, that Resident #11 has sustained a fracture to the distal end of left femur. On 10/28/24 at 4:50 P.M., the Administrator notified Resident #11's guardian of the fracture to the resident's left femur. On 10/28/24 at 5:00 P.M., the Director of Nursing (DON) conducted an audit for all residents that required two staff members' assistance regarding care concerns related to mechanical lifts. On 10/28/24 at 5:15 P.M., UM #26 initiated assessments of residents that required two staff assist including mechanical lifts for transfers to ensure no injuries occurred during transfers. On 10/28/24 at 5:30 P.M., the Administrator and the DON provided one-on-one education to CNA #35 on the Kardex, following the resident's plan of care, and mechanical lift transfers. On 10/28/24 at 6:00 P.M., Therapy Director (TD) #51 completed a transfer competency with CNA #35. On 10/28/24 at 6:10 P.M., the DON completed education with all licensed nurses, therapists, and aides on the Kardex, following the resident's plan of care, and mechanical lift transfers. On 10/28/24 at 7:40 P.M., Resident #11 returned to the facility with an order for a follow-up appointment with an orthopedic surgeon. Registered Nurse (RN) #53 completed a head-to-toe assessment and pain assessment for Resident #11. On 10/28/24 at 7:55 P.M., RN #53 notified NP #41 of Resident #11's new diagnoses of closed fracture of distal end of left femur. On 10/29/24 at 2:02 P.M., the Quality Assurance and Performance Improvement (QAPI) Committee met to review the incident involving Resident #11 with NP #41 present. Resident #11's care plan was updated to include pain management, ADLs, and falls. The DON was to initiate ongoing monitoring on 10/30/24. On 10/29/24 at 2:25 P.M., the DON notified Resident #11's guardian of the plan of care updates and the resident's guardian was in agreement. On 10/29/24 at 5:20 P.M., MDS Nurse #54 completed a review and updated all care plans for residents identified as requiring two staff assist and/or mechanical lift for transfers. On 10/30/24, the DON/designee to conduct audits of transfers to be completed three times weekly for four weeks and then weekly for four weeks to ensure transfers were occurring as indicated on the resident care plan/Kardex. Review of facility audits of transfers completed beginning 10/30/24 through 11/27/24 revealed there were no further identified concerns. This deficiency represents noncompliance investigated under Complaint Number OH00159597.

Based on medical record review, observation, staff interview, and the resident interview, the facility failed to maintain an adequate supply of food during tray service and failed to follow the facility menu. This affected four (Residents #12, #18, #19, and #20) of four residents observed for meal service. The facility census was 115 residents. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including alcohol dependence, respiratory failure, depression, psychoactive substance abuse, anxiety, chronic pain, and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 09/01/24 revealed the resident had no cognitive deficits and required supervision with activities of daily living (ADLs). Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including diabetes, heart failure, epilepsy, colon cancer, and sleep apnea. Review of the MDS for Resident #18 dated 10/30/24 revealed the resident had mild cognitive deficits and required supervision with activities of daily living. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including diabetes, morbid obesity, agoraphobia, tachycardia, and anxiety. Review of the MDS for Resident #19 dated 10/06/24 revealed the resident had no cognitive deficits and required supervision with ADLs. Review of the dietary assessment for Resident #19 dated 03/08/23 revealed pork chops were listed as a disliked food. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including diabetes, depression, convulsions, obesity, and anxiety. Review of the MDS for Resident #20 dated 11/09/24 revealed the resident had no cognitive deficits and was totally dependent on staff for ADL care. Review of the dietary assessment for Resident #20 dated 01/08/24 revealed pork was listed as a disliked food. Observation on 12/02/24 at 1:45 P.M. of meal service for Residents #12 and #18 revealed the lunch ticket listed double chocolate brownie for lunch, but there was no brownie on either tray. Resident #12's ticket indicated the resident should receive eight ounces of chocolate milk on his tray, but there was no milk on the tray. Interview on 12/02/24 at 1:58 P.M. with Certified Nursing Assistant (CNA) #30 confirmed Residents #12 and #18 did not receive brownies on their meal trays and Resident #12 did not receive chocolate milk on the meal tray as indicated by the meal tickets. CNA #30 confirmed residents frequently had missing food items on their trays, and the trays frequently did not include the items listed on the meal tickets. Interview on 12/02/24 at 2:03 P.M. with one [NAME] #20 and Kitchen Aides ([NAME]) #21 and #29) confirmed the facility did not have a kitchen manager. Interview on 12/02/24 at 2:04 P.M. with [NAME] #20 confirmed for the lunch meal on 12/02/24 the kitchen ran out of brownies so not all residents received brownies as indicated on the facility menu. Observation on 12/04/24 at 1:25 P.M. with [NAME] #20 of the tray line service revealed the service had to be stopped for 10 to 15 minutes due to running out of cabbage with 21 residents left to serve. During tray line the kitchen also ran out of chicken breast which was a substitute ordered for Residents #19 and #20 both of whom had pork listed as a disliked food. Resident #19 was given one chicken breast and a pork chop as a replacement for the second chicken breast. Resident #20 was given a cheeseburger to replace the chicken breast. Interview on 12/04/24 at 1:30 P.M. with [NAME] #20 confirmed the kitchen staff ran out of cabbage and chicken during the lunch meal services on 12/04/24. Interview on 12/04/24 at 3:15 P.M. with Resident #19 confirmed the kitchen never followed her menu choices and she usually had to send her food back. Interview on 12/04/24 at 3:20 P.M. with Resident #20 confirmed she did not eat pork but did not like the cheeseburgers made by the facility. Resident #20 confirmed on 12/04/24 the facility sent her a cheeseburger instead of sending her a chicken breast which was supposed to be the alternate selection for residents who didn't eat pork. Resident #20 confirmed she frequently didn't eat the food because it was not what she ordered, and she would ask the aides to take the food out of her room. This deficiency represents noncompliance investigated under Complaint Number OH00159757 and Complaint Number OH00159544.

Review of medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained proper infection control practices during tracheostomy care. This affected one (Resident #17) of three residents reviewed for tracheostomy care. The facility census was 111 residents. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including centrilobular emphysema, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 08/03/24 revealed the resident had intact cognition and required setup assistance with activities of daily living (ADLs.) Observation on 09/24/24 at 11:42 A.M. of tracheostomy care for Resident #17 per Licensed Practical Nurse (LPN) #21 revealed the nurse broke the sterile field when she touched the sterile gauze with her clean gloves instead of sterile gloves. LPN #21 picked up the gauze and placed it in the cleaning solution. After applying her sterile gloves, LPN #21 used the contaminated gauze to clean Resident #17's tracheostomy tube. Interview on 09/24/24 at 12:27 P.M. with LPN #21 confirmed she contaminated the sterile field and used the contaminated gauze to clean Resident #17's tracheostomy. Review of the facility policy titled Tracheostomy Care dated 08/26/24 revealed staff were to maintain an aseptic environment, to the extent possible, to reduce pathogen transmission during tracheostomy care. This deficiency represents noncompliance investigated under Complaint Number OH00157813.

Based on review of the facility menu, observation, staff interview, resident interview, and review of the facility recipes, the facility failed to serve palatable and appetizing food to the residents. This had the potential to affect all residents residing in the facility with the exception of two facility identified residents (#51, #111) who had orders to receive nothing by mouth. The facility census was 117 residents. Findings include: Review of the facility menu for 08/05/24 revealed the lunch entree was Dijon pork loin. Observation on 08/05/24 at 11:50 A.M. revealed [NAME] #126 removed a tray of pork loin from the oven that had been cooked in its own juices. On the tray line there was a container of a thick yellow substance which [NAME] #126 identified as gravy. During the tray line service [NAME] #216 used a small scoop to ladle gravy over the top of each serving of pork loin. Observation of a test tray on 08/05/24 at 1:30 P.M. revealed the tray included peas, cabbage, oven roasted potatoes and pork loin with approximately one quarter inch of a thick yellow substance on top of the meat. Many of the potatoes were still hard and undercooked and the gravy on top of the pork loin was thick, pungent, and unpalatable. Interviews on 08/05/24 at 2:00 P.M. with Resident #56, at 3:20 P.M. with Resident #114, and at 3:40 P.M. with Resident #25 and on 08/06/24 at 3:40 P.M. with Resident #110 confirmed they did not like the mustard topping on the pork loin and the entree was unpalatable and inedible. Interview on 08/05/24 at 2:48 P.M. with [NAME] #216 confirmed the Dijon pork loin had a recipe which called for the meat to be cooked in the oven in a sauce. [NAME] #216 confirmed she did not follow the recipe for the Dijon pork loin. [NAME] #216 confirmed she made a gravy for the pork loin by mixing Dijon mustard, a bit of brown sugar, and salt and pepper. [NAME] #216 confirmed she did not taste the gravy prior to serving it to the residents. Interview on 08/05/24 at 3:03 P.M. with the Administrator confirmed [NAME] #216 did not follow the recipe when preparing Dijon pork loin for the residents' lunch meal on 08/05/24. Review of the facility recipe titled Dijon pork loin undated revealed the meat should be baked at 350 degrees Fahrenheit for 60 to 75 minutes in a mixture of red peppers, green peppers, mustard, vinegar, salt, and cornstarch. The recipe did not call for any type of a gravy or topping. This deficiency represents noncompliance investigated under Complaint Number OH00156386.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff provided visual privacy while providing incontinence care to residents. This affected one (Resident #37) of two residents observed for incontinence care. The facility census was 117 residents. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including paraplegia, fusion of the spine, depression, and history of fall from ladder. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 07/08/24 revealed the resident had no cognitive deficits and required extensive assistance with activities of daily living. Observation of incontinence care for Resident #37 on 08/12/24 from 12:09 P.M. to 12:18 P.M. per two State tested Nursing Assistants (STNAs #251 and #252) revealed the aides provided incontinence care to the resident and did not draw the blinds to provide visual privacy for the resident. Two residents passed by Resident #37's window and were able to visualize the resident during incontinence care. Interview on 08/12/24 at 12:18 P.M. with STNA #251 confirmed she should have closed the blinds for Resident #37's privacy prior to providing care. STNA #251 confirmed she thought about closing the blinds about halfway through providing care but did not close them until she was done. Review of the facility policy titled Resident Rights dated 04/18/24 revealed residents had the right to visual privacy when treatments, medication, or care was being administered.

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure staff discarded expired medication. This affected one (Residents #04) of two facility-identified residents with orders for multivitamins with minerals. The facility census was 117 residents. Findings include: Review of the medical record for Resident #04 revealed an admitted [DATE] with diagnoses including emphysema, diabetes, anxiety, depression, schizoaffective disorder, and insomnia. Review of physician's orders for Resident #04 revealed an order dated 12/20/23 to administer a multivitamin with minerals tablet once daily in the morning. Review of the Minimum Data Set (MDS) assessment for Resident #04 dated 07/03/24 revealed the resident had no cognitive deficits and required supervision for activities of daily living (ADLs). Observation on 08/12/24 at 8:23 A.M. of medication administration for Resident #04 per Licensed Practical Nurse (LPN) #100 revealed the multivitamin with minerals was not available. During administration Central Supply Coordinator (CSC) #263 brought a bottle of multivitamin with minerals to LPN #100 with an expiration date of June 2024. LPN #100 placed the bottle of vitamins in the medication cart. Interview on 08/12/24 at 11:49 A.M. with LPN #100 confirmed she gave the multivitamin with minerals to Resident #04 at approximately 10:30 A.M. LPN #100 confirmed the expiration date on the bottle was June 2024 and the expired medication should not have been given. Review of the facility policy titled Storage of Medications dated August 202 revealed all expired medications would be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on record review, interview and policy review, the facility failed to prepared fortified foods according to the recipe for increased nutritional value . This affected six (Residents #19, # 46, #47, #50, #79 and #89) of six residents ordered a fortified meal. The census was 117. Findings include: Review of the fortified oatmeal recipe included oatmeal, whole milk, powder milk, sugar, and margarine. During an interview on 06/13/24 at 7:44 A.M., [NAME] #139 stated she prepares fortified oatmeal with powdered milk and butter to make it fortified. [NAME] #139 stated she does not use a recipe to know how to prepare fortified foods, including oatmeal, because she has worked at the facility so long. She stated she could not decipher the recipe because it was made for 100 portions, and she only had six residents with fortified orders. Review of facility policy titled Fortified Food Program, undated and Food Quality and Palatability dated 2023, revealed the facility will prepare food to conserve nutritive value and follow the fortified food recipes as a therapeutic intervention. This deficiency represents non-compliance investigated under Complaint Number OH00154764.

Based on observation, interview and record review, the facility failed to provide the food portions and liquids as planned by a Registered Dietitian. This affected nine (Residents #7, #11, #39, #50, #57, #72, #81, #89 and #98) residents. The facility total census was 117. Findings include: Record reviews of Residents #7, #11, #39, #50, #57, #81, #89 and #98 revealed a physician order for puree diet. Review of the breakfast spreadsheet reviewed the puree meal was to be served of six ounces of puree oatmeal, two ounces of puree sausage, and two ounces of puree bread. During an observation on 06/13/24 at 8:22 A.M., [NAME] #139 served four ounces of puree oatmeal, four ounces of puree sausage and three ounces of puree bread. During an interview on 06/13/24 at 11:27 A.M., [NAME] #139 verified she had not followed the spread sheet for puree potions. She verified she had served too little portions of the oatmeal and too much of the bread and sausage. [NAME] #139 stated she does not always follow the spreadsheet, which could affect residents on specialty ordered diets. 34291 2. Review of care plan for Resident #72, dated 12/06/23, revealed he was at risk for nutrition an hydration status. Intervention was to provide and serve diet as ordered. Review of the menu dated 06/11/24 for breakfast revealed residents were to receive either eight ounces of mile, six ounces of tea or coffee and four ounces of orange juice. During an observation on 06/11/24 at 9:00 A.M., Resident #72 was not served any milk, tea or coffee. During an observation on 06/12/24 at 9:15 A.M., Resident #72 again was not served any milk, tea or coffee. During an interview with on 06/12/24 at 9:20 A.M., Dietician #264 confirmed Resident #72's meal ticket included beverages, but he was not served them. Review of facility policy titled, Food Quality dated, 2023, revealed the facility will serve food to meet the resident's needs. This deficiency represents non-compliance investigated under Complaint Number OH00154764.

Based on observation, record review, interview and policy review, the facility failed to ensure personal hygiene was provided for residents. This affected three (Residents #72, #79, and #102) of three residents reviewed for personal hygiene. The census was 117. Findings include: 1. Review of the care plan for Resident #72, dated 10/28/23, revealed he had activities of daily living (ADL) deficits and required assistance with ADL. During observation Observations on 06/10/24 at 11:36 A.M., 06/11/24 at 9:00 A.M. and on 06/12/24 at 2:30 P.M. revealed Resident #72 had jagged nails that came over his fingers and had a yellow brownish substance under his nails. During interview on on 06/12/24 at 2:30 P.M., Licensed Practical Nurse (LPN) #237 confirmed Resident #72's nails were long, jagged, and had a yellowish brownish substance under them. 2. During an observation on 06/12/24 at 2:28 P.M., Resident #89 had long, jagged nails that had a yellowish, brownish substance under the nails. During an interview on 06/12/24 at 2:30 P.M., LPN #237 confirmed Resident #89's nails were long jagged and dirty under the nails. She stated they needed to trimmed and cleaned. 3. Review of care plan for Resident #102 dated 12/29/23 revealed he had ADL deficits and required assistance with ADL. During observation of a dressing change on 06/12/24 at 10:19 A.M., Resident #102 feet were yellowed and in between his toes was yellowish and scaly. During an interview on Interviews with on 06/12/24 at 10:30 A.M., State tested Nurse Aide (STNA) #211 and Registered Nurse (RN) #161 confirmed the resident's feet and in between the toes were yellowed and scaly and stated it doesn't look like they have been washed recently. Review of the policy titled Skin Care, undated, revealed daily hand washing will be completed with nail care to include cleaning and trimming or filing of sharp edges to prevent infection and damage to skin from scratching Residents/patients will receive skin care daily. Skin care includes, but is not limited to: foot care and moisturizing. This deficiency represents non-compliance investigated under Complaint Numbers OH00154564 and OH00154583.

Based on observation, clinical record review, staff interview, physician interview and review of the facility guidelines for prevention and treatment of [REDACTED].g. tendon or joint capsule) pressure ulcer on the bony surface above the right ankle. The facility had extensive failure in multiple areas of pressure ulcer care including assessment, physician notification, plan of care revision, monitoring and pressure relief from an immobilizer device. This resulted in Immediate Jeopardy for one (Resident #14) of three sampled residents with pressure ulcers. The facility also failed to ensure Resident #97's recurrent unavoidable Stage II pressure ulcer was reported to the physician and treatment ordered to promote healing. The facility identified five residents with pressure ulcers in a census of 107. On 09/17/10 at 3:00 P.M., the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #8 were notified Immediate Jeopardy began on 07/07/10 at 1:00 P.M. when LPN #741 identified a Stage IV pressure ulcer on Resident #14's right lower leg above the ankle under the immobilizer device. The pressure ulcer measured 3.0 centimeters (cm) by 1.5 cm; the area around the wound was red and the wound bed had yellow slough (necrotic tissue separating from the body) and yellow drainage. On 07/20/10, the Stage IV pressure ulcer was 6.5 cm long, 3.0 cm wide with slough, necrotic tissue and "appearance of tendons." The Immediate Jeopardy was removed on 07/20/10 when the facility implemented the following corrective actions: - On 07/19/10, Physical Therapist #10 assessed Resident #14 for positioning and ensured pressure relief interventions were appropriate; - On 07/20/10, Corporate RN #9 investigated and determined Resident #14 developed an avoidable pressure ulcer under the immobilizer, which had a vertical rod along the length of the device in the area of the [MEDICAL CONDITION] and resulted in a Stage IV pressure ulcer; - On 07/20/10, the DON and the restorative nursing RN #15 determined nine residents had a splint, foot brace, prosthetic device or abdominal binder which increased their risk for pressure ulcers; - On 07/20/10, nurse managers RN #15, LPN #16 and LPN #17 assessed the skin integrity for the nine residents at risk and determined none had pressure ulcers; - On 07/20/10, RN #8 obtained physician orders for daily skin inspections under the devices for the nine residents at risk and ensured plans of care and treatment administration records were revised to include the daily skin inspections; - On 07/20/10, RN #8 educated all 39 LPN and RN staff to monitor skin for reddened areas when a device was used. Education included care and prevention of pressure ulcers. Although the Immediate Jeopardy was removed when the facility identified residents at risk for pressure ulcers from devices and physician orders were implemented for daily skin assessment, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) because Resident #97's recurrent unavoidable Stage II pressure ulcer was not reported to the nurse and the physician was not notified for treatment orders to promote healing. Findings include: 1. Clinical record review revealed Resident #14 was admitted in 1999 and had current [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #14 had moderate cognitive impairment, required staff assistance for activities of daily living, including bed mobility, was incontinent and had no pressure ulcers. The care plan dated 10/21/08 for potential for tissue integrity impairment related to urinary incontinence and decreased mobility due to cognitive impairment included interventions: assess skin status; keep physician informed; follow the medical plan for treatment; keep skin clean and dry; expose to air frequently; encourage and assist to reposition; inspect skin every shift; and report changes. Nursing notes dated 06/01/10 at 3:53 A.M. by Licensed Practical Nurse (LPN) #618 revealed Resident #14 was admitted to the hospital with [REDACTED]." Nursing notes by Registered Nurse (RN) #5 dated 06/02/10 at 10:13 P.M. revealed the resident returned to the facility at 8:30 P.M. with "immobilizer in place" and pedal pulses palpable. The note did not include an assessment of skin under the immobilizer or physician clarification of the medical plan for treatment of [REDACTED]. The plan of care for tissue integrity impairment was not revised to include use of the immobilizer device and interventions to prevent pressure ulcer development under the device were not implemented. Nursing notes dated 06/03/10 at 2:31 A.M. by RN #5 titled "Braden Scale/Pressure Risk" revealed Resident #14 had no impairment related to sensory perception, skin was often moist, the resident was chairfast, mobility was very limited, nutrition was probably inadequate, friction and shear was a potential problem, and the skin had scratches on the left trunk and bruises on the right leg. The pressure ulcer assessment indicated Resident #14 was at "low risk" for pressure ulcers and interventions were in place. The assessment did not include the presence of the right leg fracture, use of the immobilizer device or condition of the skin under the device. Nursing notes dated 06/03/10 at 1:54 P.M. by LPN #11 revealed the resident's skin had good turgor, was free of redness and rashes and the resident had a knee immobilizer on the right knee. Pedal pulses were present and both feet had 1+ [MEDICAL CONDITION]. The note did not include assessment of the skin under the immobilizer device. Nursing notes dated 06/04/10 at 6:45 P.M. by LPN #606 documented the Orthopedic Surgeon #2 was contacted regarding the resident's [DIAGNOSES REDACTED]." The plan of care for tissue integrity impairment was not revised to include nursing requirements for bathing and care of the right leg due to fracture and use of the immobilizer device. Review of nursing notes dated 06/03/10 until 07/04/10 revealed there were no notes regarding bathing and care and there were no assessments of Resident #14's skin under the immobilizer device on the right leg. Nursing notes dated 07/04/10 at 6:45 A.M. by LPN #12 revealed the resident had redness on the right foot, 3+ (increased) [MEDICAL CONDITION] and the foot was "soft, tender, distended". Physician #1 was notified and ordered Bactrim DS, an antibiotic, twice daily for seven days for possible infection. Nursing notes by LPN #7 and LPN #741 dated 07/06/10 at 9:24 A.M. and 9:48 A.M. revealed Physician #1 was in "to see" the resident and there were no new orders. Review of physician progress notes [REDACTED]. Physician #1 documented the resident had [MEDICAL CONDITION], continued on Bactrim, had a right knee impaction fracture and dementia. Physician #1 did not document removal of the immobilizer device and observation of the resident's skin. Nursing notes dated 07/07/10 at 1:09 P.M. by LPN #741 revealed a new treatment order from Physician #1 for an "open area right calf". A late entry nursing note dated 07/20/10 at 12:25 P.M. by LPN #741 for 07/07/10 revealed a wound on the "right posterior lower leg" which measured 3.0 centimeters (cm) by 1.5 cm. No depth was recorded. Peri (around) the wound was red; inside the wound was yellow slough (necrotic tissue separating from the body) and yellow drainage. Nursing notes did not include an assessment of how the pressure ulcer developed, including pressure from the immobilizer device. The plan of care was not revised to include interventions to eliminate pressure and promote healing of the pressure ulcer. On 07/12/10, Physician #1 ordered the facility to contact Orthopedic Surgeon #2 to discontinue the immobilizer due to discovery of the pressure ulcer. Weekly wound measurement notes dated 07/13/10 at 1:20 P.M. by RN #8 revealed the wound on the right lower lateral leg was unstageable, Stage IV pressure ulcer for MDS purposes and defined as full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (tendons, joint capsule). RN #8 documented the pressure ulcer was oval, length 6.0 cm, width 1.5 cm, had light necrotic color wound bed with necrotic (dead) tissue and eschar (thick devitalized tissue) was present. RN #8 did not document pressure ulcer depth. RN #8 documented a request to discontinue the brace (immobilizer device) until the area was healed. Nursing notes dated 07/15/10 at 6:28 P.M. by LPN #606 revealed "ortho" did not return a call regarding discontinuing the brace on the right lower leg and "will attempt tomorrow to get order." On 07/16/10 at 8:20 A.M., LPN #606 wrote, immobilizer present on right leg; will attempt to call "ortho" back to discontinue until area on leg is healed. On 07/19/10 at 10:00 A.M., seven days after Physician #1 ordered the facility to contact Orthopedic Surgeon #2 to discontinue Resident #14 ' s immobilizer, the facility received a telephone order from Orthopedic Surgeon #2 to discontinue the knee immobilizer. Review of treatment records completed by nurses from 06/03/10 through 07/19/10 revealed the knee immobilizer was continuously applied to Resident #14's right leg. Weekly wound measurement notes dated 07/20/10 at 4:18 P.M. by RN #8 revealed the pressure ulcer was 6.5 cm long, 3.0 cm wide oval Stage IV with slough, necrotic tissue and "appearance of tendons." No pressure ulcer depth was recorded. Pressure ulcer progress notes by RN #8 showed the tendon was still exposed on 08/23/10 and 08/26/10. On 09/02/10, RN #8 documented the pressure ulcer measured 5.0 cm by 3.0 cm with no depth recorded. Eschar covered the entire ulcer bed. On 09/04/10 at 12:50 P.M., interview with RN #8 revealed she was responsible for treatment of [REDACTED]. RN #8 affirmed Resident #14 ' s plan of care was not revised to address the resident's increased risk for pressure ulcers after the right leg fracture and application of the immobilizer device. RN #8 further affirmed the plan of care was not revised when Resident #14 had a pressure ulcer from the immobilizer on 07/07/10 and the use of the device continued through 07/19/10. RN #18 also affirmed the record did not include documentation that staff checked under the immobilizer device and inspected the resident ' s skin to ensure skin integrity was maintained. RN #8 stated the pressure ulcer was Stage IV when discovered and the resident also had [MEDICAL CONDITION] and [MEDICAL CONDITION] in the right leg which increased the risk for skin breakdown from the immobilizer device. Resident #14's pressure ulcer treatment was observed on 09/17/10 at 1:15 P.M. The Stage IV pressure ulcer was located on the right lower leg bony area immediately above the right ankle. Measurement by RN #8 showed the ulcer was 5.5 cm long, 2.0 cm wide with no depth, oval shaped and covered with brown eschar. The wound bed had bright pink tissue at the margins. During interview on 09/17/10 at 9:50 A.M. with LPN #741 and LPN #606, they both stated they removed the immobilizer and inspected the resident ' s skin (times not specified); however, they did not document removal of the device or the skin inspection. During telephone interview on 09/17/10 at 1:50 P.M., Physician #1 stated Resident #14 developed a pressure ulcer from use of the immobilizer. Physician #1 read a letter from Orthopedic Surgeon #2 regarding a follow up visit for Resident #14 on 06/30/10. The letter made no reference to a pressure ulcer. Physician #1 stated on 07/12/10 she ordered staff to consult Orthopedic Surgeon #2 and get the immobilizer discontinued. During telephone interview on 09/22/10 at 10:40 A.M., LPN #741 stated the immobilizer device extended from mid-thigh to the right ankle and had a metal bar on each side. The device was secured to the leg with Velcro straps. LPN #741 stated she released the Velcro straps somewhat when the resident's ankle and foot had increased [MEDICAL CONDITION]. LPN #741 further stated she worked day shift on 07/05/10 and night shift nurse LPN #12 reported Resident #14 had a red area on the right lower leg above the ankle under the immobilizer and he applied a gauze wrap around the leg over the red area. LPN #741 further stated she worked on 07/06/10, did not remove the dressing because she thought it was scheduled for a night shift dressing change and did not realize there was no physician order for [REDACTED]. LPN #741 stated neither she nor Physician #1 opened the immobilizer to observe the skin. LPN #741 further stated, when she opened the immobilizer on 07/07/10 at 1:00 P.M., the gauze dressing dated 07/04/10 was wrapped around the resident's lower leg. When she removed the dressing, she observed the Stage IV pressure ulcer described in her late entry nursing notes for 07/07/10. Facility Guidelines for Prevention of Pressure Ulcers dated 2007 stated the facility should initiate the resident specific protocol, if appropriate, for a resident who was assessed at low risk for the development of a pressure ulcer. Assessing the skin frequently is necessary to note any areas of concern and is performed by a licensed nurse. Documentation of any skin issues should occur on the Skin Sweep Form and signed. If something is noted, it then becomes the nurse's responsibility to initiate a plan of care. The guidelines contained no protocol approved by the Medical Director with interventions for a resident with immobilization device or splint. Facility Treatment Guidelines for Pressure Ulcers and Wounds dated 2007 included: Establish and implement an individualized treatment program for any type of wound based on: type of wound, contributing factors; presence of infection and odor; presence of pain; amount of drainage; nutritional status; availability products and physician order. Assess the wound; document care provided; and develop a plan of care following the protocol pre-approved by the Medical Director. The guidelines contained no protocol approved by the Medical Director with interventions for a resident with immobilization device or splint. According to the Lippincott Manual of Nursing Practice, 7th edition, page 1008, nursing care after musculoskeletal trauma includes: relieve pressure caused by immobilization devices as prescribed; and relieve pressure on the skin to prevent development of a pressure sore. 2. Clinical record [DIAGNOSES REDACTED]. The resident ' s plan of care for potential skin breakdown dated 07/12/10 stated to inspect the feet daily for blisters, cuts, sores and report to the physician. The Minimum Data Set (MDS) assessment dated [DATE] stated the resident had modified independence for decision making, required staff assistance with bed mobility, transfer and had two pressure ulcers, Stage II and Stage III. The facility ' s monthly pressure ulcer report for September 2010 documented Resident #97 had a Stage III pressure ulcer on the left heel, which developed at the hospital, and a Stage II pressure ulcer on the right heel, which developed in the facility on 07/28/10. The document revealed the Stage II pressure ulcer on the right heel was healed on 09/16/10. LPN #970 was observed during the pressure ulcer treatments to Resident 97 ' s feet on 09/17/10 at 1:30 P.M. The resident had gauze dressings on both feet. LPN #970 stated she did not know why or by whom the resident's right foot was wrapped in gauze. LPN #970 removed the gauze and discovered a Stage II pressure ulcer to Resident #97 ' s right heel. The Stage II pressure ulcer was elongated and irregular in shape and measured 2.2 cm long and 0.3 cm wide with no depth. The surrounding skin was fragile, light pink and scarred. LPN #970 stated she was not aware of the recurring pressure ulcer on the right heel and stated there was no physician ordered treatment the resident ' s right heel. She further stated no one reported the pressure ulcer on 09/17/10. The resident was unable to state when the open area developed. Interview with RN #8 on 09/17/10 at 2:20 P.M. revealed no one reported to her that the healed Stage II pressure ulcer of the resident's right foot recurred. RN #8 did not know how the pressure ulcer recurred or why staff did not report the open area. The physician was not notified and no treatment order was obtained. RN #8 said she was responsible for weekly wound measurements and staff are supposed to report any pressure ulcers to her for follow up. This citation substantiated Complaint Control Number OH 087.