Every finding on record at Union City Care Center

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure foods were served and handled in a manner to prevent contamination. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.Findings include:1. Observation on 05/06/26 at 11:40 A.M. revealed Dietary Manager (DM) #244 wore gloves to scoop up pasta shells and green beans. DM #244, while wearing the same gloves she touched serving utensils and plates with, picked up a slice of garlic toast with the gloved hand and put it on the lunch plates. Interview on 05/06/26 at 11:59 A.M. with DM #244 confirmed she should have used kitchen tongs to pick up the bread slices and place on the plate rather than the gloved hands she used to touch serving utensils and plates. 2. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses of acute respiratory failure, generalized muscle weakness, contracture, dysphasia, major depressive disorder, anxiety disorder, and essential hypertension. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, was dependent for activities of daily living (ADLs), and required moderate assistance with transfers.Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses of Parkinson's disease, schizophrenia, chronic bronchitis, chronic obstructive pulmonary disease, bipolar disorder, muscle weakness, anxiety and fibromyalgia. Review of the MDS assessment dated [DATE] revealed Resident #36 was cognitively intact, required moderate assistance with dressing, bathing, and toileting, and required touch assistance for transfers.Observation of meal trays being passed out in the dining room on 05/04/26 at 11:38 A.M. revealed Certified Nurse Aide (CNA) #212 did not wash or sanitize her hands between passing out plates to residents. CNA #212 passed out a plate of food to Resident #3 and served him without performing hand hygiene. CNA #212 then went on to serve Resident #36 as well without performing hand hygiene in between residents.Interview with CNA #212 on 05/04/26 at 11:45 A.M. confirmed she did not perform hand hygiene between residents. CNA #212 confirmed she should have sanitized her hands after passing out one plate and before touching another plate.Review of policy titled, Handwashing/Hand Hygiene, dated 12/25, revealed hand hygiene was indicated before preparing or handling food, after touching the resident's environment, and after glove removal.

Based on medical record review, staff interview, resident representative interview, resident interview, and policy review, the facility failed to ensure quarterly care conferences were conducted. This affected four residents (#3, #7, #9, and #22) out of twelve residents reviewed for care planning. The facility census was 38.Findings include:1. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses including unspecified dementia, repeated falls, cognitive communication deficit, generalized weakness, Type II diabetes, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, required set-up assistance for activities of daily living (ADLs), and touch assistance for transfers. Record review of care plan conferences revealed the facility held a care conference for Resident #7 on 04/30/25. The next documented care conference was on 03/18/26. Interview on 05/05/26 at 1:45 PM with the Director of Nursing (DON) confirmed Resident #7's medical record did not have documentation to support care conferences were completed quarterly. 2. Review of the medical record for Resident #3 revealed an admission date of 02/06/14 with medical diagnoses including diabetes mellitus, obstructive and reflux uropathy, dementia, and history of traumatic brain injury. Review of the quarterly MDS assessment, dated 04/22/26, revealed Resident #3 had severe cognitive impairment, was dependent upon staff for toilet hygiene and bathing, and required partial/moderate staff assistance with bed mobility and transfers. Review of the medical record for Resident #3 revealed care conference notes dated 03/18/25 and 03/10/26. The conference note dated 03/10/26 revealed Resident #3's Power of Attorney (POA) could not attend the meeting and attendees included the DON, a therapy representative, and the Administrator. Review of the medical record revealed no documentation to support the facility conducted a care conference meeting after 03/18/25 until 03/10/26. Interview on 05/04/26 at 11:57 A.M. with Resident #3's representative stated he had only attended one care conference in the past year. Interview on 05/05/26 at 1:45 P.M. with the DON confirmed the medical record for Resident #3 had no documentation to support the facility conducted a care conference quarterly after 03/18/25. 3. Medical record review for Resident #9 revealed an admission date of 12/02/24 with diagnoses including but not limited to chronic kidney disease, chronic obstructive pulmonary disease, type two diabetes mellitus, epilepsy, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] for Resident #9 revealed the resident had intact cognition, required set up assistance for eating and toileting, and was independent for bed mobility and transfer. Review of the plan of care for Resident #9 revealed the resident and family opted for the resident to be a do not resuscitate comfort care only advanced directive (DNR-CCA). Interventions include to address advance directives and code status quarterly and as needed, honor responsible party and residents wishes, and invite family and friends to attend care conferences. Review of the MDS schedule for Resident #9 revealed quarterly assessments were completed on 03/12/25, 09/05/25, 03/06/26, and 04/23/26. Further review of the completed MDS assessments revealed comprehensive assessments were completed on 12/10/24. Review of the facility advance care plan/care conference documentation for Resident #9 revealed care conferences were conducted on 03/04/25, 06/03/25, and 04/15/26. Additional review revealed Resident #9 participated and signed the document on 06/03/25 and 04/15/26. Interview on 05/04/26 at 12:00 P.M. with Resident #9 stated he was not sure what a care conference was and stated maybe the facility was inviting his family. 4. Medical record review for Resident #22 revealed an admission on [DATE] with diagnoses including but not limited to type one diabetes mellitus, atherosclerotic heart disease, legal blindness, and peripheral vascular disease. Review of the comprehensive MDS assessment for Resident #22 dated 04/03/26 revealed the resident was assessed with moderate cognitive impairment; required set up assistance for eating, toileting, and bed mobility; and required supervision for transfers. Review of the facility MDS schedule for Resident #22 revealed completed quarterly MDS assessments dated 01/17/25, 07/18/25, 10/18/25, and 01/16/26. Further review of the MDS schedule for Resident #22 revealed a comprehensive assessment dated [DATE] was completed. Review of the plan of care for Resident #22 revealed the resident exhibited cognitive impairments related to long-term memory problems, impaired decision-making ability, forgetfulness, and blindness. Interventions included review drug profile to eliminate unnecessary medication, monitoring infections, pain, changes in cognition, medications as ordered, and ensure staff introduces themselves with each interaction with the resident. Review of the advance care planning care conference for Resident #22 revealed one care conference dated 04/15/26. Review of the signed participants revealed one nurse, one physical therapist and the Administrator attended the conference. Additionally, a note on the bottom on the page revealed the family member was unable to attend. Interview on 05/05/26 at 2:00 P.M. with the DON verified the facility did not have any other care conference documentation for Resident #22 or Resident #9. Additionally, the DON verified the facility only conducted one care conference for Resident #22 since the admission on [DATE]. Review of policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed the interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on medical record review, staff interview, and review of resident personal needs accounts and receipts, the facility failed maintain an accurate accounting of resident funds. This affected three (#6, #10, and #8) of three residents reviewed for resident personal funds accounts. The facility census was 38. Findings include:1. Medical record review for Resident #6 revealed an admission dated of 01/09/24 with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 revealed the resident was assessed with intact cognition and required set up assistance for eating and bed mobility, and moderate assistance for toileting and transfers. Review of the facility's petty cash receipts for Resident #6 revealed a transaction from the resident needs fund, dated 03/13/26 for $5.71. Further review of the receipts revealed the resident's initials and staff initials were of similar handwriting. A second receipt dated 04/10/26 for $9.17 for Resident #6 revealed signatures by the resident and a staff member. Both receipts had noted shopping in the description of item or service purchased section of the receipt. Review of the trust transaction history ledger for Resident #6 dated 03/09/26 to 04/30/26, included line item deductions, dated 03/13/26 for $5.71 and a line item dated 04/14/26 for $9.17. 2. Medical record review for Resident #10 revealed an admission dated 07/24/2017 with diagnoses including but not limited to dementia with agitation and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] for Resident #10 revealed the resident had intact cognition, required set up assistance for eating, and was coded as independent for bed mobility, toileting, and transfers. Review of the facility's petty cash receipts for Resident #10 revealed four transactions from the resident needs fund, the receipts dated 03/13/26 for $13.38, 03/13/26 for $6.00, 04/10/26 for $19.91, and 04/24/26 for $12.00. Further review of the receipts revealed the resident's initials and the staff member's initials were similar handwriting on both receipts dated 03/13/26. There were no initials on the 04/10/26 receipt and only the facility staff member's initials were on the 04/24/26 receipt. All four receipts had noted shopping in the description of item or service purchased section of the receipt. Review of the trust transaction history ledger for Resident #10 dated 03/03/26 to 04/30/26, included line-item deductions, dated 03/09/26 for $22.05, 03/13/26 for $6.00, 03/13/26 for $13.38, and 03/24/26 for $12.00. Additionally, the ledger contained withdraws 04/06/26 for $28.05 and 04/27/26 for $12.00. 3. Medical record review for Resident #8 revealed an admission on [DATE] with diagnoses including but not limited to heart disease and neurocognitive disorder with behaviors. Review of the quarterly MDS assessment for Resident #8 dated 04/03/26 revealed the resident was assessed with mild cognitive impairment, required set up assistance for eating, and supervision for bed mobility, toileting, and transfers. Review of the facility's petty cash receipts for Resident #8 revealed two transactions from the resident needs fund, the receipts dated 03/05/26 for $9.36 cents and 04/24/26 for $30.00. Further review of the receipts revealed the resident's initials were written in the same handwriting of the staff member on the receipt dated 03/05/26, and only the staff initials were on the 04/24/26 receipt. Both receipts had noted shopping in the description of item or service purchased section of the receipt. Review of the trust transaction history ledger for Resident #8 dated 03/03/26 to 04/30/26, included line-item deductions, 03/05/26 for $9.36 and on 04/24/26 for $30.00. Interview on 05/06/26 at 5:12 P.M. with the Administrator verified the receipts were not completed accurately and lacked the required resident and witnesses signatures. The Administrator verified some receipts did not have resident signatures or initials, some only had the Activity Director's initials, and some had no signatures at all. The Administrator verified one receipt for Resident #10 was not posted on the correct trust ledger for $19.91. The Administrator verified the amount was posted to the wrong resident and would be corrected. The Administrator additionally verified receipts for Resident #6 and Resident #10 were not balanced with the ledger on the day of the expenditure occurred. Request for facility policy related to resident trust funds was requested during the survey and not provided for review.

Based on medical record review, staff interview, and policy review, the facility failed to notify the physician of significant weight loss. This affected one (#20) out of two residents reviewed for nutrition. The facility census was 38.Findings include:Review of the medical record for Resident #20 revealed an admission date of 02/12/19 with medical diagnoses of diabetes mellitus, schizoaffective disorder, dementia with behavioral disturbances, and heart failure.Review of Resident #20's quarterly Minimum Data Set (MDS) assessment, dated 03/25/26, revealed the resident was cognitively intact, required partial/moderate staff assistance with bed mobility and transfers, was dependent upon staff for toilet hygiene, and required set-up assistance with eating. The MDS assessment indicated Resident #20 had a significant weight loss and was not on a physician prescribed weight loss program. Review of Resident #20's physician orders revealed an order dated 09/10/24 for weekly weights and an order dated 12/11/25 for a no added salt, carbohydrate-controlled diet, with regular texture and thin liquids. Review of the physician orders revealed no orders for meal supplements.Review of a significant weight loss note dated 04/18/26 revealed Resident #20 had a five percent (5%) weight loss on 03/10/26 (with a loss of 11.8 pounds), 7.5% weight loss since 01/20/26 (with a loss of 13.8 pounds), and a 10 weight loss since 10/21/25 (with a loss of 20.4 pounds). The note reveale3d Resident #20's weight fluctuations were likely related to fluid shifts and to continue to monitor weights, intakes, skin, laboratory values, and tolerance of diet. Review of the note revealed no documentation to support the facility notified the physician of the significant weight loss. Interview on 05/07/26 at 8:31 A.M. with Registered Dietician (RD) #300 stated Resident #20's had edema and her weight fluctuated due to fluid. RD #300 stated Resident #20's weight had stabilized and no supplements were recommended. RD #300 stated the facility staff are to notify the physician of any significant weight loss. Interview on 05/07/26 at 8:40 A.M. with the Director of Nursing (DON) confirmed the facility had not notified Resident #20's physician of the significant weight loss. The DON stated she was not even aware Resident #20 had a significant weight loss. Review of the facility policy titled, Weight Assessment and Interventions, revised March 2022, revealed resident weights are monitored for undesirable or unintended weight loss or gain. The policy revealed the threshold for significant unplanned and undesired weight loss would be based on the following criteria of one month with 5% weight loss was significant, greater than 5% was severe, three months with 7.5% weight loss was significant; greater than 7.5% was severe, and six months with 10% weight loss was significant; greater than 10% was severe. The policy revealed the physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss.

Based on medical record review, staff interview, and policy review, the facility failed to complete a discharge summary and a recapitulation of stay upon resident discharge. This affected two (#41 and #44) residents out of three reviewed for discharges. The facility census was 38.Findings include:1. Review of the medical record for Resident #41 revealed an admission date of 05/12/25 with medical diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, delusional disorders, hypertension, and unspecified psychosis. Resident #41 transferred to another nursing facility on 02/03/26. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, revealed the resident had moderate cognitive impairment and was independent with bed mobility, transfers, toileting, and bathing. Review of Resident #41's nursing note dated 01/14/26 at 1:51 P.M. revealed a care conference was held with the resident's Guardian via telephone. The note revealed and update was provided on transfer status, and medications, the most recent doctor note, weights, and code status were all reviewed. The note revealed per the Guardian's request, Resident $31 would be transferring to another nursing facility (date to be determined) to be closer to the Guardian and long-term girlfriend. Review of the nursing note dated 02/03/26 at 12:06 P.M. revealed Resident #41 was transferred to another nursing facility per the Guardian's request. Review of the medical record for Resident #41 revealed no documentation to support the facility completed a discharge summary or recapitulation of stay. 2. Review of the medical record for Resident #44 revealed an admission date of 03/20/26 with medical diagnoses of acute kidney failure, Parkinson's disease, asthma, dementia, and congestive heart failure. Resident #44 transferred home on [DATE].Review of Resident #44's admission MDS assessment, dated 03/28/26, the resident was assessed with severely impaired cognition, required substantial/maximum staff assistance with toilet hygiene and bathing, and partial/moderate staff assistance with bed mobility and transfers.Review of Resident #44's nursing note, dated 03/27/26 at 11:05 A.M., revealed an appeal was denied and Resident #44's son was notified of the last covered day of service being 03/28/26. The note revealed a planned discharge was set for 03/29/26.Review of the medical record for Resident #44 revealed no documentation to support the facility completed a discharge summary or recapitulation stay. Interview on 05/05/26 at 3:20 P.M. with the Director of Nursing (DON) confirmed both Resident #41 and Resident #44 discharged from the facility and neither resident's medical record had documentation to support a discharge summary or recapitulation of stay were completed.Review of the facility policy titled, Discharge Summary and Plan, revised March 2025, revealed when a resident's discharge was anticipated, a discharge summary was created, and the discharge plan was finalized to assist the resident plans for care after discharge. The policy revealed a discharge summary provides necessary information for continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. The policy revealed by the time the resident leaves the facility, the discharge summary was furnished to the provider who was assuming responsibility for care of the resident after discharge. The discharge summary may be provided in printed or electronic format, and the medical record contained a copy of the discharge summary with identity of the recipient of the summary.

Based on medical record review, staff interview, and policy review, the facility failed to develop comprehensive person-centered care plans to address resident needs. This affected two (#31 and #35) residents out of twelve residents reviewed for care plans. The facility census was 38.Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/23/24 with medical diagnoses of chronic obstructive pulmonary disease, hypertension, and major depression.Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 03/05/26, revealed the resident was assessed with severe cognitive impairment, was independent with bed mobility and transfers, required supervision with toilet hygiene, and required partial/moderate staff assistance with bathing. Review of Resident #31's physician orders revealed an order dated 03/27/26 for Zoloft (antidepressant) 50 milligram (mg) one tablet by mouth every evening for depression.Review of Resident #31's care plans revealed no documentation to support the facility developed a comprehensive person-centered care plan to monitor the resident's use of an antidepressant medication. 2. Review of the medical record for Resident #35 revealed an admission date of 03/06/26 with medical diagnoses of bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety. Review of Resident #35's significant change MDS assessment, dated 04/29/26, revealed the resident was assessed with severe cognitive impairment; required supervision with transfers, bed mobility, and eating; and was dependent upon staff for toilet hygiene. The MDS indicated Resident #35 received hospice services.Review of Resident #35's care plans revealed no documentation to support the facility developed a comprehensive person-centered care plan for hospice services that included hospice provider name, contact information, or types of services provided by hospice.Interview on 05/06/26 at 2:58 P.M. with the Director of Nursing (DON) confirmed the facility had not developed comprehensive person-centered care plans to address Resident #31's use of antidepressant medication or Resident #35's hospice care and services. Review of the facility policy titled, Care Plans, Comprehensive Person- Centered, revised March 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The policy revealed each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of his/her plan of care. The policy also revealed the residents are informed of his/her right to participate in his/her treatment and provided advance notice of care planning conferences. The policy revealed the interdisciplinary team reviewed and updates the care plan when there was a significant change in the resident's condition, when desired outcome was not met, resident has been readmitted to the facility from hospital stay and at least quarterly in conjunction with the required Minimum Data Set (MDS) assessment.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure referrals to specialized medical professionals to address impaired hearing were arranged as recommended. This affected one (#9) of one residents reviewed for hearing loss. The facility census was 38. Findings include:Medical record review for Resident #9 revealed an admission date of 12/02/24 with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes mellitus, epilepsy, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident had intact cognition. Resident #9 was coded with highly impaired hearing without hearing devices and was assessed as requiring set up assistance for eating and toileting, and was independent for bed mobility and transfer. Review of the plan of care for Resident #9 revealed the resident presented with a sensory impairment which may adversely affect participation in activities of interest related to impaired hearing and vision. Interventions included inviting the resident to programs of interest, assist with decreasing background noises as needed during activities of interest, and provide positive reassurance to the resident when attending activity programs. Review of the audiology appointment for Resident #9 dated 03/11/25 revealed the resident was alert and oriented with hearing loss with normal conversational tones. Resident #9 suffered from fetal alcohol syndrome which greatly affected his hearing and vision. Resident #9 reported left ear pain at the time of the visit. Resident #9 was treated for left sided otitis media (infection of the middle ear) with amoxicillin (antibiotic) 500 milligrams (mg) by mouth two times a day for fourteen days. A progress notes indicated a follow up with the primary care physician in fourteen days to recheck ears after antibiotic treatment was completed. Further review of the visit documentation note for Resident #9 revealed the removal of ear wax impaction and a referral to an audiologist for additional testing. Reveal of the nurse practitioner (NP) progress note for Resident #9 dated 04/09/25 revealed a visit was made for pain management. A physical examination of the head, nose, ears and throat for Resident #9 revealed no abnormalities. It was noted the resident was hard of hearing with the right ear being the best to speak into for communication. Interview and observation on 05/04/26 at 12:21 P.M. revealed Resident #9 motioning to speak into his right ear for communication and motioning to come closer. Resident #9 stated he was unable to hear from his left ear and his hearing in the right ear was very limited. Resident #9 confirmed he did not have any hearing aids at the time and has not been evaluated for them. Interview with the Administrator on 05/05/26 at 11:59 A.M. verified the referral to an audiologist was never made for Resident #9. Review of the undated facility policy titled, Referral Agreements, revealed the facility entered into referral agreements with agencies that will provide services to residents. Inquiries concerning the availability and use of the referral agencies should be directed to social services or the Administrator.

Based on medical record review, fall investigation document review, staff interview, and policy review, the facility failed to complete neurological evaluations for residents following unwitnessed falls. This affected one (#1) resident out of two residents reviewed for accidents. The facility census was 38. Findings include:Review of the medical record for Resident #1 revealed an admission date of 10/08/13 with medical diagnoses of peripheral vascular disease, Alzheimer's disease, and aortic aneurysm. Review of the Resident #1's Minimum Data Set (MDS) assessment, dated 02/24/26, revealed the resident had severely impaired cognition, required substantial/maximum assistance for transfers and bed mobility with no ambulation noted, and was dependent upon staff for toilet hygiene. The MDS assessment indicated Resident #1 sustained a fall with major injury. Review of Resident #1's fall investigation report dated 01/17/26 revealed the resident had an unwitnessed fall and was found on the floor on the side of the bed. The report revealed Resident #1 was unable to recall what happened and the resident was alert and oriented to person and place, and had no apparent injuries. The evaluation indicated Resident #1's family and the physician assistant (PA) were notified. Review of Resident #1's fall investigation report dated 02/19/26 revealed the resident had an unwitnessed fall and was found on the floor in front of his bed. The report revealed Resident #1 was alert to person only, was unable to recall what happened, and complained of hip pain. The report revealed the family and the PA were notified. Review of the fall investigations and Resident #1's medical record revealed no documentation to support the facility completed neurological evaluations after both unwitnessed falls on 01/19/26 and 02/19/26. Interview on 05/05/26 at 4:52 P.M. with the Director of Nursing (DON) stated staff are to complete and document neurological evaluations of residents after unwitnessed falls. The DON confirmed the medical record for Resident #1 had no documentation to support staff completed neurological evaluations on the resident after the unwitnessed falls on 01/17/26 and 02/19/26. Review of the facility policy titled, Falls-Clinical Protocol, revised March 2018, revealed the nurses shall assess and document/report vital signs, recent injury, musculoskeletal function, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, all current medications, and active diagnoses.

Based on medical record review, staff interview, and policy review, the facility failed to ensure collaboration with a hospice provider for development and implementation of a resident's plan of care. This affected one (Resident #35) of one residents reviewed for hospice services. The facility census was 38.Findings include:Review of the medical record for Resident #35 revealed an admission date of 03/06/26 with medical diagnoses of bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety. Review of Resident #35's significant change Minimum Data Set (MDS) assessment, dated 04/29/26, the resident was assessed with severe cognitive impairment, required supervision with transfers, bed mobility, and eating, and was dependent upon staff for toilet hygiene. The MDS assessment indicated Resident #35 received hospice services. Review of Resident #35's physician orders revealed an order dated 04/24/26 to refer the resident to hospice. Further review revealed no other hospice orders. Review of Resident #35's nursing note dated 04/23/26 at 10:29 A.M. revealed a care conference with the Guardian was held at that time and medications and code stated were reviewed. The note revealed the resident's code status was changed to Do Not Resuscitate Comfort Care (DCRCC) and the Guardian agreed to a hospice referral due to weight loss and change in condition. Review of Resident #35's hospice documentation revealed a nurse visited Resident #35 on 04/23/26, 04/24/26, 04/27/26, and 04/28/26. Further review revealed a hospice aide visited Resident #35 on 04/29/26 and 05/05/26. Review of the hospice aide progress note dated 05/05/26 revealed the facility staff provided Resident #35 with a shower because the facility staff were unaware of the hospice schedule. Review of Resident #35's hospice documentation revealed no information related to the hospice services to be provided or the frequency of the nurse or aide visits. Review of the medical record for Resident #35 revealed no documentation to support the hospice provider or facility collaborated to develop a plan of care. Interview on 05/06/26 at 2:58 P.M. with the Director of Nursing (DON) stated the facility did not conduct a care conference with the hospice provider, facility staff, and Resident #35's representative to develop plan of care. The DON confirmed Resident #35's medical record did not have documentation to support which hospice services were to be provided or the frequency of the services. Review of the facility policy titled, Hospice program, revised July 2017, revealed it was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with hospice representative and ensure that the level of care provided was appropriately based on the individual resident's needs. The facility must communicate with the hospice provider (and document such communication) to ensure that the needs of the residents are addressed and met 24 hours per day. The policy revealed the DON was to coordinate care provided to the resident by the facility staff and the hospice staff. The facility must obtain the following information from the hospice including the most recent hospice plan of care specific to each resident, the hospice election form, the physician certification/recertification, the names and contact information for hospice personnel involved in hospice care of reach resident, instructions on how to access the hospice's 24-hour on-call system, hospice medication information specific to each resident, and the hospice physician and attending physician orders specific to each resident. The policy revealed coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, staff interview, and medical record review, the facility failed to ensure medications were administered in a manner to prevent contamination. This affected two ( #18 and #32) of three residents observed for medication administration. The facility census was 38.Findings include:1. Medical record review for Resident #18 revealed an admission date of 06/03/24 with diagnoses included but not limited to severe bipolar disorder, schizoaffective disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment for Resident #18 dated 03/13/26 revealed the resident had intact cognition, required set up assistance for eating, and was independent with toileting, transfers, and bed mobility.Review of active physicians orders for Resident #18 revealed an order dated 12/15/24 for cholecalciferol tablet 1000 units with instructions to give one (1) tablet by mouth every day for vitamin supplement; an order dated 07/30/24 for docusate sodium oral capsule 100 milligrams (mg) with instructions to give 1 capsule by mouth daily for constipation; an order dated 06/03/24 for clonazepam oral tablet 1 mg with instructions to give 1 tablet by mouth three times a day for bipolar disorder; and an order for ibuprofen oral tablet 200 mg with instructions to give two (2) tablets by mouth every six hours as needed for menstrual cramping.Observation on 05/06/26 at 8:00 A.M. of Registered Nurse (RN) #103 revealed the nurse completed hand hygiene with an alcohol-based hand sanitizer. RN #103 removed keys from her uniform pocket, sorted the keys, and unlocked the medication cart. RN #103 then opened the medication drawer revealing multiple bottles of medication. RN #103 began touching and turning the bottles of medication to locate the prescribed medication. RN #103 unscrewed the lid of a bottle of cholecalciferol tablets tilted the bottle over her hand and poured 2 tablets onto her ungloved hand. RN #103 proceeded to place the 2 tablets into a medication administration cup. RN #103 then placed the bottle back into the medication cart drawer and began picking up multiple bottles of medications before locating the multi-dose bottle of docusate sodium capsules, unscrewed the lid, and poured one capsule into her ungloved hand before placing them into a medication administration cup. RN #103 placed the bottle of medication back into the drawer and again sorted through bottles to locate the multi-dose bottle of ibuprofen 200 mg tablets. RN #103 unscrewed the lid and poured 2 tablets into her ungloved hand and placed the 2 tablets into a medication administration cup. RN #103 placed the multi-dose bottle back into the medication drawer and closed the drawer. RN #103 proceeded to remove her keys from her uniform pocket, pulled a drawer open, and unlocked the narcotic box. RN #103 then touched the individual medication cards looking for the clonazepam 1 mg tablet for Resident #18. RN #103 identified the correct medication and proceeded to push the tablet through the bubble pack so the tablet landed in her ungloved hand, and placed the tablet into the medication administration cup. RN #103 then administered the medication to Resident #18.2. Medical record review for Resident #32 revealed an admission date of 11/21/25 with diagnoses that included but not limited to wedge compression fractures, right sided rib fractures, type 2 diabetes mellitus, and chronic obstructive pulmonary disease.Review of the quarterly MDS assessment for Resident #32 dated 02/26/26 revealed the resident was cognitively intact, required set up assistance for eating, and required supervision for toileting, bed mobility, and transfers.Review of active physicians orders for Resident #32 revealed an order for calcium-vitamin D with minerals oral chewable tablet 600-400 mg with instructions to give 2 tablets by mouth every day for supplement dated 12/13/25; an order dated 11/20/25 for Colace oral capsule 100 mg with instructions to give 1 capsule by mouth every day for constipation; an order for sodium chloride 1 gram (gm) with instructions to give one tablet by mouth every day for hypoosmolality and hyponatremia dated 11/22/25; and magnesium oral tablet 400 mg with instructions to give 1 tablet by mouth two times a day for supplement.Observation on 05/06/26 at 8:15 A.M. with RN #103 revealed the nurse completed hand hygiene using alcohol-based hand sanitizer. RN #103 then removed her keys from her uniform pocket, handled multiple keys prior to unlocking the medication cart, and pulled the drawer open. RN #103 began touching multiple medication bottles to locate the correct medication. RN #103 selected the medication bottle, unscrewed the lid, and poured 2 tablets of calcium-vitamin D chewable tablets into her ungloved hand before pouring the 2 tablets into a medication administration cup. RN #103 placed the bottle of calcium-vitamin D chewable tablets back into the medication cart drawer and proceeded to turn and touch multiple bottles before selecting the bottle of Colace oral capsules. RN #103 unscrewed the lid and poured 1 capsule into her ungloved hand, then placed the capsule into the medication administration cup. RN #103 repeated the same process of touching multiple bottles of medication before selecting the sodium chloride oral tablet 1 gm, unscrewed the lid, and placed the tablet into her hand before sliding the medication into the medication administration cup. RN #103 administered the medication to Resident #32.Interview on 05/06/26 at 8:37 A.M. with RN #103 verified she touched multiple surfaces after completing hand hygiene. RN #103 stated during the medication administration preparation for Resident #18 and Resident #32 she touched medications with her bare hand when removing the medications from the multiple dose bottles and should not have.Interview on 05/06/26 at 9:00 A.M. with the Director of Nursing (DON) verified nursing staff should not touch resident medication with their bare hands.Request for facility policy regarding hand hygiene during medication administration was made during the survey and not provided for review.

Based on record review and interview the facility failed to report an allegation of misappropriation of resident property. This affected one (Resident #10) of three residents reviewed. The facility census was 36.Findings Include:Review of the closed record for Resident #10 revealed she was admitted initially 08/19/25 with re-entry 10/16/25. She was discharged [DATE]. Her diagnoses included chronic pain, protein-calorie malnutrition, major depressive disorder, rheumatoid arthritis, hypertension, metabolic encephalopathy, anemia, hyperlipidemia and gastro-esophageal reflux disease. Review of her admission Minimum Data Set (MDS) dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was eight indicating moderate cognitive impairment. She required set-up assistance for eating, moderate assistance for toileting, maximal assistance for bathing, dressing and personal hygiene. Review of her Care Plan dated 08/20/25 revealed she required healthcare monitoring related to opioid use for chronic pain syndrome and refused non-med interventions. Review of the Physician's Orders for Resident #10 revealed an order for Hydrocodone (opioid)-Acetaminophen (analgesic) 10-325 milligram one tablet every six hours as needed for pain. Interview on 12/11/25 at 12:10 P.M. with the Administrator and the Director of Nursing (DON) revealed when Resident #10 was admitted in August 2025, she arrived late in the day, and her pain medication had not arrived with the evening shipment. Resident #10 called her husband who brought in her pain medication from home. The Administrator stated she instructed the nurse regarding not being able to administer home medication. She reported the Licensed Practical Nurse (LPN) #15 stated she returned the medication to the husband but the husband stated he had not received the medication. The Administrator reported she and the DON met with the nurse and the husband together with the nurse stating she returned the medication and the husband stating she had not returned them. The Administrator confirmed no Self-Reported Incident or investigation was completed. Interviews with three Certified Nurse Aides (CNA) #24, #28 and #53 on 12/11/25 between the hours of 3:05 P.M. and 3:28 P.M. revealed they had heard Resident #10's husband had brought in medication from home for his wife and alleged the nurse had not given the medication back to him. Two of the CNA's (#28 and #53) reported they had seen LPN #15 drop narcotic medication on the floor and then place them in her pocket rather than wasting them per procedure. Interview on 12/11/25 at 4:50 P.M. with the Administrator and the DON verified the husband's signature did not match the signature on the paper supplied by the nurse when he reportedly signed for receipt of the medication. The Administrator and DON stated they had not contacted the police or nursing board, and had not drug tested the nurse as she had brought in a bottle of the same medication revealing she had her own current prescription. They reported her employment was terminated two months later for other reasons. Interview on 12/11/25 at 4:11 P.M. with Resident #10's husband revealed he had brought in about 21 Hydrocodone Acetaminophen pills when Resident #10 was admitted as the pharmacy had not yet been able to deliver this medication. He verified these pills were never returned to him. He reported they had a meeting with the nurse who stated she had given him back the pills and had a paper which she stated he signed for receipt of the medication. He stated he had never signed a paper for receiving the medication and when he signed his name during the meeting, it had not matched the signature on the paper the nurse produced. The facility told him they would take care of it, and he never heard back nor received the medication. Review of the Accident and Incident Log for 2025 revealed no documentation regarding misappropriation and no incidents involving the specified resident. Review of the facility self reported incidents (SRIs) revealed no SRI for Misappropriation for Resident #10. Review of the policy on Abuse Investigation and Reporting revised December 2017 revealed all reports of abuse, neglect or misappropriation should be promptly reported to the correct agencies and thoroughly investigated by facility management. Any employee alleged to have been involved with abuse would be immediately suspended pending the results of the investigation. If the investigation revealed the employee was guilty of abuse, their employment would be terminated, and they would be reported to the appropriate professional and licensing agency. This deficiency represents non-compliance investigated under Complaint Number 2609034.

Based on record review and interview the facility failed to investigate an allegation of misappropriation. The affected one (Resident #10) of three residents reviewed. The facility census was 36.Findings Include:Review of the closed record for Resident #10 revealed she was admitted initially 08/19/25 with re-entry 10/16/25. She was discharged [DATE]. Her diagnoses included chronic pain, protein-calorie malnutrition, major depressive disorder, rheumatoid arthritis, hypertension, metabolic encephalopathy, anemia, hyperlipidemia and gastro-esophageal reflux disease. Review of her admission Minimum Data Set (MDS) dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was eight indicating moderate cognitive impairment. She required set-up assistance for eating, moderate assistance for toileting, maximal assistance for bathing, dressing and personal hygiene.Review of her Care Plan dated 08/20/25 revealed she required healthcare monitoring related to opioid use for chronic pain syndrome and refused non-med interventions. Review of the Physician's Orders for Resident #10 revealed and order for Hydrocodone (opioid)-Acetaminophen (analgesic) 10-325 milligram one tablet every six hours as needed for pain. Interview on 12/11/25 at 12:10 P.M. with the Administrator and the Director of Nursing (DON) revealed when Resident #10 was admitted in August 2025, she arrived late in the day, and her pain medication had not arrived with the evening shipment. Resident #10 called her husband who brought in her pain medication from home. The Administrator stated she instructed the nurse regarding not being able to administer home medication. She reported the Licensed Practical Nurse (LPN) #15 stated she returned the medication to the husband but the husband stated he had not received the medication. The Administrator reported she and the DON met with the nurse and the husband together with the nurse stating she returned the medication and the husband stating she had not returned them. The Administrator confirmed no Self-Reported Incident (SRI) or investigation was completed related to the allegation of missing medications. Interview on 12/11/25 at 4:11 P.M. with Resident #10's husband revealed he had brought in about 21 Hydrocodone Acetaminophen when Resident #10 was admitted . He verified these pills were never returned to him. He stated the facility told him they would take care of it, and he never heard back nor received the medication. Review of the Accident and Incident Log for 2025 revealed no documentation regarding misappropriation and no incidents involving Resident #10 were documented. Review of the facility SRIs revealed no SRI for Misappropriation for Resident #10. Review of the policy on Abuse Investigation and Reporting revised December 2017 revealed all reports of abuse, neglect or misappropriation should be promptly reported to the correct agencies and thoroughly investigated by facility management. Any employee alleged to have been involved with abuse would be immediately suspended pending the results of the investigation. If the investigation revealed the employee was guilty of abuse, their employment would be terminated, and they would be reported to the appropriate professional an licensing agency. This deficiency represents non-compliance investigated under Complaint Number 2609034.

Based on observations, staff interviews, and policy review, the facility failed to properly thaw hamburger meat, failed to ensure dishwasher temperatures achieved proper temperatures, and failed to ensure the sanitizer was working and tested properly. This had the ability to affect all residents at the facility. The facility census was 35. Findings include: 1. Observation on 04/10/23 at 8:37 A.M. revealed an approximately four inch (in) by (x) 24 in packaged tube of hamburger meat lying directly on the bottom of the first compartment of the three compartment sink. The packaged meat was submerged in approximately two inches of cool water, further observation revealed approximately one inch of the burger felt thawed and the middle remained hard. Interview on 04/10/23 at 8:49 A.M. with Dietary Staff (DS) #49 revealed she had put the hamburger in cool water in the sink to thaw at 6:45 A.M. DS #49 verified the water was not running, the burger was not fully submerged and approximately one inch of the perimeter was thawed. Review of the facility policy, Preventing Foodborne Illness-Food Handling Policy, last revised 02/18, revealed frozen foods will not be thawed at room temperature and one of the thawing processes was to submerge the item in cold running water (70 degrees) or below. 2. Observation on 04/10/23 at 8:40 A.M. revealed the dishwasher wash cycle temperature was 133 degrees and the rinse cycle was 170 degrees. The documentation on the dishwasher stated, wash cycle 150 degrees and rinse cycle 180 degrees. This was verified by Dietary Manager #27 at the time of the observation. Review of the dishwasher log for March 2023 revealed temperatures for the wash cycle were documented under 150 degrees at least once a day on 03/01/23, 03/10/23, 03/11/23 and 03/12/23. The rinse cycle temperatures were documented as less than 180 degrees at least once a day on 03/01/23 through 03/12/23. There was no documentation of temperatures after 03/12/23 until April 2023. Review of the April 2023 dishwasher log revealed temperatures for the wash cycle were documented under 150 degrees at least once a day on 04/01/23, 04/02/23, 04/05/23 through 04/10/23. The rinse cycle temperatures were documented as less than 180 degrees at least once a day from 04/01/23 through 04/10/23. Interview on 04/10/23 at 8:40 A.M. with DM #27 revealed temperatures had been documented outside of the parameters and additionally stated she failed to double check temperatures recorded from 03/13/23 through 03/31/23. She stated maintenance was aware of the temperature issue and they were awaiting a part for repair. Review of the facility's dishwasher policy, last revised 02/18, revealed the was solution temperature should be 150 degrees and the hot water sanitation rinse temperature should be 180 degrees for the current dishwasher at the facility. Observation on 04/10/23 at 9:12 A.M. of the three-compartment sink revealed the third compartment was not filled. Interview with DS #49 revealed the compartment did not hold water and she used the hose supplying the sanitizer to rinse the dishes. She proceeded to turn on the sanitation hose in order to use the test strip to verify proper sanitation. There was no reaction with the strip. Upon inspection of the hose, it was discovered the bucket under the sink containing the sanitizer did contain solution. The hose went from the bucket between the wall and the sink, it continued up and was attached to the top of the sink and ran down to the left and into the third compartment. The pink solution could be seen filling the entire circumference of the hose from the bucket running along the top of the sink, then there was an approximately 12-inch area with minimal solution and then back to it filling the entire circumference of the hose. DS #49 moved the sink from the wall where the hose was noted to be kinked and restarted the solution. The hose filled entirely with the pink solution for approximately two minutes, before a void was noted again in the same area as previously observed. A second testing with the strip again revealed no reaction. DS #49 verified the sanitation was not working or testing properly and the supplying company would be contacted. Review of the facility's infection control logs for March and April 2023 revealed no foodborne illnesses.

Based on medical record review, staff interview, guardian interview, and policy review, the facility failed to notify a resident's representative when new orders were received. This affected one (Resident #23) reviewed for change in condition. The facility census was 35. Findings include: Medical record review for Resident #23 revealed an admitted [DATE] with diagnoses including dementia without behaviors, chronic obstructive pulmonary disease, malnutrition. emphysema, acute cystitis without hematuria, metabolic encephalopathy, weight loss, bladder dysfunction, hypothyroidism, hyperlipidemia, schizoaffective disorder, major depressive disorder, anorexia, obsessive compulsive disorder, delusional disorders, essential tremor, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] with for Resident #23 revealed intact cognition. Resident #23 required limited assistance for bed mobility, extensive assistance for transfers, limited assistance for eating and extensive assist for toileting. Resident #23 was assessed with no coughing or difficulty swallowing during the look back period. Resident #23 was on a mechanically altered therapeutic diet. Review of the plan of care for Resident #23 dated 04/11/23 revealed the resident was at malnutrition/dehydration risk due to cognitive deficits, mood problems, history of weight loss, dysphagia (difficulty swallowing), and medical problems. Interventions included medications as ordered, diet per physician's order: pureed with thin consistency liquids, speech therapy as ordered, and monitor and record oral intake. Review of the progress notes dated 04/07/23 at 6:16 P.M. revealed Resident #23 coughing with food/liquid and having difficulty swallowing. A nursing measure, downgraded to pureed diet with referral to speech therapy (ST). Review of the speech therapy notes for Resident #23 dated 04/11/23 revealed new onset of increased signs and symptoms of dysphagia and coughing/choking during oral intake, indicating the need for speech therapy to access and evaluate oral function. Resident #23 choked on peaches per verbal report from state tested nursing assistant. The resident was downgraded to puree diet until an evaluation completed. Resident #23 presented with mild dysphagia with decreased oral motor strength and function resulting in increased mastication (chewing) time and decreased bolus (round mass of food) formation. Resident #23 with inconsistent swallow onset increased risk for aspiration. Interview on 04/12/23 10:27 A.M. with Therapy Director #40 stated Resident #23 was evaluated on 04/11/23 for speech therapy services. Resident #23 will be seeing the speech therapist for a couple of weeks. Interview on 04/12/23 at 11:17 A.M. with the Assistant Director of Nursing (ADON) verified Resident #23 received new orders on 04/07/23 for a diet downgrade and speech therapy. The ADON did not notify the guardian of the new orders related to the coughing spell resulting in a change in diet levels, and stated she should have. Review of facility policy titled, Change of Condition or Status, dated 2/2018 revealed the facility shall promptly notify the resident, attending physician, and resident representative of changes in the residents medical condition or status.

Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary medications when the facility failed to follow through with pharmacy and physician recommendations to decrease a medication dosage. This affected one (Resident #21) of six residents reviewed for unnecessary medications. The facility's census was 35. Findings include: Medical record review for Resident #21 revealed an admitted [DATE] with diagnoses including chronic kidney disease, morbid obesity, congestive heart failure, hypertension, anemia, alcohol induced dementia, malnutrition, osteoarthritis, noncompliance with medical treatment, schizophrenia, major depressive disorder, bariatric surgery status, anxiety, insomnia, repeated falls, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. Resident #21 required extensive assistance for bed mobility from two staff members, extensive assistance for transfers and toileting with one staff member, and supervision for eating. Resident #21 received medication from the following classifications during the assessment period: antipsychotic, antidepressant, anticoagulant, and narcotics. Review of Resident #21's plan of care revealed the resident required use of anti-coagulant medication due to history of deep vein thrombosis (blood clots) and cardiovascular disorder. Review of Resident #21's physician orders revealed an order dated 07/23/19 for Eliquis (anti-coagulant) Tablet, give 5 milligrams (mg) by mouth every day and evening shift related to acute embolism and thrombosis, discontinued on 01/18/23. Additional review revealed an order dated 01/25/23 for Eliquis Tablet 2.5 mg, give 1 tablet by mouth every day and evening shift for prophylaxis, discontinued on 01/30/23. Review of the pharmacy recommendation dated 01/13/23 revealed a recommendation was made to the physician to decrease the milligrams of Eliquis to 2.5 mg for prophylaxis two times a day. The physician agreed with the reduction and gave orders to decrease the dose on 01/16/23. Review of the Medication Administration Record (MAR) for January 2023 revealed the new recommended dose of Eliquis 2.5 mg was not initiated until 01/25/23 (nine days after the physician gave orders). Interview on 04/11/23 at 5:27 P.M. the Director of Nursing (DON) verified the recommended 2.5 mg dose of Eliquis was ordered 01/16/23, and was not initiated until 01/25/23, and stated she did not have an answer as to why the medication was not reduced as ordered.

Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary psychotropic medications when a resident received duplicate medication therapy. This affected one (Resident #27) of six residents reviewed for unnecessary medications. The facility's census was 35. Findings include: Review of medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, noncompliance with medication and medical treatment, extrapyramidal movement disorder, depression, hypertension, bipolar with manic severe with psychotic features, schizophrenia, chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. She required extensive one person assistance for dressing and toileting, limited assistance for bed mobility and personal hygiene, and was independent for transfers and eating. Further review of the medical record revealed Resident #27 was prescribed the medication, Depakote, to treat bipolar disorder. Review of the care plan revealed the resident had multiple complicating diagnoses and was at risk for anxiety and depression, which require medications to control. Interventions included administer medications as ordered, psychiatric services as ordered, and monitor mental status. Review of Resident #27's March 2023 medication orders revealed an order for Depakote Sprinkles (prescribed for bipolar disorder) 125 milligrams (mg), two capsules by mouth two times a day (8:00 A.M. and 8:00 P.M.) with a start date of 03/06/23 for five days. The second order was for Depakote Sprinkles 125 mg, one capsule at bedtime with a start date of 03/09/23. A third order for Depakote Sprinkles 125 mg, give two capsules at bedtime for five days with a start date of 03/11/23. Further review of the medical record revealed no indication facility staff communicated with the physician about the duplicate Depakote orders. Interview on 04/13/23 at 10:52 A.M. with the Director of Nursing (DON) revealed the physician had been titrating (changes to medication doses to achieve the best clinical response) Resident #27's Depakote during the month of March 2023 and verified the facility had not clarified the concurrent Depakote orders and she was unaware of the multiple Depakote orders until the survey. A request for a policy related to medication administration was made during the survey and was not provided for review.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from unnecessary [CONDITION(S)] medications when staff failed to hold an anti-anxiety medication as ordered for increased sedation. This affected one (#21) of four residents reviewed. The census was 35. Findings include: Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses included malignant neoplasm of breast, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] disorder, anxiety disorder, major depressive disorder, extrapyramidal and movement disorder, and [CONDITION(S)]. Resident #21 was assessed as being cognitively intact in a annual Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders revealed an order dated 08/26/21 for [MEDICATION(S)] 0.5 milligrams (mg) one dose by mouth (PO) twice a day, hold for increased sedation. Review of progress notes dated 09/08/21 at 6:20 A.M. revealed Resident #21 was very lethargic through the shift and required more assistance with activities of daily living (ADL's) that usual. Resident #21 had increased incontinence, drooling, flat affect, and confusion noted by staff. Resident #21 was unable to bring cup of water to mouth after it was handed to her by the nurse. Review of medication administration records (MAR) revealed lorazepam (anti-anxiety medication [MEDICATION(S)]) 0.5 mg was administered to Resident #21 on 09/08/21 at 8:00 A.M. Further review of Resident #21's medical record revealed no documentation of Resident #21 returning to baseline cognition before the administration of [MEDICATION(S)] on 09/08/21 at 8:00 A.M. There was no documentation of physician notification of Resident #21 increased lethargy. Interview with Resident #21 on 09/09/21 at 12:38 P.M. revealed she had been experiencing increased sedation and on some days she felt it was hard to stay awake. Interview with the Director of Nursing (DON) on 09/09/21 at 2:00 P.M. confirmed that Resident #21 was documented as having increased lethargy on 09/08/21 on 6:20 A.M. The DON confirmed [MEDICATION(S)] was administered to Resident #21 on 09/08/21 at 8:00 A.M. Review of the facility's policy titled Administering Medications dated revised February 2018 revealed medications must be administered in accordance with the orders, including any timeframe's. This deficiency substantiates Complaint Number OH 298.

Based on observation, staff interview, review of the Centers for Medicare and Medicaid Services (CMS) online nursing home data website, review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to have staff wear eye protection (goggles or faceshields) in resident care areas to help reduce the risk of Coronavirus (COVID-19) transmission. This had the potential to effect all the residents of the facility. The census was 31. Findings include: Observation of facility staff during tour on 03/29/21 at 11:00 A.M. revealed no facility staff wearing eye protection in resident care areas. Care staff were observed interacting with residents and entering resident rooms. Interview with Registered Nurse (RN) #55 on 03/29/21 at 11:10 A.M. confirmed she was not wearing any eye protection. RN #55 stated that the Director of Nursing (DON) had instructed staff that eye protection was not currently required in the facility. Interview with the DON on 03/29/21 at 12:45 P.M. revealed staff were not currently wearing eye protection in the facility. The DON confirmed the county the facility was located in was listed as yellow and had a positive COVID-19 rate of 6.6 percent (%) on the CMS nursing home date website. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg revealed the county in which the facility was located was experiencing a moderate spread of COVID-19 with a positivity rate of 6.6 % and was identified as yellow for data for dates from 03/10/21 through 03/23/21. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e.,goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE (personal protective equipment) supply.

Based on medical record review, staff interview, policy review, and review of Medscape (online medication information resource), the facility failed to have documented justification for the use of as needed (PRN) psychoactive medications. This affected two Residents (#30 and #35) of three reviewed. In addition the facility failed to have documented justification for an increase in the use of psychoactive medications for Resident #30. The facility census was 31. Findings include: 1. Review of Resident #30's medical record revealed an admitted d of [DATE]. Diagnoses included sleep disorder, restlessness and agitation, psychotic disorders with delusions, paranoid [CONDITION(S)], hypertension, delusion disorders, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was assessed as having severe cognitive impairment, requiring extensive assistance with activities of daily living (ADLs), and as receiving antipsychotic medications routinely. Review of the medication administration records (MAR) dated [DATE] revealed Resident #30 was given a one milliliter (ml) intramuscularly (IM) injection of [MEDICATION(S)] (an antipsychotic medication) 5 milligrams (mg) per ml on [DATE] at 7:33 P.M. Further review of the MAR revealed Resident #30 was also given a 0.5 ml IM injection of lorazepam (antianxiety medication) 2 mg per ml (mg/ml) on [DATE] at 7:34 P.M. Review of the physician orders dated [DATE] revealed [MEDICATION(S)] 5 mg/ml IM injection of 1 ml every 12 hours PRN was ordered for restlessness, agitation, and noncompliance with other medical treatment and regimen and for [MEDICATION(S)] 2 mg/ml IM injection of 0.5 ml every 12 hours PRN for restlessness, agitation , and noncompliance with other medical treatment and regimen. These were both new orders for Resident #30. An order for [MEDICATION(S)] 5 mg/ml IM injection of 1.5 ml every 12 hours PRN was dated [DATE]. This was an increase from one ml that was ordered on [DATE]. Further review of the physician orders revealed [MEDICATION(S)] was increased from one 5 mg tablet by mouth every day and evening shift to one 5 mg, one 2 mg, and one 0.5 mg tablet twice daily on [DATE]. Resident #30's [MEDICATION(S)] dose was increased from a total of 10 mg daily to a total of 15 mg daily. An order for [MEDICATION(S)] ([MEDICATION(S)]) 7.5 mg every evening shift for seven days for major depressive disorder was dated [DATE]. [MEDICATION(S)] was added as a new medication. [MEDICATION(S)] was increased to 15 mg by mouth every evening shift on [DATE]. Review of Medscape revealed [MEDICATION(S)] was classified as a first generation antipsychotic medication, [MEDICATION(S)] was classified as an antianxiety and anxiolytic medication and [MEDICATION(S)] was classified as an antidepressant medication. Review of the behavior progress notes dated [DATE] at 6:35 P.M. revealed Resident #30 slapped medications out of nurses hand, across her bed, and onto the nurse's uniform. Resident #30 was mocking the nurse and other staff when attempting to counsel her. Further review of progress notes from [DATE] through [DATE] revealed no further documentation of aggressive behavior, refusal of medications, or increased depression. No documentation of any further refusal of medications or aggressive behavior after [DATE] was noted. No documentation of physician correspondence on [DATE] was found in progress notes. Review of psychiatric nurse practitioner (PNP) notes dated [DATE] revealed staff reported that Resident #30 overall behavior seems to be fairly managed with the current [CONDITION(S)] medication regimen. Staff reported no complaints of depression, anxiety, labile mood, anorexia, or [CONDITION(S)]. Staff reported that Resident #30 was occasionally non-compliant with taking medication and for laboratory blood draws. Review of PNP notes dated [DATE] revealed on [DATE] staff reported that Resident #30 was having poor appetite and delusional ideations (deceased husband still alive). Psychiatrist was consulted and he okayed increasing [MEDICATION(S)] to 7.5 mg twice daily, monitor blood pressure (BP), and add (gradually) [MEDICATION(S)] to 15 mg at bedtime. Currently staff reported Resident #30's overall behavior continues to be marginally managed with the complaints on [DATE]. Otherwise, staff reported no complaints of depression, anxiety, labile mood, anorexia, or [CONDITION(S)]. Staff reported Resident #30 is fairly compliant with taking medications. Interview with the Director of Nursing (DON) on [DATE] at 11:25 A.M., revealed resident behaviors should be documented in the resident's medical record. There should be well-documented need for an increase in psychoactive medications. The DON was unsure if the interdisciplinary team (IDT) met to discuss Resident #30's acute behavior episode on [DATE] and her increase in psychoactive medications. The DON would re-educate staff on the need for well-documented needs for the use of PRN psychoactive medications and increase of psychoactive medications. Interview with Licensed Practical Nurse (LPN) #55 on [DATE] at 11:57 A.M., revealed the behaviors for Resident #30 on [DATE] were very unusual for her. Resident #30 had never before raised her hand to LPN #55. Resident #30 was becoming a little more touchy as of late. LPN #55 usually gets along with Resident #30 well. On [DATE] Resident #30 slapped medications out of LPN #55 hands and onto the floor. LPN #55 called the PNP and he re-instated PRN IM [MEDICATION(S)] and PRN IM [MEDICATION(S)]. The PNP had a telehealth (remote) visit per phone about Resident #30. Resident #30's routine [MEDICATION(S)] dose was increased from 5 mg to 7.5 mg twice daily and [MEDICATION(S)] IM PRN was increased. LPN #55 confirmed there was not any recent documented increases in behavior for Resident #30 besides the incident on [DATE]. LPN #55 confirmed the resident behaviors would be documented in nurse progress notes or behavior notes in the resident's electronic record. LPN #55 informed the DON about the incident with Resident #30 on [DATE]. Follow-up interview on [DATE] at 1:05 P.M., the DON confirmed there was not a documented increase of behaviors that would justify an increase of psychoactive medication use for Resident #30. Review of the policy titled Antipsychotic Medication Use updated 2016 revealed residents will not receive PRN dose of antipsychotic medications unless the medication unless the medication is necessary to treat a specific condition that is documented is the clinical record. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions. In the case of an emergency situation (that is, an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others) related to one or more of the above conditions or diagnoses, the use of antipsychotic medications must meet following additional pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication. Review of the policy titled [CONDITION(S)] Medications Ordered on an As Needed PRN BasisPPH086 dated [DATE] revealed PRN orders for non-antipsychotic, [CONDITION(S)] drugs are limited to 14 day with the following exception. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The required evaluation of a resident before writing a new PRN order for an antipsychotic entails the attending physician or prescribing practitioner directly examining and assessing the resident's current condition and progress to determine if the PRN antipsychotic order if appropriate. The new order is subject to a 14 day restriction. There was no documentation of the IDT team meeting to discuss and review Resident #30's acute episode and use of PRN psychoactive medications on [DATE] was provided. There was no documentation of Resident #30's attending physician or prescribing practitioner directly examining her before [MEDICATION(S)] PRN was started on [DATE] and increased on [DATE]. 2. Review of Resident #35's medical record revealed an admitted [DATE]. Diagnoses included hypertension, major depressive disorder, anxiety disorder, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 was assessed as having minor cognitive impairment, requiring minimal assistance with activities of daily living (ADLs), and as receiving antipsychotic medications routinely. Review of the physician order dated [DATE] revealed an order for [MEDICATION(S)] Solution 0.5 ml IM every six hours PRN for restlessness and agitation. Review of the MAR dated from [DATE] through [DATE] revealed the use of PRN [MEDICATION(S)] Solution was injected a total of eight times on the following dates [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the behavior progress note dated [DATE] at 10:45 A.M. revealed Resident #35 was yelling at staff. The resident was persistent about an appointment being scheduled. According to LPN #55, staff attempted redirection, counseling, and 1:1 with the resident before giving the PRN [MEDICATION(S)] injection. There was no further notation on how Resident #35 was at the time of the injection, or after the injection. No further monitoring of Resident #35 was noted on [DATE]. Review of the behavior progress note dated [DATE] at 5:10 P.M. revealed Resident #35 was yelling at an activity aide for turning a channel. Resident #35 became argumentative with multiple staff members. LPN #55 documented that 1:1 and redirection was attempted for Resident #35 without success. No nursing note was written stating Resident #35 was given a PRN injection of [MEDICATION(S)] at 5:35 P.M. on [DATE]. No further notation was made about the resident condition or monitoring the resident for the remainder of [DATE]. Review of the behavior progress note dated [DATE] at 12:19 A.M. revealed Resident #35 was being loud and combative as well as calling staff members names. Reassurance and redirection were ineffective, and Resident #35 was given a PRN [MEDICATION(S)] injection. Three additional nursing notes were written throughout the day on [DATE] regarding the residents' behavior. Review of nursing notes and notes written by the psychiatric nurse practitioner (PNP) from [DATE] through [DATE] confirmed Resident #35 had multiple behaviors on a regular basis. No notation was made about extending the PRN order of [MEDICATION(S)] injection with an original order date of [DATE]. No notes written by the nursing staff or PNP were noted to reevaluate the PRN order of [MEDICATION(S)] injection. Interview with the DON on [DATE] at 11:25 A.M., confirmed the original order date of [MEDICATION(S)] 2mg/2ml solution-Give 0.5 ml IM every six hours for restlessness/agitation was dated [DATE]. The DON confirmed per policy a new order for PRN [CONDITION(S)] medication should be written every 14 days. No new order was written for PRN [MEDICATION(S)] injections since the original order on [DATE]. The DON also confirmed that no documented attempt to reevaluate the PRN order of [MEDICATION(S)] or justification given for its continued use. Interview with LPN #55 on [DATE] at 11:55 A.M., confirmed the staff had given eight separate PRN [MEDICATION(S)] injections to Resident #35 from [DATE] through [DATE]. LPN #55 confirmed many instances of behavior concerns regarding Resident #35. Staff were not fully documenting on the episodes for Resident #35. LPN #55 confirmed when reviewing the nursing notes written by herself and coworkers on the days of the PRN [MEDICATION(S)] injections that sometimes it was unclear why and when the injection was given. Orders for [CONDITION(S)] medications such as [MEDICATION(S)] are renewed and reviewed every 14 days. LPN #55 confirmed this order was written on [DATE] and was never renewed. Review of the policy titled [CONDITION(S)] Medications Ordered on an As Needed PRN BasisPPH086 dated [DATE] revealed PRN orders for non-antipsychotic, [CONDITION(S)] drugs are limited to 14 day with the following exception. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The new order is subject to a 14-day restriction. This deficiency substantiates Complaint Number OH 940.

Based on observation, resident interviews, staff interviews, facility policy review, and review of personnel files, the facility failed to ensure residents were treated with dignity and respect by staff. This affected two (#28 and #33) residents reviewed for dignity and respect. This had the potential to affect all 36 residents residing in the facility. Finding include: Observation on 11/09/20 at 8:40 A.M. of Licensed Practical Nurse (LPN) #202 administering medication to Resident #28 revealed Resident #28 asked LPN #202 for Tylenol for her knee and back pain and Immodium for her diarrhea. LPN #202 did not prepare either of those two medications and entered the room with only the scheduled medications prepared in a small plastic medication cup. Resident #28 then asked How much [MEDICATION NAME] am I getting? LPN #202 stood in front of the resident very straight with her hands folded in front of her and replied, in a dismissive tone of voice Take your medications please. Resident #28 repeated the question and received the same answer, she repeated the question a third time at which time LPN #202 responded, in a disdainful tone, 500 milligrams, now take your medications. Resident #28 asked about the Tylenol and LPN #202 asked where the pain was and at what level and received the answer My back is a 10 and my knee is a seven. LPN #202 did obtain two tablets of Tylenol 325 milligrams (mg) from the cart and gave them to Resident #28. Resident #28 again asked for the Immodium and LPN #202's tone of voice became very short and terse. LPN #202 asked Resident #28 how many times had she had diarrhea and was told Three, do you need proof? Resident #28 began to comment on something and LPN #202 just turned and walked away, dismissing Resident #28's concerns. Review of the medical records of Resident #28 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/02/20, revealed Resident #28 had no cognition deficits and was independent for all activities of daily living. Interview on 11/09/20 at 9:00 A.M. with the Director of Nursing (DON) revealed staff have complained about LPN #202's behavior and LPN #202 had been counseled. Interview on 11/09/20 at 11:10 A.M. with Staff #413 revealed LPN #202 had belittled Resident #33 regarding an incontinence issue. LPN #202 had been very loud during the exchange and could be heard from a distance stating Why did you piss all over the floor like that? Are you a baby? Staff #413 added LPN #202 has been rude and discourteous to many residents and walks through the building using profanity to and about residents. Staff #413 stated their direct supervisor had been informed of the incident but that they had not gone to the Administrator. Staff #413 stated Registered Nurse (RN) #241 is also rude and mean towards Resident #28, yelling and using profanity towards her. Interview on 11/09/20 at 11:25 A.M. with Staff #333 revealed they had been informed of an incident where LPN #202 had been rude to Resident #33. Resident #33 had been incontinent of urine and LPN #202 had told the housekeeper to clean it up. The housekeeper had stated the State tested Nursing Assistants (STNA) are to clean up the mess and then housekeeper will disinfect. LPN #202 had been very loud in stating that Resident #33 had pissed all over the floor and it needed cleaned up. Staff #333 stated the DON had been informed but could not state with certainty it had be within two hours. Interview on 11/09/20 at 11:40 A.M. with Staff #525 revealed a male resident (#22) had reported Activities Director (AD) #263 had used profanity towards him on a trip to a doctor appointment. He informed Staff #525 that AD #263 had often been rude and discourteous towards him and other residents when they asked for something from the store, which is part of the AD #263's duties. Staff #525 has also heard LPN #202 use profanity towards and within hearing range of residents. Interview on 11/09/20 at 11:55 A.M. with Staff #443 revealed LPN #202 had yelled at residents in the dining room about the mess they make while eating. AD #263 refuses to allow residents their smoke breaks as a punishment for asking to get something form the store before the time it is open. Social Service (SS) #344 belittles and ignores Resident #28's request to use the phone to call her mother. Staff #443 has overheard LPN #202 and AD #263 call residents son of [***] and mother [***] s numerous times. Staff had not reported it to the DON related to fear for his/her position as LPN #202 is the niece of DON and nothing ever gets done about the allegation's others have brought to the DON's attention. Interview on 11/09/20 at 12:05 P.M. with SS #344 revealed she had been rude towards Resident #28, stating She drives me nuts. SS #344 stated Resident #28 continually requests to use the phone to call her mother, has been told no numerous times, simply ignored and sent to her room. Interview on 11/09/20 at 1:00 P.M. with DON and LPN #202 revealed this surveyor voiced concerns over the lack of dignity LPN #202 afforded to Resident #28 during medication administration. LPN #202 stated she folds her hands to stop her from waving them while talking, no disrespect intended. LPN #202 did attempt to say she had not heard Resident #28's request, but when informed she never asked her to repeat the request, she admitted she had not answered Resident #28. LPN #202 attempted to give excuses as to why she had reacted in that manner but did agree they were excuses and apologized for her actions. Interview on 11/09/20 at 2:15 P.M. with Resident #22 revealed most staff are very kind and courteous, but some are not nice. Resident #22 refused to name any specific staff stating, They will know who said it. Interview on 11/10/20 at 9:24 A.M. with Resident #33 revealed a few staff members had been rude and mean to her but refused to name the staff. Interview on 11/10/20 at 9:30 A.M., Resident #28 stated LPN #202 is usually rude and will not answer my questions. LPN #202 has denied Resident #28 access to a telephone and has told her to Go to your room. Resident #28 described this as Like I was a child. Interview on 11/10/20 at 9:45 A.M. with Assistant Director of Nursing (ADON) #255 revealed LPN #202 had received a written discipline from ADON #255 regarding an incident involving Resident #33 having been incontinent and LPN #202's reaction to that. ADON #255 stated another staff member had reported the incident to her. ADON #255 stated she had heard loud voices at the time but could not discern any specific words. ADON #255 stated she had spoken with LPN #202 on the day in question but could not recall the facts. Interview on 11/10/20 at 10:00 A.M. with Staff #272 revealed LPN #202 threatens Resident #28 with shots to make her be quiet. LPN #202 has used profanity towards residents, specifically Resident #31, telling them I don't give a[***]about what you want and Get the hell away from me. Staff #272 added AD #263 also uses profanity towards the residents. Interview on 11/10/20 at 10:15 A.M. with the DON revealed disciplines had been removed from the personnel files. When asked about LPN #202, RN #241 and AD #263, DON admitted to only LPN #202 having received a written discipline on 07/15/20 regarding Resident #33 having been incontinent. DON stated she had spoken with LPN #202 regarding the situation and no further reports have been brought forward, from anyone. The DON added LPN #202 reported the incident was over who had to clean the mess up and was discussed in front of Resident #33 and should not have been. DON denies having received any complaints about RN #255 or AD #263. Review of the personnel files of LPN #202 revealed a hire date of 05/23/17 and was silent for any disciplinary actions. After questioning the DON on 11/10/20 regarding any disciplinary action, the disciplinary action was produced and the DON stated We remove all disciplinary actions from the file before we give them to State. Review of the facility policy titled Resident Rights, dated 02/18, revealed employees shall treat all residents with kindness respect and dignity. Residents shall be allowed self-determination, access to communication with people outside the facility, and exercise their rights without interference, coercion, discrimination or reprisal from the facility. Residents shall voice grievances to the facility without fear of discrimination or reprisals. This deficiency substantiates Complaint Number OH 140.

Based on review of a closed medical record, interviews with staff, the Certified Nurse Practitioner (CNP), Coroner and the Medical Director (MD), review of a facility policy, review of the Ohio Revised Code (ORC), review of the Ohio Administrative Code (OAC) and review of staffing schedules, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) timely for one (#13) resident found unresponsive, without a pulse, respirations or blood pressure, and who was identified as a Full Code status. Life threatening harm and death occurred when Resident #13 did not receive CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#13) of three residents reviewed for an emergent change in condition and death. The facility identified a total of three current residents who were designated as having a Full Code status. The facility census was 40. On [DATE] at 3:30 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 6:30 A.M. when Resident #13 was found unresponsive, without a pulse, respirations, or blood pressure, and Licensed Practical Nurse (LPN) #110 failed to initiate CPR or contact EMS. Resident #13 expired at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 6:30 A.M., LPN #110 notified CNP #111 that Resident #13 was without vital signs and CPR had not been initiated. · On [DATE], the facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the MD to discuss the identified concern and to review/revise the CPR policy. On [DATE], the Administrator, DON and MD revised the CPR Policy. The revised policy reflected CPR is to be performed on residents who have specifically requested a Full Code advance directive. The policy documented licensed nurses cannot pronounce death or make the determination of whether CPR is appropriate in a given situation. The nurse will initiate a call for help and verify the code status of the resident. If the resident is a Full Code, call nine-one-one (911) and initiate CPR per American Heart Association (AHA) guidelines. · On [DATE], the Administrator, Assistant Administrator and DON began in-service training with all nurses regarding the facility's revised CPR policy in person or via telephone. The training was completed on [DATE]. · On [DATE], the Administrator and DON did one-on-one in-service training with LPN #110 regarding the facilities CPR policy. · On [DATE], the Administrator and DON completed medical record audits to ensure correct code status was appropriately identified for all 40 residents residing in the facility. The facility identified three current residents who are Full Codes. The Full Code status was designated on the medical record. · On [DATE], the DON and/or designee(s) will begin audits of all expired residents' medical records to ensure ongoing compliance with the CPR policy. Any concerns or deviations will be directly rectified and immediately referred to the QAPI committee toward the goal of ongoing compliance. The DON is responsible for ensuring ongoing compliance. · On [DATE] and [DATE], two (#26 and #37) additional residents who expired in the facility were reviewed and no additional concerns were identified. · On [DATE] between 11:18 A.M. and 11:50 P.M., interviews with Registered Nurses (RN) #113 and #123; State tested Nursing Assistants (STNA) #115, #116, #117 and #118; Hospitality Aides (HA) #114 and #119; Housekeeping staff #121 and #125; Social Service staff #120 and Maintenance staff #126 verified they received in-service education and were knowledgeable regarding the facility's CPR policy and when to initiate CPR. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #13's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognition deficit. The resident required limited assistance for locomotion on the unit, was independent for bed mobility and transfers, and required extensive assistance for toileting. Review of Resident #13's Resuscitation Designation document dated [DATE] revealed the resident desired CPR to be performed at the facility should the resident suffer cardiac or respiratory arrest. The document was signed by the Medical Director and Registered Nurse (RN) #123. Review of the [DATE] physician orders for Resident #13 revealed an order dated [DATE] indicating Resident #13's advanced directives were a Full Code. Review of Resident #13's comprehensive care plan revealed the Full Code status was addressed in the care plan. Review of Resident #13's [DATE] Medication Administration Record [REDACTED]. Review of Resident #13's physician progress notes [REDACTED]. Review of Resident #13's nursing progress note dated [DATE] at 3:10 A.M. revealed the residents oxygen saturation reading was 88 percent (%). Resident #13 was observed to be sitting on the bed with the oxygen tubing not applied to her face. Resident #13's belongings were observed to be on the floor and she was not answering questions directly. Resident #13 was slow to respond to staff. Resident #13's oxygen was reapplied and the resident was assisted back to bed and care was provided. The note was documented by LPN #110. Further review of the nurses notes revealed there was not further documentation regarding Resident #13's condition until [DATE] at 6:30 A.M. which documented the resident was observed to be laying diagonally across her bed on her chest with arms dangling on side and legs slightly dangling. Resident #13 appeared to have a cyanotic color to her face, hands and feet. Resident #13 was very cold to the touch with nail beds cyanotic and the resident was apneic. LPN #110 was unable to obtain a blood pressure or pulse. The DON was notified. CNP #111 was notified. Resident #13 had no family or contacts and was her own responsible person. The coroner was notified with instructions received to transport Resident #13's body to the morgue at the local hospital due to no prior funeral arrangements. Review of the physician order for [REDACTED]. revealed an order to release Resident #13's body to coroner. An interview on [DATE] at 12:00 P.M. with the Administrator and DON revealed Resident #13 expired at the facility on [DATE] at 6:30 A.M. The DON stated Resident #13 had been assessed at 3:10 A.M. when her oxygen had been off. Resident #13 had a history of [REDACTED].#110 reported on [DATE] at 6:30 A.M., Resident #13 did not respond and the resident did not have a blood pressure or pulse. Per the interview it was confirmed that LPN #110 did not initiate CPR as Resident #110 was very cold to the touch and cyanotic. The DON stated Resident #110 was a Full Code but CPR had not been initiated as LPN #110 felt it was obvious that Resident #13 had expired. The Administrator and DON stated per the facility policy, no CPR was initiated for Resident #13 as LPN #110 felt there were obvious signs of death such as Resident #13 was very cold to the touch, had evacuation (incontinent) and had stiff arms; however, the Administrator and DON confirmed the assessment regarding Resident #13 being incontinent and having stiff arms was not documented in the medical record. The Administrator and DON confirmed LPN #110 could not obtain a blood pressure or pulse and that CPR had not been initiated per Resident #13's Advanced Directive. Interview on [DATE] at 12:40 P.M. with the Coroner revealed the cause of death was ruled as complications of [MEDICAL CONDITION] and [MEDICAL CONDITION] secondary to smoking. The Coroner added he had located a son and the copy of the death certificate was sent to him. Interview on [DATE] at 12:50 P.M. with CNP #111 revealed the expectation would be to initiate CPR if any chance of revival was suspected. If the resident displayed any signs of obvious death for an extended length of time; cold to the touch, discoloration and the resident had evacuated (incontinent of bowel and or bladder) no CPR should be initiated. As per the facility policy any nurse can determine death. CNP #111 could identify the code status of Resident #13 as Full Code. CNP #111 stated Resident #13 had multiple systemic concerns. Interview on [DATE] at 12:55 P.M. with LPN #110 revealed she had observed Resident #13 on [DATE] at 3:10 A.M. and noted her oxygen had been removed and she was unable to answer questions directly and was slow to respond to staff. LPN #110 stated Resident #13's oxygen was reapplied and the resident had been assisted back to bed. LPN #110 stated she had checked on Resident #13 within the hour and noted the oxygen had been off again and LPN #110 reapplied the oxygen again and sat with Resident #13 until she started to respond appropriately. LPN #110 stated Resident #13 appeared to go to sleep and LPN #110 revealed she looked in on Resident #13 approximately two to three times between 3:10 A.M. and 6:30 A.M. and had noted the oxygen was on and she had been laying in the bed and quietly snoring. Per LPN #110 on [DATE] at 6:30 A.M. she entered Resident #13's room and observed her to be laying on the bed, diagonally on her chest with her arms and legs dangling. Resident #13 appeared to have a cyanotic color to her face, hands and feet. LPN #110 stated Resident #13 was very cold to the touch, the resident's nail beds were cyanotic and the resident was apneic. LPN #110 stated she was unable to obtain a blood pressure or a pulse. LPN #110 stated she called the DON first and then called CNP #111. LPN #110 stated CNP #111 gave orders to call the Coroner. LPN #110 stated she knew Resident #13 was a Full Code but felt she had been gone for some time, as she was very cold to the touch and her arms were starting to stiffen. LPN #110 stated she would have initiated CPR if she felt there had been any chance of revival. LPN #110 stated she had sent a text message to CNP #111 on [DATE] at approximately 4:00 A.M. regarding the resident's oxygen being off, the oxygen saturation level and the residents, mental status; however, she did not receive any response. A follow-up interview on [DATE] at 1:00 P.M. with CNP #111 revealed she could not confirm nor deny the receipt of a text message on [DATE] from LPN #110 regarding Resident #13's condition. Interview on [DATE] at 8:12 A.M. with the MD who was also Resident #13's Physician revealed he would not have expected CPR to be initiated related to the reported signs of death such as the resident being cold to the touch and lividity. It was his understanding that CNP #111 had been notified and gave the order for no resuscitation. The MD stated his expectations of nursing procedures for contact providers would be if a text was not responded to, the provider would be called, especially at 3:00 A.M. in the morning. The MD was unable to locate Resident #13's death certificate but stated Resident #13's admitting [DIAGNOSES REDACTED]. During the interview, MD stated with Resident #13's [DIAGNOSES REDACTED]. Resident #13 had been dependent on four liters of oxygen and her oxygen saturation remained in the low 90's. Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) for Adults dated [DATE], revealed when cardiac/respiratory arrest occurs CPR is to be performed by trained personnel on residents who have specifically requested a Full Code advance directive. Licensed nurses cannot pronounce death or make the determination of whether CPR is appropriate in a given situation. Review of the Ohio Revised Code (ORC) Section 4723.36 titled, Determination of Death by Certified Nurse Practitioner or Clinical Nurse Specialist, revealed a RN may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed hospice care program or any other entity that provide palliative care. Review of the Ohio Administrative Code (OAC) [DATE] titled, Pronouncement of Death, revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. According to the OAC [DATE], an LPN is not permitted to pronounce an individual's death. Review of the nursing staffing schedules revealed LPN #110 was the only nurse on duty on [DATE] at 6:30 A.M. Further review of Resident #13's medical record revealed the resident was not receiving hospice and/or palliative care during her stay at the facility.

Based on medical record review, review of personnel files, facility timesheets, and still shot photograph images, interviews with Special Agents from the Ohio Attorney General's (AG) office, staff, resident, and family interviews, interview with the Medical Director, and review of a facility policy and procedure, the facility failed to ensure staff immediately reported witnessing incidents of staff to resident physical abuse of a cognitively impaired resident to the administrator of the facility. Consequently, the facility failed to take action to protect the residents from further abuse after the incidents were witnessed, and immediately initiate an investigation into the physical abusive behavior by the perpetrators. This resulted in Immediate Jeopardy and actual harm to one (#13) of 14 residents reviewed for abuse when two staff members intentionally and willfully physically abused the resident by pinching his ear and pulling his hair on two separate occasions during the provision of personal care. Furthermore, this placed 25 additional residents (#6, #7, #8, #9, #10, #11, #14, #15, #16, #17, #18, #20, #21, #22, #23, #30, #31, #32, #33, #35, #36, #37, #38, #39 and #40) at risk for the likelihood of serious physical harm or injury as a staff member witnessed the physical abuse of the resident on more than one occasion, failed to immediately report it to the administrator, thus allowing the perpetrators to continue to provide personal care to residents requiring their assistance, who were identified by the facility as cognitively impaired and exhibited behaviors. The total facility census was 40. On 06/08/16 at 5:05 P.M. the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/05/16 at 4:41 P.M. when Hospitality Aide (HA) #70 intentionally pinched Resident #13 behind the ear after the resident grabbed HA #70's left breast. The incident was witnessed by State tested Nursing Aide (STNA) #95 who was observed at the bedside of Resident #13 assisting HA #70 with personal care when the incident occurred. The Immediate Jeopardy continued on 04/24/16 at 4:42 P.M. during a second abuse incident after Resident #13 was transferred to a geriatric (Geri) chair by STNA #95 and STNA #100. Resident #13 was observed to be pointing his hand or finger at STNA #100; however, the resident did not make physical contact with STNA #100. STNA #100 leaned toward Resident #13 and intentionally grabbed the resident's hair and pulled the resident's head toward the side which caused Resident #13's head to shift sideways toward STNA #100 at which time STNA #100 released Resident #13's hair. The second abusive incident was again witnessed by STNA #95 who was observed in the room facing Resident #13 and STNA #100 during the incident. STNA #95 did not report either incident of physical abuse immediately to the administrator. The Immediate Jeopardy was removed on 06/08/16 at 8:00 P.M. when all staff were in-serviced regarding the identification of abuse, reporting and protection of residents against abuse and the facility implemented the following corrective actions: · On 06/03/16 at 12:33 P.M., the DON suspended HA #70 and at 4:30 P.M., STNA 100 was suspended. · On 06/03/16, the DON completed a head-to-toe assessment of Resident #13. No signs of physical injuries were found and Resident #13 could not recall the incidents. · On 06/03/16, the Administrator and DON began implementing all staff in-service training regarding identification, reporting and protection of residents regarding abuse. The all staff in-service training was completed on 06/08/16 at 8:00 P.M. · The Administrator and DON will continue monthly all staff in-service training for three consecutive months (July, August and September) and randomly thereafter as directed by the Quality Assurance (QA) committee. · On 06/08/16, the DON conducted interviews with all alert and oriented residents regarding any alleged abuse incidents. There were no other allegations of abuse identified. · On 06/08/16, the DON and designees completed head to toe assessments of all 24 cognitively impaired residents to identify any signs of abuse such as marks, bruising, etc. There were no physical or psychosocial indicators of potential abuse identified. · On 06/08/16, the DON conducted an audit of all resident's medical records including nursing notes to identify any potential abuse indicators. There were no other potential abuse indicators noted. · On 06/08/16 at 7:30 P.M., STNA #95 was in-serviced by the Administrator on identification, reporting and protection of residents regarding abuse. STNA #95 was placed on a performance plan which includes weekly one-on-one performance reviews that will continue for three months · On 06/08/16, the DON implemented resident interview audits to assist in identifying abuse allegations as follows: Day one and two- all residents will be interviewed; Day three- 75% of residents will be interviewed; Day four - 50% of residents will be interviewed; Day five through Day ten- 25% of residents will be interviewed; and Day 11 forward, random interviews will be conducted quarterly and as directed by the QA committee. · On 06/09/16, the facility terminated HA #70 and STNA #100. · On 06/09/16, 13 (#6, #7, #9, #15, #17, #20, #21, #22, #30, #31, #33, #36 and #39) additional charts were reviewed of residents who were identified as being cognitively impaired. There were no indicators or suspicions of abuse noted. · On 06/09/16 between 11:47 A.M. and 12:25 P.M., Licensed Practical Nurse (LPN) #160, LPN #190, Housekeeper #170 and Activity Director #180 were interviewed and stated they were in-serviced and were knowledgeable on the identification, reporting and protection of residents against abuse. · On 06/09/16, the administrator formed an Abuse Committee comprised of the Administrator, DON, a social services designee, staff nurse designee, an STNA representative, a housekeeping representative, activities representative and a culinary representative. The Abuse Committee will meet weekly starting June 15, 2016 for three continuous weeks and then monthly thereafter. The Resident Interview Audits will be reviewed and discussed during the meeting and during quarterly QA and Performance Improvement meetings. · Beginning 06/09/16, the DON or designee will conduct observational audits of direct care staff providing resident care to residents with cognitive impairments and/or residents with behaviors to assure care is provided in a manner that promotes an abuse free environment. Random audits of at least three staff members will be performed weekly times four weeks, monthly for three months and then as directed by the QA committee. Although the Immediate Jeopardy was removed on 06/08/16, 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) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) completed on 05/24/16 revealed the resident was assessed as displaying physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing and abusing others sexually) of occurring daily. Resident #13 ' s scored a two out of 15 on the Brief Interview for Mental Status Score (BIMS) indicating the resident is severely cognitively impairment. Review of Resident #13's care plan revealed that Resident #13 was totally dependent of staff for personal care and was a two person assist for transfer. The care plan noted Resident #13 was confused, resistive to care, non-compliant and sexually inappropriate daily. Some of the listed care plan interventions were to approach the resident in a calm manner, explain procedures prior to starting, modify environment to prevent situations that trigger inappropriate care, allow resident to calm down before attempting to continue with care, redirect and cue as needed. During an interview with the Administrator and the DON on 06/07/16 at 8:10 A.M. they both stated they were not aware of any physical abuse until the Ohio AG Special Investigators notified the facility on 06/03/16. Ohio AG Special Agent #1 stated in an interview on 06/07/16 at 11:23 A.M. that HA #70 was viewed on video obtained through hidden camera forcefully pushing Resident #13 during personal care on 04/05/16 at 4:41 P.M. AG Special Agent #1 stated during the video Resident #13 grabbed HA #70's left breast while the caregiver and STNA #95 were providing personal care. AG Special Agent #1 stated that HA #70 stepped back and away from Resident #13 after he grabbed her breast, then HA #70 reached in with her right hand and pushed back forcefully over top of Resident #13. AG Special Agent #1 stated that STNA #95 was on the opposite side of Resident #13's bed and was looking directly at HA#70 and Resident #13. AG Special Agent #1 stated that there was another incident involving STNA #100 who was viewed on video obtained through hidden camera pulling Resident #13's hair during a transfer on 04/24/16 at 4:42 P.M. AG Special Agent #1 stated during the video Resident #13 was sitting on the edge of a Geri chair and pointed up at STNA #100. STNA #100 then reached out at Resident #13 with her left hand, grabbed Resident #13's hair and pulled him forward toward her. AG Special Agent #1 stated STNA #95 assisted STNA #100 with Resident #13's transfer and was standing behind Resident #13 ' s Geri chair looking at STNA #100 when Resident #13's hair was pulled. AG Special Agent #1 stated during this interview that the facility identified HA #70, STNA #95 and STNA #100 through still shot photos obtained from the video which was shown to the facility on [DATE] when the facility was notified of the allegations of physical abuse. On 06/07/16 at 2:30 P.M. an attempt was made to interview Resident #13. Resident #13 was cognitively impaired and stated he does not remember being treated roughly or being abused by staff. During an interview of 06/07/16 at 4:05 P.M., STNA #95 denied witnessing HA #70 pinch Resident #13's ear on 04/05/16. STNA #95 also denied witnessing STNA #100 pull Resident #13's hair on 04/24/16. STNA #95 further denied ever witnessing any resident abused in any manner in the facility. In an interview on 06/08/16 at 9:50 A.M. STNA #100 stated Resident #13 likes to grab staff in inappropriate places, he has grabbed and bitten her breast, he tries to shove his toes up your butt and she felt Resident #13 was fully aware of what he is doing. STNA #100 stated that Resident #13 would say no when told to stop. STNA #100 denied pulling Resident #13's hair during the transfer on 04/24/16 and she stated that she could not remember what other STNA assisted with Resident #13's transfer on 04/24/16. HA #70 confirmed in an interview on 06/08/16 at 10:42 A.M. that she pinched Resident #13 behind the ear after he had grabbed her left breast on 04/05/16. HA #70 stated she pinched Resident #13's ear as a reaction to the resident grabbing her breast. HA #70 stated the act was inappropriate, but did not feel it was abuse. HA #70 stated she had never touched a resident like that before. HA #70 stated that Resident #13 is very vulgar in how he talks and tries to pull the aides scrub top down during care. HA #70 stated that she usually tells Resident #13 no and backs up when he tries to touch her inappropriately. On 06/09/16 at 12:16 P.M. Resident #13's family member was interviewed. Resident #13's family member stated he was made aware of an abuse allegation by in October 2015 and that the family agreed to allow the Ohio AG's Office to place undercover cameras in the resident's room for an investigation regarding abuse. Resident #13's family member stated the family never suspected abuse. On 06/09/16 at 12:31 P.M. an interview with the Medical Director revealed that he has never had any concerns or suspicions of abuse at the facility. Still shot photos obtained from video surveillance was provided by the Ohio AG's Office and were viewed. These images were dated 04/05/16 and 04/24/16 and revealed the following: · Still shot photos dated 04/05/16 at 4:41:32 P.M. through 4:41:36 P.M. Resident #13 grabs the left breast of HA #70 with his left hand, HA #70 backs up and clears herself from Resident #13, HA #70 had a shocked facial appearance. HA #70 then come back toward Resident #13 and reaches towards Resident #13's upper body with her right hand/ arm extended at 4:41:34 P.M. Resident #13 then reacts to HA #70 by grabbing the HA #70's right upper arm and pushing her away at 4:41:36 P.M. STNA #95 is present in the still shot photos and is observed standing on the opposite side of the bed and facing Resident #13 and HA #70 during the incident. · Still shot photos dated 04/24/16 at 4:42:29 P.M. through 4:42:31 shows Resident #13 sitting in a Geri chair with STNA #100 standing to his left and STNA #95 standing on his right and slightly behind the Geri chair. Resident #13 is sitting in the Geri chair with his left arm extended upward at STNA #100, STNA #95 is to the side/ behind Resident #13 holding on to the Geri chair with both hands and at 4:42:29 P.M. STNA #100 reaches with her open left hand towards Resident #13 sitting in the Geri chair, STNA #95 is still observed to the side/ behind Resident #13 facing STNA #100 and holding on to the Geri chair. STNA #100's left hand makes contact with Resident #13's head and his head is pulled sideways and towards STNA #100 at 4:42:30 P.M. STNA #100's hand is released from Resident #13's head, Resident #13 is leaning toward STNA with left hand at his head at 4:42:31 P.M. The still shot photos show STNA #95 standing behind Resident #13 holding on to the Geri chair and facing STNA #100 and Resident #13 during the incident. Review of HA #70's personnel file revealed the employee was hired as a hospitality aide on 06/23/15. HA #70 completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) on 05/09/16; however, the STNA testing had not been completed at the time of the survey. HA #70 was not found in the Nurse Aide Registry. Review of HA #70's personnel file revealed there was no 90 day evaluation completed for the employee; however, HA #70 received a written warning for being rude and discourteous to a resident on 10/15/15. Further review revealed HA #70 received a written warning on 02/20/16 for failing to follow patient care policies. The review of the personnel file including a review of the driver's licenses revealed HA #70 was the aide providing care to Resident #13 on 04/05/16. Review of STNA #95's personnel file revealed the employee was hired as a STNA on 11/11/15. STNA #95 was in good standings with the Nurse Aide Registry. Review of STNA #95's personnel file revealed there was no 90 day evaluation completed for the employee. The review further revealed STNA #95 received no disciplinary action. The review of the personnel file including a review of the driver's licenses revealed STNA #95 was the aide providing care to Resident #13 on 04/24/16. Review of STNA #100's personnel file revealed the employee was hired as a STNA on 03/18/14. STNA #100 was in good standings with the Nurse Aide Registry. Review of STNA #100's personnel file revealed there was an evaluation dated 09/23/15; however, there was no concerns or disciplinary action regarding abuse reporting. The review of the personnel files including a review of the driver's licenses revealed STNA #95 was the second aide providing care to Resident #13 on 04/05/16 and 04/24/16. HA #70, STNA #95 and STNA #100's timesheets were reviewed for the dates of 04/05/16 and 04/24/16. It was determined on 04/05/16 HA #70 worked from 2:28 P.M. until 11:03 P.M. On 04/24/16, STNA #100 worked from 2:28 P.M. until 11:01 P.M. STNA #95 worked from 6:05 A.M. until 8:08 P.M. on 04/05/16 and from 2:28 P.M. until 11:01 P.M. on 04/24/16. A facility policy and procedure titled Nursing Policy/Procedure Manual regarding Abuse, revised July 2005, revealed the following: Under the section titled Abuse Prevention, resident care and treatment are monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect and mistreatment. It is the responsibility of all staff to provide a safe environment for all residents. Under the section titled Abuse Reporting, any person(s) witnessing of or having knowledge of alleged violations involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident has the responsibility to report the incident to the Administrator, Director of Nursing, or designee immediately. Under the section of Abuse Investigation it is the policy of this facility that reports of abuse are promptly and thoroughly investigated. When an incident or suspected incident of abuse is reported, the Administrator or designee investigates the incident. Under the section of Protection during and after the investigation the residents are protected from harm through frequent supervision by staff. If the alleged abuser is an employee, they shall be removed from the facility and suspended pending the results of the facility's investigation. This deficiency substantiates Complaint Number OH 793

Based on medical record review, review of personnel files, facility timesheets, and still shot photograph images, interviews with Special Agents from the Ohio Attorney General's (AG) office, staff, resident, and family interviews, interview with the Medical Director, and review of a facility policy and procedure, the facility failed to ensure staff implemented the Abuse Policy and Procedures when they did not immediately report witnessing incidents of staff to resident physical abuse of a cognitively impaired resident to the administrator of the facility. Consequently, the facility failed to take action to protect the residents from further abuse after the incidents were witnessed, and immediately initiate an investigation into the physical abusive behavior by the perpetrators. This resulted in Immediate Jeopardy and actual harm to one (#13) of 14 residents reviewed for abuse when two staff members intentionally and willfully physically abused the resident by pinching his ear and pulling his hair on two separate occasions during the provision of personal care. Furthermore, this placed 25 additional residents (#6, #7, #8, #9, #10, #11, #14, #15, #16, #17, #18, #20, #21, #22, #23, #30, #31, #32, #33, #35, #36, #37, #38, #39 and #40) at risk for the likelihood of serious physical harm or injury as a staff member witnessed the physical abuse of a resident on more than one occasion, failed to immediately report it to the administrator, thus allowing the perpetrators to continue to provide personal care to residents requiring their assistance, who were identified by the facility as cognitively impaired and exhibited behaviors. The total facility census was 40. On 06/08/16 at 5:05 P.M. the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/05/16 at 4:41 P.M. when Hospitality Aide (HA) #70 intentionally pinched Resident #13 behind the ear after the resident grabbed HA #70's left breast. The incident was witnessed by State tested Nursing Aide (STNA) #95 who was observed at the bedside of Resident #13 assisting HA #70 with personal care when the incident occurred. The Immediate Jeopardy continued on 04/24/16 at 4:42 P.M. during a second abuse incident after Resident #13 was transferred to a geriatric (Geri) chair by STNA #95 and STNA #100. Resident #13 was observed to be pointing his hand or finger at STNA #100; however, the resident did not make physical contact with STNA #100. STNA #100 leaned toward Resident #13 and intentionally grabbed the resident's hair and pulled the resident's head toward the side which caused Resident #13's head to shift sideways toward STNA #100 at which time STNA #100 released Resident #13's hair. The second abusive incident was again witnessed by STNA #95 who was observed in the room facing Resident #13 and STNA #100 during the incident. STNA #95 did not report either incident of physical abuse immediately to the administrator. The Immediate Jeopardy was removed on 06/08/16 at 8:00 P.M. when all staff were in-serviced regarding the identification of abuse, reporting and protection of residents against abuse and the facility implemented the following corrective actions: · On 06/03/16 at 12:33 P.M., the DON suspended HA #70 and at 4:30 P.M., STNA 100 was suspended. · On 06/03/16, the DON completed a head-to-toe assessment of Resident #13. No signs of physical injuries were found and Resident #13 could not recall the incidents. · On 06/03/16, the Administrator and DON began implementing all staff in-service training regarding identification, reporting and protection of residents regarding abuse. The all staff in-service training was completed on 06/08/16 at 8:00 P.M. · The Administrator and DON will continue monthly all staff in-service training for three consecutive months (July, August and September) and randomly thereafter as directed by the Quality Assurance (QA) committee. · On 06/08/16, the DON conducted interviews with all alert and oriented residents regarding any alleged abuse incidents. There were no other allegations of abuse identified. · On 06/08/16, the DON and designees completed head to toe assessments of all 24 cognitively impaired residents to identify any signs of abuse such as marks, bruising, etc. There were no physical or psychosocial indicators of potential abuse identified. · On 06/08/16, the DON conducted an audit of all resident's medical records including nursing notes to identify any potential abuse indicators. There were no other potential abuse indicators noted. · On 06/08/16 at 7:30 P.M., STNA #95 was in-serviced by the Administrator on identification, reporting and protection of residents regarding abuse. STNA #95 was placed on a performance plan which includes weekly one-on-one performance reviews that will continue for three months · On 06/08/16, the DON implemented resident interview audits to assist in identifying abuse allegations as follows: Day one and two- all residents will be interviewed; Day three- 75% of residents will be interviewed; Day four- 50% of residents will be interviewed; Day five through Day ten- 25% of residents will be interviewed; and Day 11 forward, random interviews will be conducted quarterly and as directed by the QA committee. · On 06/09/16, the facility terminated HA #70 and STNA #100. · On 06/09/16, 13 (#6, #7, #9, #15, #17, #20, #21, #22, #30, #31, #33, #36 and #39) additional charts were reviewed of residents who were identified as being cognitively impaired. There were no indicators or suspicions of abuse noted. · On 06/09/16 between 11:47 A.M. and 12:25 P.M., Licensed Practical Nurse (LPN) #160, LPN #190, Housekeeper #170 and Activity Director #180 were interviewed and stated they were in-serviced and were knowledgeable on the identification, reporting and protection of residents against abuse. · On 06/09/16, the administrator formed an Abuse Committee comprised of the Administrator, DON, a social services designee, staff nurse designee, an STNA representative, a housekeeping representative, activities representative and a culinary representative. The Abuse Committee will meet weekly starting June 15, 2016 for three continuous weeks and then monthly thereafter. The Resident Interview Audits will be reviewed and discussed during the meeting and during quarterly QA and Performance Improvement meetings. · Beginning 06/09/16, the DON or designee will conduct observational audits of direct care staff providing resident care to residents with cognitive impairments and/or residents with behaviors to assure care is provided in a manner that promotes an abuse free environment. Random audits of at least three staff members will be performed weekly times four weeks, monthly for three months and then as directed by the QA committee. Although the Immediate Jeopardy was removed on 06/08/16, 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) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) completed on 05/24/16 revealed the resident was assessed as displaying physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing and abusing others sexually) of occurring daily. Resident #13's scored a two out of 15 on the Brief Interview for Mental Status Score (BIMS) indicating the resident is severely cognitively impairment. Review of Resident #13's care plan revealed that Resident #13 was totally dependent of staff for personal care and was a two person assist for transfer. The care plan noted Resident #13 was confused, resistive to care, non-compliant and sexually inappropriate daily. Some of the listed care plan interventions were to approach the resident in a calm manner, explain procedures prior to starting, modify environment to prevent situations that trigger inappropriate care, allow resident to calm down before attempting to continue with care, redirect and cue as needed. During an interview with the Administrator and the DON on 06/07/16 at 8:10 A.M. they both stated they were not aware of any physical abuse until the Ohio AG Special Investigators notified the facility on 06/03/16. Ohio AG Special Agent #1 stated in an interview on 06/07/16 at 11:23 A.M. that HA #70 was viewed on video obtained through hidden camera forcefully pushing Resident #13 during personal care on 04/05/16 at 4:41 P.M. AG Special Agent #1 stated during the video Resident #13 grabbed HA #70's left breast while the caregiver and STNA #95 were providing personal care. AG Special Agent #1 stated that HA #70 stepped back and away from Resident #13 after he grabbed her breast, then HA #70 reached in with her right hand and pushed back forcefully over top of Resident #13. AG Special Agent #1 stated that STNA #95 was on the opposite side of Resident #13's bed and was looking directly at HA #70 and Resident #13. AG Special Agent #1 stated that there was another incident involving STNA #100 who was viewed on video obtained through hidden camera pulling Resident #13's hair during a transfer on 04/24/16 at 4:42 P.M. AG Special Agent #1 stated during the video Resident #13 was sitting on the edge of a Geri chair and pointed up at STNA #100. STNA #100 then reached out at Resident #13 with her left hand, grabbed Resident #13's hair and pulled him forward toward her. AG Special Agent #1 stated STNA #95 assisted STNA #100 with Resident #13's transfer and was standing behind Resident #13's Geri chair looking at STNA #100 when Resident #13's hair was pulled. AG Special Agent #1 stated during this interview that the facility identified HA #70, STNA #95 and STNA #100 through still shot photos obtained from the video which was shown to the facility on [DATE] when the facility was notified of the allegations of physical abuse. On 06/07/16 at 2:30 P.M. an attempt was made to interview Resident #13. Resident #13 was cognitively impaired and stated he does not remember being treated roughly or being abused by staff. During an interview of 06/07/16 at 4:05 P.M., STNA #95 denied witnessing HA #70 pinch Resident #13's ear on 04/05/16. STNA #95 also denied witnessing STNA #100 pull Resident #13's hair on 04/24/16. STNA #95 further denied ever witnessing any resident abused in any manner in the facility. In an interview on 06/08/16 at 9:50 A.M. STNA #100 stated Resident #13 likes to grab staff in inappropriate places, he has grabbed and bitten her breast, he tries to shove his toes up your butt and she felt Resident #13 was fully aware of what he is doing. STNA #100 stated that Resident #13 would say no when told to stop. STNA #100 denied pulling Resident #13's hair during the transfer on 04/24/16 and she stated that she could not remember what other STNA assisted with Resident #13's transfer on 04/24/16. HA #70 confirmed in an interview on 06/08/16 at 10:42 A.M. that she pinched Resident #13 behind the ear after he had grabbed her left breast on 04/05/16. HA #70 stated she pinched Resident #13's ear as a reaction to the resident grabbing her breast. HA #70 stated the act was inappropriate, but did not feel it was abuse. HA #70 stated she had never touched a resident like that before. HA #70 stated that Resident #13 is very vulgar in how he talks and tries to pull the aides scrub top down during care. HA #70 stated that she usually tells Resident #13 no and backs up when he tries to touch her inappropriately. On 06/09/16 at 12:16 P.M. Resident #13's family member was interviewed. Resident #13's family member stated he was made aware of an abuse allegation by in October 2015 and that the family agreed to allow the Ohio AG's Office to place undercover cameras in the resident's room for an investigation regarding abuse. Resident #13's family member stated the family never suspected abuse. On 06/09/16 at 12:31 P.M. an interview with the Medical Director revealed that he has never had any concerns or suspicions of abuse at the facility. Still shot photos obtained from video surveillance was provided by the Ohio AG's Office and were viewed. These images were dated 04/05/16 and 04/24/16 and revealed the following: · Still shot photos dated 04/05/16 at 4:41:32 P.M. through 4:41:36 P.M. Resident #13 grabs the left breast of HA #70 with his left hand, HA #70 backs up and clears herself from Resident #13, HA #70 had a shocked facial appearance. HA #70 then come back toward Resident #13 and reaches towards Resident #13's upper body with her right hand/ arm extended at 4:41:34 P.M. Resident #13 then reacts to HA #70 by grabbing the HA #70's right upper arm and pushing her away at 4:41:36 P.M. STNA #95 is present in the still shot photos and is observed standing on the opposite side of the bed and facing Resident #13 and HA #70 during the incident. · Still shot photos dated 04/24/16 at 4:42:29 P.M. through 4:42:31 shows Resident #13 sitting in a Geri chair with STNA #100 standing to his left and STNA #95 standing on his right and slightly behind the Geri chair. Resident #13 is sitting in the Geri chair with his left arm extended upward at STNA #100, STNA #95 is to the side/ behind Resident #13 holding on to the Geri chair with both hands and at 4:42:29 P.M. STNA #100 reaches with her open left hand towards Resident #13 sitting in the Geri chair, STNA #95 is still observed to the side/ behind Resident #13 facing STNA #100 and holding on to the Geri chair. STNA #100's left hand makes contact with Resident #13's head and his head is pulled sideways and towards STNA #100 at 4:42:30 P.M. STNA #100's hand is released from Resident #13's head, Resident #13 is leaning toward STNA with left hand at his head at 4:42:31 P.M. The still shot photos show STNA #95 standing behind Resident #13 holding on to the Geri chair and facing STNA #100 and Resident #13 during the incident. Review of HA #70's personnel file revealed the employee was hired as a hospitality aide on 06/23/15. HA #70 completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) on 05/09/16; however, the STNA testing had not been completed at the time of the survey. HA #70 was not found in the Nurse Aide Registry. Review of HA #70's personnel file revealed there was no 90 day evaluation completed for the employee; however, HA #70 received a written warning for being rude and discourteous to a resident on 10/15/15. Further review revealed HA #70 received a written warning on 02/20/16 for failing to follow patient care policies. The review of the personnel file including a review of the driver's licenses revealed HA #70 was the aide providing care to Resident #13 on 04/05/16. Review of STNA #95's personnel file revealed the employee was hired as a STNA on 11/11/15. STNA #95 was in good standings with the Nurse Aide Registry. Review of STNA #95's personnel file revealed there was no 90 day evaluation completed for the employee. The review further revealed STNA #95 received no disciplinary action. The review of the personnel file including a review of the driver's licenses revealed STNA #95 was the aide providing care to Resident #13 on 04/24/16. Review of STNA #100's personnel file revealed the employee was hired as a STNA on 03/18/14. STNA #100 was in good standings with the Nurse Aide Registry. Review of STNA #100's personnel file revealed there was an evaluation dated 09/23/15; however, there was no concerns or disciplinary action regarding abuse reporting. The review of the personnel files including a review of the driver's licenses revealed STNA #95 was the second aide providing care to Resident #13 on 04/05/16 and 04/24/16. HA #70, STNA #95 and STNA #100's timesheets were reviewed for the dates of 04/05/16 and 04/24/16. It was determined on 04/05/16 HA #70 worked from 2:28 P.M. until 11:03 P.M. On 04/24/16, STNA #100 worked from 2:28 P.M. until 11:01 P.M. STNA #95 worked from 6:05 A.M. until 8:08 P.M. on 04/05/16 and from 2:28 P.M. until 11:01 P.M. on 04/24/16. A facility policy and procedure titled Nursing Policy/Procedure Manual regarding Abuse, revised July 2005, revealed the following: Under the section titled Abuse Prevention, resident care and treatment are monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect and mistreatment. It is the responsibility of all staff to provide a safe environment for all residents. Under the section titled Abuse Reporting, any person(s) witnessing of or having knowledge of alleged violations involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident has the responsibility to report the incident to the Administrator, Director of Nursing, or designee immediately. Under the section of Abuse Investigation it is the policy of this facility that reports of abuse are promptly and thoroughly investigated. When an incident or suspected incident of abuse is reported, the Administrator or designee investigates the incident. Under the section of Protection during and after the investigation the residents are protected from harm through frequent supervision by staff. If the alleged abuser is an employee, they shall be removed from the facility and suspended pending the results of the facility's investigation. This deficiency substantiates Complaint Number OH 793.

Based on medical record review, review of personnel files, facility timesheets, and still shot photograph images, interviews with Special Agents from the Ohio Attorney General's (AG) office, staff, resident, and family interviews, interview with the Medical Director, and review of a facility policy and procedure, the facility failed to ensure a cognitively impaired resident was protected and free from physical abuse by facility staff members during provision of personal care. This resulted in Immediate Jeopardy and actual harm to one resident (#13) when two staff members intentionally and willfully physically abused Resident #13 by pinching his ear and pulling his hair on two separate occasions during provision of personal care. This affected one (#13) of 14 residents reviewed for abuse. The facility identified two allegations of abuse in the past three months. The facility census was 40. On 06/08/16 at 5:05 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 04/05/16 at 4:41 P.M. when Hospitality Aide (HA) #70 intentionally pinched Resident #13 behind the ear after the resident grabbed HA #70's left breast. The incident was witnessed by State tested Nursing Assistant (STNA) #95 who was observed at the bedside of Resident #13 assisting HA #70 with personal care when the incident occurred. The Immediate Jeopardy continued on 04/24/16 at 4:42 P.M. during a second abuse incident after Resident #13 was transferred to a geriatric (Geri) chair by STNA #95 and STNA #100. Resident #13 was observed to be pointing his hand or finger at STNA #100; however, the resident did not make physical contact with STNA #100. STNA #100 leaned toward Resident #13 and intentionally grabbed the resident's hair and pulled the resident's head toward the side which caused Resident #13's head to shift sideways toward STNA #100 at which time STNA #100 released Resident #13's hair. The second abusive incident was again witnessed by STNA #95 who was observed in the room facing Resident #13 and STNA #100 during the incident. The Immediate Jeopardy was removed on 06/08/16 at 8:00 P.M. when all staff were in-serviced regarding the identification of abuse and the facility implemented the following corrective actions: · On 06/03/16 at 12:33 P.M., the DON suspended HA #70 and at 4:30 P.M., STNA #100 was suspended. · On 06/03/16, the DON completed a head-to-toe assessment of Resident #13. No signs of physical injuries were found and Resident #13 could not recall the incidents. · On 06/03/16, the Administrator and DON began implementing all staff in-service training regarding identification of abuse. The all staff in-service training was completed on 06/08/16 at 8:00 P.M. · The Administrator and DON will continue monthly all staff in-service training for three consecutive months (July, August and September) and randomly thereafter as directed by the Quality Assurance (QA) committee. · On 06/08/16, the DON conducted interviews with all alert and oriented residents regarding any alleged abuse incidents. There were no other allegations of abuse identified. · On 06/08/16, the DON and designees completed head to toe assessments of all 24 cognitively impaired residents to identify any signs of abuse such as marks, bruising, etc. There were no physical or psychosocial indicators of potential abuse identified. · On 06/08/16, the DON conducted an audit of all residents' medical records including nursing notes to identify any potential abuse indicators. There were no other potential abuse indicators noted. · On 06/08/16 at 7:30 P.M., STNA #95 was in-serviced by the Administrator on abuse and abuse reporting. STNA #95 was placed on a performance plan which includes weekly one-on-one performance reviews that will continue for three months. · On 06/08/16, the DON implemented resident interview audits to assist in identifying abuse allegations as follows: Day one and two- all residents will be interviewed; Day three- 75% of residents will be interviewed; Day four- 50% of residents will be interviewed; Day five through Day ten- 25% of residents will be interviewed; and Day 11 forward, random interviews will be conducted quarterly and as directed by the QA committee. · On 06/09/16, the facility terminated HA #70 and STNA #100. · On 06/09/16, 13 (#6, #7, #9, #15, #17, #20, #21, #22, #30, #31, #33, #36 and #39) additional charts were reviewed of residents who were identified as being cognitively impaired. There were no indicators or suspicions of abuse noted. · On 06/09/16 between 11:47 A.M. and 12:25 P.M., Licensed Practical Nurse (LPN) #160, LPN #190, Housekeeper #170 and Activity Director #180 were interviewed and stated they were in-serviced and were knowledgeable on the identification of abuse. · On 06/09/16, the administrator formed an Abuse Committee comprised of the Administrator, DON, a social service designee, staff nurse designee, an STNA representative, a housekeeping representative, activities representative and a culinary representative. The Abuse Committee will meet weekly starting June 15, 2016 for three continuous weeks and then monthly thereafter. The Resident Interview Audits will be reviewed and discussed during the meeting and during quarterly QA and Performance Improvement meetings. · Beginning 06/09/16, the DON or designee will conduct observational audits of direct care staff providing care to residents with cognitive impairments and/or residents with behaviors to assure care is provided in a manner that promotes an abuse free environment. Random audits of at least three staff members will be performed weekly times four weeks, monthly for three months and then as directed by the QA committee. Although the Immediate Jeopardy was removed on 06/08/16, 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) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #13's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) assessment completed on 05/24/16 revealed the resident was assessed as displaying physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing and abusing others sexually) occurring daily. Resident #13 scored a two out of 15 on the Brief Interview for Mental Status Score (BIMS) indicating severe cognitive impairment. Review of Resident #13's care plan revealed Resident #13 was totally dependent on staff for personal care and was a two person assist for transfers. The care plan noted Resident #13 was confused, resistive to care, non-compliant and sexually inappropriate daily. Care plan interventions included to approach the resident in a calm manner, explain procedures prior to starting, modify environment to prevent situations that trigger inappropriate care, allow resident to calm down before attempting to continue with care, and to redirect and cue as needed. During an interview with the Administrator and DON on 06/07/16 at 8:10 A.M., both stated they were not aware of any physical abuse until the Ohio AG Special Agent Investigators notified the facility on 06/03/16. Ohio AG Special Agent #1 stated in an interview on 06/07/16 at 11:23 A.M., HA #70 was viewed on video, obtained through a hidden camera, forcefully pushing Resident #13 during personal care on 04/05/16 at 4:41 P.M. AG Special Agent #1 stated during the video, Resident #13 grabbed HA #70's left breast while the caregiver and STNA #95 were providing personal care. AG Special Agent #1 stated HA #70 stepped back and away from Resident #13 after he grabbed her breast, and then HA #70 reached in with her right hand and pushed back forcefully over top of Resident #13. AG Special Agent #1 stated STNA #95 was on the opposite side of Resident #13's bed and was looking directly at HA#70 and Resident #13. AG Special Agent #1 stated there was another incident involving STNA #100 who was viewed on video, obtained through hidden camera, pulling Resident #13's hair during a transfer on 04/24/16 at 4:42 P.M. AG Special Agent #1 stated during the video, Resident #13 was sitting on the edge of a Geri chair and pointed up at STNA #100. STNA #100 then reached out at Resident #13 with her left hand, grabbed Resident #13's hair and pulled him forward toward her. AG Special Agent #1 stated STNA #95 assisted STNA #100 with Resident #13's transfer and was standing behind Resident #13's Geri chair looking at STNA #100 when Resident #13's hair was pulled. AG Special Agent #1 stated the facility identified HA #70, STNA #95 and STNA #100 through still shot photographs, obtained from the video, which was shown to the facility on [DATE] when the facility was notified of the allegations of physical abuse. On 06/07/16 at 2:30 P.M., an attempt was made to interview Resident #13. Resident #13 was cognitively impaired and stated he does not remember being treated roughly or being abused by staff. During an interview on 06/07/16 at 4:05 P.M., STNA #95 denied witnessing HA #70 pinching Resident #13's ear on 04/05/16. STNA #95 also denied witnessing STNA #100 pulling Resident #13's hair on 04/24/16. STNA #95 further denied ever witnessing any resident abused in any manner in the facility. During an interview on 06/08/16 at 9:50 A.M., STNA #100 stated Resident #13 likes to grab staff in inappropriate places and he has grabbed and bitten her breast and he tries to shove his toes up your butt and she felt Resident #13 was fully aware of what he is doing. STNA #100 stated Resident #13 would say no when told to stop. STNA #100 denied pulling Resident #13's hair during the transfer on 04/24/16 and she stated she could not remember what other STNA assisted with Resident #13's transfer on 04/24/16. During an interview with HA #70 on 06/08/16 at 10:42 A.M. she confirmed she had pinched Resident #13 behind the ear after he had grabbed her left breast on 04/05/16. HA #70 stated she pinched Resident #13's ear as a reaction to the resident grabbing her breast. HA #70 stated the act was inappropriate, but did not feel it was abuse. HA #70 stated she had never touched a resident like that before. HA #70 stated Resident #13 is very vulgar in how he talks and tries to pull the aides scrub top down during care. HA #70 stated she usually tells Resident #13 no and backs up when he tries to touch her inappropriately. On 06/09/16 at 12:16 P.M., Resident #13's family member was interviewed. Resident #13's family member stated he was made aware of an abuse allegation in October 2015 and the family agreed to allow the Ohio AG's office to place undercover cameras in the resident's room for an investigation regarding abuse. Resident #13's family member stated the family never suspected abuse. On 06/09/16 at 12:31 P.M., an interview with the Medical Director revealed he has never had any concerns or suspicions of abuse at the facility. Review of still shot photographs obtained from video surveillance was provided by the Ohio AG's office and were viewed. These images were dated 04/05/16 and 04/24/16 and revealed the following: · Still shot photographs dated 04/05/16 at 4:41:32 P.M. through 4:41:36 P.M. revealed Resident #13 grabs the left breast of HA #70 with his left hand. HA #70 backs up, clears herself from Resident #13 and HA #70 has a shocked facial appearance. HA #70 then comes back toward Resident #13 and reaches towards Resident #13's upper body with her right hand/arm extended at 4:41:34 P.M. Resident #13 then reacts to HA #70 by grabbing HA #70's right upper arm and pushing her away at 4:41:36 P.M. STNA #95 is present in the still shot photographs and is observed standing on the opposite side of the bed and facing Resident #13 and HA #70 during the incident. · Still shot photographs dated 04/24/16 at 4:42:29 P.M. through 4:42:31 P.M. revealed Resident #13 sitting in a Geri chair with STNA #100 standing to his left and STNA #95 standing on his right and slightly behind the Geri chair. Resident #13 is sitting in the Geri chair with his left arm extended upward at STNA #100. STNA #95 is to the side behind Resident #13 holding onto the Geri chair with both hands and at 4:42:29 P.M. STNA #100 reaches with her open left hand towards Resident #13 sitting in the Geri chair while STNA #95 is still observed to the side/behind Resident #13's Geri chair facing STNA #100 and holding onto the Geri chair. STNA #100's left hand makes contact with Resident #13's head and his head is pulled sideways and towards STNA #100 at 4:42:30 P.M. STNA #100's hand is released from Resident #13's head and Resident #13 is leaning toward the STNA with the left hand at his head at 4:42:31 P.M. The still shot photographs show STNA #95 standing behind Resident #13 holding onto the Geri chair and facing STNA #100 and Resident #13 during the incident. Review of HA #70's personnel file revealed the employee was hired as a hospitality aide on 06/23/15. HA #70 completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) on 05/09/16; however, the STNA testing had not been completed at the time of the survey. HA #70 was not found in the Nurse Aide Registry. Review of HA #70's personnel file revealed there was no 90 day evaluation completed for the employee; however, HA #70 received a written warning for being rude and discourteous to a resident on 10/15/15. Further review revealed HA #70 received a written warning on 02/20/16 for failing to follow patient care policies. Review of the personnel file, including a review of the driver's license, revealed HA #70 was the aide providing care to Resident #13 on 04/05/16. Review of STNA #95's personnel file revealed the employee was hired as an STNA on 11/11/15. STNA #95 was in good standing with the Nurse Aide Registry. Review of STNA #95's personnel file revealed there was no 90 day evaluation completed for the employee. The review further revealed STNA #95 received no disciplinary action. Review of the personnel file, including a review of the driver's licenses, revealed STNA #95 was the aide providing care to Resident #13 on 04/24/16. Review of STNA #100's personnel file revealed the employee was hired as a STNA on 03/18/14. STNA #100 was in good standings with the Nurse Aide Registry. Review of STNA #100's personnel file revealed there was an evaluation dated 09/23/15; however, there were no concerns or disciplinary action regarding abuse reporting. Review of the personnel files, including a review of the driver's licenses, revealed STNA #95 was the second aide assisting with providing care to Resident #13 on 04/05/16 and 04/24/16. HA #70, STNA #95 and STNA #100's timesheets were reviewed for the dates of 04/05/16 and 04/24/16. Review of the timesheets revealed on 04/05/16, HA #70 and STNA #95 worked during the first abuse incident. Further review of the timesheets revealed on 04/24/16, STNA #100 and STNA #95 worked during the second abuse incident. A facility policy and procedure titled Nursing Policy/Procedure Manual regarding Abuse revised July 2005 was reviewed. According to the manual resident care and treatment are monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect or mistreatment. It is the responsibility of all staff to provide a safe environment for all residents. The policy further outlined Abuse Reporting and instructed any person(s) witnessing or having knowledge of alleged violations involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident has the responsibility to report the incident to the Administrator, Director of Nursing, or designee immediately. This deficiency substantiates Complaint Number OH 793.