Every finding on record at Vista Care Center of Milan

Based on medical record review, review of a facility medication incident investigation, review of staff statements, staff and resident interviews, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to assess and monitor for potential medication interactions and adverse medication effects. This affected two (#55, #56) of three residents reviewed for medications and had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. Diagnoses included type two diabetes mellitus, bipolar disorder, paranoid schizophrenia, anxiety, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #56's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM (pain reliever/sleep aid). Review of a physician order dated 06/13/25 revealed the resident was ordered Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth as needed for insomnia at bedtime.Review of the medical record for Resident #55 revealed an admission date of 02/21/21. Diagnoses included schizoaffective disorder bipolar type, paranoid personality disorder, and depressive disorder. Review of the MDS quarterly assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #55's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM. Review of a physician order dated 06/25/25 revealed an order for Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth every 24 hours as needed for insomnia. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed working a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and Melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Review of the staffing assignment forms from 05/21/25 through 06/04/25 revealed LPN #174 worked on unit one on 05/21/25, 05/22/25, 05/26/25, 05/27/25, 05/28/25, 06/03/25, and 06/04/25.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures. Review of Resident #56's statement dated 06/05/25 taken by Former Interim Director of Nursing (FIDON) #800 revealed the resident was asked if she had been receiving Tylenol PM last night or anytime. Resident #56 stated she had not wished to answer and had not wanted to get anyone in trouble. Resident #56 stated she would like the nurse practitioner to be asked for an order for Tylenol PM because she needed it to help her sleep. FIDON #800 noted the resident had an order for Tylenol 325 milligrams and order for Melatonin 10 mg at bedtime. Review of a statement dated 06/05/25 by LPN #174 and emailed to FIDON #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly no Tylenol PM was given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started pre-pouring the residents' nighttime medications and putting Tylenol PM in all of the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the FDON #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation. Further review of the facility investigation revealed no documentation the pharmacy was contacted. Also, there were no interviews completed with the residents residing on unit one and there was no documentation of resident assessments or monitoring. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Interview on 09/03/25 at 8:18 A.M., LPN #136 revealed LPN #174 was giving medications without an order but no longer worked here. LPN #136 revealed FDON #566 and ADON #196 were notified. LPN #136 revealed she had not witnessed LPN #174 giving medications to the residents without an order. LPN #136 revealed she heard the residents on unit one were receiving two Tylenol PM with no physician order. LPN #136 revealed she usually worked on unit one and was never told to assess or monitor the residents for adverse effects of possibly being given medications without an order. Interview on 09/04/25 at 7:43 A.M., LPN #163 revealed LPN #174 would pre-pour resident medications including blue Tylenol PM medications which the resident had no physician orders for. LPN #174 revealed she had reported the incident to FDON #566 and ADON #196. Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was giving residents Tylenol PM without an order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM. Interview on 09/04/25 at 1:09 P.M., Resident #19 was unaware if she had received Tylenol PM.Interview on 09/04/25 at 1:17 P.M., Resident #11 was not aware if he had received Tylenol PM. Interview on 09/04/25 at 12:58 P.M., Resident #56 revealed LPN #174 was giving her two Tylenol PM without a physician order. Resident #56 revealed she now had an order for the Tylenol PM, but she could only have one now even though two worked better. Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and Melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, and completion of resident assessments and monitoring for potential adverse medication reactions.Interview on 09/04/25 at 3:32 P.M., Resident #44 revealed taking medications the nurses gave her. Resident #44 revealed she was not aware if she had received any medications not ordered by the physician. Interview on 09/08/25 at 10:00 A.M., Physician #190 revealed he had been notified a nurse may have been giving medications without an order. Physician #190 revealed he would have expected nursing staff to keep an eye on the residents and monitor them closely for a change in condition and check vital signs. Physician #190 stated these things happen and this was a mild medication error, and he had not anticipated any problems for the residents. Interview on 09/08/25 at 1:10 P.M., LPN #501 revealed she had removed a Tylenol PM bottle from the unit one medication cart as no residents had physician orders for the medication. LPN #501 revealed the medication ended up back in the cart. LPN #501 revealed ADON #196 was aware. LPN #501 revealed she was not sure which residents had received the medication, if any. Interview on 09/08/25 at 4:39 P.M., Resident #67 revealed he was unaware if he had received medications without a physician order. Interview on 09/09/25 at 7:22 A.M., RN #212 revealed on 06/04/25 she saw LPN #174 put Tylenol PM and Melatonin in all the residents medication cups with their regular medication and take the cart down the hall and start passing medication. RN #212 revealed no resident had an order for Tylenol PM. RN #212 revealed she wrote a statement and took pictures of the cart and sent them to ADON #196. RN #212 revealed she had not watched LPN #174 hand the medications to the residents. Interview on 09/09/25 at 1:26 P.M., the current Director of Nursing (DON) revealed a thorough investigation was not completed for the allegation on 06/04/25 of medications being administered without an order. The DON stated she would have notified residents and resident representatives. The DON revealed the physician should be notified immediately, not two days later. The DON revealed she would have pulled the staffing schedules to check where LPN #174 had worked. The DON also revealed she would have checked allergies for the residents on unit one and notified the pharmacy to check for medication interactions. The DON revealed staff, and the potentially affected residents should have been interviewed, monitored, and assessed for adverse reactions and there should have been documentation of the notifications, interviews, monitoring, and assessments. Interview on 09/09/25 at 1:36 P.M., LPN #160 revealed on 05/21/25 she gave report to LPN #174. LPN #160 revealed she witnessed LPN #174 set up all the resident medications for unit one and put Tylenol PM in the cups, then taking the cart down the hall and start passing the medications. LPN #160 revealed during her training she noticed LPN #174 would also watch movies on her phone and sleep at the nurses station. LPN #160 stated she wrote a statement on 05/21/25 and reported the incident to ADON #196. LPN #160 revealed other nurses had previously reported LPN #174 doing the same thing to FDON #566 but nothing was ever done about it. Interview on 09/09/25 at 3:12 P.M., Resident #55 revealed a nurse used to give her two Tylenol PM. Resident #55 revealed the two Tylenol PM were helpful, but she only received one Tylenol PM now. Resident #55 was unable to remember the name of the nurse. Review of LPN #174's personnel record revealed a hire date of 04/09/23 and a termination date of 06/04/25 for performance and violation of company policy. Review of the facility policy Medication Administration, dated 12/2012 revealed prior to administration, nurses would review and confirm medication orders for each individual resident on the Medication Administration Record. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. Medications are administered in accordance with written orders of the prescriber. Medications were to be administered at the time they were prepared. Note allergies or contraindication the resident may have prior to medication administration. The individual who administers the medication dose records the administration on the residents MAR immediately following the medication being given. Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. Observe resident for medication actions/reactions and record in the nurses notes as appropriate.This deficiency represents non-compliance investigated under Complaint Number 1331531.

Based on medical record review, review of a medication incident investigation, review of staff statements, interviews with staff and residents, and review of facility policy, the facility failed to investigate allegations of abuse and neglect alleged on 05/21/25 and failed to thoroughly investigate an allegation of abuse alleged on 06/04/25. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. Diagnoses included type two diabetes mellitus, bipolar disorder, paranoid schizophrenia, anxiety, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #56's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM (pain reliever/sleep aid). Review of a physician order dated 06/13/25 revealed the resident was ordered Tylenol PM extra strength 500 milligram (mg)/25 mg, one tablet by mouth as needed for insomnia at bedtime.Review of the medical record for Resident #55 revealed an admission date of 02/21/21. Diagnoses included schizoaffective disorder bipolar type, paranoid personality disorder, and depressive disorder. Review of the MDS quarterly assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #55's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM. Review of a physician order dated 06/25/25 revealed an order for Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth every 24 hours as needed for insomnia. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed working a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 noted during training LPN #174 would watch movies and sleep on her shift. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Further review of the investigation revealed there was no documentation the allegations reported on 05/21/25 were investigated. Review of the staffing assignment forms from 05/21/25 through 06/04/25 revealed LPN #174 worked on unit one on 05/21/25, 05/22/25, 05/26/25, 05/27/25, 05/28/25, 06/03/25, and 06/04/25.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures. Review of Resident #56's statement dated 06/05/25 taken by Former Interim Director of Nursing (FIDON) #800 revealed the resident was asked if she had been receiving Tylenol PM last night or anytime. Resident #56 stated she had not wished to answer and had not wanted to get anyone in trouble. Resident #56 stated she would like the nurse practitioner to be asked for an order for Tylenol PM because she needed it to help her sleep. FIDON #800 noted the resident had an order for Tylenol 325 milligrams and order for melatonin 10 mg at bedtime. Review of a statement dated 06/05/25 by LPN #174 and emailed to FIDON #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly no Tylenol PM was given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started pre-pouring the residents' nighttime medications and putting Tylenol PM in all of the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the FDON #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation. Further review of the facility investigation revealed no documentation the pharmacy was contacted. Also, there were no interviews completed with the residents residing on unit one and there was no documentation of resident assessments or monitoring. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Interview on 09/03/25 at 8:18 A.M., LPN #136 revealed LPN #174 was giving medications without an order but no longer worked here. LPN #136 revealed FDON #566 and ADON #196 were notified. LPN #136 revealed she had not witnessed LPN #174 giving medications to the residents without an order. LPN #136 revealed she heard the residents on unit one were receiving two Tylenol PM with no physician order. LPN #136 revealed she usually worked on unit one and was never told to assess or monitor the residents for adverse effects of possibly being given medications without an order. Interview on 09/04/25 at 7:43 A.M., LPN #163 revealed LPN #174 would pre-pour resident medications including blue Tylenol PM medications which the resident had no physician orders for. LPN #174 revealed she had reported the incident to FDON #566 and ADON #196. Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was giving residents Tylenol PM without an order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM. Interview on 09/04/25 at 1:09 P.M., Resident #19 was unaware if she had received Tylenol PM.Interview on 09/04/25 at 1:17 P.M., Resident #11 was not aware if he had received Tylenol PM. Interview on 09/04/25 at 12:58 P.M., Resident #56 revealed LPN #174 was giving her two Tylenol PM without a physician order. Resident #56 revealed she now had an order for the Tylenol PM but she could only have one now even though two worked better. Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, and the completion of resident assessments and monitoring for potential adverse medication reactions.Interview on 09/04/25 at 3:32 P.M., Resident #44 revealed taking medications the nurses gave her. Resident #44 revealed she was not aware if she had received any medications not ordered by the physician. Interview on 09/08/25 at 10:00 A.M., Physician #190 revealed he had been notified a nurse may have been giving medications without an order. Physician #190 revealed he would have expected nursing staff to keep an eye on the residents and monitor them closely for a change in condition and check vital signs. Physician #190 stated these things happen and this was a mild medication error, and he had not anticipated any problems for the residents. Interview on 09/08/25 at 1:10 P.M., LPN #501 revealed she had removed a Tylenol PM bottle from the unit one medication cart as no residents had physician orders for the medication. LPN #501 revealed the medication ended up back in the cart. LPN #501 revealed ADON #196 was aware. LPN #501 revealed she was not sure which residents had received the medication, if any. Interview on 09/08/25 at 4:39 P.M., Resident #67 revealed he was unaware if he had received medications without a physician order. Interview on 09/09/25 at 7:22 A.M., RN #212 revealed on 06/04/25 she saw LPN #174 put Tylenol PM and melatonin in all the residents medication cups with their regular medication and take the cart down the hall and start passing medication. RN #212 revealed no resident had an order for Tylenol PM. RN #212 revealed she wrote a statement and took pictures of the cart and sent them to ADON #196. RN #212 revealed she had not watched LPN #174 hand the medications to the residents. Interview on 09/09/25 at 1:26 P.M., the current Director of Nursing (DON) revealed a thorough investigation was not completed for the allegation on 06/04/25 of medications being administered without an order. The DON stated she would have notified residents and resident representatives. The DON revealed the physician should be notified immediately, not two days later. The DON revealed she would have pulled the staffing schedules to check where LPN #174 had worked. The DON also revealed she would have checked allergies for the residents on unit one and notified the pharmacy to check for medication interactions. The DON revealed staff, and the potentially affected residents should have been interviewed, monitored, and assessed for adverse reactions and there should have been documentation of the notifications, interviews, monitoring, and assessments. Interview on 09/09/25 at 1:36 P.M., LPN #160 revealed on 05/21/25 she gave report to LPN #174. LPN #160 revealed she witnessed LPN #174 set up all the resident medications for unit one and put Tylenol PM in the cups, then taking the cart down the hall and start passing the medications. LPN #160 revealed during her training she noticed LPN #174 would also watch movies on her phone and sleep at the nurses station. LPN #160 stated she wrote a statement on 05/21/25 and reported the incident to ADON #196. LPN #160 revealed other nurses had previously reported LPN #174 doing the same thing to FDON #566 but nothing was ever done about it. Interview on 09/09/25 at 3:12 P.M., Resident #55 revealed a nurse used to give her two Tylenol PM. Resident #55 revealed the two Tylenol PM were helpful, but she only received one Tylenol PM now. Resident #55 was unable to remember the name of the nurse. Review of LPN #174's personnel record revealed a hire date of 04/09/23 and a termination date of 06/04/25 for performance and violation of company policy. Review of the undated facility policy Psychotropic Drug and Unnecessary Drug Use, revealed the use of chemical restraints was not consistent with the facility guidelines or standard of practice. A chemical restraint was viewed as an approach done by staff for their own convenience or to discipline the resident. Review of the undated facility policy Abuse Prohibition, revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. A thorough investigation of all alleged violations would be conducted. Any alleged allegation was to be communicated immediately to the Administrator or designee. Residents would be assessed by the Director of Nursing or designee. The attending physician would be notified, along with family or responsible party. Residents would be interviewed if cognitively able to communicate. All alleged violation concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. Allegations involving abuse or result in serious bodily injury would be reported to the state agency within two hours after the alleged incident was discovered. Reporting of allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the state agency within five working days of the incident.This deficiency represents non-compliance investigated under Complaint Number 1331531.

Based on review of facility self-reported incidents, review of a medication incident investigation, review of staff statements, interviews with staff, and review of facility policy, the facility failed to report allegations of abuse and neglect. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed she had worked a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 noted during training LPN #174 would watch movies and sleep on her shift. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Further review of the investigation revealed there was no documentation the allegations reported on 05/21/25 were investigated.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures.Review of a statement dated 06/05/25 by LPN #174 and emailed to the Former Interim Director of Nursing (FIDON) #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly, no Tylenol PM were given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started pre-pouring the residents' nighttime medications and putting Tylenol PM in all the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the Former Director of Nursing (FDON) #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation.Review of the facility self-reported incidents (SRI) revealed the incidents alleged on 05/21/25 and 06/04/25 had not been reported to the state agency. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications.Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was giving residents Tylenol PM without an order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM.Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, or completion of resident assessments and monitoring for potential adverse medication reactions. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Review of the undated facility policy Psychotropic Drug and Unnecessary Drug Use, revealed the use of chemical restraints was not consistent with the facility guidelines or standard of practice. A chemical restraint was viewed as an approach done by staff for their own convenience or to discipline the resident. Review of the undated facility policy Abuse Prohibition, revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. A thorough investigation of all alleged violations would be conducted. Any alleged allegation was to be communicated immediately to the Administrator or designee. Residents would be assessed by the Director of Nursing or designee. The attending physician would be notified, along with family or responsible party. Residents would be interviewed if cognitively able to communicate. All alleged violation concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. Allegations involving abuse or result in serious bodily injury would be reported to the state agency within two hours after the alleged incident was discovered. Reporting of allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the state agency within five working days of the incident.This deficiency represents non-compliance investigated under Complaint Number 1331531.

Based on review of the medical record, review of a fall investigation, review of staffing assignment records, interviews with staff and residents, and policy review, the facility failed to ensure a resident was reevaluated for transfer assistance after a change in condition and ensure a safe resident transfer. Additionally, the facility failed to ensure falls were immediately reported, immediate post-fall assessments were completed and ensure the completion of a thorough fall investigation. This affected one (#7) of three residents reviewed for falls and had the potential to affect 56 residents residing on unit one and unit two. The facility census was 87. Review of the medical record for Resident #7 revealed an admission date of 02/21/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, acquired absence of right leg below the knee, type two diabetes mellitus, and a diabetic foot ulcer. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was at risk for falls.Review of a physician order dated 12/08/23 revealed the resident required the assistance of one staff and pivot transfer with walker. The order was discontinued on 07/01/25. Review of a physical therapy Discharge summary dated [DATE] revealed the resident required supervision or touching assistance with transfers. The resident was discharged from therapy using a walker.Review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the plan of care initiated on 02/23/23 revealed the resident had impaired mobility and relied on staff for assistance with activities of daily living (ADL ' s). The resident had a right leg prosthesis. Interventions included extensive assistance by staff with transferring, use of walker for transfers with pivot and the care plan was noted as resolved on 01/22/25. On 01/22/25 the resident was noted as requiring weight bearing assistance with sit to stand, lying to sitting, and transfers. On 02/19/25 an intervention was added for mechanical lift transfers until new prosthetic was received. Review of a nurse ' s note dated 01/27/25 at 1:26 P.M. revealed Resident #7 had a three centimeter (cm) in length by 2.5 cm in width blister noted to the right anterior stump. The resident stated his prosthetic rubs and caused the blister, red patches were also noted. The nurse practitioner was notified with new wound care orders received. The blister was noted as healed on 02/10/25.Review of a nurse ' s note dated 01/28/25 at 8:54 A.M. revealed the resident was scheduled to have his prosthetic leg evaluated by a provider on 02/13/25. There was no documentation in the medical record of the resident attending the appointment. Review of a nurse ' s note dated 01/30/25 at 9:39 A.M. revealed Resident #7 was not wearing prosthetic to right stump related to pain/ill fitting. Appointment scheduled for adjustment. Review of a physician order dated 01/30/25 revealed to not wear prosthetic to right stump until after follow up with orthopedics. Further review of the medical record revealed no documentation the resident ' s transfer status was reevaluated after the inability to wear the right lower extremity prosthesis. Review of the weight documentation revealed the resident weighed 236 pounds on 01/20/25 and 238 pounds on 02/19/25. Review of an incident report dated 02/19/25 at 1:25 P.M. revealed a nursing assistant informed the nurse Resident #7 had a fall two days ago. The resident revealed he had fallen and landed on his buttocks. The nursing assistants helped him up with the help of his roommate to hold the chair then put him back in bed and left the room. Review of statement dated 02/19/25 by Certified Nursing Assistant (CNA) #601 revealed on 02/17/25 CNA #602 went to transfer Resident #7, and he fell. CNA #601 revealed she was only in the room to watch. CNA #601 revealed CNA #602 fell on top of Resident #7. CNA #602 told CNA #601 not to report the fall because Resident #7 was fine and was not hurt. Review of statement dated 02/19/25 by CNA #602 revealed on 02/17/25 Resident #7 said he needed to have a bowel movement. CNA #602 stated normally we transfer to the toilet in shower room but a resident was using the toilet, so we laid Resident #7 down and after he was done, CNA #601 and myself transferred him. Resident #7 was on part of the chair and slid. We asked the resident ' s roommate Resident #67 to push the chair under him while we lifted him into the chair. CNA #602 stated Resident #7 never touched the floor that he was aware of. CNA #602 revealed we were told Resident #7 was either a two assist or a mechanical lift. Review of a statement dated 02/19/25 by CNA #99 revealed CNA #601 notified her at home that Resident #7 fell when CNA #602 attempted to get the resident out of bed with a stand/pivot transfer. CNA #602 and CNA #601 had not used the mechanical lift. CNA #601 stated CNA #602 landed on top of the resident. CNA #601 stated CNA #602 told her not to say a word about the incident. CNA #601 stated she reported the incident to LPN #174. CNA #99 revealed she returned to work today 02/19/25 and Resident #7 ' s roommate was asking questions. CNA #99 revealed she reported the incident to the nurse who notified Former Director of Nursing (FDON) #566. Review of an undated statement by Licensed Practical Nurse (LPN) #136 revealed CNA #99 reported CNA #601 told her CNA #602 dropped a resident and to not tell anyone. CNA #99 stated Resident #7 ' s roommate told her about what happened. LPN #136 reported the incident to FDON #566. Review of a statement by LPN #174 dated 02/19/25 revealed no one had reported any falls to her in the past three days. Review of a nurses note dated 02/19/25 at 1:45 P.M. revealed a nursing assistant reported she was told a fall had occurred for Resident #7. Resident #7 verified the fall stating it happened two days ago. The nurse reported the incident to FDON #566. The resident was assessed with no injuries noted. The nurse practitioner was notified of the fall on 02/19/25.Review of a physician order dated 02/19/25 revealed for the resident to transfer with a mechanical lift as needed. An order dated 02/20/25 revealed to transfer with mechanical lift every shift.Review of a nurses note dated 02/20/25 at 8:42 A.M. revealed the resident denied pain and his range of motion was within normal limits. The resident voiced no complaints regarding the fall on 02/17/25. Review of a nurses note dated 02/20/25 at 9:06 A.M. revealed therapy was consulted and gave the okay to make the resident a mechanical lift transfer at this time until his appointment to evaluate his prosthesis. Nursing department made aware of the change and care plan would be updated to change in transfer. Review of a therapy fall screen dated 02/20/25 revealed the resident had transfer concerns and ambulation concerns, used a forward wheeling walker, felt unsteady standing or walking, had had a change in mobility and activities of daily living. The therapy note revealed the resident would be evaluated for therapy after his orthopedic appointment. The resident reported a fall when transferred by two nursing assistants. The resident was unable to wear right lower extremity prosthesis due to improper fit. Staff to use mechanical lift for transfers.Interview on 09/08/25 at 11:12 A.M., Resident #7 revealed CNA #602 and CNA #601 tried to lift him out of bed without using the mechanical lift. Resident #7 stated CNA #602 was facing him and put his arms around his back and had not had a good grip on him. Resident #7 stated he slipped and fell to the floor. Resident #7 stated CNA #602 was not using a gait belt. Resident #7 stated CNA #602 had not fallen on him but some of CNA #602 ' s weight was on the resident. Resident #7 reported he was not injured. Resident #7 revealed staff usually used the mechanical lift to transfer him since 12/2024 but CNA #602 had not wanted to wait and get the lift. Resident #7 revealed staff were using the lift because he could no longer wear his prosthetic leg due to wounds on his leg and his leg getting bigger. Resident #7 revealed CNA #602 asked him not to report the fall because he would get in trouble and CNA #601 agreed with CNA #602 to not report the fall. Resident #7 revealed he was not using his walker. Interview on 09/08/25 at 1:36 P.M., Rehabilitation Director (RD) #150 revealed Resident #7 had blisters and could not wear his prosthetic leg. RD #150 revealed the resident had a fall and after the fall she had recommended staff to use the mechanical lift to transfer the resident. TD #150 revealed she was not notified when Resident #7 ' s blister occurred or his inability to wear his prosthesis, or she would have reevaluated the resident. Interview on 09/08/25 at 2:34 P.M., CNA #152 revealed Resident #7 was a one assist when he could wear his prosthetic leg and was a two assist when he could not wear it which had been for a while. Interview on 09/08/25 at 3:01 P.M., the Administrator revealed Resident #7 had missed his appointment to have his prosthesis evaluated on 02/13/25 because he was sick. Interview on 09/08/25 at 4:39 P.M. with Resident #67 (Resident #7 ' s former roommate) revealed he could not recall Resident #7 falling or assisting staff with a wheelchair for Resident #7. Resident #67 stated if Resident #7 had a fall then he must not have been in the room. Interview on 09/09/25 at 11:07 A.M., the Director of Nursing (DON) revealed for a fall investigation, statements should be completed, the resident assessed, notifications made to the physician and family/responsible party and ensure interventions were in place and new interventions were appropriate. The DON revealed falls were discussed in morning meeting and a follow up interdisciplinary note was documented. Further interview with the DON revealed a thorough fall investigation had not been completed for Resident #7. The DON revealed since staff had not reported the fall then follow up resident interviews and assessments should have been completed on all potentially affected residents to ensure other falls had not been reported. The DON verified there was no documentation if staff had used a gait belt or the resident ' s walker or what interventions were in place at the time of the fall. The DON revealed the resident should have been reevaluated for transfers when he could no longer use his prosthetic leg. Review of the staffing schedules from 02/03/25 through 02/17/25 revealed CNA #601 and CNA #602 were assigned to residents on unit one and unit two. Interview on 09/09/25 at 11:10 A.M., Corporate MDS Registered Nurse (CMDSRN) #622 verified there was no reevaluation of the resident ' s ability to transfer when he could no longer wear his prosthesis. Interview on 09/09/25 at approximately 11:00 A.M. with Assistant Director of Nursing (ADON) #196 revealed Resident #7 was not using his prosthetic leg prior to his fall. ADON #196 revealed she thought staff were using the mechanical lift to transfer the resident. ADON #196 was not sure why the resident was not using his walker. ADON #196 revealed if the resident was not using his prosthesis then we would have discussed that in morning meeting. ADON #196 revealed RD #150 was present at morning meetings and would have been aware the resident may have needed reevaluated for transfers. Interview on 09/09/25 at 12:18 P.M., CNA #602 revealed CNA #601 assisted him to transfer Resident #7 from the bed to the wheelchair. CNA #602 stated they were on each side of the resident to lift him to the wheelchair. CNA #602 revealed Resident #7 started sliding out of the wheelchair and we asked the resident ' s roommate to push the wheelchair back under the resident. CNA #602 revealed they were not using a gait belt and should have used a gait belt during the transfer. CNA #602 also verified they were not using the resident ' s walker and he could not recall the resident ever using a walker. CNA #602 stated the resident was not using his prosthetic leg and it was not safe to transfer the resident with one person. CNA #602 revealed he had not reported the incident because he had not considered it a fall because the resident ' s bottom touched his foot and not the floor. CNA #602 revealed he should have reported the incident to the nurse. CNA #602 denied falling on the resident. CNA #602 denied the resident required a mechanical lift transfer. Interview on 09/09/25 at 4:21 P.M., Quality Assurance Registered Nurse (QARN) #180 revealed staff should have used a gait belt when transferring Resident #7 and should have been using his walker per his physician orders and plan of care. Review of the personnel records for CNA #601 and CNA #602 revealed both were terminated for not reporting Resident #7 ' s fall on 02/17/25. Review of the undated facility policy Fall Management revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The care plan would be updated routinely and with significant change in the resident ' s condition. Review of the facility procedural guidelines Safe Patient Handling and Mobility, revealed to consult with physical therapy for best transfer methods for resident and physical therapy would conduct a functional assessment. Staff were to use a gait belt, sling, or lapboard (as needed), lateral transfer device, mechanical lift or stand assist lift device for transfers. If the resident was partially or not at all able to assist and was greater than 200 pounds then use a ceiling lift with supine sling, a lateral transfer device or air-assisted device with three caregivers. This deficiency represents non-compliance investigated under Complaint Number 2570390, Complaint Number 1331531, and Complaint Number 1331530.

Based on medical record review, resident interview, staff interview and facility policy review, the facility failed to ensure physician orders were accurately transcribed and residents received the correct medications. This affected two (#61 and #29) of seven residents reviewed for medication administration. The facility census was 84. Findings Include: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, dementia with behavioral disturbance and psychotic episodes, mood disturbance, anxiety disturbance, and Bipolar disorder. Review of the most recent significant change minimum data set (MDS) 3.0 assessment dated [DATE], revealed the resident had severe cognitive impairment, delusions, and hallucinations. The resident had verbal behavioral symptoms directed towards others, behavioral symptoms not directed towards others, and rejection of care coded on the assessment. Review of Resident #61's medical record revealed the resident was unable to be his own responsible party. Review of Resident #61's orders revealed the resident had orders for Austedo 12 milligrams (mg) two tablets twice daily dated 06/06/24 and discontinued on 11/05/24. Austedo XR 24 hour 12 mg daily dated 01/08/25 to be administered from 01/09/25 and discontinued on 01/16/25, Austedo XR 24 hour 18 mg daily dated 01/08/25 to be administered from 01/17/24 and discontinued on 01/24/25, Austedo XR 24 hour 24 mg daily dated on 01/08/25 to be administered starting 01/25/25 and discontinued 02/01/25, and Austedo XR 24 hour 30 mg daily dated on 01/08/25 to start on 02/02/25. Review of Resident #61's medication administration record (MAR) for December 2024, January 2025, and February 2025 revealed Resident #61 received no doses of Austedo in December 2024, and in January his orders for Austedo were initiated as ordered on 01/08/25. Interview on 03/12/25 at 8:37 A.M. with Licensed Practical Nurse (LPN) #103 confirmed she received an order for Resident #61 on 12/26/24 for Austedo 6 mg twice daily for Huntington's disease from the physician and she transcribed the medication order into another resident's medical record in error, and did not transcribe the order for Resident #61. Interview on 03/12/25 at 8:47 A.M. with the Director of Nursing (DON), confirmed there was a medication error related to LPN #103 transcribing a physician order for Austedo into the wrong resident's medical record. The DON stated, during a quarterly quality assurance meeting on 02/15/25 the error was discovered. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder, asthma, hypertension, and chronic obstructive pulmonary disease (COPD). Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact. The resident required minimal assistance to no assistance from staff with activities of daily living (ADL). Review of the form titled Nursing Home Note completed by the practitioner dated 01/12/25 revealed the resident was seen by the practitioner for a monthly visit and multiple medical issues. Upon entering the room, found resident calm, alert, and lying in bed. The resident does not appear to be in distress or discomfort. Impression and Plan Schizoaffective disorder: the resident was following with psychiatric services. On Paliperidone (antipsychotic), Remeron (antidepressant), and Austedo (used to treat tardive dyskinesia and chorea related to Huntington's disease). Review of progress notes dated 2/7/2025 at 12:55 P.M. revealed the resident is currently on hospice. He does not take any medications, and he had no concerns or issues with staff or activities. Review of the medication administration record (MAR) for Resident #29 revealed the resident had an order for Austedo 6 mg twice a day for Huntington's disease dated 12/26/24 with a discontinuation date of 02/07/25. Review of Resident #29's MARs for December 2024, January 2025 and February 2025 revealed the resident received Austedo on the evening of 12/31/24, on the morning of 01/01/25, and on the morning and evening of 01/10/25. Interview on 03/11/25 at 10:48 A.M. with Resident #29 the Resident stated, I usually don't take my medications as I hate taking them. They are always trying to get me to take them, but I don't like them. I have never had any reactions to the medications or taking the medications. I just mainly want to be left alone. I don't really want to be here, but it is what it is. I feel safe and the staff treat me with respect and dignity, but I would rather be home. Interview on 03/12/25 at 8:47 A.M. with the Director of Nursing (DON) confirmed Resident #29 had Austedo 6 mg twice daily transcribed into his medical record in error, and the resident received four doses of the medication but refused the rest of the doses offered by the facility staff. The DON confirmed Resident #29 frequently refuses his medications from the staff. Review of a policy titled Medication Administration Policy and Procedures, dated 02/2017, revealed medication shall be administered in accordance with a valid physician order. This deficiency represents non-compliance investigated under Master Complaint Number OH00162968.

Based on record review, staff interview, and facility policy review, the facility failed to ensure staff implemented the facility abuse policy by reporting a potential incident of physical abuse, this affected one, Resident #22, of seven residents reviewed for abuse. The facility census was 84. Findings Include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, morbid obesity, Bipolar disorder, anxiety disorder, cognitive communication deficit, schizoaffective disorder and psychosis due to unknown physiological condition. Review of the most recent quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was severely cognitively impaired and required extensive assistance to dependence of two persons for completing her activities of daily living (ADLs). Review of census records revealed Resident #22 was not her own responsible party but relied on her representatives to make all necessary medical and financial decisions. Review of the care plan dated 01/09/24 revealed Resident #22 had noted behaviors such as socially inappropriate verbal outbursts, screaming out profanities, yelling at other residents, and rejection of care. The resident also will transfers herself out of bed and will roll on the floor. Resident #22's interventions included to provide a calm relaxing environment, one on one care as needed, offer to sit in the common area and to take the resident outside as weather permits or as she request, (assure proper clothing and footwear). Review of internal facility incident dated 02/14/25 revealed on 12/31/24 between 7:30 P.M. and 9:15 P.M., a formerly employed LPN, designated for charge of Unit 300 notified Certified Nursing Assistant (CNA) #108 that Resident #22, who was located in the common area celebrating the upcoming New Year, was engaging in inappropriate verbal outburst using vulgarities and disrupting the other residents in close proximity. CNA #108 applied appropriate weather wear on Resident #22 and exited the building to the landing just outside the back door for re-direction, which is listed in Resident #22's care plan as an intervention. CNA #107 who is no longer employed at the facility witnessed this type of redirection and alleged this type of re-direction was inappropriate and possible abuse but failed to immediately report this incident due to possible retaliation from the LPN, Director of Nursing (DON), and Administration. Upon finally notifying a fell ow Registered Nurse (RN) on 01/17/25, the RN immediately notified Social Service Director (SSD) #104. SSD #104 immediately referred this information to the Administrator and DON in which an immediate investigation was launched and concluded on 02/14/25 revealing unsubstantiated of abuse. Interview on 03/11/25 at 11:00 AM with CNA #108 confirmed he was the CNA caring for Resident #22 on 12/31/24. The CNA stated between 7:30 P.M. and 9:30 P.M., the nurse on duty instructed him to place appropriate wear on Resident #22 and take the resident just outside the entrance/exit door of the unit to re-direct the resident due to loud yelling and the resident being over stimulated, due to the staff and residents being in the common activity room to celebrate the New Year. CNA #108 stated Resident #22 had no verbalization indicating she did not want to go outside. The CNA verified the resident had on a gown, socks, a jacket and was covered with two blankets as it was chilly outside but there was no snow or other inclement weather. Resident #22 was re-directed within two to three minutes and returned to the festivities in the activities room. The nurse on the hall also removed Resident #22 in the same manner later that evening for the same issue and returned to the common activity room after re-direction within two to three minutes wearing the same attire. Resident #22 remained cooperative throughout the remainder of the evening to celebrate the New Year and staff were able to paint the resident's nails. CNA #108 reveaeld the staff utilized many different diversions to re-direct Resident #27. The resident usually sits in her room on the floor on a mat and they had already attempted this. Taking the resident outside was another option for re-direction and she at times will go out and be with the smoking residents, even though the resident is a non-smoker. Telephone interview on 03/11/25 at 11:58 A.M. with former CNA #107 revealed she was working on the 300 unit on the day shift on 12/31/24 and stayed over for overtime floating between the 200 unit and 300 unit. Resident #22 was observed yelling and screaming at around 7:30 P.M. and another CNA was instructed by the on-duty nurse to remove Resident #22 to the outside for re-direction. It was cold out and CNA #108 placed blankets on Resident #22 prior to going outside and stood outside the back door for about three minutes until the resident calmed down. The staff did this about four or five times throughout the evening. The resident calmed down each time, but CNA # 107 stated she thought it was too cold out for this to go on. CNA #107 confirmed she did not report this incident until she told a different nurse sometime in the middle of January, around the 17th of the month. CNA #107 stated she didn ' t come forward immediately due to fear the DON would terminate her employment or retaliate against her, which is why she stated she told another nurse. CNA #107 stated I think that the other nurse that I told this to on 01/17/25, immediately went to the social services person (SSD #104) and that person immediately told the Administrator and DON. CNA #107 verified there was no physical harm done to the SR when this all happened that night. Interview with the Director of Nursing (DON) on and 03/12/25 at 8:47 AM revealed staff utilized many different diversions to re-direct Resident #22, including sitting in her room on the floor on a mat and taking the resident outside. The DON confirmed the resident will often go outside with the smoking residents even though she is a non-smoker as she likes this. Interview with the Administrator, Regional Quality Assurance Nurse #109, and DON on 03/12/25 at 1:48 P.M. confirmed CNA #107 did not timely report a possible incident of abuse to the facility administration. The Administrator confirmed the facility had not reported the incident to the state agency or law enforcement once the facility was made aware of the allegation as the facility viewed the incident as an unsubstantiated incident based on the staff following the care plan and there was no harm caused to Resident #22. Review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revealed: A. all new hires will be trained on the facility policy on Abuse, Neglect, Exploitation of Residents and Misappropriation of Property during the orientation process prior to commencement of work. B. Training shall include: Appropriate interventions to deal with aggression and catastrophic events. C. How staff should report their knowledge of allegations without fear of reprisal and how employees can express their grievances. Investigation of all alleged violations are to be communicated immediately to the Administrator or designee, to which an investigation procedure will be commenced immediately. This deficiency represents non-compliance investigated under Master Complaint Number OH00162968.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of the facility investigation, review of law enforcement reports, review of fire department reports, review of body camera footage, law enforcement interviews, and review of policy for the secure unit, the facility failed to provide adequate supervision to ensure a resident at risk for elopement and residing on a secured unit did not elope from the facility. This resulted in Immediate Jeopardy and placed the resident at risk for potential serious life-threatening harm and/or injuries when Resident #69 left the facility without staff knowledge, was missing for over five hours before staff identified him as missing and was subsequently found 11 hours later at a residence 20 miles from the facility in a different county. This affected one (#69) of three residents (#24, #63 and #69) reviewed for risk of elopement. The facility census was 86. On 10/01/24 at 10:22 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 09/15/24 when Resident #69 was picked up by a local police officer at 11:15 A.M. walking on an interstate near the facility. The police officer transported the resident to a location 20 miles from the facility. The facility was unaware the resident was not in the building until Register Nurse (RN) #304 could not locate the resident at 4:40 P.M. Resident #69 was found by a deputy sheriff 20 miles away in another county at approximately 10:30 P.M., at the resident's prior residence, sitting in a lawn chair in the front yard with emesis on his clothing. The Immediate Jeopardy was removed on 09/16/24 and the deficiency was corrected on 09/27/24 when the facility completed the following corrective actions: On 09/15/24 at 5:45 P.M., the DON notified the local police department Resident #69 was missing. A search was initiated with staff in vehicles and on foot searching surrounding areas. On 09/15/24, a Root Cause Analysis was completed by the Administrator, DON, Regional Director of Operation (RDO) #500 and Regional Quality Assurance Nurse (RQAN) #410. A plan of correction was started for the failure of direct care staff on the behavior unit to follow policy and procedure for supervision with outside time. On 09/15/24 at 6:02 P.M., the DON initiated a Count In/Count Out form for all residents exiting to the courtyard for supervised smoke breaks. The DON notified the physician, guardian, and residents' sister with guardian approval, Resident #69 was missing. On 09/15/24 at 6:30 P.M., the DON/designee began audits for the completion of the Count In/Count Out form for resident smoke breaks. These audits will be completed four times a week, times four weeks. On 09/15/24 at approximately 9:00 P.M., the DON began education to all staff regarding elopement, notification, resident supervision during outside times, and the abuse policy. The education was completed on 09/16/24 at 9:00 P.M. On 09/15/24 at 11:00 P.M., Resident #69 arrived back to the facility, returned to the secured unit, and was placed on one-on-one supervision. Licensed Practical Nurse (LPN) #294 completed a head-to-toe assessment of the resident with no major injuries found. Resident #69 was sent to the emergency room (ER) for evaluation and treatment related to the elopement. On 09/15/24 at 11:33 P.M., LPN #301 and LPN #351 began to assess all residents for elopement risk with care plans updated. All assessments were completed on 09/16/24 by approximately 5:00 A.M. On 9/16/24 at 9:00 A.M., the Quality Assurance Performance Improvement (QAPI) committee met to review the elopement and develop a plan. On 9/16/24 at 11:00 A.M., the DON updated the Elopement book. On 09/16/24 at 3:00 P.M., Maintenance Director #299 completed an elopement drill. On 09/16/24, daily audits were completed by Maintenance Director #299 and/or the 300 Unit nurse of the south and north gates in the courtyard to ensure they were locked. These audits continued through 09/27/24. On 09/17/24, Resident #69 was discharged to a sister facility with increased supervision levels. On 09/27/24, Maintenance Director #299 installed sensory alarms on the south and north gates in the courtyard. A motion detector was placed outside of the north gate. On 09/27/24, Maintenance Director #299/designee began audits three times a day until further notice to ensure the south and north gates are latched with alarms and motion detector in working order. On 09/27/24, Maintenance Director #299 educated all staff on checking the gates to ensure they were latched with alarms and motion detector in working order at every smoke break and documenting the check. On 10/08/24, the medical records for two additional residents (#24 and#63) identified as having an elopement risk, were reviewed. There were no identified concerns regarding elopements. Findings Include: Review of the medical record for Resident #69 revealed he was admitted on [DATE] and discharged on [DATE]. Diagnoses included paranoid schizophrenia, schizoaffective disorder of bipolar type, Torsades de Pointes (a type of atypical heart rhythm), chronic obstructive pulmonary disease, and adult failure to thrive. The resident resided on the secured unit. Review of the Brief Interview of Mental Status (BIMS), dated 09/16/24, revealed Resident #69 had intact cognition. Review of the elopement evaluation dated 06/25/24 revealed the resident was at moderate elopement risk. Review of the plan of care dated 02/17/21 revealed Resident #69 was at risk for injury related to smoking. Interventions revealed to provide supervision at all times when smoking. A care plan dated 11/30/21 identified the need for a secured unit related to agitation, fixed delusions paranoia and exit seeking. Review of the care plan dated 02/11/24 for elopement/wandering related to exit-seeking behaviors included interventions to follow facility elopement procedures, monitor and report changes in behaviors, and resident resides on a secure unit. Review of the progress note dated 09/15/24 at 10:44 P.M., written by LPN #294, revealed Resident #69 returned to facility at this time. The resident was alert and oriented to four spheres. Resident #69 shows no signs and symptoms of distress. Full head to toe skin assessment performed finding one abrasion to the right forearm. Resident placed on one-on-one supervision until transport to ER. On 09/16/24 at 12:34 A.M., Resident #69 was sent to the hospital for evaluation and treatment related to elopement. Documentation at 4:00 A.M. revealed Resident #69 returned from the ER. At 3:48 P.M a BIMS was completed with Resident #69 scoring a 14, which identified intact cognition. On 09/17/24 at 1:30 P.M., Resident #69 was transferred to a sister facility. Review of the facility investigation revealed an interview statement dated 09/15/24 at 2:50 P.M. by State tested Nurse Aide (STNA) #380. The statement revealed she took residents, including Resident #69, out to smoke at 2:40 P.M. She did not realize Resident #69 did not come back in with the rest of the residents. When the nurse was passing medications, she realized Resident #69 was not in the facility and staff started searching for him around 4:45 P.M. Review of the facility investigation revealed an interview statement dated 09/15/24 by RN #304. RN #304 revealed at 4:45 P.M. she went to take Resident #69 his medication. Resident #69 was not in his room and his food tray was on the bedside table. She asked STNA #380 and STNA #288 if Resident #69 was in the facility. They stated he was in the facility and was at the last smoke time (2:30 P.M.) RN #304 and both STNAs started looking for Resident #69, searching the unit and throughout the building. RN #304 noted they alerted the manager on duty and the local police department. RN #304 added she had seen Resident #69 at 2:40 P.M. She had the cigarettes locked up in the medication room and she had to get cigarettes for staff to give to residents. Review of the interview statement dated 09/15/24 for STNA #288 revealed smokers went out at 2:40 P.M. and STNA #380 took the smokers out. Around 4:25 P.M., the meal trays arrived and STNA #288 and STNA #380 passed the trays. STNA #288 stated she had fed two residents and STNA #380 had taken the tray cart down the hall. RN #304 could not find Resident #69 to give him his medication. They started looking in all resident rooms and bathrooms and could not find him. They went to the doors at the end of the hallway and looked out. The gate was unlocked and wide open. They noticed Resident #69's dinner tray had not been touched. RN #304 notified management they could not find Resident #69. Review of the interview statement dated 09/15/24 by LPN #301 revealed Resident #69 arrived back to the facility via a sheriff's vehicle. Resident #69 was paranoid at baseline and believed he was under arrest and reluctant to get out of the vehicle. LPN #301 stated she was able to get him to come out of the vehicle. While walking into the facility Resident #69 stated he had Quite an adventure and his legs were tired. Deputy #400 stated the resident had thrown up in the back seat. There was evidence of emesis on Resident #69's shirt and jeans. She asked Resident #69 how he got to the neighboring county, and he stated a nice person at the church gave him a ride. Resident #69 stated he got sick because the church feeds you good, but you never know how long the food was sitting out. Resident stated when he was gone, he did smoke some marijuana he got from a guy from the church. When assisting resident with removing his soiled sweatshirt there was a small abrasion noted to right arm/wrist area. Resident #69 stated he had fallen while walking but had no complaints of pain or any other visible injuries at that time. Review of the facility investigation revealed an interview was conducted with Resident #15 on 09/15/24 at 11:55 P.M. by LPN #301 and Social Service Designee #309. Resident #15 stated he was laying on the bench and he saw Resident #69 hop the fence. Resident #69 didn't say where he was going. Review of the facility investigation revealed an interview was conducted with Resident #23 on 09/16/24 by Activity Director #354. Resident #23 revealed the day before she had seen the back door to the unit was open and more specifically the gate by the back door was open. Review of the facility investigation revealed an interview was conducted with Resident #27 on 09/16/24 by Activity Director #354. Resident #27 revealed the day before she had seen Resident #69 right after lunch before smoke break. She stated after lunch the outside gate by the back of the unit door was open. Interview on 09/30/24 at 10:00 A.M. with RN #304 revealed she was the nurse working Unit Three when Resident #69 eloped. RN #304 stated the last time Resident #69 was seen by staff was at 2:30 P.M. smoke break on 09/15/24, when STNA #380 took the residents who smoked outside. RN #304 stated she had not seen Resident #69 all afternoon. At 4:40 P.M. she had medication for him and when she was looking for him, she realized he was missing. RN #304 stated staff started looking for Resident #69 and at 5:30 P.M. she notified the DON Resident #69 was missing. RN #304 stated the police found him in a neighboring county at an old address. Interview on 09/30/24 at 10:24 A.M. with the DON revealed Resident #69 went out to smoke, got left outside and he eloped. The last time he was seen was 09/15/24 around 2:40 P.M. The DON stated at 4:40 P.M. RN #304 went to give him medication and he was missing. The DON stated she was not notified until 5:33 P.M. and then she notified the Administrator. The DON stated Resident #69 was an elopement risk, had talked about leaving the facility, and he was very delusional. The DON stated the police were notified of Resident #69's elopement and a search began. Resident #69 was found at 10:30 P.M., at his old address, sitting on a bench with a Mountain Dew. When Resident #69 returned to the facility with the deputy, the resident stated he had the time of his life while he was gone. He stated he was in a neighbor's yard while he was gone. The DON stated STNA #380 took Resident #69 out for a smoke, and he slipped out the back gate. The DON stated he had not had any previous elopements. Interview on 09/30/24 at 10:30 A.M. with the Administrator revealed Resident #69 went out for a smoke break at 2:30 P.M. on 09/15/24 with staff and did not come back into the facility. Resident #69 left the facility through a gate in the courtyard. She was notified at approximately 5:45 P.M. and a full search was started. Resident #69 was found in a neighboring county, about 20 miles away from the facility. The Administrator stated a full investigation was started immediately. Review of the local township fire department incident report dated 09/15/24 at 6:32 P.M. revealed the fire department was notified Resident #69 had eloped. They arrived at the facility at 6:42 P.M. and were cleared at 10:50 P.M. The narrative documented they were dispatched for missing male from the facility. The fire department assisted the police with searching for Resident #69 with two [NAME] and a K-9 Unit. Resident #69 was located at 11:15 P.M. at 5618 Cleveland Rd East (U.S. Route 6) in the neighboring county. Review of the local county sheriff department office incident report dated 09/15/24 at 7:01 P.M. revealed the local police and fire department were made aware at approximately 5:43 P.M. Resident #69 was missing from the facility. Deputy #400 was directed to go to 5618 U.S. Route 6 as a place of interest where Resident #69 could be. Resident #69 was located at that address sitting in a lawn chair with vomit on his lap. Resident #69 stated he was at the address to meet his girlfriend who allegedly was enroute from another town. Resident #69 eventually allowed Deputy #400 to transport him back to the nursing home. While enroute to the nursing home Deputy #400 asked Resident #69 how he got to the address with the resident stating a female police officer assisted with transporting him. Upon arriving to the facility Resident #69 was transferred to the care of the nursing staff. Later Deputy #400 went through call logs and discovered Officer #401 was out with Resident #69 earlier in the day, at approximately 11:20 A.M., when she was called for a welfare check at U.S. Route 250 and [NAME] Rd. Dispatch informed Deputy #400 that Officer #401 showed enroute to 5618 U.S. Route 6 with Resident #69 in the vehicle. Review of Deputy #400's body camera footage revealed on 09/15/24 at 10:30 P.M. Resident #69 was found at 5618 U.S. Route 6 sitting in a lawn chair with vomit on his clothes. Resident #69 identified himself and stated he had eaten at a church and that made him sick, and he vomited. Resident #69 stated he was waiting for his girlfriend who was coming from another town. Deputy #400 was able to get Resident #69 in his vehicle to return to the facility. In the police cruiser Resident #69 stated a lady sheriff gave him a ride to this county. Interview on 10/01/24 at 11:03 A.M. with Deputy #400 revealed Resident #69 was sitting in front of an apartment building in a lawn chair. He had emesis on his lap and on the ground. Resident #69 knew his name and where he was. Resident #69 stated he received a ride from a female police officer when he was on U.S. Route 250 and [NAME] Rd. Deputy #400 stated he returned him to the facility. Review of the local police department Investigative Report titled Courtesy Ride revealed on 09/15/24 at 11:15 A.M. Police Officer #401 received an anonymous caller requesting a welfare check for a man wearing a blue hoodie walking on U.S. 250 near [NAME] Road. The anonymous caller explained the man appeared to be stumbling and believed he fell down at one point as she passed him. As Police Officer #401 approached the man she did not see him stumble or fall and he was walking slowly. The man identified himself giving the name of Resident #69. He stated he was walking to a nearby town. Police Officer #401 did not want to leave him. The man asked if she could take him home and the residential address in the system showed as 5618 Cleveland Road in [NAME]. The officer explained she could not go too far out of her jurisdiction, but she would take him as far as she could. Resident #69 appeared alert and oriented. The report indicated Resident #69 was dropped off on Cleveland Road West, near Center Street, in [NAME]. Review of the local police department Investigative Report titled Follow-up Investigation, signed by the Chief #402 on 09/17/24 at 7:55 A.M. revealed on 09/15/24 they received a call at 5:43 P.M. about a missing resident at the local nursing facility. It was later determined on 09/15/24 around 11:15 A.M. Police Officer #401 responded to U.S. 250 to provide a courtesy ride to a person later determined to be Resident #69. The charge nurse, RN #304's, written statement indicated the resident was seen at 2:40 P.M. as she had cigarettes locked in the medication room and she had to get cigarettes for resident smoke break. STNA #380's written statement indicated she took Resident #69 out to smoke at 2:40 P.M. and she didn't realize he did not come back in with them. It is now known the two employees could not have had eyes on Resident #69 at this time due to him being in the [NAME] area, dropped off by Police Officer #401. Resident #69 left the facility sometime before 11:15 A.M. and was gone for approximately twelve hours. The DON described a portion of their policy and procedure was to physically check residents every two hours. She admitted this was not done and described the failures that day as systemic. Review of the facility policy titled The Secured Unit at CHS [NAME], dated 4/15/22, revealed rounds are to be done every hour to visually observe residents. This deficiency represents non-compliance identified during the investigation of Master Complaint Number OH00158810 and Complaint Number OH00158195.

Based on medical record review, staff interview, resident interview, review of Controlled Drug Receipt/Record/Disposition Form, and policy review, the facility failed to ensure medications to relieve pain were obtained in a timely manner for administration. This resulted in Actual Harm to Resident #05 when her physician-ordered supply of a narcotic analgesic, Oxycodone, was exhausted on 09/14/24 at 4:00 A.M. and the facility did not timely obtain a new written prescription from the ordering provider. This delay in obtaining a new prescription led to Resident #05 not receiving the medication for 91 hours which led to the resident experiencing chronic pain horrible, rated her pain at a 10/10, indicating the worst possible pain, and ultimately requiring an emergency department visit on the afternoon of 09/17/24 to obtain a dose of Oxycodone and a short-term written prescription. This affected one (Resident #05) of three residents reviewed for pain management. The facility census was 86. Findings include: Review of the medical record for Resident #05 revealed an admitted [DATE]. Medical diagnoses included chronic pain, hereditary and idiopathic neuropathy, radiculopathy, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment, dated 07/29/24, revealed Resident #05 to be cognitively intact. Resident #05 required physical assistance with activities of daily living (ADLs) and was dependent on mobility. Resident #05 was coded as having frequent pain, rated 06/10 on the assessment. She was recorded as having received scheduled pain medications and as needed (PRN) pain medication during the seven-day lookback period. The resident was not recorded as having received any non-pharmacological interventions to manage pain. Review of Resident #05's care plan, revised on 07/19/24, revealed the resident was at risk for an alteration in comfort related to a hip fracture, neuropathy, spinal stenosis, radiculopathy, bilateral congenital hip deformities, osteoarthritis, and gout. Listed interventions included to administer medications as ordered to manage pain, reposition for comfort, provide rest periods as needed, therapy referral as needed, and use pain scale as reported by resident. Review of Resident #05's pre-admission hospital records dated 07/15/24-07/17/24, revealed the discharge instructions listed the resident's care was to be managed by Skilled Nursing Facility (SNF) providers. Resident #05's hospital face sheet listed Outside Provider #101 as the resident's primary care provider in the community. Review of Resident #05's visit note from Outside Provider #101's office revealed the resident saw Nurse Practitioner (NP) #115 on 09/04/24. The visit note stated the reason for the visit was listed as a chief complaint of referral, with the resident having presented to the office for a face-to-face visit to get a motorized scooter and a referral to pain management. The note listed the resident had arthralgias (joint pain) and back pain, identifying pain in her legs, lower back, hands, knees, and right shoulder, with the pain rated as a 10 on a scale of 0-10 The visit note indicated an order was placed for an ambulatory referral to pain management. Listed diagnoses associated with the office visit included neuropathy, congenital hip dysplasia, facet arthritis of the lumbosacral region, chronic pain syndrome, closed fracture of multiple bones of the right lower leg, bilateral foot drop, and generalized weakness. Review of Resident #05's physician's orders revealed an order dated 08/05/24 for gabapentin (a medication used to aid in controlling nerve-related pain) 800 milligrams (mg) four times daily. Resident #05 also had an order dated 09/05/24 for Oxycodone 10 mg, one tablet by mouth every eight hours as needed for pain. This order was discontinued on 09/14/24. Review of Resident #05's progress notes from September 2024 revealed a note dated 09/04/24 indicating the resident went to an appointment with Outside Provider #101 and clarification was needed for a medication order. A note dated 09/05/24 noted a nurse found new orders from Resident #05's doctor from appointment to give Oxycodone 10 mg tablet with gabapentin at 6:00 A.M., 12:00 P.M., 6:00 P.M., and 12:00 A.M. Subsequent notes on 09/05/24 at 12:39 P.M. and 2:19 P.M., on 09/06/24 at 2:02 P.M., and on 09/09/24 at 11:44 A.M., revealed attempts to contact Outside Provider #101 for clarification on medication order. A note dated 09/09/24 at 3:11 P.M. revealed the facility received a fax prescription from Outside Provider's office, but the script needed clarified. A subsequent note timed 3:27 P.M. revealed a nurse spoke with a representative with Outside Provider #101's office and the office was faxing orders to the facility. A note dated 09/10/24 at 3:12 P.M. revealed a nurse called and left a message to clarify an order received via fax. There were no further notations of attempts to clarify Resident #05's pain medication order or written prescription until a note dated 09/14/24 at 3:52 A.M., when a note revealed the resident was given the last dose of her PRN Oxycodone. A staff nurse called the pharmacy and there was no new written script on file. The note indicated a controlled substance page was listed in the doctor's binder but was unsigned. The on-call provider does not refill narcotics and the information will be passed onto the next shift. Review of Resident #05's Controlled Drug Receipt/Record/Disposition Form, revealed the resident's last dose of Oxycodone was signed out of the controlled drug storage on 09/14/24 at 4:00 A.M. Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #05's routine gabapentin was administered as ordered. Resident #05's PRN Oxycodone was administered two to three times daily from 09/05/24 through 09/13/24. Only one dose of Oxycodone was administered on 09/14/24, at 3:55 A.M. There was no recorded Oxycodone administered to Resident #05 on 09/15/24, 09/16/24, or 09/17/24. Oxycodone 10 mg was recorded as administered to Resident #05 on 09/18/24 at 12:00 A.M. Subsequent review of progress notes from 09/14/24 through 09/16/24 revealed no documented attempts to contact Resident #05's Outside Provider #101, Medical Director #200, or an on-call provider to address Resident #05's pain medication. There was no note reflecting the as-needed Oxycodone had been ordered to be discontinued by a physician. Review of Resident #05's Occupational Therapy Evaluation and Plan of Care, dated 09/16/24, revealed the resident was noted to have pain that interfered and/or limited her functional activity, pain that interferes with sleep, and noted that nursing was to address pain. Review of a progress note dated 09/17/24 at 1:58 P.M. revealed the Director of Nursing (DON) documented she spoke with Outside Provider #101's office regarding the pain medication prescription for Resident #05. The office representative stated Outside Provider #101 was under the impression at the last visit that Resident #05 was under the facility care for pain medication orders and the DON clarified that was not the case. Office representative stated Outside Provider #101 will manage the resident's pain and will send a script as soon as possible. The DON informed the office the facility would not be writing scripts for Resident #05's pain medication. Review of a progress note dated 09/17/24 at 3:06 P.M. revealed Resident #05 requested to go to a local hospital's emergency room (ER) for pain. Resident #05 was aware the pain medication prescription was on the way but still wanted to go. The note included no assessment of Resident #05's pain describing the pain rating, and location or characteristics of her pain. A subsequent note revealed the resident later returned from the ER with a new three-day Oxycodone prescription which was faxed to pharmacy upon her return. Review of the Emergency Department records, dated 09/17/24, revealed Resident #05 presented to the ER from the nursing home for a medication refill. Resident #05 had been receiving Oxycodone from her primary care provider (PCP) for chronic pain for quite some time. The note indicated no provider was currently writing her pain medication prescriptions and Resident #05 was sent to the ER so she could be medicated and have her prescription refilled. Resident #05 reported she had been out of her Oxycodone for the last five days and complained of diffuse pain, chronic in nature. Resident #05 rated her pain at a 10 on a numeric 0-10 scale, indicating 10 as the worst possible pain. The notes indicated she received a dose of Oxycodone 10 mg one tablet while in the ER and was discharged back to the facility with an order for a three-day supply of Oxycodone. The note indicated the facility needed to coordinate with Resident #05's PCP and figure out how she would be getting her medications refilled from here on out. Review of a physician order dated 09/17/24 for Oxycodone 10 mg one tablet every eight hours routine for three days. A subsequent order dated 09/19/24 continued the Oxycodone 10 mg one tablet routinely three times daily for an additional three days, through 09/21/24. An order dated 09/22/24 listed Oxycodone 10 mg one tablet three times daily routine for chronic pain for a duration of 30 days Review of Resident #05's subsequent Controlled Drug Receipt/Record/Disposition Form revealed a card of Oxycodone was listed as filled by the pharmacy on 09/17/24, and the first dose from the new supply was administered to Resident #05 at the facility on 09/17/24 at 11:00 P.M. An interview on 10/01/24 at 2:22 P.M. with Resident #05 revealed she has chronic and neuropathic pain in her bilateral legs, feet, hands, and knees. She stated the facility ran out of her pain medication multiple times, but around 09/17/24, she had to go to the ER to get her pain addressed after she had not received her Oxycodone for multiple days. Resident #05 stated she had asked to go to the ER multiple times and cried because she was in horrible pain. The resident stated the longer she goes without pain medications, the longer it takes to get back the pain back under control. Resident #05 stated she had taken Oxycodone for year for chronic pain and at the time she was finally transported to theER on [DATE] she rated her pain at a 10/10, indicating the worst possible pain. A subsequent interview with Resident #05 on 10/02/24 at 2:58 P.M. revealed her chronic pain was under control at that time as she had received her medication. Resident #05 stated she received a dose of her Oxycodone today and the medication only helps ensure her pain does not get to an excruciating level. Resident #05 stated she is never pain free as she lives with chronic pain all throughout her body and had done so for years. An interview on 10/03/24 at 10:48 A.M. with the DON revealed she was familiar with Resident #05 and the pain management concern, as the local Ombudsman had asked her for information regarding this resident. The DON stated Outside Provider #101 was Resident #05's PCP in the community, was the one managing her pain, and continued to prescribe Resident #05's pain while a resident of the facility. The DON confirmed Resident #05 had gone to an outside appointment on 09/04/24 and returned with orders to continue with the pain medication Oxycodone and to it with gabapentin. The DON stated the office did not send a new handwritten script as required by the facility's pharmacy to fill the medication order. Nurses attempted to phone Outside Provider #101's office without success. On 09/17/24, Resident #05 did want to go to the ER as the resident stated she was in excruciating pain, even though the script for the pain medication was on the way. Resident #05 went to the ER, they gave her a dose of Oxycodone, and she returned to the facility with a few days' supply of Oxycodone. The DON stated the facility still did not receive the fax scripts, so she drove the Outside Provider #101's office to obtain the written script herself, and scheduled Resident #05 future appointments with the provider to avoid any future unnecessary delay. The DON who confirmed the resident went from 09/14/24 at approximately 4:00 A.M. to 09/17/24 at 11:00 P.M. with no Oxycodone available or administered to Resident #05. The DON confirmed there was no note indicating any provider had discontinued Resident #05's Oxycodone orders. The DON also confirmed there were no recorded attempts to contact Medical Director #200 as nursing staff know he would not write for Resident #05's pain medication. The DON verified there was a delay in obtaining clarification and a written prescription to obtain Resident #05's pain medication. Interviews conducted on 10/07/24 between 1:21 P.M. and 1:35 P.M. with Licensed Practical Nurse (LPN) #331 and LPN #295 confirmed Resident #05 had chronic and ongoing pain that was difficult to manage. Both reported they had diligently worked to call and phone Outside Provider #101 to get the required script. Both reported they had not contacted the facility providers, as Outside Provider #101 was the one prescribing Resident #05's medication. LPN #295 stated Resident #05 was dependent on staff for care and mobility and reported the resident's legs frequently got twisted up when moving, she had really bad neuropathy, and limb contractures. Review of the undated policy titled Pain Management defined pain as an individual resident's unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is highly subjective and it can be difficult to obtain objective markers. The licensed nurse will gather the following information as it applies to the resident while they are performing the pain assessment: history of pain and past treatment regimen, characteristics of pain (including intensity, descriptors, pattern, location, frequency, timing, and duration), impact of pain on day-to-day activities, strategies to reduce pain, additional symptoms that may come about with pain such as nausea or anxiety, review of current medical conditions and medications, and a discussion of the resident's goals for pain management. If the resident is assessed to be experiencing pain, the nurse will explore pharmacological and non-pharmacological interventions. The documentation in the clinical record must reflect the ongoing communication between the prescribe and the staff for the most optimal use and management of pain medications. This deficiency represents non-compliance investigated under Complaint Number OH00158190.

Based on observation, and staff interview, the facility failed to ensure safe and sanitary storage of food items in the kitchen. This affected all 86 residents residing in the facility. The facility census was 86. Findings include: Observation on [DATE] beginning at approximately 7:35 A.M. of the facility refrigerator and walk-in cooler revealed the following items: a container of undated and unlabeled sliced cheese, a container of undated and unlabeled baked beans, two undated and unlabeled cups containing a brown substance, one box containing tortilla shells which expired on [DATE], one box of puff pastry sheets which expired on [DATE], one box of burritos which was delivered in [DATE] and one box of tuna with an expiration date of [DATE]. Concurrent interview with Dietary [NAME] (DC) #343 confirmed the findings.

Based on observation, resident and staff interview, review of the menu and review of the dietary spreadsheet, the facility failed to ensure food was served per the facility menu and spreadsheet. This had the potential to affect all 86 residents residing in the facility who received food from the facility. The facility census was 86. Findings include: Interview on 10/01/24 at 4:55 P.M. with Resident #63 revealed the resident thought meal portion sizes were too small. Review of the weekly menu revealed the regular meal for breakfast on 10/07/24 was choice of cereal, cheese omelet, toast, jelly, and margarine. Review of the menu spreadsheet for breakfast on 10/07/24 revealed residents would receive two slices of toast. Observations during meal service on 10/07/24, beginning at approximately 7:20 A.M., revealed Dietary [NAME] (DC) #342 was plating meals. DC #342 was observed placing one slice of toast on each meal plate. Interview on 10/07/24 at approximately 7:34 A.M. with DC #342 confirmed they had served one slice of toast instead of two. DC #342 verified residents were supposed to receive two slices of toast with the breakfast meal.

Based on observation, staff and resident interview, medical record review, review of facility policy, review of infection control logs and review of glucometer manufacturer instructions, the facility failed to ensure residents with communicable diseases were appropriately isolated and failed to ensure proper personal protective equipment (PPE) was utilized for residents in transmission-based precautions (TBP). This affected two residents (#09 and #14) of two residents reviewed for TBP. Additionally, the facility failed to ensure proper disinfection of shared glucometers. This affected one resident (#04) of one resident reviewed for glucometer use. The facility identified 24 residents with glucometer checks. Lastly, the facility failed to perform hand hygiene during wound treatment and further failed to implement enhanced-barrier precautions (EBP) during high contact wound care activities. This affected one resident (#71) of one resident reviewed for wounds. The facility identified four residents who required wound care. These deficient infection control practices had the potential to affect all 86 residents residing in the facility. The facility census was 86. Findings include: 1. Review of the facility infection control logs from September 2024 revealed the facility identified an outbreak of Covid-19 beginning on 09/05/24. On 09/05/24, thirteen residents (#83, #80, #30, #139, #56, #03, #32, #28, #58, #70, #78, #85, and #46) tested positive for Covid-19. Of these residents, Resident #28 remained in the same room with her Covid-19 negative roommate (Resident #77) and Resident #30 remained in the same room with her Covid-19 negative roommate (Resident #50) On 09/12/24, during weekly Covid-19 testing, seven additional residents (#64, #84, #77, #74, #53, #23, and #76) tested positive for Covid-19. Of these residents, Resident #74 remained in the same room with her Covid-19 negative roommate (Resident #71), Resident #23 remained in the same room with her Covid-19 negative roommate (Resident #47), Resident #76 remained in the same room with her Covid-19 negative roommate (Resident #48), and Resident #53 remained in the same room with his Covid-19 negative roommate (Resident #63). On 09/19/24 there were no newly identified cases of Covid-19 within the facility. On 09/26/24, during weekly Covid-19 weekly testing, one additional resident, Resident #09 tested positive for Covid-19. Resident #09 remained in the same room with her Covid-19 roommate (Resident #14). Observation on 09/30/24 revealed signage on the door to Resident #09's room indicating the resident was on airborne isolation precautions. PPE, including gowns, gloves, N95 respirator masks and surgical masks were available outside the door. A placard on the wall outside the door revealed Resident #09 and Resident #14 resided in the room. Observation on 09/30/24 at 12:03 P.M. revealed Resident #14 was in the communal dining room seated at a table with two other residents. Resident #14 was not wearing a mask. A subsequent observation on 10/01/24 at 2:21 P.M. revealed Resident #14 in the activity room, unmasked, with three other unnamed residents seated at the same table participating in an activity. Observation on 10/02/24 at 7:55 A.M. of Resident #09 revealed the resident was in the bed closest to the door of the room. She was noted to have a dry cough. Concurrent interview with Resident #09 revealed she had tested positive for Covid-19 the previous Thursday and had been feeling unwell since then. Resident #09 stated her roommate, Resident #14, was not positive for Covid-19. Continued observation of Resident #09's room revealed an oscillating fan was in place on an approximately 4.5 foot tall dresser and was in the on position. The curtains between the resident's beds were pulled. Resident #09's roommate, Resident #14, was observed asleep in the bed near the window during the observation. Resident #14 did not have a mask on. Review of a progress note dated 09/26/24 at 2:59 P.M. (entered as a late entry on 10/01/24 at 9:07 A.M.) revealed Resident #14's roommate tested positive for Covid. The resident was informed of the need to move rooms but was unwilling. Resident #14 was educated on the risk of staying in the room. There was no mention that Resident #14's guardian/responsible party was notified. An interview on 10/01/24 with the Assistant Director of Nursing (ADON) Infection Preventionist (IP) #351 revealed the facility performed weekly Covid-19 testing on all residents every Thursday. ADON IP #351 confirmed the facility was cohorting positive and negative residents because residents refused to move rooms. ADON IP #351 confirmed the residents' and roommates' records contained no evidence that the facility offered multiple rooms, had provided any resident with personal protective equipment, or informed residents of the need to isolate if they refused to move rooms. ADON IP #351 confirmed this was not a good practice for preventing the spread of infection as many residents move freely around the facility. ADON IP #351 additionally stated no increased Covid-19 testing was performed on the Covid-19 negative roommates of the infected roommates even though the roommates would be considered close contacts. Observation on 10/02/24 at 7:55 A.M. with Resident #09 revealed the resident lying in bed. State tested Nursing Assistant (STNA) #312 entered the resident's room to provide a cup of ice water to the resident. STNA #312 was observed to be wearing an N95 respirator mask overtop of a surgical mask. STNA #312 was wearing glasses and made a comment that her glasses were fogging up. STNA #312 removed her gown and gloves in the resident's room, but did not remove or discard her mask upon exiting. Interview on 10/02/24 at 8:06 A.M. with STNA #312 revealed she always wore her N95 mask overtop of a surgical mask, as the N95 mask hurt her nose. STNA #312 additionally stated she was unsure if that was acceptable or not, but that was her practice. STNA #312 stated the facility provided periodic training on infection control but she did not recall anything specific about masking rules. STNA #312 verified her N95 mask did not seal well overtop of the surgical mask, as if it did her glasses would not have fogged up. Interview on 10/07/24 at 3:01 P.M. with ADON IP #351 confirmed it was not permitted for staff to be wear a N95 mask overtop of a surgical masks when caring for residents in isolation for Covid-19. Review of the policy Covid 19 Testing of Staff and Residents, revised September 2024, revealed upon identification of an individual with symptoms consistent with Covid-19, or who tests positive for Covid-19, take actions to prevent the transmission of Covid-19. If a resident is known to have been exposed or is symptomatic, the facility will follow transmission-based precautions. Patients should be placed in transmission-based precautions based on close contact with someone infected. Patients can be removed from transmission-based precautions after seven days following the exposure if they do not develop symptoms and all viral testing as described for asymptomatic individuals following close contact is negative. The resident will be cared for by health care providers using a N95 or higher-level respirator, eye protection, gloves and gown. They should not participate in group activities. 2. Observation on 10/02/24 at 7:29 A.M. revealed Licensed Practical Nurse (LPN) #296 checking Resident #04's blood glucose level. LPN #296 retrieved a glucometer, gloves, a lancet and glucometer test strips, knocked, and entered Resident #04's room. LPN #296 proceeded to check Resident #04's blood glucose level. LPN #296 removed her gloves and exited the room, returning the glucometer to the top of the cart. LPN #296 then retrieved an alcohol swab and cleaned off the top part of the glucometer before returning the glucometer to the top right drawer of the medication cart. Interview on 10/02/24 at 7:35 A.M. with LPN #296 verified she cleaned the glucometer with an alcohol swab. LPN #296 stated she had worked at the facility for approximately two years and she was trained to clean the glucometer with an alcohol swab. LPN #296 further stated she had no idea if that was right or wrong, but that was her usual process of cleaning the glucometer after use. LPN #296 verified the glucometers were shared between the residents who required blood glucose checks and were not resident-specific glucometers. Interview on 10/07/24 at 3:01 P.M. with ADON IP #351 revealed glucometers should be cleaned with healthcare grade bleach wipes after each resident use. Additionally, ADON IP #351 stated the glucometer should dry completely before the next use. ADON IP #351 confirmed glucometers should not be cleaned using alcohol swabs. Review of the blood glucose monitoring system user instruction manual, revised April 2021, revealed the disinfection procedure was needed to prevent transmission of blood-borne pathogens. The manual identified various brands of hospital-grade disinfectant wipes and stated only wipes with Environmental Protection Agency (EPA) registration numbers listed in the tables had been validated for use in cleaning and disinfecting the meter. 3. Observation on 10/02/24 at 6:16 A.M. revealed ADON IP #351 and Wound Nurse Practitioner (NP) #400 performing wound care and a wound assessment on Resident #71's sacral wound. Upon entering the room, signage indicating EBP were required was listed on the door to the room. ADON IP #351 and Wound NP #400 entered the room, applied gloves, and provided privacy. Neither were observed to apply a gown. NP #400 assisted in positioning Resident #71 on her right side, while ADON IP #351 removed the resident's soiled dressing and discarded it in a bag on the floor. Following the removal of the soiled dressing, ADON IP #351 did not change her gloves. She proceeded to obtain a measuring tool, assisted in measuring Resident #71's sacral wound, retrieved supplies to cleanse the wound, and applied a new dressing her Wound NP #400's orders, all while wearing the original pair of gloves. Interview on 10/02/24 at 6:44 A.M. with ADON IP #351 verified neither she, nor Wound NP #400, wore a gown while providing Resident #71's wound care. ADON IP #351 confirmed EBP were in use and staff must wear gloves and a gown for high-contact resident care activities, which included wound care for any skin opening requiring a dressing. ADON IP #351 stated she was confused about EBP and stated she thought that was for an infected or an acute, non-healing wound, but verified the signage on Resident #71's door indicated any wound required gown and glove use. She stated EBP was still fairly new to her and confusing, and wearing a gown did not cross her mind. ADON IP #351 confirmed she was the facility's IP and was responsible for oversight of the facility's infection control program. A follow-up interview on 10/07/24 at 3:01 P.M. revealed ADON IP #351 confirmed she did not follow the proper infection control technique during Resident #71's wound care when she did not change her gloves after removing the soiled dressing from the resident's wound. Review of the facility policy titled Clean Dressing Change, undated, included steps to apply clean gloves; loosen tape and remove the soiled dressing; pull glove over the dressing and discard into the plastic or biohazard bag; wash your hands thoroughly; open dry/clean dressing by pulling corners of the exterior wrapping outward, touching only the exterior surface; using clean technique open other products and pour prescribed cleansing solution into a clean basin or tray; put on clean gloves; cleanse the wound and apply the ordered treatment and dressing and secure with tape.

Based on observation, staff interviews and resident interviews, the facility failed to ensure the facility was clean and in good repair. This affected all 32 residents (on unit-3 secured unit), (#1, #2, #6, #7, #10, #12, #15, #18, #22, #23, #24, #26, #27, #34, #36, #37, #39, #40, #46, #47, #48, #53, #55, #57, #63, #66, #69, #76, #79, #85, #189 and #190) that reside on the secure unit. The facility census is 86. Findings include: Observations on 09/30/24 at 9:18 A.M., of the secured unit revealed there were holes in the drywall in the hallways all sizes are approximately in size. The hole by room [ROOM NUMBER] (size 5 inches (in) by (x) 5 in, a hole by room [ROOM NUMBER] 12 in x 10 in, two patches by room [ROOM NUMBER] drywall broken area 5 in x 5 in and 8 in x 5 in, hall by back door has drywall off size 5 foot (ft) x 50ft. and on the other wall two holes 18 in x 18 in and 8 in x 6 in, around the corner hole 8 in x 5 in by room [ROOM NUMBER], hole between dining room doors 5 in x 5 in, between room [ROOM NUMBER] and 314 there were three holes size of fist, room [ROOM NUMBER] there was a hole 84 in x 2 ft insulation showing by the bathroom door and was occupied by Resident #15. The floor in room [ROOM NUMBER] black [NAME] on floor bathroom smells of urine 11 tiles off the wall in bathroom black around toilet and floor. Interview on 09/30/24 at 10:00 A.M., with Resident #15 stated he was moved into room [ROOM NUMBER] a few days ago and the big hole in the wall was already there. Resident #15 stated Resident #46 had punched holes in the walls. He stated he did not like the hole in the wall and wanted to move to another room. Observations on 10/03/24 at 9:59 A.M., revealed on the secured unit, the bathroom between room [ROOM NUMBER] (Resident #12, #35) and 317 (Resident #6 and #20) tiles around the toilet area missing 19 tiles on one side and 12 tile on the other side. Observations of 6-10 gnats flying around in the bathroom, the floor had heavy build up of dirt and dark discolor around the base of the toilet and looked to be black mold behind the tiles that are missing. Resident #35 stated the bathroom walls have been this way since she has been there. In room [ROOM NUMBER] (Resident #6 and #20) heating baseboard missing cover and part on the laying on the floor laying on floor. Observation on 10/03/24 at 10:10 A.M., of Housekeeper (HK) #335 cleaning room [ROOM NUMBER] (Resident #37), stated she cleans all resident rooms every day, but she cannot get the smell out of some of the bathrooms and the floors and tiles have not been fixed in years. HK #335 stated she cleans the rooms, and they still look terrible and smell. Interview on 10/03/24 at 10:13 A.M., with Resident #15 stated he was moved out of room [ROOM NUMBER] and moved to a new room due to the huge hole in the wall. Was glad he got moved but stated he does not have any sheets on his bed and had to sleep in the bed with no sheets. Interview on 10/03/24 at 10:16 A.M., with Certified Nurse Aide #289 stated the tiles in bathroom have been that since she started working here. Interview on 10/03/24 at 11:21 A.M., and observations with Administrator, verified all above environment concerns and verified concerns need to be addressed. The Administrator stated she is getting estimates on the drywall holes from Resident # hitting the walls. The Administrator verified there was no documentation of repairs being completed and was unable to give the surveyor any policies for deep cleaning or that repairs were scheduled to be fixed. The Administrator stated Resident #46 was a resident that had been discharged to a sister facility last week and he would punch holes in the walls when he got agitated. The maintenance could not stay up with all the holes. The Administrator verified that Resident #15 never should have been put in a room that needed repairs.

Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents were treated in a respectful and dignified manner by staff. This affected two (#26 and #27) and had the potential to affect ten other unnamed residents who were in attendance at a smoke break. Additionally, the facility also failed to ensure indwelling urinary catheter drainage bags were covered in a dignified manner. This affected two (#68, and #41) of two residents observed for catheter care. The faciliy census was 58. Findings include: 1. Observation on 10/01/24 at 2:54 P.M., during an attempted interview with Resident #28, inaudible voices were heard coming from the resident's room after knocking on the door. Upon opening the door slightly, both Resident #28 and her roommate were not observed to be in the room. Loud voices were heard, and it appeared a television was on in the room. Upon additional inspection, the window in the room was wide open and overlooked the courtyard where there was multiple residents smoking in the presence of one staff member. The staff member was standing with her back towards the window. The staff member was clearly and loudly yelling I have worked 78 hours this week, not this pay period, this week. She took her left index finger, raised an outstretched arm, and loudly yelled don't play with me, I will end this break as she waved her outstretched left arm and pointed index finger from side-to-side as she stated each word. Unnamed residents were seated, smoking, and facing the staff member and said nothing in response. The surveyor immediately proceeded to the facility's courtyard and approached the staff member, Certified Nursing Assistant (CNA) #289. Interview on 10/01/24 at 2:56 P.M., with CNA #289 confirmed she did work 78 hours in the past week at the facility, which she confirmed was voluntary after she had missed a few days while being out sick. CNA #289 stated she had been yelling, but was not yelling at the residents directly, rather she was just trying to vent to the residents. CNA #289 stated she was angry and had just been counseled by the Director of Nursing (DON) a few moments earlier after she was on her phone and not watching the residents during the beginning of this smoke break. CNA #289 stated she was frustrated at the situation, but verified her yelling and venting to residents was not a dignified, respectful or professionally appropriate interaction. Twelve residents were outside in the courtyard at the time of the observation. A follow up interview on 10/01/24 at 3:01 P.M., with Resident #27, who was outside and witnessed CNA #289's verbal outburst, reported she liked CNA #289, but felt uncomfortable with her yelling and stated she wasn't sure what all that was about. A follow up interview on 10/01/24 at 3:04 P.M., with Resident #26, who was outside and witnessed CNA #289's verbal outburst, revealed she hated when people yell. Resident #26 stated she had been minding her own business, was walking around the courtyard and the yelling had startled her. An interview on 10/02/24 at 2:34 P.M., with the Administrator and DON discussed professional standards of conduct. The DON confirmed she had addressed CNA #289 the prior afternoon, 10/01/24, during a smoke break as she had been on her phone and was not appropriately supervising the 300-hallway's scheduled smoke break. The Administrator and DON were informed of CNA #289's interactions with residents during the scheduled smoke break on 10/01/24, and verified yelling at residents, for any reason, and venting to residents would not be considered an appropriate, respectful, or dignified interaction. 2. Review of the medical record for Resident #68 revealed an admitted [DATE]. Medical diagnoses included neuromuscular dysfunction of the bladder, urinary retention, and a history of a cerebral infarction. Review of Resident #68's Minimum Data Set (MDS) annual assessment, dated 07/07/24, revealed the resident had intact cognition. The resident was identified to have an indwelling urinary catheter and was dependent on staff for toileting. Review of Resident #68's care plan, dated 06/14/23, revealed the resident has an alteration in elimination related to an indwelling Foley (urinary) catheter related to neuropathic bladder and retention of urine. Listed interventions included to change Foley catheter per physician's orders, provide Foley catheter care every shift, and to keep Foley catheter bag below the level of the bladder. Review of Resident #68's physician's orders revealed an order dated 05/31/24 for a 24-french sized suprapubic catheter (urinary catheter inserted through a surgically-created opening in the lower abdomen), cleanse the site with soap and water every shift and cover with a dry dressing. Resident #68 additionally had an order dated 05/31/24 to cover the urinary drainage bag every shift for privacy. Observation on 09/30/24 at 11:50 A.M., revealed Resident #68 in bed, his urinary catheter drainage bag was hanging on the side of the left side of the bed, and contained approximately 600 milliliters (ml) of yellow urine, visible from the doorway to the room. A subsequent observation on 10/02/24 at 7:56 A.M., revealed Resident #68 in bed with his urinary catheter drainage bag remained uncovered with approximately 300 ml of yellow urine visible in the bag. Interview on 10/02/24 at 7:56 A.M., with Certified Nursing Assistant (CNA) #323 verified Resident #68's urinary catheter drainage bag was uncovered. CNA #323 confirmed the urinary drainage bags were supposed to be covered and she was unsure why Resident #68's was not. Observation on 10/03/24 at 9:42 A.M., revealed Resident #68 in bed with his eyes closed. His urinary drainage bag was uncovered and hanging on the edge of the left side of the bed with approximately 400 ml of yellow urine visible in the bag. Interview on 10/03/24 at 9:54 A.M., with CNA #323 and CNA #319 confirmed the uncovered urinary drainage bag. Interview and observations on 10/08/24 at 9:32 A.M., with Resident #68 revealed he was awake, alert and in bed. Resident #68's urinary drainage bag was covered. Resident #68 confirmed a few days prior a staff member provided him a sling for his urinary drainage bag. Resident #68 stated it was nice to not have his urine bag on display for everyone to see. 49793 3. Review of Resident #41's medical record revealed an admitted [DATE]. Medical diagnoses included type II diabetes mellitus with hyperglycemia, above right knee amputation, chronic obstructive pulmonary disease (COPD), below left knee amputation, obstructive uropathy and reflux uropathy. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment, dated 09/10/24, revealed the resident had no cognitive impairment with a BIMS score of 15. Resident #41 was coded to have a indwelling urinary catheter. Review of Resident #41's physician order, dated 05/31/24, revealed an order for a Foley (indwelling urinary) catheter due to a diagnosis of obstructive uropathy. The physician's order included foley catheter 18 french (fr),15 cubic centimeter (cc) balloon draining to gravity, report any change issues or concerns with drainage to physician every shift, change foley monthly on the 16th of the month. 18 fr Coude Foley 15 cc into balloon every night shift starting on the 15th and ending on the 16th every month, catheter tubing secured with leg band/statlock; alternate leg daily, in the morning for catheter care, and cover for urinary drainage bag every shift for privacy and dignity. Review of Resident #41's care plan, revised on 09/25/24, revealed Resident #41 required an indwelling urinary catheter. Interventions listed in the care plan included to cover the drainage bag to promote dignity. Observation on 09/30/24 at 11:26 A.M., and on 10/01/24 at 8:52 A.M., revealed Resident #41 lying in bed. Resident #41's urinary drainage bag was hanging on the bed uncovered, with yellow urine visible in the drainage bag. 10/01/24 01:27 PM resident seated in wheelchair with Foley bag uncovered sitting on foot rest of wheelchair while sitting in hallway with Resident #41 holding conversation with another resident. Interview on 10/01/24 at 1:27 P.M., with Licensed Practical Nurse (LPN) #327 verified the urinary drainage bag was uncovered. LPN #327 stated the drainage bag should be covered, and normally the facility used drainage bags with attached vinyl coverings. Resident #41 stated to LPN #327 that the catheter bag cover is located on the side of the wheelchair, and the aide just didn't place it in there like they do all of the time. The staff just place it on his foot rest. Interview with the Resident #41 on 10/03/24 1:10 P.M., stated he does care if the Foley bag is covered. Resident #41 stated he liked that it is in the cover because he is usually out in the hallway and activity room where there are other people. Resident #41 stated he doesn't want to have the Foley bag catch in the wheel of his wheelchair and have it pulled out. Resident #41 stated the staff usually keep it under my blanket and on my foot rest of the chair and not in the cover, because when they hang it on the side, it will get tangled up in the wheel. He stated it does bother him that it is uncovered and the one aide stated today, the reason that it is in the cover bag is because the state is in the building. Resident #41 stated he can't remember the name of the girl (aide). Interview on 10/03/24 at 2:46 P.M., with Director of Nursing (DON) revealed the nursing staff have been trained in the rights and dignity/customer service and the foley catheters are at all times to be covered for the dignity of the residents. Review of the undated policy titled Dignity, revealed demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. Review of the undated policy titled Foley Catheter Care, revealed the nursing staff will provide foley catheter care per physician's order and as needed, which includes placing foley catheter drainage bag inside of a privacy bag to maintain the resident's rights and dignity. This deficiency represents non-compliance investigated under OH00158190.

Based on medical record review, staff interview, review of the Certification and Licensure System (CALS) and review of facility policy, the facility failed to report a resident elopement to the state agency. This affected one resident (#69) of three residents reviewed for elopement risk. The facility census was 86. Findings include: Review of the medical record for Resident #69 revealed he was admitted on [DATE] and discharged on [DATE]. Diagnoses included paranoid schizophrenia, schizoaffective disorder of bipolar type, Torsades de Pointes (a type of atypical heart rhythm), chronic obstructive pulmonary disease, and adult failure to thrive. The resident resided on the secured unit. Review of the Brief Interview of Mental Status (BIMS), dated 09/16/24, revealed Resident #69 had intact cognition. Review of the elopement evaluation dated 06/25/24 revealed the resident was at moderate elopement risk, on 06/05/24 elopement risk was moderate elopement risk and on 03/04/24 elopement risk was high elopement risk. Review of the plan of care dated 11/30/21 revealed Resident #69 needed a secured unit related to agitation, fixed delusions, paranoia and exit seeking. Review of the care plan dated 02/11/24 for elopement/wandering related to exit-seeking behaviors included interventions to follow facility elopement procedures, monitor and report changes in behaviors and resident resides on a secure unit. Review of the progress note dated 09/15/24 at 10:44 P.M., written by Licensed Practical Nurse (LPN) #294, revealed Resident #69 returned to facility at this time. The resident was alert and oriented to four spheres. Resident #69 shows no signs and symptoms of distress. Full head to toe skin assessment performed finding one abrasion to the right forearm. Resident placed on one-on-one supervision until transport to ER (emergency room ). On 09/16/24 at 12:34 A.M., Resident #69 was sent to the hospital for evaluation and treatment related to elopement. Interview on 09/30/24 at 10:00 A.M. with LPN #304 revealed she was the nurse working unit three when Resident #69 eloped on 09/15/24. At 4:40 P.M. she had medication for him and was unable to locate the resident and realized he was missing. LPN #304 stated she notified the Director of Nursing (DON) at 5:50 P.M. that Resident #69 was missing. Review of CALS from 09/15/24 through 09/30/24 revealed no evidence the facility reported Resident #69's elopement from the facility on 09/15/24 to the state agency. Interview on 09/30/24 at 10:30 A.M. with the Administrator confirmed she did not report the elopement to the state agency because she did not feel it met the criteria for reporting. Review of the facility policy titled Abuse Prohibition, dated September 2020, revealed all alleged violations concerning abuse, neglect, misappropriation of property and injuries of unknown origin are reported immediately to the Administrator/Designee. Allegations that involve abuse or result in serious bodily injury will be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident is discovered. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. This deficiency represents noncompliance investigated under Master Complaint Number OH00158810.

Based on observation, staff interview and record review, the facility failed to ensure residents met the criteria to be admitted to and reside on the secure unit. This affected one (#5) of three residents reviewed for involuntary seclusion. The facility census is 86. Findings include: Review of Resident #5's medical record revealed and admitted [DATE]. Diagnoses included neuropathy, muscle weakness, lack of coordination, and anxiety. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed resident had intact cognition. Review of the census revealed Resident #5 was placed on the secure unit upon admission and was moved to another unit on 08/26/24. Review of the care plan dated 07/17/24 revealed no care plan related to the secure unit. Review of the admission packet dated 07/17/24 revealed section P (elopement risk) revealed resident has made no attempts to exit the facility, resident is alert and oriented to person, place and time and bedfast. Wanders or elopement risk was never, will not elope from facility through review date. Review of the physician orders for July to present date revealed no order for Resident #5 to be placed on the secure unit. Review of the progress note dated 08/26/24 at 3:51 P.M., revealed Resident #5 was moved off unit 3 (secure unit) per no longer meeting the requirements to be on the unit. She was happy to be moved off unit. No other documentation on why Resident #5 was placed on the secure unit. Review of the elopement assessment dated [DATE] revealed low risk 2.0. There was no documentation of clinical criteria was met for placement on the secured, interdisciplinary team review of placement or that resident was told or given the code so she could leave the unit on her own. Observation of the secure unit (unit-3) on 09/30/24 at 9:00 A.M., revealed it was secured by a door with a code to access the unit or to get off the unit. Interview on 10/01/24 at 2:22 P.M., with Resident #5 stated she was admitted on the secure unit (unit-3) due to this was the only bed available. She was Ok with it but was never told she could come off the unit at anytime and they did not tell her the code to the door so she could leave the unit if she wanted to. The staff act like it is a prison not a nursing home/rehab. Interview on 10/07/24 at 10:45 A.M., with the Director of Nursing (DON) verified Resident #5 was put in the secure unit due to no beds available on any other unit. Resident #5 was told about this and was in agreement. The DON stated Resident #5 was not given the access code to leave the unit or told that she could come off the unit when she wanted to. Resident #5 was a low elopement risk and should have been able to come off the secure unit as she wanted. The DON verified when there was no bed available on the other unit's resident are asked if they will take a bed on the secure unit but never gave them a code to the door so they could leave the unit on their own. The DON verified Resident #5 was not given the door code so she could leave the unit on her own and did not tell Resident #5 that she was allowed to leave the unit when she wanted to.

Based on record review, staff interview and policy review the facility failed to ensure medications were given as ordered. This affected one (#291) of three residents reviewed for medication administration. The census was 86. Findings included: Review of the medical record for Resident #291 revealed an admitted [DATE]. Diagnoses included alcoholic cirrhosis of liver, suicidal ideations and major depression. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #291 had intact cognition. Review of the telephone order dated 09/24/24 from Nurse Practitioner (NP) #421 to start Prozac (antidepressant) 10 milligrams (mg) by mouth daily for anxiety and depression and to follow up with psychiatric services for depression. Review of the physician telephone order from medical doctor (MD) #200 dated 09/24/24 revealed Prozac 40 mg by mouth daily signed by nurse on 09/30/24. Review of the Medication Administration Report (MAR) for September 2024 revealed Prozac 10 mg was given on 09/26/24 and discontinued on 09/29/24. Prozac 40 mg was started on 09/30/24. Interview on 10/03/24 at 9:48 A.M., with Resident #291 stated he did go without his Prozac for 6 days. Resident #291 stated Prozac had been increased by the MD #200 and it was not started for six days. He had to keep asking the nurse about the medication and then finally she found the order on a clipboard behind the nurse's station, Licensed Practical Nurse (LPN) #327 finally put the order in, and the medications was increased. Interview on 10/08/24 at 9:29 A.M., with Director of Nursing (DON) verified Resident #291 had the order for the increase of Prozac a week earlier then when the medication was not given. Interview on 10/08/24 at 10:44 A.M., with LPN #327 stated Resident #291 got an order from the nurse practitioner for Prozac 10 mg and to follow-up with psychiatric service for depression. Resident #291 seen the psychiatrist MD #200 later in the day and the Prozac was increased to 40 mg. LPN #327 verified Resident #291 did not receive Prozac 10 mg until 09/26/24 and then started Prozac 40 mg on 09/30/24. LPN #327 stated Resident #291 was questioning her on why he was not receiving Prozac 40 mg since it was increased on 09/24/24. LPN #327 stated she started looking for the order and found it on a clipboard on 09/30/24 and that is when she put the order in. Review of the policy titled, Medication Administration, General Guidelines, dated 2007 revealed medications are administered as prescribed.

Based on staff interview, record review, and policy review, the facility failed to ensure timely laboratory testing to monitor therapeutic drug levels for psychotropic medications was completed as ordered. This affected one (#29) of three residents reviewed for mood and behavior. The facility census was 86. Findings include: Review of Resident #29's medical record revealed an admitted [DATE]. Medical diagnoses included schizophrenia, drug-induced parkinsonism, and lack of coordination. Review of Resident #29's Minimum Data Set (MDS) quarterly assessment, dated 07/04/24 revealed the resident had intact cognition. Resident #29 was recorded as having hallucinations but no other behaviors or rejection of care. Review of Resident #29's care plan, dated 01/04/21, revealed the resident was at risk for side effects related to psychotropic medications. Listed interventions included to administer medications as ordered and to administer and monitor laboratory tests as ordered and as needed and report results to the physician and/or nurse practitioner. Review of Resident #29's physician's orders included an order dated 04/06/22 for Lithium Carbonate 300 milligrams (mg), give 1 tablet by mouth in the morning. Resident #29 also had an order dated 01/19/21 for Divalproex Sodium 500 mg, give two tablets (to total 1000 mg) once daily at bedtime. Both medications were listed to treat schizophrenia. Review of Resident #29's laboratory orders revealed an order dated 04/08/21 to check Lithium level every two months. Resident #29 also had an order dated 12/30/23 to check labs, including a Depakote (valproic acid) level, every three months. Review of Resident #29's laboratory results from October 2023 to October 2024 revealed the resident had a lithium and valproic acid level (to monitor the therapeutic level of Depakote or divalproex in the bloodstream) drawn on 03/07/24. The reported lithium level was 0.3 millimoles/liter (mmol/L), with the report indicating the resulted value was low, with normal range between 0.6 and 1.3 mmol/L. Resident #29's valproic acid level was 78 micrograms (mcg)/milliliter (ml), within normal range. The report was initialed by Nurse Practitioner (NP) #510 with a note which stated send to psych. Resident #29 also had a lithium level drawn on 09/11/24, with a result of 0.3 mmol/L, indicating low. Review of Resident #29's progress notes revealed no indication the 03/07/24 or 09/11/24 laboratory results had been reported to the psychiatric provider. Review of Resident #29's Psychiatry Progress Notes, authored by Psychiatric Nurse Practitioner (Psych NP) #555, dated 03/19/24, 05/14/24, 06/11/24, 07/09/24, 08/06/24, and 10/01/24, all included laboratory results from a visit dated 08/24/23. The notes dated 06/11/24, 07/09/24, and 10/01/24 indicated there were no recent laboratory results available for review. Interview on 10/03/24 at 9:57 A.M., with Licensed Practical Nurse (LPN) #331 revealed she was unsure of the process for how laboratory testing is done. LPN #331 stated she just knows the laboratory technicians come to the facility in the early morning hours while night shift is still here, and lab only comes between Tuesday and Friday. If she obtains a laboratory order from a provider, she inputs the order into the electronic medical record, and then it is passed on verbally to the next shift. LPN #331 stated she was unsure how the laboratory technicians would know what laboratory testing needs done each day unless they check with the nurse upon arrival. Interview on 10/03/24 at 2:59 P.M., with Assistant Director of Nursing (ADON) Infection Preventionist (IP) #351 revealed when providers write orders for laboratory or radiology testing, the nurse who takes the order is responsible for transcribing the order into the resident's electronic medical record, and inputting the order into the laboratory's online portal. ADON IP #351 reported all nurses have credentials to input orders into the laboratory online portal. Resident #29's laboratory results for the last year were reviewed, and ADON IP #351 confirmed multiple laboratory testing had gotten missed for Resident #29's therapeutic drug level monitoring. A follow up interview on 10/08/24 at 1:18 P.M., with ADON IP #351 provided a copy of Resident #29's valproic acid and lithium level which were drawn earlier on 10/08/24. The report listed the valproic acid level as 108, indicating above the therapeutic range of 50-100 mcg/ml, and the lithium level was 0.3 mmol/L, a continued low result. ADON IP #351 stated the results had not yet been reported to the provider but would be soon. Review of the undated policy titled, Lab Draws, revealed the nurse will review lab orders written by physicians and clarify orders as needed. The nurse accepting the order will enter the ordered lab into the lab computer to communicate the order draw requirements with the lab. The nurse will transcribe the ordered lab onto the treatment record, making certain to include the names of the ordered labs, as well as the date that the lab is to be drawn. Lab results will be reported to the physician and/or nurse practitioner per policy.

Based on observation, staff interview and review of facility meal tickets, the facility failed to ensure resident's food preferences were followed for Resident #29 and Resident #62. Additionally, the facility failed to ensure meal tickets accurately reflected resident preferences for Resident #80. Lastly, the facility failed to offer Resident #80 an alternative for the breakfast meal. This affected three (#29, #62, and #80) of four residents reviewed for food preferences. The facility census was 86. Findings include: 1. Review of Resident #29's meal ticket for the lunch meal on 09/30/24 revealed the resident was to receive ice cream with the daily lunch meal. Observation on 09/30/24, beginning at approximately 11:34 A.M., of the lunch meal service revealed Resident #29 did not receive any ice cream with their meal. Interview on 09/30/24 at 12:19 P.M. with Dietary Aide (DA) #348 verified Resident #29 did not receive ice cream and further stated the facility was out of ice cream. 2. Review of Resident #62's meal ticket for the lunch meal on 09/30/24 revealed the resident was to receive ice cream with the daily lunch meal. Observations on 09/30/24, beginning at approximately 11:34 A.M., of the lunch meal service revealed Resident #62 did not receive any ice cream with the lunch meal. Resident #62 was observed telling DA #348 that he was supposed to receive ice cream. DA #348 stated the facility did not have any ice cream. Interview on 09/30/24 at 12:19 P.M. with DA #348 revealed Resident #62 failed to receive the requested item due to the facility being out of ice cream. 3. Review of Resident #80's meal ticket for the lunch meal on 09/30/24 revealed the resident disliked and was not to be served rice. Observations on 09/30/24, beginning at approximately 11:34 A.M., of the lunch meal service revealed Resident #80 received rice with their meal. Interview on 09/30/24 at 12:19 P.M. with DA #348 verified Resident #62 received rice, although it was listed as a dislike and not to serve on their meal ticket. Interview on 09/30/24 at 12:37 P.M. with Dietary [NAME] (DC) #343 also verified Resident #62 received rice with the lunch meal. Observations on 10/07/24, beginning at approximately 7:20 A.M., of the kitchen revealed DC #344 stated Resident #80 did not like omelets so they were not going to eat breakfast. DC #342, who was plating food for the breakfast meal, stated okay. Interview on 10/07/24 at 7:44 A.M. with DC #344 revealed the breakfast menu was set and there were no alternatives offered to residents who did not want or like what was on the menu for breakfast. DC #344 reported alternatives were only available for the lunch and dinner meals.

Based on observation, staff interview, record review, and policy review, the facility failed to timely develop a comprehensive care plan based on resident needs and implement care planned interventions. This affected two (#72 and #46) of 21 residents reviewed for care planning. The facility census was 86. Findings include: 1. Review of the medical record for Resident #72 revealed an admitted [DATE]. Medical diagnoses included left femur fracture, chronic obstructive pulmonary disease (COPD), muscle weakness, and pneumonia. Review of Resident #72's Minimum Data Set (MDS) Admission/Medicare 5-day assessment, dated 07/17/24, revealed the resident was recorded to have intact cognition. Resident #72 had no recorded behaviors. Review of Resident #72's care plan, dated 07/15/24, revealed the resident only had a partially completed care plan which listed care plan focus of activities, wounds, and nutrition. Resident #72 was listed as a smoker but there was no listed interventions identifying if the resident was a supervised smoker or independent. Resident #72 had no care plan mentioning any activities of daily living (ADL) needs, any medication or diagnosis-specific monitoring that was required, any mention of discharge planning, or mention of code status for Resident #72. Interview on 10/07/24 at 1:16 P.M., with the Director of Nursing (DON) discussed Resident #72 was having behaviors, specifically he had been following a female resident, had referred to the resident as his girlfriend and had made sexually inappropriate comments at the female resident on a few occasions. Interview on 10/08/24 at 8:59 A.M., with MDS Coordinator #301 confirmed she does care plans for the residents of the facility and completes them after completing their initial MDS assessment. MDS Coordinator #301 confirmed Resident #72's care plan was incomplete and a comprehensive care plan was not developed. MDS Coordinator #301 stated she missed Resident #72's care plan as a lot of admissions came around the same time as Resident #72. 2. Review of Resident #49's medical record revealed an admitted [DATE]. Diagnoses included hypertension, retention of urine, unspecified convulsions, depression, anxiety, dementia, bipolar disorder, and delusional disorders. Review of the fall risk assessment dated [DATE], revealed Resident #49 was a risk for falls. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired. The resident was independent for sitting to standing. Review of Resident #49's plan of care dated 04/30/23, revealed the resident had potential for falls and potential injury related to medication use, dementia, bipolar disorder, anxiety, impaired mobility, history of cardiovascular accident, and delusions. Interventions included non-skid strips to floor in front of chair following a fall on 10/21/23. Review of Resident #49's active physician orders identified an order dated 10/22/23 for non-skid strips on floor in front of recliner to prevent sliding when standing up from wheelchair. Review of the nursing progress notes for 10/21/23 through 10/01/24 revealed Resident #49 sustained falls while in his room on 10/22/23, 11/26/23, and 02/27/24. There was no evidence the non-skid strips were in place at the time of each fall. Observations on 09/30/24 at 11:16 A.M. and on 10/02/24 at 1:20 P.M., of Resident #49 revealed the resident was seated in a recliner in his room. There were no non-skid strips in place in the room or in front of the recliner. Observation and interview on 10/02/24 at 5:04 P.M., with State tested Nurse Aide #322 verified Resident #49 did not have non-skid strips in front of their recliner. Review of the undated policy titled, Fall Management, revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. Review of the undated policy titled, Care Plan and Advanced Care Plan Process, revealed the interdisciplinary team will coordinate with the resident and/or their responsible party for participation in developing an appropriate care plan for the resident's needs or wishes specific to person-centered care, based on the assessment process within required time frames. The comprehensive interdisciplinary plan of care is developed within seven days after the completion of the comprehensive (MDS) assessment. The resident and/or their sponsor will be invited to participate in the development of their comprehensive care plan through the advanced care planning process on admission, quarterly, with significant change, and as needed. The team directs care planning towards achieving and maintaining the highest practicable physical, psychosocial, and functional status including advanced directives.

Based on staff interview, record review, review of infection control logs, and policy review, the facility failed to notify the residents' representative and physician of positive COVID-19 test results. This affected three (#23, #76, and #53) of 24 resident reviewed for infection control practices. The facility census was 86. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Medical diagnoses included paranoid schizophrenia, depression, and asthma. Resident #23 had a listed guardian. Review of the facility's infection control log for [DATE] revealed Resident #23 tested positive for COVID-19 during routine weekly testing on [DATE]. Review of Resident #23's progress notes for [DATE] revealed a note dated [DATE] at 3:21 P.M., indicating the resident was in the common area observing a group trivia activity, but was no actively participating. The resident denied having any health concerns. A review of subsequent progress notes revealed no evidence the resident's COVID-19 positive test result had been documented in the medical record, and no evidence the resident's guardian or provider had been notified. 2. Review of the medical record for Resident #76 revealed an admitted [DATE]. Medical diagnoses included traumatic brain injury, schizophrenia, and delusional disorder. Resident #76 had a listed guardian. Review of Resident #76 MDS quarterly assessment, dated [DATE], revealed the resident had intact cognition. The resident was noted to have hallucinations, delusions, and daily verbal and wandering behaviors. Review of the facility's infection control log for [DATE] revealed Resident #76 tested positive for COVID-19 during routine weekly testing on [DATE]. Review of Resident #76's progress note from [DATE] revealed no evidence the resident's COVID-19 positive test result had been documented in the medical record, and no evidence the resident's guardian or provider had been notified. 3. Review of the closed medical record for Resident #53 revealed an admitted [DATE]. Medical diagnoses included dementia, chronic atrial fibrillation, and muscle weakness. Resident #53 expired at the facility under hospice care on [DATE]. Resident #53 had a listed guardian. Review of Resident #53's MDS Admission/Medicare 5-day assessment, dated [DATE], revealed the resident had severely impaired cognition. Review of the facility's infection control log for [DATE] revealed Resident #53 tested positive for COVID-19 during routine weekly testing on [DATE]. Review of Resident #53's progress note from [DATE] revealed no evidence the resident's COVID-19 positive test result had been documented in the medical record, and no evidence the resident's guardian or provider had been notified. Interview on [DATE] at 1:03 P.M., with Assistant Director of Nursing (ADON) Infection Preventionist (IP) #351 confirmed there was no documentation in Resident #23, Resident #76, or Resident #53's medical record reflecting their positive COVID-19 test results and no notification to the physician or guardian/responsible party. Review of the undated policy titled, Status Change in Resident Condition - Notification, revealed the facility will promptly notify the resident, his/her attending physician, and responsible party of changes in the resident's condition and/or status. The licensed nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on observations, review of medical records, review of a facility Self-Reported Incident (SRI), review of emergency room documentation, the rape center report and review of a police report, interviews with staff, residents and the local police officer and review of the facility's policy on abuse, the facility failed to ensure one cognitively impaired female resident was free from alleged sexual abuse. This resulted in Immediate Jeopardy for one (#62) resident who was alleged to have been sexually abused by Resident #26. This affected one (#62) of five residents reviewed for potential sexual abuse in a total facility census of 91. On 09/11/13 at 6:10 P.M., the Director of Nursing (DON) and Administrator were notified that Immediate Jeopardy began on 08/31/13 at 12:30 P.M. when Resident #62 alleged that she had been sexually assaulted by Resident #26. Resident #62's allegation of sexual abuse was reported to Registered Nurse (RN) #12, the charge nurse on duty, multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not address the allegation or assess Resident #62 and Resident #26 despite being told about the incident. LPN #15 reported for duty at 10:30 P.M., was made aware of the allegation by STNA #40 and was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down". Resident #62 was sent to the hospital for evaluation and subsequently sent to the Sexual Assault Care Unit where a rape kit was obtained. The Immediate Jeopardy was removed on 09/12/13 at 2:30 P.M. when Resident #26 was placed on one-on-one supervision. 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) until it was corrected on 09/12/13 at 8:45 P.M. when the facility implemented the following corrective actions: ? On 09/01/13, at an unspecified time, Resident #62 was transported to the hospital emergency room for evaluation. The emergency room record documented Resident #62 arrived at the hospital at 1:00 A.M. ? On 09/01/13, at an unspecified time, Resident #62 returned to the facility and was placed in a room close to the nurse's station for monitoring. ? On 09/01/13 at 10:00 A.M., the police were notified by the facility to transport the rape kit from the rape center to be processed. ? On 09/01/13 in the afternoon (no time specified), Resident #26 was moved from the locked unit, where Resident #62 was residing, to the unsecured front hallway of the facility and placed in a private room. The facility began 15 minute checks on Resident #26. ? On 09/12/13 at 2:30 P.M., the facility began one-on-one monitoring of Resident #26 documenting his whereabouts on the Safety Check Log every 15 minutes. ? On 09/12/13, all residents at risk of potential abuse were interviewed by staff. All resident verbalized they had not been harmed by any residents or staff. ? On 09/12/13 at 8:45 P.M., all employees had been in-serviced on the facility abuse policy entitled Resident Abuse Prevention Practices and the Crime Reporting Policy. ? On 09/12/13 between 11:30 A.M. and 11:45 A.M., interviews with State tested Nurse Aides' (STNAs) #70 and #71 and Licensed Practical Nurse (LPN) #6 and #160 confirmed they had been in-serviced on the facility's abuse and crime reporting policies and what actions staff were to take if an allegation of abuse was reported to them. ? On 09/13/13, the psychologist and psychiatrist assessed both Resident #26 and #62. Both residents received Behavioral Management Plans from the psychologist. If efforts to implement interventions per the Behavior Management Plans are unsuccessful, staff are to notify both the psychologist and psychiatrist. ? On 09/13/13, 09/14/13 and 09/15/13, review of the Safety Check Logs verified Resident #26 was receiving one-on-one monitoring with documentation every 15 minutes as required. ? On 09/14/13, observations of Resident #26 at 12:40 P.M., 1:11 P.M., 1:16 P.M., 1:21 P.M., 1:35 P.M., 2:55 P.M. and 2:58 P.M. verified the resident was receiving one-on-one supervision at all times. ? On 09/15/13, observations of Resident #26 at 2:15 P.M., 2:35 P.M., 3:01 P.M., 3:04 P.M. and 3:14 P.M. again verified the resident was receiving one-on-one supervision with documentation every 15 minutes of the resident's whereabouts and activities. Findings include: Review of the medical record of Resident #62 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "History and Physical" dated 07/27/13 documented the resident is alert and answers questions appropriately with good eye contact. She presents with a flat affect and is a poor historian with dates. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/02/13, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5. Resident #62 displays feelings of depression and hopelessness. Resident #62 displayed verbal and physical behavioral symptoms directed towards others on one to three days of the seven day assessment period. Resident #62 required limited assistance of one staff member for bed mobility, transfers and ambulation in her room. Resident #62 required extensive assistance for locomotion off the unit, dressing and toilet use and was identified as being frequently incontinent of urine and wears incontinent briefs for clothing protection. Review of the medical record of Resident #26 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment, dated 02/09/13, revealed the resident has severe cognitive decline. Resident #26 displayed symptoms of [MEDICAL CONDITION] with continuous inattentiveness, fluctuating disorganized thinking and verbal and physical behaviors toward others. Resident #26 required supervision with toilet use and eating and limited assistance of one staff member for dressing and bathing. Resident #26 was assessed as being continent of bowel and bladder. Review of the initial facility Self-Reported Incident (SRI) form dated 09/01/13 documented the facility received an allegation of sexual assault on 08/31/13. The SRI documented Resident #62 informed STNA (#10) that Resident #26 "touched her and put it in her". Resident #62 was sent to the hospital for examination. The psychologist was contacted for assessment of Resident #62 and Resident #26. A report was made to the local police department. Resident #26 was interviewed and denied the allegation. The Administrator was notified of the alleged sexual abuse on 08/31/13 at 11:00 P.M. by the Director of Nursing. The facility concluded the allegation was unsubstantiated as the evidence indicates that abuse did not occur. Review of the emergency room record dated 09/01/13 documented Resident #62 arrived at the local hospital at 1:00 A.M. At that time, there was no Sexual Assault Nurse Examiner (SANE) available to complete a sexual assault assessment on Resident #62. As a result, the resident was then transported to a local rape clinic at approximately 3:00 A.M. that was 40 miles from the local hospital. At 5:20 A.M., LPN #15 was informed that a rape kit had been obtained and requested the facility inform local law enforcement to transport the rape kit. Review of the Assault History Report conducted by the Sexual Assault Nurse Examiner (SANE), dated 09/01/13 at 4:20 A.M. revealed an anatomical diagram of Resident #62's body. There were three scratches identified on the resident's right inner thigh and the resident stated "the bad guy did it." The diagrams revealed slight redness to the labia with a thick white drainage. The vaginal visualization revealed a white discharge. The narrative report documented in the patient's own words "He came into my room and he took my diaper off and put his penis in me. He sexually bruised me trying to push it in and then went into my vagina. I kept telling him, don't do that. He said he's going to do it again." A rape kit was obtained and arrangements made with the facility to notify the local police to transport the rape kit. Review of the facility's investigation revealed a written statement documented by STNA #10 on 09/01/13 at 8:00 A.M regarding the incident that occurred on 08/31/13. STNA #10 documented she saw Resident #62 leaving Resident #26's room. STNA #10 asked the resident what she was doing in his (Resident #26) room. Resident #62 replied with the question "What?" STNA #10 then went to Resident #26's room and asked him why Resident #62 was in his room. He responded she (Resident #62) came in here and I pushed her out. During the last rounds (checking on residents assigned to STNA #10's care) STNA #10 took Resident #62 into her room to change her pants because she was wet and Resident #62 stated he (Resident #26) tore off her brief and felt all over her body. She stated he then pushed her into the bathroom and expletive (F***ED) her (Resident #62's words). STNA #10 proceeded to fill out Behavior Symptoms Checklists and informed staff to keep an eye on both residents. STNA #10 reported the incident to Registered Nurse (RN) #12 who stated there was nothing we could do because we didn't witness the incident. Review of the Behavior Symptoms Checklist for Resident #26 dated 08/31/13 revealed STNA #10 had check marked the code box of inappropriate sexual behavior. STNA #10 documented she asked the resident about Resident #62 being in his room and the yellow incontinent brief in his trash can. He replied he "did not touch her" . STNA #10 documented she reported the incident to RN #12. Review of a written statement by LPN #15, regarding the 08/31/13 incident, documented the DON was notified on 08/31/13 at 10:45 P.M. after STNA #40 reported to her the sexual assault allegation made by Resident #62. LPN #15 was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down". Resident #62 was then sent to the hospital for evaluation. On 09/10/13 at 5:43 P.M., interview with STNA #30 revealed she was working the evening shift on 08/31/13. During the STNA shift to shift report at approximately 2:30 P.M., STNA #10 informed her and STNA #40, she had just changed Resident #62 and she was incontinent of urine but did not have an incontinent brief on. STNA #10 asked Resident #62 what happened to her brief. Resident #62 stated, "He ripped it off me then expletive (F***ED) me." Upon going into Resident #26's room, STNA #10 found a torn up brief in his trash can and a wet spot on the front of his pants. STNA #30 stated at approximately 10:30 P.M. to 10:45 P.M., when LPN #15 came on duty, LPN #15 notified the DON of the sexual abuse allegation. On 09/10/13 at 10:15 P.M., interview with STNA #40 revealed she came into work on the 3:00 P.M. to 11:00 P.M. shift on 08/31/13. During STNA rounds, STNA #10 informed her of her observations and Resident #62's allegations. STNA #40 stated she went into Resident #26's room with STNA #10 and found an incontinent brief ripped apart and in the trash can and pieces on his bed. Resident #26 had a wet spot in the front of his pants. STNA #40 stated the wet spot was not urine because when the resident had been incontinent in the past it was a much larger area and would wet his pant legs and soak into the back of his pants. STNA #40 asked Resident #26 to change his pants and he kept repeating very nervously, "I did not do it", over and over. STNA #40 stated she observed Resident #26 to be nervous and his repetitive statements to be very untypical behavior for him. STNA #40 stated RN #12 was told about the alleged incident and finding in Resident #26's room multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not address the allegation or assess Resident #62 and Resident #26 despite being told about the incident. On 09/10/13 at 10:45 P.M., interview with LPN #15 revealed she came into work at 10:30 P.M. on 08/31/13. After receiving nursing report from RN #12, STNA #40 approached LPN #15 and asked if she was aware of the sexual assault allegation that happened today between Resident #62 and Resident #26. LPN #15 stated RN #12 did not inform her about any alleged incident. When STNA #40 relayed the alleged incident, LPN #15 instructed STNA #40 to call the DON immediately and tell her about the alleged incident. STNA #40 called the DON and relayed the details of the alleged incident between Resident #26 and #62. The DON asked to speak with LPN #15, instructed her to get a witness (LPN #6), assess the resident, get her statement and she would notify the Administrator. LPN #15 called RN #12 back to the floor and asked her if she was aware of the sexual assault allegation and she affirmed knowledge of the incident but stated she was busy and "blew it off". LPN #15 called LPN #6 to witness the assessment of Resident #62. LPN #15 stated she asked the resident if there had been a problem earlier today. Resident #62 stated that Resident #26 "ripped off her brief, stuck it in and went up and down on the bed." Resident #62 stated that she hurt at the time but did not hurt now. LPN #15 called the DON and told her she was sending Resident #62 to the hospital to be checked out and she was told the Administrator did not want her sent out to the hospital. The Administrator called LPN #15 and was very angry that LPN #15 was sending Resident #62 to the hospital. Despite the Administrator's objection, LPN #15 stated she sent Resident #62 to the hospital for evaluation where she was then transferred to the rape center. When the Administrator was informed the resident had been transferred to the rape center she was furious with LPN #15. LPN #15 verified in talking to the local hospital during the night the resident's story remained consistent from what she had told LPN #15 to what she told the nurses and the doctor at the hospital. On 09/10/13 at 11:15 P.M., interview with LPN #6 revealed on 08/31/13, shortly after shift report, she received a call from LPN #15 and she sounded upset. She went to the secured unit and witnessed an assessment of Resident #62's perineum. LPN #6 verified the resident was upset about the alleged incident stating, "He ripped my brief off and put it in me". LPN #6 stated she also witnessed RN #12 stating she was busy and "blew" the alleged incident off. On 09/11/13 at 9:22 A.M., interview with Police Captain #50 revealed on 09/01/13 at approximately 10:00 A.M, he received a call from the facility's Administrator simply stating there had been a rape in the facility on 08/31/13 and he needed to pick up a rape kit from the rape center. The Administrator offered the address of the rape center but no detailed report of the alleged rape. Police Captain #50 requested the staff working during the alleged sexual assault incident on 08/31/13, report to the police station to provide statements. Review of the written statements obtained by the police and the written statements in the facility's investigation of the incident were found to be consistent. Police Captain #50 stated at 8:30 A.M. on 09/11/13, LPN #15 notified him that the Administrator had a male nurse, RN #60 assess Resident #26 on the morning of 09/01/13. RN #60 assessed Resident #26 on 09/01/13 as instructed and found two pubic hairs under the foreskin of Resident #26's penis. LPN #15 stated RN #60 placed the pubic hairs in a small plastic bag and took them to the Administrator, who threw the hairs in the trash. On 09/11/13 at 11:29 A.M., interview with RN #60 revealed he came to work on 09/01/13 at approximately 6:30 A.M. and was scheduled on Secured Unit 3 where Resident #62 and Resident #26 were residing. During shift report, LPN #15 informed RN #60 about the incident of alleged sexual assault between Resident #62 and Resident #26 the previous day, 08/31/13. RN #60 stated the Administrator asked him to do a physical assessment of Resident #26. On 09/01/13 at 9:45 A.M., RN #60 completed a physical assessment and observed Resident #26 was not circumcised so he pushed back his foreskin and removed two pubic hairs. He placed the pubic hairs in a plastic bag and gave them to the Administrator. The Administrator then threw the hairs in the trash. RN #60 stated to the Administrator, "You might want to keep that because this could be evidence". The Administrator responded, "Well doesn't Resident #26 have pubic hair?" RN #60 stated Secure Care Unit Manager (RN) #145 witnessed the Administrator disposing of the hairs. On 09/11/13 at 11:59 A.M., interview with STNA #10 corroborated the written statements and interviews of facility staff confirming the incident that took place between Resident #26 and #62 on 08/31/13. Additionally, she verified she had informed RN #12 of the alleged sexual assault incident several times throughout the 3:00 P.M. to 11:00 P.M. shift. Observations on 09/11/13 at 1:15 P.M. revealed Resident #26 was standing in the hallway of Unit 2 with his back against the wall. Resident #26 appeared to be staring at a female resident and two female visitors. Resident #26 remained in the hallway for approximately five minutes until the visitor left. Observations on 09/11/13 at 6:20 P.M., revealed Resident #26 standing in the Unit 1 hallway outside of room [ROOM NUMBER], which two females reside in. Resident #26 was standing with his back against the wall outside the room. Resident #26 was looking from side to side, up and down the hallway. Resident #26 moved from the area at 6:24 P.M. when a nurse pushed a medication cart down the hallway. There was no staff present in the hallways of Unit 2 or Unit 1 during these observations. Resident #62 was unable to be observed or interviewed until 09/12/13, when she returned to the facility from the hospital and was placed back on the Secure Care Unit in a room close to the nurse's station. On 09/12/13 at 6:30 P.M., interview with Resident #62 revealed she had no recollection of the alleged incident. On 09/12/13 at 7:00 P.M., an attempt to interview Resident #26 was made; however, Resident #26 walked away and would not answer any questions. On 09/13/13 at 12:20 P.M., interview with the Administrator revealed on 09/01/13 she asked RN #60 if he would complete a physical assessment on Resident #26. RN #60 assessed the resident and found pubic hairs under the foreskin of his penis. The Administrator verified she threw the pubic hairs in the trash, stating she did not want his pubic hair. The Administrator stated she felt the allegation of sexual assault did not happen because Resident #62 is delusional. The Administrator also verified the staff failed to inform her about the alleged incident for several hours. Resident #26 was not assessed by a medical professional at the time she became aware of the incident. Both residents had an evaluation by the psychologist on 09/02/13. The Administrator confirmed both Resident #62 and #26 remained on the locked unit of the facility until an unspecified time in the afternoon on 09/01/13 when Resident #26 was moved to a private room on Unit 2, outside of the locked unit. Resident #26 was placed on 15 minute checks after the move. Review of the facility's undated abuse policy entitled, "Resident Abuse Prevention Practices" revealed Sexual Abuse is defined as sexual harassment, sexual coercion or physical sexual assault. Under Section III entitled Prevention of Abuse, it directs all staff to pay particular attention to residents with needs and behaviors which might precipitate conflict or neglect. These residents will be assessed, have a care plan to meet these problems and will be monitored closely. Under Section VI entitled Protection of the Resident, it notes any resident that has been abused will be provided treatment as needed, including medical, psychological and social intervention. It is understood that this facility may have residents who are confused and at times that confusion leads to aggressive incidents. The facility will make every effort to protect all residents from harm and keep such occurrences under control. This deficiency substantiates Master Complaint Number OH 768.

Based on observations, review of medical records, review of a facility Self-Reported Incident (SRI) , review of emergency room documentation, the rape center and police reports, interviews with staff, residents and the local police officer and review of the facility's policies entitled Resident Abuse Prevention Practices and Injuries of Unknown Source, the facility failed to implement their policies regarding immediate reporting of an allegation of sexual abuse to the administrator, thoroughly investigating the allegation and taking action to protect residents from further abuse after Resident #62 alleged she was sexually assaulted by Resident #26 . This resulted in Immediate Jeopardy for one (#62) of six residents reviewed for alleged sexual abuse and 89 additional residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55,#56, #57, #58, #59, #61, #63, #64, #65, #66, #67, #68, #69, #70, #72, #73, #74, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #89, #91, #92, #93, #94, #95, #96, #97, #98, #103, and #104) who lived on the Secured Care Unit (3) and the Unsecured Units (1 and 2) as the alleged perpetrator was moved from the secured unit to the unsecured unit. Additionally, the facility failed to immediately report an incident of alleged sexual abuse between Residents' #95 and #73 and failed to implement their policy regarding reporting and investigating bruises of unknown origin for Resident #63 that was not Immediate Jeopardy. This affected two (#95 and #73) of six residents reviewed for abuse and one (#63) of three residents reviewed for falls. The facility census was 91. On 09/11/13 at 6:10 P.M., the Director of Nursing (DON) and Administrator were notified that Immediate Jeopardy began on 08/31/13 at 12:30 P.M. when Resident #62 alleged that she had been sexually assaulted by Resident #26. Resident #62's allegation of sexual abuse was reported to Registered Nurse (RN) #12, the charge nurse on duty, multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not immediately report the allegation to administrative staff, take action to ensure protection of the alleged victim and other residents on the secured/unsecured unit and immediately initiate an investigation into the incident. LPN #15 reported for charge nurse duty at 10:30 P.M., was made aware of the allegation by SNTA #40 and was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down ". Resident #62 was sent to the hospital for evaluation and subsequently sent to the Sexual Assault Care Unit where a rape kit was obtained. The Immediate Jeopardy was removed on 09/12/13 at 2:30 P.M. when Resident #26 was placed on one-on-one supervision and the facility implemented the following corrective actions: ? On 09/01/13, at an unspecified time, Resident #62 was transported to the hospital emergency room for evaluation. The emergency room record documented Resident # 62 arrived at the hospital at 1:00 A.M. ? On 09/01/13, at an unspecified time, Resident #62 returned to the facility and was placed in a room close to the nurse's station for monitoring. ? On 09/01/13 at 10:00 A.M., the police were notified by the facility to transport the rape kit from the rape center to be processed. ? On 09/01/13 in the afternoon (no time specified), Resident #26 was moved from the locked unit, where Resident #62 was residing, to the unsecured front hallway of the facility and placed in a private room. The facility began 15 minute checks on Resident # 26. ? On 09/12/13 at 2:30 P.M., the facility began one-on-one monitoring of Resident #26 documenting his whereabouts on the Safety Check Log every 15 minutes. ? On 09/12/13, all residents at risk of potential abuse were interviewed by staff. All resident verbalized they had not been harmed by any residents or staff. ? On 09/12/13 at 8:45 P.M., all employees had been in-serviced on the facility abuse policy entitled Resident Abuse Prevention Practices and the Crime Reporting Policy. ? On 09/12/13 between 11:30 A.M. and 11:45 A.M., interviews with State tested Nurse Aides' (STNAs) #70 and #71 and Licensed Practical Nurse (LPN) #6 and #160 confirmed they had been in-serviced on the facility's abuse and crime reporting policies and what actions staff were too take if an allegation of abuse was reported to them. ? On 09/13/13, the psychologist and psychiatrist assessed both Resident #26 and #62. Both residents received Behavioral Management Plans from the psychologist. If efforts to implement interventions per the Behavior Management Plans are unsuccessful, staff are to notify both the psychologist and psychiatrist. ? On 09/13/13, 09/14/13 and 09/15/13, review of the Safety Check Logs verified Resident #26 was receiving one-on-one monitoring with documentation every 15 minutes as required. ? On 09/14/13, observations of Resident #26 at 12:40 P.M., 1:11 P.M., 1:16 P.M., 1:21 P.M., 1:35 P.M., 2:55 P.M. and 2:58 P.M. verified the resident was receiving one-on-one supervision at all times. ? On 09/15/13, observations of Resident #26 at 2:15 P.M., 2:35 P.M., 3:01 P.M., 3:04 P.M. and 3:14 P.M. again verified the resident was receiving one-on-one supervision with documentation every 15 minutes of the resident ' s whereabouts and activities. 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) because the facility had not in-serviced staff on reporting injuries of unknown source to the Administrator and DON and initiating a specific investigation report per facility policy. Findings include: 1. Review of the medical record of Resident #62 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "History and Physical" dated 07/27/13 documented the resident is alert and answers questions appropriately with good eye contact. She presents with a flat affect and is a poor historian with dates. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/02/13, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5. Resident #62 displays feelings of depression and hopelessness. Resident #62 displayed verbal and physical behavioral symptoms directed towards others on one to three days of the seven day assessment period. Resident #62 required limited assistance of one staff member for bed mobility, transfers and ambulation in her room. Resident #62 required extensive assistance for locomotion off the unit, dressing and toilet use and was identified as being frequently incontinent of urine and wears incontinent briefs for clothing protection. Review of the medical record of Resident # 26 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment, dated 02/09/13, revealed the resident has severe cognitive decline. Resident #26 displayed symptoms of [MEDICAL CONDITION] with continuous inattentiveness, fluctuating disorganized thinking and verbal and physical behaviors toward others. Resident #26 required supervision with toilet use and eating and limited assistance of one staff member for dressing and bathing. Resident #26 was assessed as being continent of bowel and bladder. Review of the initial facility Self-Reported Incident (SRI) form dated 09/01/13 documented the facility received an allegation of sexual assault on 08/31/13. The SRI documented Resident #62 informed STNA (#10) that Resident #26 "touched her and put it in her". Resident #62 was sent to the hospital for examination. The psychologist was contacted for assessment of Resident #62 and Resident #26. A report was made to the local police department. Resident #26 was interviewed and denied the allegation. The Administrator was notified of the alleged sexual abuse on 08/31/13 at 11:00 P.M. by the Director of Nursing. The facility concluded the allegation was unsubstantiated as the evidence indicates that abuse did not occur. Review of the emergency room record dated 09/01/13 documented Resident #62 arrived at the local hospital at 1:00 A.M. At that time, there was no Sexual Assault Nurse Examiner (SANE) available to complete a sexual assault assessment on Resident # 62. As a result, the resident was then transported to a local rape clinic at approximately 3:00 A.M. that was 40 miles from the local hospital. At 5:20 A.M., LPN #15 was informed that a rape kit had been obtained and requested the facility inform local law enforcement to transport the rape kit. Review of the Assault History Report conducted by the Sexual Assault Nurse Examiner (SANE), dated 09/01/13 at 4:20 A.M. revealed an anatomical diagram of Resident #62's body. There were three scratches identified on the resident's right inner thigh and the resident stated "the bad guy did it." The diagrams revealed slight redness to the labia with a thick white drainage. The vaginal visualization revealed a white discharge. The narrative report documented in the patient's own words "He came into my room and he took my diaper off and put his penis in me. He sexually bruised me trying to push it in and then went into my vagina. I kept telling him, don't do that. He said he's going to do it again." A rape kit was obtained and arrangements made with the facility to notify the local police to transport the rape kit. Review of the facility's investigation revealed a written statement documented by STNA #10 on 09/01/13 at 8:00 A.M regarding the incident that occurred on 08/31/13. STNA #10 documented she saw Resident #62 leaving Resident #26's room. STNA #10 asked the resident what she was doing in his (Resident #26) room. Resident #62 replied with the question "What?" STNA #10 then went to Resident #26's room and asked him why Resident #62 was in his room. He responded she (Resident #62) came in here and I pushed her out. During the last rounds (checking on residents assigned to STNA #10's care) STNA #10 took Resident #62 into her room to change her pants because she was wet and Resident #62 stated he (Resident #26) tore off her brief and felt all over her body. She stated he then pushed her into the bathroom and expletive (F***ED) her (Resident #62's words). STNA #10 proceeded to fill out Behavior Symptoms Checklists and informed staff to keep an eye on both residents. STNA #10 reported the incident to Registered Nurse (RN) #12 who stated there was nothing we could do because we didn' t witness the incident. Review of the Behavior Symptoms Checklist for Resident #26 dated 08/31/13 revealed STNA #10 had check marked the code box of inappropriate sexual behavior. STNA #10 documented she asked the resident about Resident #62 being in his room and the yellow incontinent brief in his trash can. He replied he "did not touch her". STNA #10 documented she reported the incident to RN #12. Review of a written statement by LPN #15, regarding the 08/31/13 incident, documented the DON was notified on 08/31/13 at 10:45 P.M. after STNA #40 reported to her the sexual assault allegation made by Resident #62. LPN # 15 was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down". Resident #62 was then sent to the hospital for evaluation. On 09/10/13 at 5:43 P.M., interview with STNA #30 revealed she was working the evening shift on 08/31/13. During the STNA shift to shift report at approximately 2:30 P.M., STNA #10 informed her and STNA # 40, she had just changed Resident #62 and she was incontinent of urine but did not have an incontinent brief on. STNA #10 asked Resident #62 what happened to her brief. Resident # 62 stated, "He ripped it off me then expletive (F***ED) me." Upon going into Resident #26's room, STNA #10 found a torn up brief in his trash can and a wet spot on the front of his pants. STNA #30 stated at approximately 10:30 P.M. to 10:45 P.M., when LPN #15 came on duty, LPN #15 notified the DON of the sexual abuse allegation. On 09/10/13 at 10:15 P.M., interview with STNA #40 revealed she came into work on the 3:00 P.M. to 11:00 P.M. shift on 08/31/13. During STNA rounds, STNA #10 informed her of her observations and Resident # 62's allegations. STNA #40 stated she went into Resident #26's room with STNA #10 and found an incontinent brief ripped apart and in the trash can and pieces on his bed. Resident #26 had a wet spot in the front of his pants. STNA #40 stated the wet spot was not urine because when the resident had been incontinent in the past it was a much larger area and would wet his pant legs and soak into the back of his pants. STNA #40 asked Resident #26 to change his pants and he kept repeating very nervously, "I did not do it ", over and over. STNA #40 stated she observed Resident #26 to be nervous and his repetitive statements to be very untypical behavior for him. STNA #40 stated RN #12 was told about the alleged incident and finding in Resident #26's room multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not address the allegation or assess Resident #62 and Resident #26 despite being told about the incident. On 09/10/13 at 10:45 P.M., interview with LPN #15 revealed she came into work at 10:30 P.M. on 08/31/13. After receiving nursing report from RN #12, STNA #40 approached LPN #15 and asked if she was aware of the sexual assault allegation that happened today between Resident #62 and Resident #26. LPN #15 stated RN #12 did not inform her about any alleged incident. When STNA #40 relayed the alleged incident, LPN #15 instructed STNA #40 to call the DON immediately and tell her about the alleged incident. STNA #40 called the DON and relayed the details of the alleged incident between Resident #26 and #62. The DON asked to speak with LPN #15, instructed her to get a witness (LPN #6), assess the resident, get her statement and she would notify the Administrator. LPN #15 called RN #12 back to the floor and asked her if she was aware of the sexual assault allegation and she affirmed knowledge of the incident but stated she was busy and "blew it off". LPN #15 called LPN #6 to witness the assessment of Resident #62. LPN #15 stated she asked the resident if there had been a problem earlier today. Resident #62 stated that Resident #26 "ripped off her brief, stuck it in and went up and down on the bed." Resident #62 stated that she hurt at the time but did not hurt now. LPN #15 called the DON and told her she was sending Resident #62 to the hospital to be checked out and she was told the Administrator did not want her sent out to the hospital. The Administrator called LPN #15 and was very angry that LPN #15 was sending Resident #62 to the hospital. Despite the Administrator's objection, LPN #15 stated she sent Resident #62 to the hospital for evaluation where she was then transferred to the rape center. When the Administrator was informed the resident had been transferred to the rape center she was furious with LPN #15. LPN #15 verified in talking to the local hospital during the night the resident's story remained consistent from what she had told LPN #15 to what she told the nurses and the doctor at the hospital. On 09/10/13 at 11:15 P.M., interview with LPN #6 revealed on 08/31/13, shortly after shift report, she received a call from LPN #15 and she sounded upset. She went to the secured unit and witnessed an assessment of Resident #62's perineum. LPN #6 verified the resident was upset about the alleged incident stating, "He ripped my brief off and put it in me". LPN #6 stated she also witnessed RN #12 stating she was busy and "blew" the alleged incident off. On 09/11/13 at 9:22 A.M., interview with Police Captain #50 revealed on 09/01/13 at approximately 10:00 A.M, he received a call from the facility's Administrator simply stating there had been a rape in the facility on 08/31/13 and he needed to pick up a rape kit from the rape center. The Administrator offered the address of the rape center but no detailed report of the alleged rape. Police Captain #50 requested the staff working during the alleged sexual assault incident on 08/31/13, report to the police station to provide statements. Review of the written statements obtained by the police and the written statements in the facility's investigation of the incident were found to be consistent. Police Captain #50 stated at 8:30 A.M. on 09/11/13, LPN #15 notified him that the Administrator had a male nurse, RN #60 assess Resident #26 on the morning of 09/01/13. RN #60 assessed Resident #26 on 09/01/13 as instructed and found two pubic hairs under the foreskin of Resident #26's penis. LPN #15 stated RN #60 placed the pubic hairs in a small plastic bag and took them to the Administrator, who threw the hairs in the trash. On 09/11/13 at 11:29 A.M., interview with RN #60 revealed he came to work on 09/01/13 at approximately 6:30 A.M. and was scheduled on Secured Unit 3 where Resident #62 and Resident #26 were residing. During shift report, LPN #15 informed RN #60 about the incident of alleged sexual assault between Resident #62 and Resident #26 the previous day, 08/31/13. RN #60 stated the Administrator asked him to do a physical assessment of Resident #26. On 09/01/13 at 9:45 A.M., RN #60 completed a physical assessment and observed Resident #26 was not circumcised so he pushed back his foreskin and removed two pubic hairs. He placed the pubic hairs in a plastic bag and gave them to the Administrator. The Administrator then threw the hairs in the trash. RN #60 stated to the Administrator, "You might want to keep that because this could be evidence". The Administrator responded, "Well doesn't Resident #26 have pubic hair?" RN #60 stated Secure Care Unit Manager (RN) #145 witnessed the Administrator disposing of the hairs. On 09/11/13 at 11:59 A.M., interview with STNA #10 corroborated the written statements and interviews of facility staff confirming the incident that took place between Resident #26 and #62 on 08/31/13. Additionally, she verified she had informed RN #12 of the alleged sexual assault incident several times throughout the 3:00 P.M. to 11:00 P.M. shift. Observations on 09/11/13 at 1:15 P.M. revealed Resident # 26 was standing in the hallway of Unit 2 with his back against the wall. Resident #26 appeared to be staring at a female resident and two female visitors. Resident #26 remained in the hallway for approximately five minutes until the visitor left. Observations on 09/11/13 at 6:20 P.M., revealed Resident #26 standing in the Unit 1 hallway outside of room [ROOM NUMBER], which two females reside in. Resident#26 was standing with his back against the wall outside the room. Resident #26 was looking from side to side, up and down the hallway. Resident #26 moved from the area at 6:24 P.M. when a nurse pushed a medication care down the hallway. There was no staff present in the hallways of Unit 2 or Unit 1 during these observations. Resident #62 was unable to be observed or interviewed until 09/12/13, when she returned to the facility from the hospital and was placed back on the Secure Care Unit in a room close to the nurse's station. On 09/12/13 at 6:30 P.M., interview with Resident #62 revealed she had no recollection of the alleged incident. On 09/12/13 at 7:00 P.M., an attempt to interview Resident #26 was made; however, Resident #26 walked away and would not answer any questions. On 09/13/13 at 12:20 P.M., interview with the Administrator revealed on 09/01/13 she asked RN #60 if he would complete a physical assessment on Resident #26. RN #60 assessed the resident and found pubic hairs under the foreskin of his penis. The Administrator verified she threw the pubic hairs in the trash, stating she did not want his pubic hair. The Administrator stated she felt the allegation of sexual assault did not happen because Resident # 62 is delusional. The Administrator also verified the staff failed to inform her about the alleged incident for several hours. Resident #26 was not assessed by a medical professional at the time she became aware of the incident. Both residents had an evaluation by the psychologist on 09/02/13. The Administrator confirmed both Resident #62 and #26 remained on the locked unit of the facility until an unspecified time in the afternoon on 09/01/13 when Resident #26 was moved to a private room on Unit 2, outside of the locked unit. Resident #26 was placed on 15 minute checks after the move. Review of the facility's undated abuse policy entitled, "Resident Abuse Prevention Practices" revealed Sexual Abuse is defined as sexual harassment, sexual coercion or physical sexual assault. Under Section III entitled Prevention of Abuse, it directs all staff to pay particular attention to residents with needs and behaviors which might precipitate conflict or neglect. These residents will be assessed, have a care plan to meet these problems and will be monitored closely. Under Section V entitled Investigation, it indicates alleged, suspected, or observed abuse, ....will be reported immediately to the nurse on duty by the individual who suspects or witnesses the occurrence. The nurse will report this information to the Administrator, or in her absence, to the Director of Nursing. Any alleged occurrence will be thoroughly investigated by the Administrator and the Director of Nursing or their designee. The investigation will begin immediately after receiving a complaint of abuse. Under Section VI entitled Protection of the Resident, it notes any resident that has been abused will be provided treatment as needed, including medical, psychological and social intervention. It is understood that this facility may have residents who are confused and at times that confusion leads to aggressive incidents. The facility will make every effort to protect all residents from harm and keep such occurrences under control. 2. Review of the medical record of Resident #63 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the current physicians' orders include, [MEDICATION NAME] (an anticoagulant), daily. The current plan of care also indicates the resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions included monitoring for bruising and petichia. Review of nurse's notes dated 08/31/13 at 4:50 P.M., revealed the resident experienced a fall. There were no signs of injury at the time of the fall. Nurse's notes of 09/01/13 at 2:00 P.M., indicated the resident was noted to have a large bruise and swelling to the resident's right foot. Review of nurses notes, dated 09/02/13 indicate the resident has a large hematoma on the left hip. The resident was transported to the emergency room for an evaluation. Review of the emergency room documentation dated 09/02/13 indicates the resident had an X-ray and computerized topography (CT) scan for the bruise to the left hip and pelvis with no evidence of injury. A laboratory test on 09/02/13 at 5:34 P.M. indicates the resident's International Ratio (INR) was elevated at 3.59. This indicated the resident's blood was not clotting normally and there was an increased risk for signs of bleeding. There was no evidence of any investigation into the origin of the hematoma on the left hip. An interview on 09/12/13 at 1:00 P.M. with LPN #8 revealed she noted the bruise on the residents left hip on 09/02/13. LPN #8 began an incident report but did not complete it or get statements from staff. Review of nurse's notes dated 09/06/13 at 11:30 A.M., revealed LPN #14 and LPN #6 observed Resident #63's right and left hip/thigh/buttock areas. The right hip was noted to have three areas of dark purple with greenish/yellow perimeters, each measuring the length of an index finger. The left hip/thigh/buttock area was noted to have dark purple area with greenish/yellow color perimeter extending approximately three inches below gluteal fold extending to back of thigh. The area was noted to extend thee inches above the gluteal slit into the sacral/lower lumbar area. Additional review of nurse's notes dated 09/06/13 at 1:30 P.M., noted bilateral upper extremities to have scattered dark and purple and red bruises which included three dark purple bruises with yellow/greenish edges. The left buttock has a dark purple bruise, approximately the size of a football, covering 90% of cheek with edges having yellow/green bruising noted. There was no evidence of any investigation into the origin of the new bruising to the right hip and bilateral upper extremities. An interview on 09/12/13 at 5:20 P.M., with LPN #14 revealed she had observed Resident #63's right hip bruises on 09/06/13. She noted the areas in the nurse's notes and reported this information to the Corporate Nurse. She had been informed by the floor nurse that this injury was a result of a fall on 08/31/13 and was unaware of this being the first time the right hip bruise was noted. LPN #14 indicated she felt someone with a fall related bruise would develop any bruising within 24 hours. An observation on 09/12/13 at 2:00 P.M., of Resident #63's hips revealed the resident had a large bruised area from the sacrum extending across the left buttocks, down the left thigh, until approximately six inches above the left knee. The bruise varies in color from deep purple to red to green in various areas. The right hip has two bruised areas approximately four inches long by one and a half inch wide. These observations were made with LPN #6. An interview on 09/12/13 at 2:45 P.M. with the Director of Nursing revealed they did not investigate the cause of the bruises to Resident #63's hips and arms as they felt they were related to the resident's fall on 08/31/13. The Director of Nursing did verify the resident's INR was elevated on 09/02/13. A review of the undated facility policy entitled (Injuries of Unknown Source) revealed incidents should be reported to the Administrator and Director of Nursing. Bullet #4 A indicated Identification of unknown injury, initiate a specific investigation report. The policy also indicated the administrator shall review all injuries of unknown source. 3. Review of a facility SRI dated 08/18/13, alleging sexual abuse, revealed Resident #95 inappropriately touched Resident #73's breasts and the incident was witnessed by STNA #172. Interview with the DON on 09/13/13 at 3:40 P.M., verified STNA #172 reported the incident to RN #283 on the date the incident occurred (08/18/13), however, RN #283 failed to immediately notify the Administrator. Review of Resident #73 and #95's medical records revealed documentation of the incident and administration was notified. The DON verified the state agency was not notified of the alleged sexual abuse by the administration of the facility until 08/26/13. This deficiency substantiates Master Complaint Number OH 768. This deficiency represents continued non-compliance from the complaint survey of 08/15/13.

Based on observations, review of medical records, review of a facility Self-Reported Incident (SRI), review of emergency room documentation, the rape center and police reports, interviews with staff, residents and the local police officer and review of the facility's policy on abuse, the facility failed to immediately report an allegation of sexual abuse to the administrator, thoroughly investigate the allegation and take action to protect residents from further abuse after Resident #62 alleged she was sexually assaulted by Resident #26 . This resulted in Immediate Jeopardy for one (#62) of six residents reviewed for alleged sexual abuse and 89 additional residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55,#56, #57, #58, #59, #61, #63, #64, #65, #66, #67, #68, #69, #70, #72, #73, #74, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #89, #91, #92, #93, #94, #95, #96, #97, #98, #103, and #104) who lived on the Secured Care Unit (3) and the Unsecured Units (1 and 2) as the alleged perpetrator was moved from the secured unit to the unsecured unit. Additionally, the facility failed to immediately report an incident of alleged sexual abuse between Residents' #95 and #73 and failed to report and investigate bruises of unknown origin for Resident #63 that was not Immediate Jeopardy. This affected two (#95 and #73) of six residents reviewed for abuse and one (#63) of three residents reviewed for falls. The facility census was 91. On 09/11/13 at 6:10 P.M., the Director of Nursing (DON) and Administrator were notified that Immediate Jeopardy began on 08/31/13 at 12:30 P.M. when Resident #62 alleged that she had been sexually assaulted by Resident #26. Resident #62's allegation of sexual abuse was reported to Registered Nurse (RN) #12, the charge nurse on duty, multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not immediately report the allegation to administrative staff, take action to ensure protection of the alleged victim and other residents on the secured/unsecured unit and immediately initiate an investigation into the incident. LPN #15 reported for charge nurse duty at 10:30 P.M., was made aware of the allegation by SNTA #40 and was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down". Resident #62 was sent to the hospital for evaluation and subsequently sent to the Sexual Assault Care Unit where a rape kit was obtained. The Immediate Jeopardy was removed on 09/12/13 at 2:30 P.M. when Resident #26 was placed on one-on-one supervision and the facility implemented the following corrective actions: ? On 09/01/13, at an unspecified time, Resident #62 was transported to the hospital emergency room for evaluation. The emergency room record documented Resident # 62 arrived at the hospital at 1:00 A.M. ? On 09/01/13, at an unspecified time, Resident #62 returned to the facility and was placed in a room close to the nurse's station for monitoring. ? On 09/01/13 at 10:00 A.M., the police were notified by the facility to transport the rape kit from the rape center to be processed. ? On 09/01/13 in the afternoon (no time specified), Resident #26 was moved from the locked unit, where Resident #62 was residing, to the unsecured front hallway of the facility and placed in a private room. The facility began 15 minute checks on Resident # 26. ? On 09/12/13 at 2:30 P.M., the facility began one-on-one monitoring of Resident #26 documenting his whereabouts on the Safety Check Log every 15 minutes. ? On 09/12/13, all residents at risk of potential abuse were interviewed by staff. All resident verbalized they had not been harmed by any residents or staff. ? On 09/12/13 at 8:45 P.M., all employees had been in-serviced on the facility abuse policy entitled Resident Abuse Prevention Practices and the Crime Reporting Policy. ? On 09/12/13 between 11:30 A.M. and 11:45 A.M., interviews with State tested Nurse Aides' (STNAs) #70 and #71 and Licensed Practical Nurse (LPN) #6 and #160 confirmed they had been in-serviced on the facility' abuse and crime reporting policies and what actions staff were too take if an allegation of abuse was reported to them. ? On 09/13/13, the psychologist and psychiatrist assessed both Resident #26 and #62. Both residents received Behavioral Management Plans from the psychologist. If efforts to implement interventions per the Behavior Management Plans are unsuccessful, staff are to notify both the psychologist and psychiatrist. ? On 09/13/13, 09/14/13 and 09/15/13, review of the Safety Check Logs verified Resident #26 was receiving one-on-one monitoring with documentation every 15 minutes as required. ? On 09/14/13, observations of Resident #26 at 12:40 P.M., 1:11 P.M., 1:16 P.M., 1:21 P.M., 1:35 P.M., 2:55 P.M. and 2:58 P.M. verified the resident was receiving one-on-one supervision at all times. ? On 09/15/13, observations of Resident #26 at 2:15 P.M., 2:35 P.M., 3:01 P.M., 3:04 P.M. and 3:14 P.M. again verified the resident was receiving one-on-one supervision with documentation every 15 minutes of the resident's whereabouts and activities. 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) because the facility had not in-serviced staff on reporting injuries of unknown source to the Administrator and DON and initiating a specific investigation report per facility policy. Findings include: 1. Review of the medical record of Resident #62 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "History and Physical" dated 07/27/13 documented the resident is alert and answers questions appropriately with good eye contact. She presents with a flat affect and is a poor historian with dates. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/02/13, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5. Resident #62 displays feelings of depression and hopelessness. Resident #62 displayed verbal and physical behavioral symptoms directed towards others on one to three days of the seven day assessment period. Resident #62 required limited assistance of one staff member for bed mobility, transfers and ambulation in her room. Resident #62 required extensive assistance for locomotion off the unit, dressing and toilet use and was identified as being frequently incontinent of urine and wears incontinent briefs for clothing protection. Review of the medical record of Resident #26 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment, dated 02/09/13, revealed the resident has severe cognitive decline. Resident #26 displayed symptoms of [MEDICAL CONDITION] with continuous inattentiveness, fluctuating disorganized thinking and verbal and physical behaviors toward others. Resident #26 required supervision with toilet use and eating and limited assistance of one staff member for dressing and bathing. Resident #26 was assessed as being continent of bowel and bladder. Review of the initial facility Self-Reported Incident (SRI) form dated 09/01/13 documented the facility received an allegation of sexual assault on 08/31/13. The SRI documented Resident #62 informed STNA (#10) that Resident #26 "touched her and put it in her". Resident #62 was sent to the hospital for examination. The psychologist was contacted for assessment of Resident #62 and Resident #26. A report was made to the local police department. Resident #26 was interviewed and denied the allegation. The Administrator was notified of the alleged sexual abuse on 08/31/13 at 11:00 P.M. by the Director of Nursing. The facility concluded the allegation was unsubstantiated as the evidence indicates that abuse did not occur. Review of the emergency room record dated 09/01/13 documented Resident #62 arrived at the local hospital at 1:00 A.M. At that time, there was no Sexual Assault Nurse Examiner (SANE) available to complete a sexual assault assessment on Resident #62. As a result, the resident was then transported to a local rape clinic at approximately 3:00 A.M. that was 40 miles from the local hospital. At 5:20 A.M., LPN #15 was informed that a rape kit had been obtained and requested the facility inform local law enforcement to transport the rape kit. Review of the Assault History Report conducted by the Sexual Assault Nurse Examiner (SANE), dated 09/01/13 at 4:20 A.M. revealed an anatomical diagram of Resident #62's body. There were three scratches identified on the resident's right inner thigh and the resident stated "the bad guy did it." The diagrams revealed slight redness to the labia with a thick white drainage. The vaginal visualization revealed a white discharge. The narrative report documented in the patient's own words "He came into my room and he took my diaper off and put his penis in me. He sexually bruised me trying to push it in and then went into my vagina. I kept telling him, don't do that. He said he's going to do it again." A rape kit was obtained and arrangements made with the facility to notify the local police to transport the rape kit. Review of the facility's investigation revealed a written statement documented by STNA #10 on 09/01/13 at 8:00 A.M regarding the incident that occurred on 08/31/13. STNA #10 documented she saw Resident #62 leaving Resident #26's room. STNA #10 asked the resident what she was doing in his (Resident #26) room. Resident #62 replied with the question "What?" STNA #10 then went to Resident #26's room and asked him why Resident #62 was in his room. He responded she (Resident #62) came in here and I pushed her out. During the last rounds (checking on residents assigned to STNA #10's care) STNA #10 took Resident #62 into her room to change her pants because she was wet and Resident #62 stated he (Resident #26) tore off her brief and felt all over her body. She stated he then pushed her into the bathroom and expletive (F***ED) her (Resident #62's words). STNA #10 proceeded to fill out Behavior Symptoms Checklists and informed staff to keep an eye on both residents. STNA #10 reported the incident to Registered Nurse (RN) #12 who stated there was nothing we could do because we didn't witness the incident. Review of the Behavior Symptoms Checklist for Resident #26 dated 08/31/13 revealed STNA #10 had check marked the code box of inappropriate sexual behavior. STNA #10 documented she asked the resident about Resident #62 being in his room and the yellow incontinent brief in his trash can. He replied he "did not touch her". STNA #10 documented she reported the incident to RN #12. Review of a written statement by LPN #15, regarding the 08/31/13 incident, documented the DON was notified on 08/31/13 at 10:45 P.M. after STNA #40 reported to her the sexual assault allegation made by Resident #62. LPN # 15 was instructed by the DON to assess Resident #62. At the time of the assessment, she documented Resident #62 stated "He (Resident #26) tore off my diaper and put it in me and the bed went up and down". Resident #62 was then sent to the hospital for evaluation. On 09/10/13 at 5:43 P.M., interview with STNA #30 revealed she was working the evening shift on 08/31/13. During the STNA shift to shift report at approximately 2:30 P.M., STNA #10 informed her and STNA # 40, she had just changed Resident #62 and she was incontinent of urine but did not have an incontinent brief on. STNA #10 asked Resident # 62 what happened to her brief. Resident # 62 stated, "He ripped it off me then expletive (F***ED) me." Upon going into Resident #26's room, STNA #10 found a torn up brief in his trash can and a wet spot on the front of his pants. STNA #30 stated at approximately 10:30 P.M. to 10:45 P.M., when LPN #15 came on duty, LPN #15 notified the DON of the sexual abuse allegation. On 09/10/13 at 10:15 P.M., interview with STNA #40 revealed she came into work on the 3:00 P.M. to 11:00 P.M. shift on 08/31/13. During STNA rounds, STNA #10 informed her of her observations and Resident # 62's allegations. STNA #40 stated she went into Resident #26's room with STNA #10 and found an incontinent brief ripped apart and in the trash can and pieces on his bed. Resident #26 had a wet spot in the front of his pants. STNA #40 stated the wet spot was not urine because when the resident had been incontinent in the past it was a much larger area and would wet his pant legs and soak into the back of his pants. STNA #40 asked Resident #26 to change his pants and he kept repeating very nervously, "I did not do it", over and over. STNA #40 stated she observed Resident #26 to be nervous and his repetitive statements to be very untypical behavior for him. STNA #40 stated RN #12 was told about the alleged incident and finding in Resident #26's room multiple times throughout the 3:00 P.M. to 11:00 P.M. shift. RN #12 did not address the allegation or assess Resident #62 and Resident #26 despite being told about the incident. On 09/10/13 at 10:45 P.M., interview with LPN #15 revealed she came into work at 10:30 P.M. on 08/31/13. After receiving nursing report from RN #12, STNA #40 approached LPN #15 and asked if she was aware of the sexual assault allegation that happened today between Resident #62 and Resident #26. LPN #15 stated RN #12 did not inform her about any alleged incident. When STNA #40 relayed the alleged incident, LPN #15 instructed STNA #40 to call the DON immediately and tell her about the alleged incident. STNA #40 called the DON and relayed the details of the alleged incident between Resident #26 and #62. The DON asked to speak with LPN #15, instructed her to get a witness (LPN #6), assess the resident, get her statement and she would notify the Administrator. LPN #15 called RN #12 back to the floor and asked her if she was aware of the sexual assault allegation and she affirmed knowledge of the incident but stated she was busy and "blew it off". LPN #15 called LPN #6 to witness the assessment of Resident #62. LPN #15 stated she asked the resident if there had been a problem earlier today. Resident #62 stated that Resident #26 "ripped off her brief, stuck it in and went up and down on the bed." Resident #62 stated that she hurt at the time but did not hurt now. LPN #15 called the DON and told her she was sending Resident #62 to the hospital to be checked out and she was told the Administrator did not want her sent out to the hospital. The Administrator called LPN #15 and was very angry that LPN #15 was sending Resident #62 to the hospital. Despite the Administrator's objection, LPN #15 stated she sent Resident #62 to the hospital for evaluation where she was then transferred to the rape center. When the Administrator was informed the resident had been transferred to the rape center she was furious with LPN #15. LPN #15 verified in talking to the local hospital during the night the resident's story remained consistent from what she had told LPN #15 to what she told the nurses and the doctor at the hospital. On 09/10/13 at 11:15 P.M., interview with LPN #6 revealed on 08/31/13, shortly after shift report, she received a call from LPN #15 and she sounded upset. She went to the secured unit and witnessed an assessment of Resident #62's perineum. LPN #6 verified the resident was upset about the alleged incident stating, "He ripped my brief off and put it in me". LPN #6 stated she also witnessed RN #12 stating she was busy and "blew" the alleged incident off. On 09/11/13 at 9:22 A.M., interview with Police Captain #50 revealed on 09/01/13 at approximately 10:00 A.M, he received a call from the facility's Administrator simply stating there had been a rape in the facility on 08/31/13 and he needed to pick up a rape kit from the rape center. The Administrator offered the address of the rape center but no detailed report of the alleged rape. Police Captain #50 requested the staff working during the alleged sexual assault incident on 08/31/13, report to the police station to provide statements. Review of the written statements obtained by the police and the written statements in the facility's investigation of the incident were found to be consistent. Police Captain #50 stated at 8:30 A.M. on 09/11/13, LPN #15 notified him that the Administrator had a male nurse, RN #60 assess Resident #26 on the morning of 09/01/13. RN #60 assessed Resident #26 on 09/01/13 as instructed and found two pubic hairs under the foreskin of Resident #26's penis. LPN #15 stated RN #60 placed the pubic hairs in a small plastic bag and took them to the Administrator, who threw the hairs in the trash. On 09/11/13 at 11:29 A.M., interview with RN #60 revealed he came to work on 09/01/13 at approximately 6:30 A.M. and was scheduled on Secured Unit 3 where Resident #62 and Resident #26 were residing. During shift report, LPN #15 informed RN #60 about the incident of alleged sexual assault between Resident #62 and Resident #26 the previous day, 08/31/13. RN #60 stated the Administrator asked him to do a physical assessment of Resident #26. On 09/01/13 at 9:45 A.M., RN #60 completed a physical assessment and observed Resident #26 was not circumcised so he pushed back his foreskin and removed two pubic hairs. He placed the pubic hairs in a plastic bag and gave them to the Administrator. The Administrator then threw the hairs in the trash. RN #60 stated to the Administrator, "You might want to keep that because this could be evidence". The Administrator responded, "Well doesn't Resident #26 have pubic hair?" RN #60 stated Secure Care Unit Manager (RN) #145 witnessed the Administrator disposing of the hairs. On 09/11/13 at 11:59 A.M., interview with STNA #10 corroborated the written statements and interviews of facility staff confirming the incident that took place between Resident #26 and #62 on 08/31/13. Additionally, she verified she had informed RN #12 of the alleged sexual assault incident several times throughout the 3:00 P.M. to 11:00 P.M. shift. Observations on 09/11/13 at 1:15 P.M. revealed Resident # 26 was standing in the hallway of Unit 2 with his back against the wall. Resident #26 appeared to be staring at a female resident and two female visitors. Resident #26 remained in the hallway for approximately five minutes until the visitor left. Observations on 09/11/13 at 6:20 P.M., revealed Resident #26 standing in the Unit 1 hallway outside of room [ROOM NUMBER], which two females reside in. Resident#26 was standing with his back against the wall outside the room. Resident #26 was looking from side to side, up and down the hallway. Resident #26 moved from the area at 6:24 P.M. when a nurse pushed a medication care down the hallway. There was no staff present in the hallways of Unit 2 or Unit 1 during these observations. Resident #62 was unable to be observed or interviewed until 09/12/13, when she returned to the facility from the hospital and was placed back on the Secure Care Unit in a room close to the nurse ' s station. On 09/12/13 at 6:30 P.M., interview with Resident #62 revealed she had no recollection of the alleged incident. On 09/12/13 at 7:00 P.M., an attempt to interview Resident #26 was made; however, Resident #26 walked away and would not answer any questions. On 09/13/13 at 12:20 P.M., interview with the Administrator revealed on 09/01/13 she asked RN #60 if he would complete a physical assessment on Resident #26. RN #60 assessed the resident and found pubic hairs under the foreskin of his penis. The Administrator verified she threw the pubic hairs in the trash, stating she did not want his pubic hair. The Administrator stated she felt the allegation of sexual assault did not happen because Resident # 62 is delusional. The Administrator also verified the staff failed to inform her about the alleged incident for several hours. Resident #26 was not assessed by a medical professional at the time she became aware of the incident. Both residents had an evaluation by the psychologist on 09/02/13. The Administrator confirmed both Resident #62 and #26 remained on the locked unit of the facility until an unspecified time in the afternoon on 09/01/13 when Resident #26 was moved to a private room on Unit 2, outside of the locked unit. Resident #26 was placed on 15 minute checks after the move. Review of the facility's undated abuse policy entitled, "Resident Abuse Prevention Practices" revealed Sexual Abuse is defined as sexual harassment, sexual coercion or physical sexual assault. Under Section III entitled Prevention of Abuse, it directs all staff to pay particular attention to residents with needs and behaviors which might precipitate conflict or neglect. These residents will be assessed, have a care plan to meet these problems and will be monitored closely. Under Section V entitled Investigation, it indicates alleged, suspected, or observed abuse, ....will be reported immediately to the nurse on duty by the individual who suspects or witnesses the occurrence. The nurse will report this information to the Administrator, or in her absence, to the Director of Nursing. Any alleged occurrence will be thoroughly investigated by the Administrator and the Director of Nursing or their designee. The investigation will begin immediately after receiving a complaint of abuse. Under Section VI entitled Protection of the Resident, it notes any resident that has been abused will be provided treatment as needed, including medical, psychological and social intervention. It is understood that this facility may have residents who are confused and at times that confusion leads to aggressive incidents. The facility will make every effort to protect all residents from harm and keep such occurrences under control. 2. Review of the medical record of Resident #63 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of current physicians' orders include, [MEDICATION NAME] (an anticoagulant), daily. The current plan of care also indicates the resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions included monitoring for bruising and petichia. Review of nurse's notes dated 08/31/13 at 4:50 P.M., revealed the resident experienced a fall. There were no signs of injury at the time of the fall. Nurse's notes of 09/01/13 at 2:00 P.M., indicated the resident was noted to have a large bruise and swelling to the resident's right foot. Review of nurses notes, dated 09/02/13 indicate the resident has a large hematoma on the left hip. The resident was transported to the emergency room for an evaluation. Review of the emergency room documentation dated 09/02/13 indicates the resident had an X-ray and computerized topography (CT) scan for the bruise to the left hip and pelvis with no evidence of injury. A laboratory test on 09/02/13 at 5:34 P.M., indicates the resident's International Ratio (INR) was elevated at 3.59. This indicated the resident's blood was not clotting normally and there was an increased risk for signs of bleeding. There was no evidence of any investigation into the origin of the hematoma on the left hip. An interview on 09/12/13 at 1:00 P.M. with LPN #8 revealed she noted the bruise on the residents left hip on 09/02/13. LPN #8 began an incident report but did not complete it or get statements from staff. Review of nurse's notes dated 09/06/13 at 11:30 A.M., revealed LPN #14 and LPN #6 observed Resident #63's right and left hip/thigh/buttock areas. The right hip was noted to have three areas of dark purple with greenish/yellow perimeters, each measuring the length of an index finger. The left hip/thigh/buttock area was noted to have dark purple area with greenish/yellow color perimeter extending approximately three inches below gluteal fold extending to back of thigh. The area was noted to extend thee inches above the gluteal slit into the sacral/lower lumbar area. Additional review of nurse's notes dated 09/06/13 at 1:30 P.M., noted bilateral upper extremities to have scattered dark and purple and red bruises which included three dark purple bruises with yellow/greenish edges. The left buttock has a dark purple bruise, approximately the size of a football, covering 90% of cheek with edges having yellow/green bruising noted. There was no evidence of any investigation into the origin of the new bruising to the right hip and bilateral upper extremities. An interview on 09/12/13 at 5:20 P.M., with LPN #14 revealed she had observed Resident #63's right hip bruises on 09/06/13. She noted the areas in the nurses' notes and reported this information to the Corporate Nurse. She had been informed by the floor nurse that this injury was a result of a fall on 08/31/13 and was unaware of this being the first time the right hip bruise was noted. LPN #14 indicated she felt someone with a fall related bruise would develop any bruising within 24 hours. An observation on 09/12/13 at 2:00 P.M., of Resident #63's hips revealed the resident had an large bruised area from the sacrum extending across the left buttocks, down the left thigh, until approximately six inches above the left knee. The bruise varies in color from deep purple to red to green in various areas. The right hip has two bruised areas approximately four inches long by one and a half inch wide. These observations were made with LPN #6. An interview on 09/12/13 at 2:45 P.M. with the Director of Nursing revealed they did not investigate the cause of the bruises to Resident #63's hips and arms as they felt they were related to the resident's fall on 08/31/13. The Director of Nursing did verify the resident's INR was elevated on 09/02/13. A review of the undated facility policy entitled (Injuries of Unknown Source) revealed incidents should be reported to the Administrator and Director of Nursing. Bullet #4 A indicated Identification of unknown injury, initiate a specific investigation report. The policy also indicated the administrator shall review all injuries of unknown source. 3. Review of a facility SRI dated 08/18/13, alleging sexual abuse, revealed Resident #95 inappropriately touched Resident #73's breasts and the incident was witnessed by STNA #172. Interview with the DON on 09/13/13 at 3:40 P.M., verified STNA #172 reported the incident to RN #283 on the date the incident occurred (08/18/13), however, RN #283 failed to immediately notify the Administrator. Review of Resident #73 and #95's medical records revealed documentation of the incident and administration was notified. The DON verified the state agency was not notified of the alleged sexual abuse by the administration of the facility until 08/26/13. This deficiency substantiates Master Complaint Number OH 768. This deficiency represents continued non-compliance from the complaint survey of 08/15/13.

Based on medical record review, staff and resident interview, and review of facility policies entitled " Safety/supervision and Shaving", the facility failed to maintain adequate supervision when a resident was utilizing a disposable razor blade. This resulted in actual harm when Resident #5 swallowed the top of a disposable razor with the cap on and required an invasive procedure to remove the razor blade. This affected one (#5) of three residents review for accidents with the potential to affect the 32 residents residing on the secured unit. The facility census is 91. Findings include: Review of Resident #5's medical record reveals an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 was assessed as having behavioral symptoms that were not directed toward others occurring daily. Behavioral symptoms was triggered in the care area assessment (CAA) summary and CAA worksheet reveals a history of self-harm via ingesting small objects. Review of care plan for impaired behavior dated 070/2/13 revealed Resident #5's behaviors include being verbally abusive, cursing, yelling, attentions seeking, making false accusations, threats to fall, obsessing, swallowing chap stick cap, threatening staff. Interventions to behaviors include administer medications and monitor for side effects, monitor for any changes in mental status, maintain a consistent environment as much as possible, remove all potential harmful items from her room, and routine room sweeps. Review of nurse's notes dated 09/02/13 at 9:00 A.M., revealed Resident #5 stated she swallowed the top of a disposable razor with the cap still on because she was upset. Resident #5's room was checked and a broken disposable razor stick was found in her room. The physician was notified and an order was given for Resident #5 to be sent out for an x-ray. Nurse's notes dated 09/02/13 at 10:00 A.M., revealed Resident #5 was sent out the hospital. Review of hospital history and physical examination [REDACTED]. Resident #5 was at the hospital due to swallowing a disposable razor blade with the cap still on. An EGD (esophagogastroduodenoscopy- a test to examine the lining of the esophagus, stomach and first part of the small intestine) was performed. The razor blade with the cap was removed from the stomach. Interview with Licensed Practical Nurse (LPN) #19 on 09/10/13 at 9:30 A.M., revealed residents on the secured unit are not allowed to have razors in their personal hygiene boxes. Resident personal hygiene boxes are kept locked in the shower room. The staff is to give personal hygiene boxes to resident and provide supervision while the resident has the box. If a resident requests a razor, they are given a safety razor from the facility supply and are only used under direct supervision of staff. After razors are used they are disposed in a sharps container. Interview with Resident #5 on 09/12/13 on 7:05 P.M. revealed she swallowed a disposable razor with the top still on for attention. The razor was in her personal hygiene box and staff left her unattended with her personal hygiene box. Interview with Licensed Practical Nurse (LPN) #8 on 09/13/13 at 12:25 P.M. revealed she was working the secured unit on 09/02/13 during the time of the incident. Resident #5 turned her call light on and LPN #8 responded. Upon entering room LPN #8 observed Resident #5 in possession of her personal hygiene box unattended by staff. Resident #5 told LPN #8 she had swallowed a razor and revealed a razor stick with the razor and cap missing. Resident #5 told LPN #8 the razor was found in her shower box. LPN #8 further stated staff is to be with residents at all times when they are in possession of their personal hygiene boxes and verified no staff were supervising Resident #5 at time of the incident. Interview with Director of Nursing on 09/13/13 at 3:25 P.M., revealed razors are not to be kept in personal hygiene boxes. Personal hygiene boxes are to be checked for potentially harmful items before giving them to the resident. She further states the personal hygiene boxes are not part of the weekly room checks performed by the nursing assistants. Review of undated facility policy entitled, "Shaving" revealed residents should not have razors or shave unattended. Review of undated facility policy entitled "Safety and supervision" revealed all residents will be supervised appropriately based on their personal history and judgment of the Director of Nursing and Program Director or designees. Procedure for the facility includes weekly room checks performed by nursing assistants for unsafe objects (including razors). Unsafe items will be safely stored for the resident by the facility. This deficiency substantiates Master Complaint Number OH 768.