Every finding on record at Wapakoneta Manor

Based on medical record review, staff interview, and review of facility policy, the facility failed to address pharmacy recommendations in a timely manner. This affected two (#57 and #61) of five reviewed for unnecessary medications. The census was 67. Findings include: 1.Review of Resident #57's medical record revealed an admission date of 09/16/25. Diagnoses included hypokalemia, breast cancer, anxiety disorder, and depression. Review of a quarterly Minimum Data Set (MDS) date 06/04/26 revealed Resident #57 was receiving an anti-depressant medication. Review of a pharmacy a recommendation dated 05/23/26 revealed Sertraline (antidepressant) 175 milligrams (mg) was recommended to be administer in the A.M. (morning) instead of being administered at bedtime (HS) because of causing insomnia and irritability which may disrupt sleep patterns. Further review revealed the recommendation was signed per verbal order on 07/21/26 to agree with changing the schedule. Review of a pharmacy recommendation dated 06/10/26 revealed Melatonin (sleep aide supplement) 10 mg was recommended for a dose reduction due to being administered for behavioral issues since 09/17/25. Further review revealed the recommendation was not yet signed by a physician, Review of physician orders revealed Sertraline 175 mg was changed to HS administration on 07/21/26. Melatonin 10 mg had been order since 09/17/25 and a dose reduction was not attempted. Interview with [NAME] President of Nursing (VPN) #118 confirmed the pharmacy recommendations for Sertraline and Melatonin were not addressed timely. 2. Review of the medical record of Resident #61 revealed an admission date of 7/24/20. Diagnoses include chronic obstructive pulmonary disease, diverticulitis of intestine, and hyperlipidemia. Review of the pharmacy recommendation dated 4/29/26 for Resident #61 revealed clinical monitoring request for Ezetimibe (antihyperlidemic), please consider checking a fasting lipid panel as the last results are from 3/2025. There was no documented response to the recommendation. Review of the pharmacy recommendation dated 5/23/26 revealed the pharmacist recommended evaluating the continued use of Lactobacillus (probiotic) with a response received on 7/21/26. Review of the pharmacy recommendation dated 6/10/26 indicated Resident #61 is receiving Trelegy (bronchodialator combination) inhaler and a recommendation to update the order to instruct resident to rinse mouth after use. This recommendation had no response documented. Interview on 7/22/26 at 2:18 P.M. with DIrector fo Nursing (DON) and VP of Nursing #118 provided verification of the delay in responding to the pharmacy recommendations. Review of the policy titled Medication Regimen Review dated 5/1/26, revealed the drug regimen of each resident is reviewed at least once a month, and the facility shall provide answers to the pharmacy recommendations. The facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on record review, resident interviews, and staff interviews the facility failed to ensure medications were administered as ordered related to not having a continuous supply of prescribed medications. This affected two residents, (#3 and #43) of five residents reviewed for medications. The facility census was 67. Findings include:Top of Form1.Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with a readmission date of 06/14/26. Diagnoses for Resident #3 include paraplegia, fracture of thoracic vertebra, bipolar disorder, neuromuscular dysfunction of bladder, and neurogenic bowel.Review of Resident #3 comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and had pain assessed at a 10 out of 1-10 pain scale.Review of the paper documents in Resident #3's chart revealed on 06/24/26 the physician ordered Oxycodone (opioid) 15 milligrams (mg) tablet every four hours as needed for pain for 28 days. Per the prescription 168 tablets were to be dispersed.Review of the Medication Administration Record (MAR) dated 06/2026 to 07/2026 revealed Resident #3 was administered 68 Oxycodone pills as of 07/20/26. On 07/20/26 there was documentation there were no Oxycodone tablets available for Resident #3.Review of Resident #3's Narcotic Records dated 06/25/26 to 07/13/26 revealed on 06/25/26 the pharmacy dispensed 30 pills on 06/24/26, 30 pills on 07/03/26 and 18 pills on 07/13/26, for a total of 68 pills.Review of Resident #3's progress notes dating from 07/01/26 to 07/21/26 revealed on 07/20/26 the nurse documented the provider was notified the resident was out of Oxycodone and there were no pills available in the emergency supply.Interview on 07/20/26 at 9:36 A.M. with Resident #3 revealed the resident expressed concerns regarding the availability of his prescribed pain medications. Resident #3 stated the staff tell him the pharmacy had not provided the entire number of medications and the resident had to wait on the delay from pharmacy.Observation on 07/21/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #153 during a narcotic count in the medication cart for B-Hall revealed there was 28 Oxycodone pills for Resident #3. LPN #153 stated there were multiple days when Resident #3 was without Oxycodone due to the pharmacy not supplying the full physician order to the facility. LPN #153 stated during those incidents the nurse will contact pharmacy request another delivery of the medication. LPN #153 stated the pharmacy will deliver the medications during the next drop-off day, twice a week. LPN #153 stated there is an emergency contingency supply, but the physician had to order the medication to be removed from the emergency contingency supply.Interview on 07/21/26 with [NAME] President of Nursing (VPN) #118 verified the written order for Oxycodone provided by the physician for Resident #3 documented 168 tablets were to be dispensed and the resident was administered 67 and pharmacy only dispensed 68 pills. VPN #118 verified there were times when Resident #3 requested his as needed pain medication, Oxycodone, and there was no supply of the medication for the resident in the facility as the staff were awaiting a delivery from pharmacy.Interview on 07/22/26 at 8:30 A.M. with Pharmacy Account Manager (PAM) #222 verified the pharmacy does not send the entire amount of pills ordered by the physician at the start of an order. PAM #222 stated the pharmacy awaits the notifications from staff when the medication supply is low and then the pharmacy will dispense the remaining amount of medication. PAM #222 verified there was a delay in supply and there were times and dates there was no Oxycodone medication available for Resident #3 in the facility due to the pharmacy not supplying the medications per their protocols. 2. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #43 include staphylococcal arthritis, methicillin resistant staphylococcus aureus(MRSA) infection, internal orthopedic prosthetic device, diabetes type two, coronary artery disease, and chronic kidney failure.Review of Resident #43's MDS comprehensive assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS dated [DATE] revealed Resident #43 was not to be in isolation or quarantine for active infectious disease.Review of Resident #43's physician prescribed medications dated 06/10/26 revealed an order for Cathflo Activase 2 mg to be administered through central line for blockage. On 06/03/26 the physician ordered Resident #43 to receive Vancomycin (antibiotic) 750 mg intravenously one time a day for MRSA infection until 07/01/26. On 06/06/26 the physician ordered Resident #43 to receive Vancomycin 750 mg two times a day for MRSA which was discontinued on 06/13/26. On 06/14/26 Resident #43 was ordered to receive Vancomycin 1000 mg intravenously two times a day for MRSA which was discontinued on 06/30/26. On 07/02/26 Resident #43 was ordered to receive Vancomycin 1000 mg intravenously one time a day for MRSA which was discontinued 07/08/26.Further review of Resident #43's physician orders revealed on 06/08/26 the resident was ordered to receive Hydromorphone (opioid) 4 mg every six hours as needed for pain.Review of the progress note dated 06/10/26 the facility 'ran out of pain medication' notified the pharmacy and was instructed to go to another local pharmacy due to the pharmacy not delivering the medication until the next shipment. Per the note dated 06/10/26 Resident #43's IV access port was clogged, and the nurse was unable to administer medications through the IV line. The nurse received an order for Cathflo (anti-clogging agent) and notified pharmacy to dispense of the medication. Per the note dated 06/12/26 the nurse was able to administer the Cathflo, two days after medication was requested from the pharmacy.Further review of Resident #43's medical records including provider progress notes, progress notes, medication administration record (MAR), and physician orders revealed the resident missed eight doses of IV Vancomycin in 06/2026 and two doses of IV Vancomycin due to the medication not being available from pharmacy. Per the records the resident missed six doses of requested Hydromorphone from 06/15/26 to 06/16/26.Interview on 07/21/26 at 7:45 A.M. with Resident #43 stated his main concern was receiving prescribed medications from the pharmacy. Per Resident #43 the nursing staff have educated him when he is missing his medications due to pharmacy supply. Resident #43 stated in 06/2026 his IV port was clogged and it took days for the nursing staff to get the medication to unclog the port in order for him to receive his IV antibiotic. Resident #43 stated then when he finally was able to re-start his IV antibiotics the medication was administered per physician order due to not being in the facility from pharmacy. Resident #43 stated there were also times he did not receive his requested as needed pain medication due to availability.Interview on 07/21/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #153 during a narcotic count in the medication cart for B-Hall verified there were times in 06/2026 when Resident #43 did not receive his prescribed medications due to pharmacy not delivering the prescriptions in a timely manner.Interview on 07/21/26 with VPN #118 verified the written orders and missing medications for Resident #43 and stated there had been an issue with the resident refusing medications until he received his pain medications, which were not available, and then his IV antibiotics due to not being able to infuse them through the port in 06/2026.Bottom of Form

Based on observation, review of the facility policy, resident interview, and staff interview the facility failed to follow proper protocols for residents in isolation precautions. This affected one resident, Resident #43, out of three residents reviewed for isolation precautions. The current census is 67. Findings include:Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #43 include staphylococcal arthritis, methicillin resistant staphylococcus aureus infection (MRSA), internal orthopedic prosthetic device, diabetes type two, coronary artery disease, and chronic kidney failure.Review of the physician orders for Resident #43 dated 06/06/26 revealed an order for contact isolation for MRSA infection in right hip.Review of Resident #43's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Further review of the MDS dated [DATE] revealed Resident #43 was not to be in isolation or quarantine for active infectious disease.Review of the provider note dated 07/12/26 revealed the Nurse Practioner (NP) documented Resident #43 was receiving intravenous antibiotics due to MRSA infection in the right hip wound.Observation on 07/20/26 at 9:33 A.M. of Resident #43's room revealed no evidence the resident was in isolation. No Personal Protective Equipment (PPE) was noted outside of the resident's room in the hallway or in the resident's room itself.Observation on 07/21/26 at 7:42 A.M. of the outside of Resident #43's room revealed no evidence the resident was to be in any type of isolation protocols.Interview on 07/21/26 at 7:45 A.M. with Resident #43 stated staff wear gloves whenever providing care but rarely do they wear gowns. Resident #43 stated he was unsure what type of isolation he was ordered to be in.Observation on 07/23/26 at 7:10 A.M. of the B-hall where Resident #43 resides revealed there were no PPE carts with any PPE located anywhere near Resident #43's room. Observed in Resident #43's room behind the door was a sign indicating the resident was to be in Enhanced Barrier Precautions. No gowns were observed, no cart with PPE, and the gloves were noted to be on the wall in the bathroom of the resident's room.Interview on 07/23/26 at 7:22 A.M. with Licensed Practical Nurse (LPN) #244 verified there was no signage, no PPE carts, and no gowns for Resident #43. LPN #244 stated she received report the resident was in contact isolation and she has her own supply of gowns she wore while providing care for him. LPN #244 stated the facility protocols were for carts to be in the hallway, signage on the door in the halls, and PPE to be supplied for staff providing care.Interview on 07/23/26 at 8:00 A.M. with Infection Control Preventionist (ICP) #109 revealed all carts had been removed from the B-hall and gowns were placed in each of the residents' room who are in any type of isolation. ICP #109 stated she removed all signage on the outside of the residents' rooms indicating which type of isolation the resident was currently ordered.Review of the facility policy titled, Transmission Based Isolations Precautions revealed all residents with orders to be in isolation will have signage placed outside of the residents' rooms with education on type of PPE to be worn while providing care to the resident. Per the policy PPE will be made available to be donned prior to entry of the residents' rooms to provide care.

Based on observation, medical record review, staff interview, and policy review, the facility failed to complete adequate wound assessments and failed to ensure pressure-reducing interventions were in place as ordered. This affected one (#11) of three residents reviewed for pressure ulcers. The facility census was 58. Findings include: Review of the medical record for Resident #11 revealed admitted [DATE]. The resident was admitted with diagnoses including congestive heart failure, type two diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #11 required required moderate assistance for transfers, maximum assistance for bed mobility, was dependent for toileting hygiene, and required supervision for eating. Resident #11 was assessed at risk for pressure ulcers, but none were observed at the time of the assessment. Review of a progress note by Licensed Practical Nurse (LPN) #108 dated 05/23/24 documented a wound on Resident #11's right great toe. A treatment for antibiotic ointment was initiated and the Director of Nursing was contacted. There were no measurements or further description of the wound documented until it was seen by Wound Physician (WP) #99 on 06/04/24. Record review of Resident #11's May 2024 treatment administration record (TAR) revealed the treatment for triple antibiotic to the right great toe twice daily was completed as ordered. Review of the physician orders revealed an order for bilateral heel boots or float heels on pillows while in bed with a start date of 06/04/24. Review of WP #99's progress note dated 06/04/24 revealed Resident #11's wound was documented a stage three pressure ulcer (full-thickness skin loss) to the right great toe measuring 0.5 centimeters (cm) long by 0.7 cm wide by 0.1 cm deep. Observation on 06/10/24 at 11:04 A.M. of Resident #11 revealed he did not have heel boots on while lying on his low air loss mattress in bed. Observation on 06/10/24 at 12:33 P.M. revealed Occupational Therapy Assistant (OTA) #106 was overheard asking LPN #101 if Resident #11 was supposed to have his heel boots on. LPN #101 answered that if the resident was in bed, he needed them on. OTA #106 stated she would apply them. Observation on 06/10/24 at 12:37 P.M. revealed OTA #106 applied the heel protectors on Resident #11. Interview at the time of observation with OTA #106 revealed the resident's family asked about the heel boots and she verified with his nurse the resident should have them on while in bed. OTA #106 confirmed the resident's heels had not been floated and the heel protectors were not on while the resident was in bed. OTA #106 acknowledged Resident #11 had therapy earlier in the day from around 10:00 A.M. to around 11:00 A.M., and staff had gotten him out of bed, so she was unable to answer if the boots had been present prior to therapy. Interview on 06/10/24 at 5:12 P.M. with the Director of Nursing (DON) acknowledged she was aware of the 05/23/24 progress note regarding the wound to Resident #11's right great toe, but denied she had been informed of the wound by LPN #108. The DON shared she was not made aware of a wound until family had requested it be assessed. The DON verified there was no description or measurements of the right great toe wound and no further assessment was made of the area until 06/04/24. Interview on 06/11/24 at 11:11 A.M. with LPN #108, regarding her 05/23/24 progress note about Resident #11's right toe wound, revealed she believed the area was a crack due to the dryness of his feet, and believed she measured the area in a risk assessment. A second interview with the DON on 06/11/24 at 11:34 A.M. verified there was no measurement in the risk assessment because the wound was identified as a crack. Review of the facility policy titled, Pressure Ulcer Policy, dated 04/29/16, revealed should a pressure area develop the wound would be monitored are least weekly and contain the location and staging, size, drainage, and characteristics, pain if present, and wound bed and surrounding tissue description. Interventions and monitoring would be implemented to promote healing. This deficiency represents non-compliance investigated under Complaint Number OH00154544 and continued non-compliance from the survey exited 05/16/24.

Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to ensure interventions were in place to prevent the development of a pressure ulcer. This resulted in actual harm when Resident #07 acquired a stage four pressure ulcer to his left heel while at the facility. Additionally, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected two (#07 and #51) of three residents reviewed for pressure ulcers. The census was 62. Finding include: 1. Review of Resident #07's medical record revealed an admitted [DATE]. Diagnoses listed included type II diabetes mellitus, congestive heart failure, skin cancer, obesity, major depressive disorder, and stage four pressure ulcer of left heel. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #07 had a stage four pressure ulcer, lower extremity impairment to both sides, and was cognitively intact. Review of the, Braden Scale for Predicting Pressure Sore Risk, dated 12/26/23 revealed Resident #07's score was 13 (moderate risk). Review of a care plan initiated 06/05/23 revealed Resident #07 had the potential for skin breakdown, slow wound healing and pressure ulcer/injury development related to impaired mobility, diabetes, myositis and incontinence of bowel and bladder. No pressure relieving interventions were added until 01/04/24. Review of facility wound assessments revealed an unstageable pressure ulcer measuring 2 centimeters (cm) by (x) 3 cm was discovered to Resident #07's left heel on 01/04/24. Further review of Resident #07's medical record revealed no interventions implemented to relieve pressure to heels or feet prior to 01/04/24. There was no documentation of any refusals of pressure relieving interventions for heels or feet by Resident #07. The only intervention was skin prep (liquid film-forming skin protectant) ordered on 12/20/23 and discontinued on 01/04/24. Review of wound physician progress notes dated 01/09/24 revealed Resident #07 had a stage four pressure ulcer on the left heel measuring 1.5 cm x 1.5 cm x 0.3 cm. The wound bed was covered with 100% slough (dead tissue, usually cream or yellow in color) which was debrided (removed). Review of wound physician progress notes dated 05/14/24 revealed Resident #07 continues to have the stage four pressure ulcer to the left heel. The ulcer now measures 1 cm x 0.6 cm x 0.3 cm with 20% slough and 80% granulation tissue (new tissue developed over a wound bed). Observation of Resident #07's pressure ulcer treatment on 05/14/24 at 3:58 P.M. revealed a pressure ulcer to the posterior heel. The wound was measured by Physician #407 to be 1 cm x 0.6 cm x 0.3 cm. Interview with Physician #407 on 05/14/24 at 4:07 P.M. revealed when Resident #07 was first assessed for the left heel pressure ulcer on 01/09/24, it was a stage four with visible bone. Physician #407 removed eschar on the initial visit on 01/09/24. The left heel pressure ulcer was debrided on multiple visits. Interview with the Director of Nursing (DON), Administrator, and Corporate Registered Nurse (CRN) #361 on 05/15/24 at 2:00 P.M. confirmed there was no documentation of interventions being implemented to prevent Resident #07's left heel stage four pressure ulcer. There was no documentation of Resident #07 refusing pressure ulcer prevention interventions. 2. Review of Resident #51's medical record revealed an admitted [DATE]. Diagnoses listed included malnutrition, type two diabetes mellitus, aphasia, hemiplegia, hemiparesis, pneumonia, and encephalopathy. Review of the admission MDS assessment dated [DATE] revealed Resident #51 was assessed by staff as being severely cognitively impaired and having a stage four pressure ulcer. Review of physician orders revealed an order dated 05/07/24 for sacrum: clean wound with wound cleaner, pat dry, apply Dakins (antiseptic wound solution) moistened gauze, cover with gauze island bordered dressing twice a day. An order for right heel was clean wound with wound cleaner, apply calcium alginate (absorbent wound dressing) to wound bed, cover with bordered gauze dressing, change daily and PRN (as needed). Observation of Resident #51's pressure ulcer treatment on 05/14/24 at 4:15 P.M. revealed Licensed Practical Nurse (LPN) #331 did not cleanse the right heel pressure ulcer or the sacral ulcer after removing old wound dressings and completing new wound treatments. Interview with LPN #331 on 05/14/24 at 4:41 P.M. confirmed she did not cleanse Resident #51's pressure ulcers after removing old dressings and completing new treatments. Review of the facility's policy titled, Pressure Ulcer Policy, dated approved 04/29/16 revealed a resident who enters the facility without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical condition demonstrates they are unavoidable. All residents will be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed. Appropriate preventative interventions will be implemented. (i.e. wheelchair cushion, offloading heels, etc.) All residents will be placed on a pressure reducing mattress. The facility will use a Pressure Risk Assessment to assess each resident's degree of risk for developing a pressure ulcer. A resident with a pressure ulcer will receive interventions and monitoring to promote healing, prevent infection and prevent new ulcers from developing. All residents will be placed on a pressure reducing mattress upon entering the facility, and no photographs of pressure ulcers will be obtained by the facility. A stage IV pressure ulcer was defined as full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. An unstageable pressure ulcer was defined as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black). This deficiency represents non-compliance investigated under Complaint Number OH00153353.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident comprehensive care plans had interventions for psychiatric disorders. This affected one (Resident #18) of two reviewed for care planning. The census was 62. Findings Include: Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses listed included Post-Traumatic Stress Disorder (PTSD), major depressive disorder, anxiety disorder, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact with a diagnoses of PTSD. Interview with Resident #18 on 05/13/24 at 2:33 P.M. revealed she had not had a care conference since admission. Review of Resident #18's comprehensive care plan revealed PTSD was not listed and no interventions were in place. Interview with Corporate Registered Nurse (CRN) #361 on 05/14/24 at 3:50 P.M. confirmed a PTSD diagnosis and interventions were not listed on Resident #18's comprehensive care plan. Review of the facility's policy titled, Comprehensive Care Plan, revised 11/02/16 revealed the facility will develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on review of contract with dialysis center, review of facility policy, observation of care, interview with resident, and interview with staff, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented. This affected two (Residents #51 and #52) of three residents reviewed for EBP. The current census is 62. Findings include: 1. Review of the medical record for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #52 included peritonitis, diabetes type two, chronic kidney disease, dependence on peritoneal dialysis, and hypotension. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had no brief interview for mental status coded as no interview due to resident never understood. Per the assessment the resident was receiving peritoneal dialysis. Review of Resident #52's care plan dated 01/20/24 revealed a focus for receiving Peritoneal (PD) dialysis services through Fresenius. Interventions included encourage resident to attend appointments, monitor labs and report to physician, and monitor and report any signs or symptoms of infections to access site, redness, swelling, warmth or drainage. Review of Resident #52's physician orders dated 04/16/24 revealed an order for cycler starting 04/16/24, three bags of yellow 1.5% 6000 milliters (ml). Per the order dated 03/09/24 at 4:00 P.M. use one bag of 2500 ml 1.5% yellow one time a day. Interview on 05/13/24 at 10:30 A.M. with Resident #52 revealed the resident stated he was concerned regarding infections due to recent admissions to the hospital. Resident #52 stated some nursing staff do not follow the precautions, such as wearing gowns, while performing care. Observation on 05/14/24 at 7:30 A.M. with Licensed Practical Nurse (LPN) #276 ending the PD cycle for Resident #52's night time PD revealed the nurse did not put on a gown upon entry to the resident's room. LPN #276 was observed disconnecting Resident #52 from the PD cycler and applying a new cap to the catheter. LPN #276 was observed checking all connections and explaining each step of the procedure during care. EBP sign was visibly hanging above the head of the bed. LPN #276 verified Resident #52 was in EBP isolation due to the PD procedure and verified she did not put on a gown for the care being provided. Interview on 05/14/24 at 7:55 A.M. with Resident #52 revealed the resident stated he has not witnessed any staff wearing a gown during his PD procedures and stated he understood the reasoning behind the EBP isolation procedures. Review of the facility policy titled, 'Dialysis Care Policy,' dated 04/04/18, revealed the facility will provide the dialysis treatments using the appropriate infection control practices. Review of the contract for the dialysis center with the facility dated 05/15/19 revealed the facility is responsible to follow infection control practices consistent with the infection control policies and practices. 36303 2. Review of Resident #51's medical record revealed an admitted [DATE]. Diagnoses included malnutrition, type two diabetes mellitus, aphasia, hemiplegia, hemiparesis, pneumonia, and encephalopathy. Review of an admission MDS assessment dated [DATE] revealed Resident #51 was assessed by staff as being severely cognitively impaired and having a stage four pressure ulcer. Resident #51 had a feeding tube. Observation on 05/14/24 at 4:15 P.M. revealed a sign was posted above the head of Resident #51's bed informing staff that Resident #51 was in EBP. Observation on 05/14/24 at 4:29 P.M. revealed State tested Nursing Assistant (STNA) #317 entered the room to assist LPN #331 with Resident #51's wound care, incontinence care, and repositioning. STNA #317 put on gloves but did not put on a gown. STNA #317 then assisted with turning and repositioning Resident #51 while LPN #331 provided wound and incontinence care. Interview with LPN #331 on 05/14/24 at 4:41 P.M. confirmed Resident #51 was in EBP due to pressure ulcer and a feeding tube. LPN #331 confirmed STNA #317 did not put on a gown when assisting with the care of Resident #51. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022 revealed an impervious gown should be worn when high-contact resident care activities are being performed. High contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing Attends (incontinence briefs) or assisting with toileting, device care or use:, central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing.

Based on observations, record review, staff interviews, and policy review, the facility failed to ensure Resident #210's catheter bag was covered to promote dignity. This affected one (Resident #210) of one residents reviewed for dignity. The facility census was 62. Findings include: Review of Resident #210's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #210's physician's orders revealed an order dated 05/13/24 to use privacy bag for catheter bag every shift. Observation on 05/13/24 at 9:50 A.M. revealed Resident #210's Foley catheter bag, with urine present, hanging on the bed side dresser visible from the hallway. There was no privacy bag present. Observation on 05/14/24 at 9:40 A.M. revealed Resident #210 resting in bed with the Foley catheter bag, with urine present, hanging on bedframe on the right side of bed without a Foley privacy bag, visible from hallway. Observation on 05/15/24 at 11:38 A.M. revealed Resident #210 in therapy department for therapy services without a Foley catheter privacy bag, urine was present in Foley catheter bag. Interview on 05/15/24 at 11:38 A.M. with Certified Occupational Therapy Assistant (COTA) #408 confirmed Resident #210 was in the therapy department for therapy services without a Foley privacy bag with urine present. Interview on 05/15/24 at 11:46 A.M. with State tested Nursing Assistant (STNA) #275 confirmed Resident #210's Foley catheter bag with urine present was visible from the hallway and has not had a privacy bag all day. STNA #275 was not aware of where the privacy covers are. Review of the Quality of Life Policy dated 04/15/13 revealed, The Manor will care for the residents in a manner and in an environment that promotes maintenance or enhancement of each residents quality of life.

Based on medical record review and staff interview, the facility failed to hold care conferences with residents. This affected (Residents #07 and #18) of two residents reviewed for care conferences. Additionally, the facility also failed to implement fall interventions and update the care plan after falls. This affected one (Resident #209) of three reviewed for falls care planning. The census was 62. Findings Include: 1. Review of Resident #07's medical record revealed an admitted [DATE]. Diagnoses listed included type II diabetes mellitus, congestive heart failure, skin cancer, obesity, major depressive disorder, and stage four pressure ulcer of left heel. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had a stage four pressure ulcer, lower extremity impairment to both sides, and was cognitively intact. Interview with Resident #07 on 05/14/24 at 8:28 A.M. revealed he had not had any recent care conferences. Further review of Resident #07's medical record revealed a care conference was last held on 11/06/23. 2. Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses listed included Post-Traumatic Stress Disorder (PTSD), major depressive disorder, anxiety disorder, and type two diabetes mellitus. Review of the admission MDS dated [DATE] revealed Resident #18 was cognitively intact. Interview with Resident #18 on 05/13/24 at 2:33 P.M. revealed she had not had a care conference since admission. Further review of Resident #18's medical record revealed no documentation of a care conference being held with Resident #18. Interview with Corporate Registered Nurse (CRN) #361 on 05/14/24 at 2:50 P.M. revealed care conferences were not held with Resident #07 since November 2023. CRN #361 confirmed a care conference had not been held with Resident #18. 48570 3. Review of Resident #209's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation and unspecified dementia, unspecified severity, with psychotic disturbance. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #209 was cognitively intact. Resident #209 required assistance with showers, dressing, bed mobility, transfers, and ambulating. Review of Resident #209's physician orders revealed an order dated 04/27/24 for a high low bed every shift for fall risk. Review of the progress note dated 04/28/24 at 3:04 P.M. revealed Resident #209 yelling out for help. The resident was found lying on the floor between the wall and his bed. Resident #209 stated he was trying to pull the covers back on his bed and lost his balance. The resident was reminded to use call light for assistance with ambulation and transfers. Further review of the progress note dated 05/12/24 at 5:47 A.M. revealed Resident #209 found on floor in the bathroom. Resident #209 stated he was getting dizzy after pulling up pants. The resident was found between the toilet and wall. The resident's call light was pinned onto pants and he was educated to use call light when getting up or have any need or assistance. Review of Resident #209's care plan revealed the facility did not update the resident's care plan with interventions after the falls on 04/28/24 and 05/12/24. Interview on 05/16/24 at 9:01 A.M. with the Director of Nursing (DON) confirmed Resident #209 fell on [DATE] at 3:04 P.M. and on 05/12/24 at 5:47 A.M. and the facility failed to update the care plan with interventions.

Based on medical record review, staff interview, review of the American Journal of Nursing website, and policy review, the facility failed to fully assess a resident after a fall, prior to the resident having been moved. This affected one (#10) out of three residents reviewed for falls. The facility census was 54. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Resident #10's medical diagnoses included but were not limited to chronic obstructive pulmonary disease, peripheral vascular disease, and pulmonary hypertension. Resident #10 was discharged to the hospital on 02/18/23. Review of Resident #10's admission Minimum Data Set (MDS) assessment, dated 02/17/23, revealed Resident #10 had intact cognition. Resident #10 required extensive one person assistance for bed mobility, transfers, and toileting. Resident #10 had one fall with major injury since admission to the facility. Review of Reident #10's care plan for risk of falls revealed it was initiated on 02/10/23 with interventions of a safe environment with even floors, free from spills and clutter, glare free light and a working and reachable call light. Review of Resident #10's progress note, dated 02/17/23, revealed Licensed Practical Nurse (LPN) #18 was called to Resident #10's room by State tested Nursing Assistant (STNA) #17. The documentation revealed STNA #17 was standing beside Resident #10 when Resident #10 got lightheaded, fainted, and fell hitting her bottom on the floor. Review of Resident #10's hospital results for the computed tomography (CT) scan of the lumbar spince without contrast, dated 02/18/23, revealed Resident #10 was found to have a acute compression fracture of the L2 (vertebra) and acute bilateral ala sacral fractures. Interview on 03/15/23 at 12:51 P.M. with STNA #17 revealed she had assisted Resident #10 to the bedside commode, which was right beside her bed. Resident #10 stood up, and STNA #17 went to pull the bedside commode away from Resident #10 in order to assist Resident #10 with getting back to bed. Resident #10 became dizzy and fainted. STNA #17 stated she was able to catch Resident #10, but not before Resident #10's bottom hit the floor. STNA #17 verified she had a hold of the top portion of Resident #10 and Resident #10 did not hit her head. STNA #17 stated she then went to the hall and yelled to alert the nurse to come to the room. LPN #18 came to the room and STNA #17 stated LPN #18 told her to put Resident #10 into the bed while she got supplies for an assessment. STNA #17 verified she moved Resident #10 prior to Resident #10 being assessed by the nurse. Interview on 03/15/23 at 2:06 P.M. with LPN #18 revealed STNA #17 stepped into the hall and alerted her Resident #10 had fallen. LPN #18 stated she got her assessment supplies and when she entered the room, STNA #17 was in the process of standing Resident #10. LPN #18 then assisted STNA #17 with the transfer. LPN #18 then assessed Resident #10 whose only complaint was pelvic pain. LPN #18 verified Resident #10 was transfered from the floor prior to LPN #18 assessing Resident #10. Interview with the Director of Nursing (DON) on 03/15/23 at 2:27 P.M., revealed the facility policy didn't specify whether or not to move a resident prior to having been assessed after a fall but the DON indicated it would be the expectation for staff to not move a resident after a fall prior to them having been assessed. Review of the American Journal of Nursing web page titled When a Fall Occurs, located at https://journals.lww.com/ajnonline/Citation/2007/11000/When_a_Fall_Occurs__Four_steps_to_take_in_response.30.aspx#:~:text=Before%20moving%20the%20patient%2C%20ask,Check%20the%20cranial%20nerve, revealed staff should not assume there has been no injury. Before moving the resident, ask the resident what caused the fall and assess any associated symptoms. Then, staff should conduct a comprehensive assessment. Review of the facility policy titled accidents and incidents policy, last revised 04/2016, revealed a licensed professional nurse shall examine all victims for any physical injuries.

Based on resident record review and staff interview; the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected four (#18, #22, #41, and #45) of 14 residents reviewed for accuracy of the MDS assessment. The census was 44. Findings include: 1. Review of the medical record of Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessments dated 06/10/22 and 07/15/22 revealed no brief interview of mental status (BIMS) nor mood assessment being completed as required. Interview on 09/01/22 at 8:57 A.M. with Director of Clinical Support #174 provided verification of the MDS assessment incompleteness. 2. Review of Medical Record for Resident #22 admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS dated [DATE] revealed no BIMS or mood assessment being completed. Interview on 09/01/22 at 8:57 A.M. with Director of Clinical Support #174 provided verification of the MDS assessment incompleteness. 3. Review of Medical Record for Resident #41 admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] for Resident #41 revealed resident was coded for no unhealed pressure ulcers. Records indicated resident had a stage four pressure ulcer to sacral area. Interview on 08/31/22 at 10:12 A.M. with RN #166 verified the MDS was incorrect for Resident #41. MDS #166 verified Resident #41 had a stage four pressure wound. 4. Review of the medical record for Resident #45 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress notes dated 07/17/22 at 4:41 P.M. revealed Resident #45 was transferred to the hospital for a change of condition. Review of a discharge return not anticipated MDS assessment target date 07/17/22, revealed Resident #45 had an unplanned discharged to community. Interview on 08/30/22 at 2:59 P.M. with RN #166 verified the discharge MDS dated [DATE] for Resident #45 was not accurate. The RN verified the resident was not discharged to the community.

Based on medical record review, observations and staff interview, the facility failed to maintain a safe environment when medications were left unattended by staff. This directly affected one resident (#31) and had the possibility to affect seven residents (#2, #3, #13, #34, #36, #39, and #43) identified by the facility as being independently mobile and cognitively impaired, residing in the D hall. The facility census was 44. Findings include: Review of the medical record of Resident #31 revealed an admitted [DATE]. Diagnoses include [CONDITION(S)] of native coronary artery with other forms of [CONDITION(S)] pectoris, chronic [CONDITION(S)], hypertensive [CONDITION(S)] with heart failure, acute embolism and [CONDITION(S)] of unspecified deep veins of unspecified lower extremity, presence of cardiac pacemaker, history of alcohol dependence, uninhibited neuropathic bladder, gastro-[CONDITION(S)] reflux disease, [CONDITION(S)] with lower urinary tract symptoms, feeling of incomplete bladder emptying, and presence of urogenital implants. Review of the quarterly minimum data set assessment dated [DATE] revealed he had moderate cognition deficit and required supervision with set-up help only with eating. Observation on 08/29/22 at 10:41 A.M. revealed a small plastic cup with seven medication tablets and or caplets, sitting on the bed of Resident #31. He stated I will take those when I get my Ensure. An interview with Registered Nurse (RN) #178 verified the caplets and tablets were left at his bedside and included aspirin 81 milligrams (mg), [MEDICATION(S)] one mg, omeprazole 10 mg, [MEDICATION(S)] 75 mg, [MEDICATION(S)] 100 mg caplet, [MEDICATION(S)] 25 mg, and [MEDICATION(S)] five mg. RN #178 then proceeded to begin to exit the room, leaving the medications and the surveyor further asked about the medications being left at the bedside. Resident #31 stated yesterday they gave me a Boost to take these with. RN #178 took the medications to the cart and obtained a boost drink and returned and Resident #31 took the medications without difficulty. The facility identified seven residents (#2, #3, #13, #34, #36, #39, and #43) who are independently mobile and cognitively impaired, that reside on the D hall and that could potentially access the unattended/unsecured medications.

Based on observation, resident interview, and staff interview, the facility failed to serve meals in the dining room due to staffing issues. This potentially affected 40 residents (with exception of Residents #3, #13, #18, and #40 who preferred to eat in their rooms) who receive meals from the kitchen. The census was 44. Findings include: Observation of dining on 08/29/22 at 7:30 A.M. revealed no residents were eating in the dining room. Interview on 08/29/22 at 7:30 A.M. with State tested Nursing Assistant/Medical Records (STNA #134) who was working as a cook stated all meal trays were being served on the nursing floors. STNA #134 stated that no residents were eating in the dining room due to being short staffed. Interview on 08/29/22 at 3:46 P.M. with Administrator stated they were not sure why residents were not eating in the dining room. Administrator stated they would find out what the protocol for the facility was. Interview on 08/31/22 at 11:24 A.M. with Dietary Aide #139 stated they were told that there was not enough staff to assist residents with eating in the dining room. Interview on 08/31/22 at 11:40 A.M. with Resident #39 stated they did not like eating in their room and preferred to eat in the dining room. Resident #39 stated the facility closed the dining room a while ago due to COVID and never re opened it. Interview on 08/31/22 at 11:42 A.M. with Resident #36 stated they liked to eat in the dining room and socialize with other residents. Interview on 08/31/22 at 11:45 A.M. with Residents (#28 and #4) indicated they used to go the dining room for meals and preferred eating in the dining room. Interview on 08/31/22 at 1:51 P.M. with Dietary Tech #145 stated the dining room was closed due to staffing. Observations throughout the survey revealed no residents eating in the dining room. Review of policy titled Meal Service, Meal Delivery Service revised 01/01/18 revealed facility would serve food to residents in dining room and room trays using meal tickets by the Nutrition Services Personnel. Nutrition Services Assistant would deliver meals by cart and room tray list would be provided to Nutrition Services prior to meal service. All residents were encouraged to eat their meals in the dining room and if a resident remained in their room, nursing was to give Nutrition Services a room service list 30 minutes prior to the start of meal service.

Based on interview, and record review the facility failed to ensure treatments were completed as ordered. This affected one (Resident #41) of two residents reviewed for wounds. The census was 44. Findings include: Review of Medical Record for Resident #41 admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] for Resident #41 revealed resident is cognitively intact. Resident #41 required extensive assist of two for Activities of Daily Living (ADL's) and had a catheter and [CONDITION(S)]. MDS indicated Resident #41 did not have any unhealed pressure ulcers. Review of pharmacy delivery sheet revealed Acetic Acid 0.25 percent (%) solution (1000 milliliters) was delivered on 07/09/22, 07/23/22, 08/02/22, and 08/23/22. Review of Skin/Wound note dated 07/25/22 at 7:08 A.M. for Resident #41 revealed dressing changed to coccyx/sacral area. Previous dressing had red/tan and green drainage. Dressing was soaked with blood. Wound bed was beefy red in color with slight macerations to surrounding areas. Skin around wound was red and bleeding. Wound was cleansed with normal saline and wet to dry dressing soaked in normal saline due to being out of regular solution. Wound was covered with three abdominal pads, covered with a blue brief, and secured with tape. Review of Skin/Wound note dated 08/19/22 at 2:51 A.M. for Resident #41 revealed dressing changed to coccyx/sacral area. Previous dressing had red/tan and green drainage. Dressing was soaked with blood. Wound bed was beefy red in color with slight macerations to surrounding areas. Wound had a strong odor. Skin around wound was red and bleeding. Wound was cleansed with normal saline and wet to dry dressing soaked in normal saline due to being out of regular solution. Wound was covered with three abdominal pads, covered with a blue brief and secured with tape. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 7:00 P.M. shift. Interview on 08/31/22 at 3:44 P.M. with Clinical Educational Specialist (CES #179) verified treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . CES #179 verified that treatment was not completed per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of August 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff to pack wound with wet to dry kerlix and cover with abdominal pads, dry dressings and secured with [MEDICATION(S)] tape.

Based on observation and staff interview, the facility failed to post daily nurse staffing information. This affected 44 residents who reside in the facility. The census was 44. Findings include: Observation on 08/30/22 at 7:28 A.M. of daily staffing tool at entryway revealed a date of 08/23/22. Interview on 08/30/22 at 7:30 A.M. with Corporate Director of Clinical Services (CODC) #174 verified staffing tool was dated 08/23/22.

Based on medical record review, facility investigation review, witness statement review, policy reviews, employee file review, staff and resident interviews, the facility failed to ensure a resident was free from mental and verbal abuse, when a staff member verbally threaten a resident for the continual use of call light. This affected one (#2) of three residents reviewed for abuse. The facility identified four allegations of abuse in the past 60 days. The facility census was 50. Findings include: Review of the medical record for the Resident #2 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed the resident had no cognitive deficits but did have other behavioral symptoms not directed towards others for four to six days. The resident required extensive assistance with all activities of daily living except for limited assistance with eating. An indwelling catheter and an ostomy were present. The resident had frequent pain and no falls. Review of progress notes dated 01/30/22 through 02/01/22 revealed no concerns regarding the use of a call light. Review of a written investigation by the Director of Nursing (DON) regarding the allegations of physical abuse to Resident #2, dated 02/01/22, revealed Temporary Nurse Aide (TNA) #22 informed DON, Licensed Practical Nurse (LPN) #26 had made physical threats to Resident #2 on the night of 01/30/22 going into 01/31/22. The investigation revealed the DON interviewed Resident #2 on 02/01/22 at 2:34 P.M. Resident #2 stated she was comfortable with LPN #26 but stated the nurse that night told her she was using her call light too much, and further told her she would take my call light away. Review of a facility investigation interview dated 02/01/22 with TNA #22, completed by the Administrator, revealed during the second hour of rounds, Resident #2 put her call light on. TNA #22 stated LPN #26 stated if Resident #2 put the call light on one more time, LPN #26 was going to break the resident's fingers and TNA #22 thought the nurse was joking and told the nurse TNA #22 was not going to tell the resident that. LPN #26 got up and went toward the resident's room and TNA #22 followed her. TNA #22 informed the Administrator LPN #26 told Resident #2, if she continued to use the call light she was going to break the resident's fingers, then told TNA #22, she had told the resident and she was not going to deal with her putting her call light on like the other night. TNA #22 further told the Administrator when she made her next rounds, the resident's call light was on the floor and Resident #2 told her it was because she did not want to be tempted to use it. Review of an undated statement documented by Social Service Director (SSD) #20 (after SSD #20 had interviewed Resident #2) revealed staff did get upset with her, when she used her call light too much but denied anyone had threatened her regarding the use of her call light. She stated the resident did tell her the staff told her to quit using her call light so much, but she used it because she had pain. She denied anyone had threatened to break her fingers. When asked about the resident throwing her call light on the floor because she was scared to use it, the resident informed the SSD #20, she did not throw it on the floor but did throw it in a chair because she did not want to make the staff mad. The report further stated LPN #26 and the blonde State tested Nurse Aide (TNA) who wore her hair in a bun (identified by the facility as TNA #22) both told her that night they were done with her and not to pull the call light again, so I threw it on my chair so I did not make them mad. The facility's investigation further revealed LPN #24 had been interviewed and stated Resident #2 had been on her call light a lot that night and had wanted pain medication. She stated LPN #26 stated she had already medicated her and she could not keep putting her call light on. Review of LPN #26's employee file revealed an Employee Disciplinary Record dated 02/03/22, indicating LPN #26 was provided disciplinary action due to conducting herself improperly. Review of TNA #22 employee file revealed an Employee Conference dated 02/03/22 stating TNA #22 was provided education on requirements for reporting suspected abuse, neglect, as well as privacy, confidentiality and protocols during and beyond investigations and re-educated on proper communications with staff and residents. It further revealed the employee had just been hired on 01/13/22. Interview with Resident #2 on 02/22/22 at 8:40 A.M., revealed staff told her she used her call light too much. She stated one night she did have an issue with LPN #26 and TNA #22. The staff told her they were upset, she had put her call light too much. She stated LPN #26 threatened to take her call light away if she used it again, so the resident stated she threw her call light on the chair, so she would not be tempted to use it. She stated she was not scared of LPN #26, but it did make her feel bad and embarrassed her. Interview with LPN #26 on 02/22/22 at 10:14 A.M., revealed she and Resident #2 had a good relationship and liked to joke around. She stated on the night in question, the resident had been on her call light several times. LPN #26 stated she did not remember if she told the resident she was going to take away the call light, and she may have. LPN #26 denied making a statement threatening to break the resident's fingers, but if it ever came up in conversation, it was joking and the resident would joke with her about it. She stated one night the resident had turned while they were working with her and placed her fingers where the rail would have hurt the fingers if they moved the rail, so she asked the resident to move her fingers so they were not broken She stated at that time the resident sated to her, if fingers were going to be broken, to make it on her left side which was already paralyzed. LPN #26 stated the resident brought it up jokingly since that point, but she had never wanted to hurt the resident. LPN #26 again stated she did not remember if she told the resident she would take away the call light if she used it again, but if the resident said she did, she could have. Interview with LPN #24 on 02/22/22 at 11:00 A.M,. revealed she was on duty the night of the allegation of abuse. She stated Resident #2 had been on her call light a lot that night. She stated she did not hear anything regarding LPN #26 threatening to break the resident's fingers or take her call light away. Interview with the Administrator on 02/22/22 at 10:30 A.M., revealed the Administrator had received the allegation of potential abuse to Resident #2 on 02/01/22 from the Director of Nursing and immediately started an investigation. She stated they spoke with the staff on duty (LPN #24, LPN #26 and TNA #22) on that hall as well as the resident. She stated Resident #2 denied any physical threats had been made and the resident was not afraid of LPN #26 so they decided there had not been abuse, so there was no report made of it. She stated the facility did investigate the allegations and did provide disciplinary action to LPN #26 regarding her. She further stated she had not felt there had been verbal or emotional abuse but did verify the investigation had revealed the resident did tell the DON the nurse threatened to take her call light away. Review of policy titled Abuse, Neglect and/or Misappropriation of Resident Property Policy dated 04/22/21 revealed the facility would not tolerate abuse or neglect of its residents. It was the facility's policy to investigate all allegations involving abuse, neglect or misappropriation of resident property and to report known or suspected abuse, neglect or misappropriation of resident property in accordance with the law. Any employee who suspected a resident had been abused were to report the suspicion to the facility. If the Administrator determined or suspected abuse had occurred, the Administrator was required to notify the Department of Health. The policy further revealed only physical abuse, sexual abuse, neglect or misappropriation needed to be reported and allegations of injuries of unknown origin or verbal abuse did not need to be reported to the Ohio Department of Health. If the conclusion of the report was abuse, neglect or misappropriation was not substantiated or suspected, it was not required to be reported to the Ohio Department of Health This deficiency substantiated Complaint Number OH 092.

Based on medical record review, facility investigation review, review of witness statements, review of facility policy and staff interviews, the facility failed to implement the abuse policy on reporting of alleged abuse. This affected one (#2) of three residents reviewed for abuse. The facility identified four allegations of abuse in the past 60 days. The facility census was 50. Findings include: Review of the medical record for the Resident #2 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had no cognitive deficits but did have other behavioral symptoms not directed towards others for four to six days. The resident required extensive assistance with all activities of daily living except for limited assistance with eating. An indwelling catheter and an ostomy were present. The resident had frequent pain and no falls. Review of progress notes dated 01/30/22 through 02/01/22 revealed no concerns regarding the use of a call light. Review of a facility interview dated 02/01/22 with Temporary Nurse Aide (TNA) #22 by the Administrator revealed during the second hour of rounds, Resident #2 put her call light on. TNA #22 stated she observed Licensed Practical Nurse (LPN) #26 state if the resident put it on one more time, she was going to break the resident's fingers and she thought the nurse was joking and told the nurse she was not going to tell the resident that, so the nurse got up and went toward the resident's room and TNA #22 followed her. TNA #22 informed the Administrator, LPN #26 told the resident if she continued to use the call light she was going to break the resident's fingers, then told the TNA #22, she had told the resident and she was not going to deal with her putting her call light on like the other night. TNA #22 further told the Administrator when she made her next rounds, the resident call light was on the floor and the resident told her it was because she did not want to be tempted to use it. Review of a written investigation by the Director of Nursing regarding the allegations of physical abuse to Resident #2, dated 02/01/22, revealed TNA #22 informed her LPN #26 had made physical threats to the resident on the night of 01/30/22 going into 01/31/22. It revealed the DON interviewed Resident #2 on 02/01/22 at 2:34 P.M. and the resident was comfortable with LPN #26 but stated the nurse that night told her she was using her call light too much, and further told her she would take my call light away. Review of a statement from Social Service Director (SSD) #20 after SSD #20 had interviewed the resident, which revealed staff did get upset with her when she used her call light too much but denied anyone had threatened her regarding the use of her call light. She stated the resident did tell her the staff told her to quit using her call light so much, but she used it because she had pain. She denied anyone had threatened to break her fingers. When asked about the resident throwing her call light on the floor because she was scared to use it, the resident informed the SSD she did not throw it on the floor but did throw it in a chair because she did not want to make the staff mad. The report further stated LPN #26 and the blonde TNA who wore her hair in a bun (identified by the facility as TNA #22) both told her that night they were done with her and not to pull the call light again, so I threw it on my chair so I did not make them mad. Interview with the Administrator on 02/22/22 at 10:30 A.M., revealed she had received the allegation of potential abuse to Resident #2 on 02/01/22 from the Director of Nursing and immediately started an investigation. She stated they spoke with the staff on duty (LPN #24, LPN #26 and TNA #22) on that hall as well as the resident. She stated Resident #2 denied any physical threats had been made and the resident was not afraid of LPN #26 so they decided there had not been abuse, so there was no report made of it. She stated the facility policy did reveal allegations of abuse were to be reported to the Ohio Department of Health. She further stated she had not felt there had been verbal or emotional abuse but did verify the investigation had revealed the resident did tell the DON the nurse threatened to take her call light away. Review of facility policy Risk Occurrence Immediate Notification Policy dated 05/09/17 revealed all risk occurrences were to be reported to the Administrator/Director of Nursing (DON) within 24 hours of the incident, or immediately, if the situation warrants. A reportable occurrence included the involvement of any one or combination of residents, employees volunteers, agency personnel, visitors, relatives, vendors, independent contractor or sub-contractors. Occurrences to be reported included incidents of unknown origin, unexpected or unusual death, misappropriation of resident property, stage three of higher pressure ulcers, unexplained loss of 15 percent of body weight, improper medication administration, accident or injury involving a non-resident, resident elopement, complaints, concerns, accusations or demands suggesting improper treatment or negligence, significant injuries requiring medical treatment outside the facility, medical record request or contact by media, police or governmental investigation. Mental abuse included but was not limited to humiliation, harassment and threats of punishment or deprivation. Review of facility policy Abuse, Neglect and/or Misappropriation of Resident Property Policy dated 04/22/21 revealed the facility would not tolerate abuse or neglect of its residents. It was the facility's policy to investigate all allegations involving abuse, neglect or misappropriation of resident property and to report known or suspected abuse, neglect or misappropriation of resident property in accordance with the law. Any employee who suspected a resident had been abused were to report the suspicion to the facility. If the Administrator determined or suspected abuse had occurred, the Administrator was required to notify the Department of Health. The policy further revealed only physical abuse, sexual abuse, neglect or misappropriation needed to be reported and allegations of injuries of unknown origin or verbal abuse did not need to be reported to the Ohio Department of Health. If the conclusion of the report was abuse, neglect or misappropriation was not substantiated or suspected, it was not required to be reported to the Ohio Department of Health. This deficiency substantiated Complaint Number OH 092.

Based on medical record review, facility investigation review, review of witness statements, review of facility policies, staff and resident interviews, the facility failed to report an allegation of abuse to the state agency. This affected one (#2) of three residents reviewed for abuse. The facility identified four allegations of abuse in the past 60 days. The facility census was 50. Findings include: Review of the medical record for the Resident #2 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had no cognitive deficits but did have other behavioral symptoms not directed towards others for four to six days. The resident required extensive assistance with all activities of daily living except for limited assistance with eating. An indwelling catheter and an ostomy were present. The resident had frequent pain and no falls. Review of progress notes dated 01/30/22 through 02/01/22 revealed no concerns regarding the use of a call light. Review of a facility interview dated 02/01/22 with Temporary Nurse Aide (TNA) #22 by the Administrator revealed during the second hour of rounds, Resident #2 put her call light on. TNA #22 stated she observed Licensed Practical Nurse (LPN) #26 stated if the resident put it on one more time, she was going to break the resident's fingers and she thought the nurse was joking and told the nurse she was not going to tell the resident that, so the nurse got up and went toward the resident's room and TNA #22 followed her. TNA #22 informed the Administrator, LPN #26 told the resident if she continued to use the call light she was going to break the resident's fingers, then told the TNA #22, she had told the resident and she was not going to deal with her putting her call light on like the other night. TNA #22 further told the Administrator when she made her next rounds, the resident call light was on the floor and the resident told her it was because she did not want to be tempted to use it. Review of a written investigation by the Director of Nursing regarding the allegations of physical abuse to Resident #2, dated 02/01/22, revealed TNA #22 informed her LPN #26 had made physical threats to the resident on the night of 01/30/22 going into 01/31/22. It revealed the DON interviewed Resident #2 on 02/01/22 at 2:34 P.M. and the resident was comfortable with LPN #26 but stated the nurse that night told her she was using her call light too much, and further told her she would take my call light away. Review of a statement from Social Service Director (SSD) #20 after SSD #20 had interviewed the resident, which revealed staff did get upset with her when she used her call light too much but denied anyone had threatened her regarding the use of her call light. She stated the resident did tell her the staff told her to quit using her call light so much, but she used it because she had pain. She denied anyone had threatened to break her fingers. When asked about the resident throwing her call light on the floor because she was scared to use it, the resident informed the SSD she did not throw it on the floor but did throw it in a chair because she did not want to make the staff mad. The report further stated LPN #26 and the blonde TNA who wore her hair in a bun (identified by the facility as TNA #22) both told her that night they were done with her and not to pull the call light again, so I threw it on my chair so I did not make them mad. Interview with Resident #2 on 02/22/22 at 8:40 A.M., revealed staff told her she used her call light too much. She stated one night she did have an issue with Licensed Practical Nurse (LPN) # 26 and TNA #22. Who told her they were upset she had put her call light too much. She stated LPN #26 threatened to take her call light away if she used it again, so the resident stated she threw her call light on the chair so she would not be tempted to use it. She stated she was not scared of LPN #26 but it did make her feel bad and embarrassed her. When asked about the resident throwing her call light on the floor because she was scared to use it, the resident informed the SSD she did not throw it on the floor but did throw it in a chair because she did not want to make the staff mad. The report further stated LPN #26 and the blonde TNA who wore her hair in a bun ( identified by the facility as TNA #22) both told her that night they were done with her and not to pull the call light again, so I threw it on my chair so I did not make them mad. Interview with the Administrator on 02/22/22 at 10:30 A.M., revealed she had received the allegation of potential abuse to Resident #2 on 02/01/22 from the Director of Nursing and immediately started an investigation. She stated they spoke with the staff on duty (LPN #24, LPN #26 and TNA #22) on that hall as well as the resident. She stated Resident #2 denied any physical threats had been made and the resident was not afraid of LPN #26 so they decided there had not been abuse, so there was no report made of it. She stated the facility policy did reveal allegations of abuse were to be reported to the Ohio Department of Health. She stated the facility did investigate the allegations and did provide disciplinary action to LPN #26 regarding her. She further stated she had not felt there had been verbal or emotional abuse but did verify the investigation had revealed the resident did tell the DON the nurse threatened to take her call light away. Review of facility policy Risk Occurrence Immediate Notification Policy dated 05/09/17 revealed all risk occurrences were to be reported to the Administrator/Director of Nursing (DON) within 24 hours of the incident, or immediately, if the situation warrants. A reportable occurrence included the involvement of any one or combination of residents, employees volunteers, agency personnel, visitors, relatives, vendors, independent contractor or sub-contractors. Occurrences to be reported included incidents of unknown origin, unexpected or unusual death, misappropriation of resident property, stage three of higher pressure ulcers, unexplained loss of 15 percent of body weight, improper medication administration, accident or injury involving a non-resident, resident elopement, complaints, concerns, accusations or demands suggesting improper treatment or negligence, significant injuries requiring medical treatment outside the facility, medical record request or contact by media, police or governmental investigation. Mental abuse included but was not limited to humiliation, harassment and threats of punishment or deprivation. Review of facility policy Abuse, Neglect and/or Misappropriation of Resident Property Policy dated 04/22/21 revealed the facility would not tolerate abuse or neglect of its residents. It was the facility's policy to investigate all allegations involving abuse, neglect or misappropriation of resident property and to report known or suspected abuse, neglect or misappropriation of resident property in accordance with the law. Any employee who suspected a resident had been abused were to report the suspicion to the facility. If the Administrator determined or suspected abuse had occurred, the Administrator was required to notify the Department of Health. The policy further revealed only physical abuse, sexual abuse, neglect or misappropriation needed to be reported and allegations of injuries of unknown origin or verbal abuse did not need to be reported to the Ohio Department of Health. If the conclusion of the report was abuse, neglect or misappropriation was not substantiated or suspected, it was not required to be reported to the Ohio Department of Health. This deficiency substantiated Complaint Number OH 092.

Based on record review, observation, review of the facility's policy, staff interview, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to implement proper infection control practices including proper hand hygiene and not changing and/or disinfecting personal protective equipment (PPE) in between resident rooms to prevent the spread of COVID-19. This affected three (Resident #4, #5 and #6) of three residents reviewed for infection control. This had the potential to affect six residents (Resident #4,#5, #6, #8, #9 and #10) that resided on the B hall. The facility census was 71. Finding include: Review of the facility's list of residents revealed Resident #4, #5, #6, #8, #9 and #10 resided on the B hall. The orange and green zone rooms were not separated on the B hall. Resident #4, #5 and #6's rooms were noted to be in the facility's orange zone and marked as droplet precautions. It stated Resident #4, #5 and #6 were in quarantine status related to going out of the facility for multiple appointments. Resident #8, #9 and #10's rooms were noted to be in the facility's green zone. It explained Resident #8, #9 and #10 were not in quarantine or isolation status. Observation and interview on 03/12/21 at 11:40 A.M. in B hall, an orange zone, revealed Registered Nurse (RN) #210 was observed exiting Resident #5's room, a droplet isolation room, removed a blue surgical mask that was on top of her N95, and took another blue surgical mask out of the clean bin and put on the new mask, then used hand sanitizer. RN #210 verified she should had performed hand hygiene after removing her used blue surgical mask and getting out a mask of the clean bin. RN #210 also verified she did not clean her face shield after exiting the isolation room and wore the same face shield in other areas of the community. Observation and interview on 03/12/21 at 11:45 A.M. revealed State tested Nurse Aide (STNA) #320 donned personal protective equipment (PPE) including a gown, gloves and applied a blue surgical mask over a N95 mask along with a face shield before entering Resident #4's room that was marked as droplet isolation on their door frame and in the orange zone. STNA #320 took a meal tray into the room and opened up the meal tray for the resident. STNA #320 exited the room without removing any of the PPE. STNA #320 then went and took another meal tray off the cart and delivered the tray to Resident #6's room, a droplet isolation room, STNA #320 exited the room without removing the PPE and took another tray off the cart and delivered the meal tray to Resident #5's room, which was another room in droplet isolation. STNA #320 removed PPE prior to leaving the room, but did not wash his hands. Interview on 03/12/21 at 11:53 A.M. with STNA #320 verified he did not remove the PPE after exiting the rooms and wore the same PPE in all three rooms he entered and did not wash his hands after removing his gloves. He also verified he did not clean his face shield after exiting all the isolation rooms and wore the same face shield in other areas of the community. Review of the facility's policy titled Zone PPE Protocol, dated 02/25/21, revealed gowns and gloves should be removed prior to exiting each room on the orange zone An universal face shield should be removed as close as possible to the exit of the orange zone. A new universal face shield should be used to wear in other areas of the community. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20, revealed Healthcare Personnel (HCP) should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions, put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, put on clean, non-sterile gloves upon entry into the patient room or care area, and put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area.

Based on interviews with staff and Local Health Department (LHD) personnel, review of staffing schedule, review of Coronavirus 2019 (COVID-19) staff screening logs, review of personnel timecard, review of facility policy, review of electronic mail (email) communication and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to send a State tested Nurse Aide (STNA #500) home pending COVID-19 test results after having symptoms of COVID-19 to potentially prevent the spread of COVID-19. This had the potential to affect 10 (#1, #2, #4, #5, #6, #7, #8, #9, #10 and #11) residents whom resided on B-Hall and 24 (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34 and #35) residents whom resided on D-Hall. Additionally, the facility failed to immediately report confirmed or suspected cases of COVID-19 to the LHD. This had the potential to affect all 67 residents residing at the facility. The facility census was 67. Findings include: 1. Interview on 10/08/20 at 1:40 P.M. the Administrator confirmed STNA #500 called off on 09/26/20 and 09/27/20 due to having a sore throat. The Administrator further confirmed STNA #500 did not have COVID-19 symptoms on 09/29/30 and 09/30/20 and was permitted to work on those day. The Administrator verified STNA #500 was tested on [DATE] and they received positive results on 09/30/20. The facility confirmed this had the potential to affect 10 (#1, #2, #4, #5, #6, #7, #8, #9, #10 and #11) residents who resided on B-Hall and 24 (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34 and #35) residents who resided on D-Hall. Interview on 10/08/20 at 2:00 P.M. LHD Personnel #100 confirmed STNA #500 had onset of symptoms of COVID-19 on 09/25/20 and called off work on 09/26/20 and 09/27/20. LHD Personnel #100 confirmed STNA #500 worked at the facility on 09/29/20 and 09/30/20. LHD Personnel #100 stated the expectation was the facility should have had STNA #500 tested for COVID-19 prior to returning to work. Interview on 10/08/20 at 3:28 P.M. STNA #500 confirmed she had symptoms of a sore throat starting on 09/25/20. STNA #500 stated she was not scheduled to work on 09/25/20 and she had called off on 09/26/20 and 09/27/20 due to the sore throat. STNA #500 confirmed she was not directed to her primary care physician to be tested prior to returning to work. STNA #500 reported she worked on 09/29/20 and 09/30/20 and was tested by the facility on 09/28/20. STNA #500 further confirmed she did not have symptoms of COVID-19 on 09/29/20 or 09/30/20. STNA #500 stated she was escorted out of the facility on 09/30/20 due to testing positive for COVID-19. STNA #500 could not remember for sure which hallways she worked on 09/29/20 and 09/30/20. Review of staffing schedule dated 09/29/20 revealed STNA #500 was scheduled to work from 3:00 P.M. to 11:00 P.M. on the B-Hall. Review of STNA #500's timecard revealed STNA #500 was punched in from 2:55 P.M. to 11:12 P.M. on 09/29/20 and was scheduled to work on B-Hall. Further review revealed STNA #500 was punched in from 2:55 P.M. to 6:55 P.M. on 09/30/20 and was scheduled to work D-Hall. Review of COVID-19 staff screening logs revealed STNA #500 was screened prior to working on 09/29/20 and 09/30/20. Review of facility's staff testing log revealed STNA #500 was tested on [DATE] and positive results were received on 09/30/20. Review of facility policy titled, HCF COVID-19 Protocol, updated 10/01/20, revealed if an employee with symptoms is identified as potential COVID-19, the employee should be referred to their personal physician or health care provider for [DIAGNOSES REDACTED]. 2. Interview on 10/08/20 at 2:00 P.M. LHD Personnel #100 revealed the facility had taken up to a day and a half to report positive COVID-19 cases and sometimes notification was coming from the hospital rather than the facility. E-mail received on 10/11/20 from the Administrator verified there was no record kept of when the LHD was contacted regarding positive COVID-19 cases. Interview on 10/13/20 at 9:19 A.M. the Administrator confirmed the facility has 10 active and confirmed residents with COVID-19. The Administrator further confirmed there was no evidence of positive COVID-19 cases being reported to the LHD immediately, but that e-mails would be sent to the LHD going forward. The facility confirmed this had the potential to affect all 67 residents residing in the facility. Review of facility policy titled, HCF COVID-19 Protocol, updated 08/06/20, revealed the care community must notify the LHD when COVID-19 is suspected or confirmed in a resident or health care provider and to document date and time of notification. Review of information from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) revealed the health department should be notified about residents or health care professionals (HCP) with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or three residents or HCP with new-onset respiratory symptoms within 72 hours of each other.

Based on medical record review, review of a facsimile (fax), review of a squad run report, staff, physician, medical director and family interview, and review of a facility policy, the facility failed to provide adequate care and treatment for [REDACTED]. This resulted in Immediate Jeopardy when the facility failed to provide the physician adequate information regarding a change in condition for Resident #80 when the resident began having frequent dry heaving, increased nausea, and large dark brown emesis with what appeared to be old blood one month following a small bowel resection. Subsequently, Resident #80 was found not breathing, the resident did not respond to resuscitative measures, and was pronounced dead at the facility. This affected one (#80) of four residents reviewed for death. The facility identified five residents who passed away in the past six months that were not receiving Hospice services. The facility census was 75. On [DATE] at 12:59 P.M., the Licensed Nursing Home Administrator (LNHA) and Regional Director of Clinical Services were notified Immediate Jeopardy began on [DATE] at 12:17 A.M. when the facility failed to appropriately update the physician on Resident #80's significant change of condition which included the resident vomiting three times, experiencing constant dry heaving, nausea and that a standing order for [MEDICATION NAME] (antiemetic drug) was implemented. Licensed Practical Nurse (LPN) #223 sent a fax to the physician's office on a weekend, no telephone call was placed, and no additional attempts to contact the physician were made until [DATE] at 6:00 P.M. The resident and family requested the resident be sent to the hospital for evaluation, but the resident was not sent. Subsequently, Resident #80 was found not breathing on [DATE] at 9:30 P.M. Resident #80 was provided with cardiopulmonary resuscitation (CPR); however, the resident did not respond to the CPR and was pronounced dead at the facility. The Immediate Jeopardy was removed on [DATE] when the facility completed all staff in-service training regarding appropriate response to a change in a resident's condition and implemented the following corrective actions: · On [DATE] at approximately 10:06 P.M., paramedics arrived at the facility and took over the care of Resident #80. · On [DATE], the LNHA/designee began in-service training for all nurses regarding the appropriate procedure to follow when a resident demonstrates a change in condition. The in-service included the following areas: informing the physician of an accident, change in condition, or a need for significant treatment alteration; appropriate notification methods when contacting a physician and what actions to take if the physician cannot be reached in a reasonable timeframe. On [DATE] the in-service training was completed with all nurses. · On [DATE], the LNHA/designee implemented an audit tool that will be utilized by the Director of Nursing (DON)/designee. Five resident charts will be audited weekly for four weeks for appropriate response to significant changes of condition. The findings and any concerns will be reported to the Quality/Assurance and Performance Improvement (QAPI) committee for immediate follow-up. · On [DATE] at 5:27 P.M., the LNHA/designee audited all residents residing in the facility in the last 30 days for significant change of condition and appropriate staff response including physician notification. No concerns were identified. · During interviews on [DATE] between 8:59 A.M. and 9:05 A.M., Registered Nurse (RN) #213 and #217, and LPN #220 verified they had received training prior to working on [DATE] regarding physician notification of change in resident status, appropriate methods for contacting the physician, what to do when the physician cannot be reached, and appropriate documentation. · On [DATE], review of the medical records of three (#228, #229, #230) additional residents with non-Hospice related deaths revealed facility staff had responded appropriately and physician notification was timely. No concerns were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #80's medical record revealed an admission date of [DATE] after an acute hospital stay where the resident underwent [REDACTED]. [DIAGNOSES REDACTED]. The medical record revealed Resident #80 was a Full Code resuscitative status. Review of the Minimum Data Set (MDS) assessment, dated [DATE] revealed the resident was assessed using the brief interview for mental status (BIMS) tool, which revealed the resident had a score of 15 out of 15, indicating no impairment in cognition. According to the MDS, Resident #80 did not have a condition or chronic disease that may have resulted in a life expectancy of less than six months. Furthermore, the MDS documented Resident #80 had no guardian or legally authorized representative, and the resident was expected to be discharged to the community. Review of a nursing progress note dated [DATE] at 10:20 P.M. revealed the resident's appetite was poor, and the resident was having nausea. The note further revealed the physician had been updated and they were awaiting a response from the physician. Review of the faxes sent to the physician revealed the first fax regarding Resident #80's condition was faxed to the physician's office on Sunday, [DATE] at 12:17 A.M. by LPN #223. The fax documented Resident #80 had vomited three times that day, was experiencing constant dry heaving and nausea. The fax also revealed documentation of a previous order of [MEDICATION NAME] 25 milligrams (mg) intramuscular (IM) every six hours as needed for nausea and vomiting; however, the fax did not indicate whether the [MEDICATION NAME] was administered or not. Further review of the second fax that was sent to the physician's office by LPN #226 on Sunday, [DATE] at 6:01 P.M. revealed Resident #80 had complaints of frequent nausea, dry heaves and poor appetite. The fax also revealed the resident had received [MEDICATION NAME] 25 mg IM with little effectiveness and requested an order for [REDACTED]. Review of the nursing note dated [DATE] at 6:00 P.M. revealed Resident #80 had a large, brown colored emesis with flecks of old blood present. [MEDICATION NAME] had been given per order at 4:25 P.M. with little effectiveness noted. The resident's vital signs included a blood pressure of ,[DATE] millimeters of mercury (mm HG), a pulse rate of 103 beats per minute, a temperature of 97.6 degrees Fahrenheit (F) axillary, a respiratory rate of 18 per minute with respirations that were easy, non-labored. The resident's blood sugar was checked and was 92 milligrams per deciliter (mg/dL). Loose brown stools were noted. The physician was notified about the resident's condition and requests to go to the emergency room (ER), and the physician stated to wait on going to the ER and have the resident follow-up with the surgeon who performed her surgery at a prescheduled appointment the next day. A new order for [MEDICATION NAME] was received. Review of the nursing note dated [DATE] at 6:30 P.M. revealed Resident #80's family had been updated on the resident's condition change and the fact the physician did not want to send the resident to the ER. The family indicated they felt like the resident should go to the ER, but they were unable to transport. The resident did not want to be transported by squad due to the cost. The physician was notified a second time, with an update on the resident and family's concerns. The physician again stated that she did not want the resident to go to the ER and wanted the resident to be seen by the surgeon the following day. Review of the nursing note dated [DATE] at 11:19 P.M. revealed at 9:15 P.M. Resident #80 was noted to be resting in bed with eyes closed by an aide. At 9:30 P.M. the aide reported to LPN #226 that something was wrong with Resident #80. The resident was found not breathing, code status was verified as Full Code, CPR was initiated, and nine-one-one (911) was called. Paramedics arrived at the facility and time of death was called by the paramedic via physician at the hospital at 10:06 P.M. The family and physician were notified. Review of the call report for the rescue squad dated [DATE] revealed there was a call placed from the facility to the police department on [DATE] at 9:44 P.M. The report revealed the call was placed because there was a resident at the facility that was not breathing, and that CPR was in process. The report further revealed that the rescue squad was put back in service at 10:13 P.M. Further review of the full squad run report dated [DATE] revealed the squad was dispatched to the facility due to a [MEDICAL CONDITION] in progress and upon arrival to the facility CPR was being provided to Resident #80. Resident #80 was unresponsive, and the initial cardiac event was unwitnessed. Staff stated they last saw Resident #80 on [DATE] at 9:15 P.M. and went in to check on her at 9:43 P.M. and called 911. Advanced cardiac life support was provided to Resident #80 without success. The emergency medical personnel provided a report of Resident #80's condition to the physician at the hospital and an order to discontinue resuscitation efforts was given. Resident #80's death was recorded on [DATE] at 10:06 P.M. Telephone interview with LPN #226 on [DATE] at 4:12 P.M. revealed she was Resident #80's nurse on [DATE] and [DATE], and was the nurse caring for the resident at the time of death. Resident #80 began feeling badly on [DATE], and this continued into [DATE]. The resident's complaints included nausea and a decreased appetite. According to LPN #226, the resident did not have emesis for her until 6:00 P.M. on [DATE], at which time the resident had a large brown emesis with flecks of old blood in it. She assessed the resident and notified the physician of the change in condition, which was the policy when a resident experienced a change in condition, and a hospital transfer was requested. LPN #226 stated the physician did not provide the order to transfer the resident to the hospital, so the nurse did not transfer the resident. LPN #226 stated she felt the resident needed to be sent to ER and almost went against the doctor's order not to transfer. LPN #226 further stated there was no contact made to the medical director. The DON was contacted that night; however, this was after the resident expired. Telephone interview on [DATE] at 4:40 P.M. with attending Physician #645 revealed the first time of notification of a change in Resident #80's condition was via telephone on [DATE] at 6:00 P.M. She was unaware the resident had been feeling badly all weekend because she did not receive the faxes that were sent to her office by the facility over the weekend until she got to the office on Monday, [DATE]. On [DATE] at 6:00 P.M., the physician received a phone call from the nurse caring for Resident #80 stating the resident was nauseated and had an emesis. The physician does not recall the nurse telling her of Resident #80's request to go to the hospital. She does recall a second phone call sometime that evening with an update on the resident and does not recall being told of the resident's request to transfer to the hospital during this phone call but did tell the nurse to make sure the resident got to her follow-up surgeon appointment the next day. If she would have known Resident #80 had not been doing well all weekend and had multiple episodes of emesis she would have transferred the resident to the ER. Physician #645 completed the death certificate for Resident #80 and cited acute coronary syndrome (ACS) as the cause of death. The official death certificate was requested by the survey team on [DATE]. Interview with the Medical Director on [DATE] at 5:38 P.M. revealed that if a resident has a change in condition and the nurse feels the resident needs to be seen in the ER, or if the resident requests to be transferred to the ER the physician is notified. If the physician does not wish to send the resident to the ER and it is still felt that the resident needs to go, the expectation is that the nurse would call the Medical Director to review the situation. Interview with Resident #80's family member on [DATE] at 5:28 P.M. revealed that the care of the resident while at the facility was ok, I guess, except them not taking her to the hospital. Interview on [DATE] at 1:58 P.M. with LPN #223 revealed that she took care of Resident #80 on [DATE] into [DATE] from 11:00 P.M. to 7:00 A.M. LPN #223 stated she does remember the resident having nausea and one emesis. After consulting with another nurse, she decided to use a set of attending Physician #645's orders signed by the physician on [DATE]. [MEDICATION NAME] 25 mg IM was on the list, and LPN #223 entered the order into the computer, faxed the physician to notify of use of the standing order, pulled the medication from the contingency box and administered the medication to Resident #80. She stated this should have been noted on Resident #80's Medication Administration Record [REDACTED]. Interview on [DATE] at 1:40 P.M. with Regional Director of Clinical Services revealed the facility does not have standing orders. During a follow up interview on [DATE] at 1:50 P.M. with Regional Director of Clinical Services revealed there is a book of standing orders in the facility and that she was unaware this standing order book existed. These standing orders were used for Resident #80, on [DATE] when LPN #223 initiated the order for [MEDICATION NAME] 25 mg IM. Review of a facility policy titled Notification of Changes Policy, dated [DATE], revealed the facility must inform the physician immediately of a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, or a decision to transfer or discharge the resident from the facility.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observations, medical record review, review of personnel files, review of a facility self-reported incident (SRI), observation of a social media photograph, resident and staff interviews, review of the facility's employee handbook and review of the Abuse policy and procedure, the facility failed to ensure staff immediately reported witnessing an incident of mental and emotional abuse of a cognitively impaired resident by a facility staff member during the provision of personal care and take action to protect the residents after the incident occurred. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#10) when State tested Nurse Aide (STNA) #80 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was on the commode in a compromised position without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#10) of three residents reviewed for abuse. On 12/21/16 at 12:55 P.M., the Administrator was notified that Immediate Jeopardy began on 12/05/16 at approximately 9:30 P.M. when STNA #80 took a picture of Resident #10 sitting on the commode, in need of perineal care after an incontinent episode as a result of a [MEDICAL CONDITION] bag bursting, with partial body parts exposed and fecal matter on the skin, surrounding areas, and the floor. STNA #80 proceeded to show co-workers the picture on her personal cell phone and also posted the picture on a social media website identified as Snap Chat with a contemptuous comment noting Oh how I love my job. The picture was witnessed by multiple staff members and potentially by others in the community on Snap Chat. The Immediate Jeopardy was removed on 12/08/16 when all staff were in-serviced regarding the identification of abuse, the abuse policy and procedures, and utilization of cellular phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 12/19/16 when the facility implemented the following: · On 12/05/16 at 10:48 P.M., the facility Administrator began an investigation into STNA #80 taking a compromising photograph of Resident #10. · On 12/05/16 at 11:00 P.M., STNA #80 was removed from patient care and placed on Administrative leave. · On 12/05/16 at 11:38 P.M., the facility reported the incident to the department of health. · On 12/05/16 at 11:45 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy and cell phone procedures per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility's policy and procedure on abuse and cell phone usage with photographing using mobile devices. · On 12/06/16, the Director of Nursing (DON) or designee interviewed 15 alert and oriented residents with no other reports of inappropriate photographs being taken. · On 12/08/16, all staff re-education was completed prior to working. · On 12/09/16, STNA #80 was terminated due to the violation of facility policy regarding Abuse, Neglect, Exploitation and Misappropriation of Resident Property. · On 12/12/16, the facility began weekly audits of phone usage by staff, three times a week for four weeks. · On 12/21/16, interviews were conducted with Licensed Practical Nurses (LPN) #96, #101, #103 and #104, Registered Nurse (RN) #97, and STNAs #98 and #100. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they stated they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy. · On 12/21/16, review of Resident #20 and #21's medical records revealed no concerns with potential abuse or privacy. · On 12/21/16, review of two current facility SRIs revealed no concerns. · On 12/21/16, review of facility audits dated 12/12/16 at 8:05 A.M., 12/14/16 at 4:00 P.M., 12/16/16 at 6:00 A.M. and 12/19/16 at 9:00 A.M. revealed staff were not using cellular phones and/or photographing mobile devices while on duty. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimal Data Set (MDS) assessment completed on 11/09/16 assessed the resident as having severe impaired cognition. Resident #10 required assistance with activities of daily living including dressing, toileting and bathing. Review of a facility SRI, dated 12/05/16, revealed the Administrator received a call from the facility charge nurse (RN #90) stating an STNA (#91) reported she found a photograph of a facility resident on a social media site called Snap Chat. The Administrator reported immediately to the facility and sent STNA #80 home and notified her of suspension pending investigation. The Administrator immediately initiated an SRI and an investigation. Upon investigation, STNA #80 was terminated from facility. The facility investigation was completed on 12/09/16 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap Chat revealed Resident #10 sitting on the bathroom commode with a high rise seat. The picture revealed a roll of toilet paper next to the left of the resident in the toilet paper holder. Resident #10's pants were down to her ankles and her incontinence brief was in the middle of her thighs. Resident #10's left arm and thigh were exposed, along with the resident's lower abdomen, with a percutaneous endoscopic gastrostomy (PEG) feeding tube lying across her left thigh. Part of Resident #10's [MEDICAL CONDITION] bag and a large amount of fecal matter was visible on the floor next to the resident's left side. The caption on the photograph stated, Oh how I love my job with STNA # 80's name noted in the corner of the photograph. Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having her picture taken and posted to social media. Review of the witness statement by RN #90, dated 12/05/16, revealed on 12/05/16 at 10:48 P.M. STNA #91 reported to her, STNA #92 had a photograph of Resident #10 that had been posted on the social media site Snap Chat by STNA #80. RN #90 stated she called the Administrator. Review of the witness statement by STNA #92, dated 12/05/16, revealed she received two text messages from her friends regarding a posting by STNA #80. STNA #92 stated she confronted STNA #80 about the photograph of a resident on Snap Chat where everyone can see. STNA #92 stated she was not sure what to do. She approached STNA #91 and told her, who then reported it. STNA #91 told STNA #92 she had seen more than one picture but only one was posted. Review of the witness statement by STNA #93, dated 12/05/16, documented STNA #80 took a picture of Resident #10 on the toilet with her bag off and stool on the floor. STNA #80 showed STNA #93 while she was providing care to Resident #45. STNA #93 was aware of the Health Insurance Portability and Accountability Act (HIPPA). STNA #93 told STNA #80 she would get in trouble. Review of the witness statement by STNA #91, dated 12/06/16, revealed STNA #92 told her of seeing Resident #10's photograph on Snap Chat with a busted [MEDICAL CONDITION] bag. STNA #91 stated she immediately reported it to RN #90. During an interview on 12/21/16 at 8:03 A.M. with the Administrator, she stated she had received a call from RN #90 who had stated STNA #91 and #92 reported the photograph of Resident #10 on Snap Chat to her. The Administrator stated she was at the facility within thirty minutes. She stated she did try to talk with Resident #10 and stated the resident was not aware a picture had been taken of her. The Administrator stated staff are now not allowed to keep their phones on their persons at all. If any staff member is seen on the floor with their phone, the Administrator is notified. The Administrator verified there was no information documented in Resident #10's medical record about the incident as she did not feel it was necessary because the resident was not aware a photograph had been taken. On 12/21/16 at 9:16 A.M., interview with STNA #91 revealed she reported the photograph of Resident #10 to RN #90. STNA #91 stated STNA #80 was showing everyone at break time around 9:30 P.M., where STNA #95 and #93 were also present. STNA #91 stated she told STNA #80 it was a violation and she did not seem to care. STNA #91 stated STNA #92 has Snap Chat and observed the picture there. STNA #91 stated she did not report the picture until STNA #92 saw it on social media. Interview on 12/21/16 at 9:30 A.M. with the Administrator revealed she would have been humiliated if it was herself in the picture. The Administrator verified the photograph was of Resident #10 and was taken and posted on the social media website Snap Chat by STNA #80. The Administrator stated this was a violation of their Abuse policy. The Administrator stated STNA #80 was having a bad night and even questioned herself if she should post the picture. Interview on 12/21/16 at 9:31 A.M. with STNA #92 revealed she had received a text message while she was on break from people who do not work at the facility saying how bad the job was. The people sending the messages had observed the picture on Snap Chat. No resident's name was documented on the post; just a reference to work. STNA #92 stated STNA #80, STNA #95 and STNA #93 were in the breakroom with her at the time. STNA #92 stated she got mad and said she would not want pictures of her grandma taken like that. STNA #92 went to STNA #91 for guidance since she is a newer nurse aide. They both then reported it to RN #90. On 12/21/16 at 11:00 A.M., an interview was attempted with Resident #10. The resident was not aware of person, place, time or situation. Observation of Resident #10 at the time of the interview, noted Resident #10 to be clean and appropriately dressed. Resident #10 was in a wheel chair and able to propel it freely about the facility. Review of STNA #80' s personnel file revealed a hire date of 09/07/16. STNA #80 completed the orientation and signed acknowledgement she had received and reviewed the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, Resident Rights and the Employee Handbook for the use of cell phones. STNA #80 received a termination notice on 12/09/16 for verbal, emotional, physical abuse of resident, co-worker, family member, visitor or supervisor. The notice was signed by the Administrator on 12/09/16. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/16/16 revealed all staff are prohibited from taking or using photographs of any type of recording in any manner that would demean or humiliate a resident. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. The policy indicated staff should report all incidents/allegations immediately to the Administrator or designee. The policy indicated documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the resident's representative and any treatment provided. Review of the undated Employee Handbook under the section of Personal Cell Phones/camera-equipped Mobile devices/Text Messages revealed the use of personal cellular phones during working hours is strictly prohibited. Cell phones are to only be used during authorized breaks and in an area restricted to employee use only such as the lunch room or locker area. While an employee is performing their job duties, cellular phones must be kept in the employee's bag or locker. Employees may not take digital or still photographs or record video footage with personal devices for personal use while at the facility. This prohibition includes the use of a camera function or video recording function on cellular telephones or personal digital assistants. Under the Social Media section the policy indicates the facility expects staff to exercise good judgment when using social media platforms and will not tolerate unlawful or inappropriate communication on these sites. This deficiency substantiates complaint number OH 400.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observations, medical record review, review of personnel files, review of a facility self-reported incident (SRI), observation of a social media photograph, resident and staff interviews, review of the facility's employee handbook and review of the Abuse policy and procedure, the facility staff failed to implement the facility policy to ensure a cognitively impaired resident was free from mental and emotional abuse by a facility staff member during provision of personal care, ensure staff immediately reported witnessing an incident of mental and emotional abuse of a cognitively impaired resident by a facility staff member and take action to protect the residents after the incident occurred. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#10) when State tested Nurse Aide (STNA) #80 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was on the commode in a compromised position without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#10) of three residents reviewed for abuse. On 12/21/16 at 12:55 P.M., the Administrator was notified that Immediate Jeopardy began on 12/05/16 at approximately 9:30 P.M. when STNA #80 took a picture of Resident #10 sitting on the commode, in need of perineal care after an incontinent episode as a result of a [MEDICAL CONDITION] bag bursting, with partial body parts exposed and fecal matter on the skin, surrounding areas, and the floor. STNA #80 proceeded to show co-workers the picture on her personal cell phone and also posted the picture on a social media website identified as Snap Chat with a contemptuous comment noting Oh how I love my job. The picture was witnessed by multiple staff members and potentially by others in the community on Snap Chat. The Immediate Jeopardy was removed on 12/08/16 when all staff were in-serviced regarding the identification of abuse, the abuse policy and procedures, and utilization of cellular phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 12/19/16 when the facility implemented the following: · On 12/05/16 at 10:48 P.M., the facility Administrator began an investigation into STNA #80 taking a compromising photograph of Resident #10. · On 12/05/16 at 11:00 P.M., STNA #80 was removed from patient care and placed on Administrative leave. · On 12/05/16 at 11:38 P.M., the facility reported the incident to the department of health. · On 12/05/16 at 11:45 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy and cell phone procedures per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility's policy and procedure on abuse and cell phone usage with photographing using mobile devices. · On 12/06/16, the Director of Nursing (DON) or designee interviewed 15 alert and oriented residents with no other reports of inappropriate photographs being taken. · On 12/08/16, all staff re-education was completed prior to working. · On 12/09/16, STNA #80 was terminated due to the violation of facility policy regarding Abuse, Neglect, Exploitation and Misappropriation of Resident Property. · On 12/12/16, the facility began weekly audits of phone usage by staff, three times a week for four weeks. · On 12/21/16, interviews were conducted with Licensed Practical Nurses (LPN) #96, #101, #103 and #104, Registered Nurse (RN) #97, and STNAs #98 and #100. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they stated they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy. · On 12/21/16, review of Resident #20 and #21's medical records revealed no concerns with potential abuse or privacy. · On 12/21/16, review of two current facility SRIs revealed no concerns. · On 12/21/16, review of facility audits dated 12/12/16 at 8:05 A.M., 12/14/16 at 4:00 P.M., 12/16/16 at 6:00 A.M. and 12/19/16 at 9:00 A.M. revealed staff were not using cellular phones and/or photographing mobile devices while on duty. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimal Data Set (MDS) assessment completed on 11/09/16 assessed the resident as having severe impaired cognition. Resident #10 required assistance with activities of daily living including dressing, toileting and bathing. Review of a facility SRI, dated 12/05/16, revealed the Administrator received a call from the facility charge nurse (RN #90) stating an STNA (#91) reported she found a photograph of a facility resident on a social media site called Snap Chat. The Administrator reported immediately to the facility and sent STNA #80 home and notified her of suspension pending investigation. The Administrator immediately initiated an SRI and an investigation. Upon investigation, STNA #80 was terminated from facility. The facility investigation was completed on 12/09/16 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap chat revealed Resident #10 sitting on the bathroom commode with a high rise seat. The picture revealed a roll of toilet paper next to the left of the resident in the toilet paper holder. Resident #10's pants were down to her ankles and her incontinence brief was in the middle of her thighs. Resident #10's left arm and thigh were exposed, along with the resident's lower abdomen, with a percutaneous endoscopic gastrostomy (PEG) feeding tube lying across her left thigh. Part of Resident #10's [MEDICAL CONDITION] bag and a large amount of fecal matter was visible on the floor next to the resident's left side. The caption on the photograph stated, Oh how I love my job with STNA #80's name noted in the corner of the photograph. Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having her picture taken and posted to social media. Review of the witness statement by RN #90, dated 12/05/16, revealed on 12/05/16 at 10:48 P.M. STNA #91 reported to her, STNA #92 had a photograph of Resident #10 that had been posted on the social media site Snap Chat by STNA #80. RN #90 stated she called the Administrator. Review of the witness statement by STNA #92, dated 12/05/16, revealed she received two text messages from her friends regarding a posting by STNA #80. STNA #92 stated she confronted STNA #80 about the photograph of a resident on Snap Chat where everyone can see. STNA #92 stated she was not sure what to do. She approached STNA #91 and told her, who then reported it. STNA #91 told STNA #92 she had seen more than one picture but only one was posted. Review of the witness statement by STNA #93, dated 12/05/16, documented STNA #80 took a picture of Resident #10 on the toilet with her bag off and stool on the floor. STNA #80 showed STNA #93 while she was providing care to Resident #45. STNA #93 was aware of the Health Insurance Portability and Accountability Act (HIPPA). STNA #93 told STNA #80 she would get in trouble. Review of the witness statement by STNA #91, dated 12/06/16, revealed STNA #92 told her of seeing Resident #10's photograph on Snap Chat with a busted [MEDICAL CONDITION] bag. STNA #91 stated she immediately reported it to RN #90. During an interview on 12/21/16 at 8:03 A.M. with the Administrator, she stated she had received a call from RN #90 who had stated STNA #91 and #92 reported the photograph of Resident #10 on Snap Chat to her. The Administrator stated she was at the facility within thirty minutes. She stated she did try to talk with Resident #10 and stated the resident was not aware a picture had been taken of her. The Administrator stated staff are now not allowed to keep their phones on their persons at all. If any staff member is seen on the floor with their phone, the Administrator is notified. The Administrator verified there was no information documented in Resident #10's medical record about the incident as she did not feel it was necessary because the resident was not aware a photograph had been taken. On 12/21/16 at 9:16 A.M., interview with STNA #91 revealed she reported the photograph of Resident #10 to RN #90. STNA #91 stated STNA #80 was showing everyone at break time around 9:30 P.M., where STNA #95 and #93 were also present. STNA #91 stated she told STNA #80 it was a violation and she did not seem to care. STNA #91 stated STNA #92 has Snap Chat and observed the picture there. STNA #91 stated she did not report the picture until STNA #92 saw it on social media. Interview on 12/21/16 at 9:30 A.M. with the Administrator revealed she would have been humiliated if it was herself in the picture. The Administrator verified the photograph was of Resident #10 and was taken and posted on the social media website Snap Chat by STNA #80. The Administrator stated this was a violation of their Abuse policy. The Administrator stated STNA #80 was having a bad night and even questioned herself if she should post the picture. Interview on 12/21/16 at 9:31 A.M. with STNA #92 revealed she had received a text message while she was on break from people who do not work at the facility saying how bad the job was. The people sending the messages had observed the picture on Snap Chat. No resident's name was documented on the post; just a reference to work. STNA #92 stated STNA #80, STNA #95 and STNA #93 were in the breakroom with her at the time. STNA #92 stated she got mad and said she would not want pictures of her grandma taken like that. STNA #92 went to STNA #91 for guidance since she is a newer nurse aide. They both then reported it to RN #90. On 12/21/16 at 11:00 A.M., an interview was attempted with Resident #10. The resident was not aware of person, place, time or situation. Observation of Resident #10 at the time of the interview, noted Resident #10 to be clean and appropriately dressed. Resident #10 was in a wheel chair and able to propel it freely about the facility. Review of STNA #80's personnel file revealed a hire date of 09/07/16. STNA #80 completed the orientation and signed acknowledgement she had received and reviewed the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, Resident Rights and the Employee Handbook for the use of cell phones. STNA #80 received a termination notice on 12/09/16 for verbal, emotional, physical abuse of resident, co-worker, family member, visitor or supervisor. The notice was signed by the Administrator on 12/09/16. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/16/16 revealed all staff are prohibited from taking or using photographs of any type of recording in any manner that would demean or humiliate a resident. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. The policy indicated staff should report all incidents/allegations immediately to the Administrator or designee. The policy indicated documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the resident's representative and any treatment provided. Review of the undated Employee Handbook under the section of Personal Cell Phones/camera-equipped Mobile devices/Text Messages revealed the use of personal cellular phones during working hours is strictly prohibited. Cell phones are to only be used during authorized breaks and in an area restricted to employee use only such as the lunch room or locker area. While an employee is performing their job duties, cellular phones must be kept in the employee's bag or locker. Employees may not take digital or still photographs or record video footage with personal devices for personal use while at the facility. This prohibition includes the use of a camera function or video recording function on cellular telephones or personal digital assistants. Under the Social Media section the policy indicates the facility expects staff to exercise good judgment when using social media platforms and will not tolerate unlawful or inappropriate communication on these sites. This deficiency substantiates complaint number OH 400.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observations, medical record review, review of personnel files, review of a facility self-reported incident (SRI), observation of a social media photograph, resident and staff interviews, review of the facility's employee handbook, review of resident's rights and review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure, the facility failed to ensure a cognitively impaired resident's rights to privacy and confidentiality were maintained by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#10) when State tested Nurse Aide (STNA) #80 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while on the resident was on the commode in a compromised position without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#10) of three residents reviewed for abuse. On 12/21/16 at 12:55 P.M., the Administrator was notified that Immediate Jeopardy began on 12/05/16 at approximately 9:30 P.M. when STNA #80 took a picture of Resident #10 sitting on the commode, in need of perineal care after an incontinent episode as a result of a [MEDICAL CONDITION] bag bursting, with partial body parts exposed and fecal matter on the skin, surrounding areas, and the floor. STNA #80 proceeded to show co-workers the picture on her personal cell phone and also posted the picture on a social media website identified asSnap Chat with a contemptuous comment noting Oh how I love my job. The picture was witnessed by multiple staff members and potentially by others in the community on Snap Chat. The Immediate Jeopardy was removed on 12/08/16 when all staff were in-serviced regarding the identification of abuse, the abuse policy and procedures, maintaining the residents rights to privacy and confidentiality during the provision of personal care and utilization of cellular phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 12/19/16 when the facility implemented the following: · On 12/05/16 at 10:48 P.M., the facility Administrator began an investigation into STNA #80 taking a compromising photograph of Resident #10. · On 12/05/16 at 11:00 P.M., STNA #80 was removed from patient care and placed on Administrative leave. · On 12/05/16 at 11:38 P.M., the facility reported the incident to the department of health. · On 12/05/16 at 11:45 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy, cell phone usage when providing procedures, maintain resident's privacy during care, per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility' s policy and procedure on abuse and cell phone usage with photographing using mobile devices. · On 12/06/16, the Director of Nursing (DON) or designee interviewed 15 alert and oriented residents with no other reports of inappropriate photographs being taken. · On 12/08/16, all staff re-education was completed prior to working. · On 12/09/16, STNA #80 was terminated due to the violation of facility policy regarding Abuse, Neglect, Exploitation and Misappropriation of Resident Property . · On 12/12/16, the facility began weekly audits of phone usage by staff, three times a week for four weeks. · On 12/21/16, interviews were conducted with Licensed Practical Nurses (LPN) #96, #101, #103 and #104, Registered Nurse (RN) #97, and STNAs #98 and #100. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they stated they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy, and reviewing residents rights to privacy and confidentiality. · On 12/21/16, review of Resident #20 and #21's medical records revealed no concerns with potential abuse or provision of privacy. · On 12/21/16, review of two current facility SRIs revealed no concerns. · On 12/21/16, review of facility audits dated 12/12/16 at 8:05 A.M., 12/14/16 at 4:00 P.M., 12/16/16 at 6:00 A.M. and 12/19/16 at 9:00 A.M. revealed staff were not using cellular phones and/or photographing mobile devices while on duty. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimal Data Set (MDS) assessment completed on 11/09/16 assessed the resident as having severe impaired cognition. Resident #10 required assistance with activities of daily living including dressing, toileting and bathing. Review of a facility SRI, dated 12/05/16, revealed the Administrator received a call from the facility charge nurse (RN #90) stating an STNA (#91) reported she found a photograph of a facility resident on a social media site called Snap Chat. The Administrator reported immediately to the facility and sent STNA #80 home and notified her of suspension pending investigation. The Administrator immediately initiated an SRI and an investigation. Upon investigation, STNA #80 was terminated from facility. The facility investigation was completed on 12/09/16 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap Chat revealed Resident #10 sitting on the bathroom commode with a high rise seat. The picture revealed a roll of toilet paper next to the left of the resident in the toilet paper holder. Resident #10's pants were down to her ankles and her incontinence brief was in the middle of her thighs. Resident #10's left arm and thigh were exposed, along with the resident's lower abdomen, with a percutaneous endoscopic gastrostomy (PEG) feeding tube lying across her left thigh. Part of Resident #10's [MEDICAL CONDITION] bag and a large amount of fecal matter was visible on the floor next to the resident's left side. The caption on the photograph stated, Oh how I love my job with STNA #80's name noted in the corner of the photograph. Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having her picture taken and posted to social media. Review of the witness statement by RN #90, dated 12/05/16, revealed on 12/05/16 at 10:48 P.M. STNA #91 reported to her, STNA #92 had a photograph of Resident #10 that had been posted on the social media site Snap Chat by STNA #80. RN #90 stated she called the Administrator. Review of the witness statement by STNA #92, dated 12/05/16, revealed she received two text messages from her friends regarding a posting by STNA #80. STNA #92 stated she confronted STNA #80 about the photograph of a resident on Snap Chat where everyone can see. STNA #92 stated she was not sure what to do. She approached STNA #91 and told her, who then reported it. STNA #91 told STNA #92 she had seen more than one picture but only one was posted. Review of the witness statement by STNA #93, dated 12/05/16, documented STNA #80 took a picture of Resident #10 on the toilet with her bag off and stool on the floor . STNA #80 showed STNA #93 while she was providing care to Resident #45. STNA #93 was aware of the Health Insurance Portability and Accountability Act (HIPPA). STNA #93 told STNA #80 she would get in trouble. Review of the witness statement by STNA #91, dated 12/06/16, revealed STNA #92 told her of seeing Resident #10's photograph on Snap Chat with a busted [MEDICAL CONDITION] bag. STNA #91 stated she immediately reported it to RN #90. During an interview on 12/21/16 at 8:03 A.M. with the Administrator, she stated she had received a call from RN #90 who had stated STNA #91 and #92 reported the photograph of Resident #10 on Snap Chat to her. The Administrator stated she was at the facility within thirty minutes. She stated she did try to talk with Resident #10 and stated the resident was not aware a picture had been taken of her. The Administrator stated staff are now not allowed to keep their phones on their persons at all. If any staff member is seen on the floor with their phone, the Administrator is notified. The Administrator verified there was no information documented in Resident #10's medical record about the incident as she did not feel it was necessary because the resident was not aware a photograph had been taken. On 12/21/16 at 9:16 A.M., interview with STNA #91 revealed she reported the photograph of Resident #10 to RN #90. STNA #91 stated STNA #80 was showing everyone at break time around 9:30 P.M., where STNA #95 and #93 were also present. STNA #91 stated she told STNA #80 it was a violation and she did not seem to care. STNA #91 stated STNA #92 has Snap Chat and observed the picture there. STNA #91 stated she did not report the picture until STNA #92 saw it on social media. Interview on 12/21/16 at 9:30 A.M. with the Administrator revealed she would have been humiliated if it was herself in the picture. The Administrator verified the photograph was of Resident #10 and was taken and posted on the social media website Snap Chat by STNA #80. The Administrator stated this was a violation of their Abuse policy. The Administrator stated STNA #80 was having a bad night and even questioned herself if she should post the picture. Interview on 12/21/16 at 9:31 A.M. with STNA #92 revealed she had received a text message while she was on break from people who do not work at the facility saying how bad the job was. The people sending the messages had observed the picture on Snap Chat. No resident's name was documented on the post; just a reference to work. STNA #92 stated STNA #80, STNA #95 and STNA #93 were in the breakroom with her at the time. STNA #92 stated she got mad and said she would not want pictures of her grandma taken like that. STNA #92 went to STNA #91 for guidance since she is a newer nurse aide. They both then reported it to RN #90. On 12/21/16 at 11:00 A.M., an interview was attempted with Resident #10. The resident was not aware of person, place, time or situation. Observation of Resident #10 at the time of the interview, noted Resident #10 to be clean and appropriately dressed. Resident #10 was in a wheel chair and able to propel it freely about the facility. Review of STNA #80' s personnel file revealed a hire date of 09/07/16. STNA #80 completed the orientation and signed acknowledgement she had received and reviewed the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, Resident Rights and the Employee Handbook for the use of cell phones. STNA #80 received a termination notice on 12/09/16 for verbal, emotional, physical abuse of resident, co-worker, family member, visitor or supervisor. The notice was signed by the Administrator on 12/09/16. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/16/16 revealed all staff are prohibited from taking or using photographs of any type of recording in any manner that would demean or humiliate a resident. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. The policy indicated staff should report all incidents/allegations immediately to the Administrator or designee. The policy indicated documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the resident's representative and any treatment provided. Review of the undated Employee Handbook under the section of Personal Cell Phones/camera-equipped Mobile devices/Text Messages revealed the use of personal cellular phones during working hours is strictly prohibited. Cell phones are to only be used during authorized breaks and in an area restricted to employee use only such as the lunch room or locker area. While an employee is performing their job duties, cellular phones must be kept in the employee's bag or locker. Employees may not take digital or still photographs or record video footage with personal devices for personal use while at the facility. This prohibition includes the use of a camera function or video recording function on cellular telephones or personal digital assistants. Under the Social Media section, the policy indicates the facility expects staff to exercise good judgment when using social media platforms and will not tolerate unlawful or inappropriate communication on these sites. This deficiency substantiates complaint number OH 400.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observations, medical record review, review of personnel files, review of a facility self-reported incident (SRI), observation of a social media photograph, resident and staff interviews, review of the facility's employee handbook and review of the Abuse policy and procedure, the facility failed to ensure a cognitively impaired resident was free from mental and emotional abuse by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#10) when State tested Nurse Aide (STNA) #80 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was on the commode in a compromised position without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#10) of three residents reviewed for abuse. On 12/21/16 at 12:55 P.M., the Administrator was notified that Immediate Jeopardy began on 12/05/16 at approximately 9:30 P.M. when STNA #80 took a picture of Resident #10 sitting on the commode, in need of perineal care after an incontinent episode as a result of a [MEDICAL CONDITION] bag bursting, with partial body parts exposed and fecal matter on the skin, surrounding areas, and the floor. STNA #80 proceeded to show co-workers the picture on her personal cell phone and also posted the picture on a social media website identified asSnap Chat with a contemptuous comment noting Oh how I love my job. The picture was witnessed by multiple staff members and potentially by others in the community on Snap Chat. The Immediate Jeopardy was removed on 12/08/16 when all staff were in-serviced regarding the identification of abuse, the abuse policy and procedures, and utilization of cellular phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 12/19/16 when the facility implemented the following: · On 12/05/16 at 10:48 P.M., the facility Administrator began an investigation into STNA #80 taking a compromising photograph of Resident #10. · On 12/05/16 at 11:00 P.M., STNA #80 was removed from patient care and placed on Administrative leave. · On 12/05/16 at 11:38 P.M., the facility reported the incident to the department of health. · On 12/05/16 at 11:45 P.M., the Administrator and/or designee began re-educating all staff members on the abuse policy and cell phone procedures per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility' s policy and procedure on abuse and cell phone usage with photographing using mobile devices. · On 12/06/16, the Director of Nursing (DON) or designee interviewed 15 alert and oriented residents with no other reports of inappropriate photographs being taken. · On 12/08/16, all staff re-education was completed prior to working. · On 12/09/16, STNA #80 was terminated due to the violation of facility policy regarding Abuse, Neglect, Exploitation and Misappropriation of Resident Property. · On 12/12/16, the facility began weekly audits of phone usage by staff, three times a week for four weeks. · On 12/21/16, interviews were conducted with Licensed Practical Nurses (LPN) #96, #101, #103 and #104, Registered Nurse (RN) #97, and STNAs #98 and #100. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they stated they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy. · On 12/21/16, review of Resident #20 and #21' s medical records revealed no concerns with potential abuse or privacy. · On 12/21/16, review of two current facility SRIs revealed no concerns. · On 12/21/16, review of facility audits dated 12/12/16 at 8:05 A.M., 12/14/16 at 4:00 P.M., 12/16/16 at 6:00 A.M. and 12/19/16 at 9:00 A.M. revealed staff were not using cellular phones and/or photographing mobile devices while on duty. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimal Data Set (MDS) assessment completed on 11/09/16 assessed the resident as having severe impaired cognition. Resident #10 required assistance with activities of daily living including dressing, toileting and bathing. Review of a facility SRI, dated 12/05/16, revealed the Administrator received a call from the facility charge nurse (RN #90) stating an STNA (#91) reported she found a photograph of a facility resident on a social media site called Snap Chat. The Administrator reported immediately to the facility and sent STNA #80 home and notified her of suspension pending investigation. The Administrator immediately initiated an SRI and an investigation. Upon investigation, STNA #80 was terminated from facility. The facility investigation was completed on 12/09/16 and substantiated the allegation of abuse for Resident #10. Observation of the photograph posted to the social media site Snap Chat revealed Resident #10 sitting on the bathroom commode with a high rise seat. The picture revealed a roll of toilet paper next to the left of the resident in the toilet paper holder. Resident #10's pants were down to her ankles and her incontinence brief was in the middle of her thighs. Resident #10's left arm and thigh were exposed, along with the resident's lower abdomen, with a percutaneous endoscopic gastrostomy (PEG) feeding tube lying across her left thigh. Part of Resident #10's [MEDICAL CONDITION] bag and a large amount of fecal matter was visible on the floor next to the resident's left side. The caption on the photograph stated, Oh how I love my job with STNA #80's name noted in the corner of the photograph. Review of Resident #10's nursing notes, progress notes, social service notes, and assessments revealed no documentation of the incident of the resident having her picture taken and posted to social media. Review of the witness statement by RN #90, dated 12/05/16, revealed on 12/05/16 at 10:48 P.M. STNA #91 reported to her, STNA #92 had a photograph of Resident #10 that had been posted on the social media site Snap Chat by STNA #80. RN #90 stated she called the Administrator. Review of the witness statement by STNA #92, dated 12/05/16, revealed she received two text messages from her friends regarding a posting by STNA #80. STNA #92 stated she confronted STNA #80 about the photograph of a resident on Snap Chat where everyone can see. STNA #92 stated she was not sure what to do. She approached STNA #91 and told her, who then reported it. STNA #91 told STNA #92 she had seen more than one picture but only one was posted. Review of the witness statement by STNA #93, dated 12/05/16, documented STNA #80 took a picture of Resident #10 on the toilet with her bag off and stool on the floor. STNA #80 showed STNA #93 while she was providing care to Resident #45. STNA #93 was aware of the Health Insurance Portability and Accountability Act (HIPPA). STNA #93 told STNA #80 she would get in trouble. Review of the witness statement by STNA #91, dated 12/06/16, revealed STNA #92 told her of seeing Resident #10's photograph on Snap Chat with a busted [MEDICAL CONDITION] bag. STNA #91 stated she immediately reported it to RN #90. During an interview on 12/21/16 at 8:03 A.M. with the Administrator, she stated she had received a call from RN #90 who had stated STNA #91 and #92 reported the photograph of Resident #10 on Snap Chat to her. The Administrator stated she was at the facility within thirty minutes. She stated she did try to talk with Resident #10 and stated the resident was not aware a picture had been taken of her. The Administrator stated staff are now not allowed to keep their phones on their persons at all. If any staff member is seen on the floor with their phone, the Administrator is notified. The Administrator verified there was no information documented in Resident #10's medical record about the incident as she did not feel it was necessary because the resident was not aware a photograph had been taken. On 12/21/16 at 9:16 A.M., interview with STNA #91 revealed she reported the photograph of Resident #10 to RN #90. STNA #91 stated STNA #80 was showing everyone at break time around 9:30 P.M., where STNA #95 and #93 were also present. STNA #91 stated she told STNA #80 it was a violation and she did not seem to care. STNA #91 stated STNA #92 has Snap Chat and observed the picture there. STNA #91 stated she did not report the picture until STNA #92 saw it on social media. Interview on 12/21/16 at 9:30 A.M. with the Administrator revealed she would have been humiliated if it was herself in the picture. The Administrator verified the photograph was of Resident #10 and was taken and posted on the social media website Snap Chat by STNA #80. The Administrator stated this was a violation of their Abuse policy. The Administrator stated STNA #80 was having a bad night and even questioned herself if she should post the picture. Interview on 12/21/16 at 9:31 A.M. with STNA #92 revealed she had received a text message while she was on break from people who do not work at the facility saying how bad the job was. The people sending the messages had observed the picture on Snap Chat. No resident's name was documented on the post; just a reference to work. STNA #92 stated STNA #80, STNA #95 and STNA #93 were in the breakroom with her at the time. STNA #92 stated she got mad and said she would not want pictures of her grandma taken like that. STNA #92 went to STNA #91 for guidance since she is a newer nurse aide. They both then reported it to RN #90. On 12/21/16 at 11:00 A.M., an interview was attempted with Resident #10. The resident was not aware of person, place, time or situation. Observation of Resident #10 at the time of the interview, noted Resident #10 to be clean and appropriately dressed. Resident #10 was in a wheel chair and able to propel it freely about the facility. Review of STNA #80' s personnel file revealed a hire date of 09/07/16. STNA #80 completed the orientation and signed acknowledgement she had received and reviewed the Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, Resident Rights and the Employee Handbook for the use of cell phones. STNA #80 received a termination notice on 12/09/16 for verbal, emotional, physical abuse of resident, co-worker, family member, visitor or supervisor. The notice was signed by the Administrator on 12/09/16. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/16/16 revealed all staff are prohibited from taking or using photographs of any type of recording in any manner that would demean or humiliate a resident. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. The policy indicated staff should report all incidents/allegations immediately to the Administrator or designee. The policy indicated documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the resident's representative and any treatment provided. Review of the undated Employee Handbook under the section of Personal Cell Phones/camera-equipped Mobile devices/Text Messages revealed the use of personal cellular phones during working hours is strictly prohibited. Cell phones are to only be used during authorized breaks and in an area restricted to employee use only such as the lunch room or locker area. While an employee is performing their job duties, cellular phones must be kept in the employee's bag or locker. Employees may not take digital or still photographs or record video footage with personal devices for personal use while at the facility. This prohibition includes the use of a camera function or video recording function on cellular telephones or personal digital assistants. Under the Social Media section the policy indicates the facility expects staff to exercise good judgment when using social media platforms and will not tolerate unlawful or inappropriate communication on these sites. This deficiency substantiates complaint number OH 400.

Based on observation, medical record review and staff interview, the facility failed to ensure that a fall prevention device was functional for one (Resident #114) of three residents reviewed. This resulted in actual harm when Resident #114 sustained a fall resulting in a fracture of her left arm and pelvis. In addition, the facility failed to implement physician ordered fall interventions for one (Resident #102) of three residents reviewed for falls. The facility census was 90. Findings include : 1. Review of Resident #114's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) admission assessment dated [DATE] revealed that the resident had moderate cognitive impairment with a brief interview for mental status, (BIMS) score of 9 (a score of 8-12=moderately impaired cognition). The resident was assessed as requiring supervision of one staff member and the use of a walker for transfers and ambulation. The resident was assessed as having sustained a fall in the six months prior to admission sustaining a left hip fracture. Review of the residents," Fall Risk Assessment", dated 09/23/13 upon admission revealed that the resident was assessed as being a high risk for falls. Review of the plan of care dated 01/06/14 revealed the resident was at risk for falls related to injuries due to the use of psychotropic medications, seizure disorder and chronic back pain. The goal was to have no fall related injuries through the next review. The interventions included encouraging the resident to use her walker and to ensure the resident had on non-skid footwear. On 03/04/14, a new intervention was added to the plan of care for a pressure pad alarm to be placed in the bed and chair and to leave the door open at all times except during care. Review of the resident's nurses notes dated 02/27/14 at 3:45 P.M. revealed that the resident was found on the floor of the bathroom in her room by a nurse aide. The resident was found to have a bruise above her right eyebrow and a large purple bruise on her left hand. Review of Resident #114's fall risk assessment dated [DATE] revealed the resident was assessed as being a high risk for fall . The intervention was to encourage the resident to use the call light. On 03/04/14 the resident was assessed as being a high risk for falls and the intervention was to use a a personal tab alarm while in bed. Review of Resident #114's physician telephone order dated 03/04/14 revealed that a pressure pad alarm was to be placed in the bed and chair to decrease injuries from falls. A physician telephone order on 03/04/14 revealed to discontinue the pressure pad alarm to the bed and chair and to add a personal alarm to the bed and chair. Review of the nurses notes dated 03/04/14 at 11:00 P.M. revealed that the resident was observed lying on the floor in her room. She denied injury and stated that only her bottom hurt. When asked what happened she stated 'it happens". The physician was notified and an order was received for a personal tab alarm to be placed on the resident to alert staff of unassisted ambulation. Review of the nurses notes dated 03/06/14 revealed that the resident was crying due to low back and right hip pain. The physician was notified and the x-rays were ordered. The x-ray revealed a healed fracture of the right hip and the pubic rami was unremarkable. Review of nurses note dated 03/15/14 at 2:45 A.M. revealed that the resident was observed lying on her left side on the floor. The resident refused to go to the hospital at that time and wanted the x-ray to come to the facility. On 3/15/14 at 3:15 A.M., the note revealed that the resident had changed her mind and wanted to go to the hospital at which time she was sent to the hospital. On 03/15/14 at 7:50 A.M., it was documented that the resident was admitted to the hospital for fractures she had sustained from a fall. Review of the x-rays taken at the hospital on [DATE] revealed the resident's left shoulder showed osteopenia with a commuted impacted fracture of the proximal humerus and minimally displaced fractures of the left sided ischium and pubis rami. Review of Resident #114's significant change in status MDS dated [DATE] revealed that the resident had severe cognitive impairment with the a BIMS of 4 (a score of 00-7=severe cognitive impairment). She was assessed as being non-ambulatory and did not transfer. The assessment stated that the resident had fallen, resulting with a major injury of fractures. Review of the," Nursing Post Fall Investigation", revealed that the resident was last observed at 12:30 A.M. coming back from the bathroom. At 2:45 A.M. the resident was found on floor and the alarm was not sounding as the alarm was turned off. Review of the residents fall investigation completed by the Director of Nursing (DON) revealed there was a written statement dated 03/21/14 written by State tested Nursing Aide (STNA) #44. The statement revealed that the alarm was not going off when Resident #114 fell on [DATE]. The statement documented at on 03/15/14 at 1:40 A.M., STNA #44 checked the resident and the alarm was turned off and unplugged and she turned it back on. At 12:30 A.M., STNA #46 was passing ice and found the alarm shut off also and had reported this to her prior to her checking the resident at 1:40 A.M. During an interview with Registered Nurse (RN) #48 on 04/08/14 at 11:00 A.M. revealed that in follow up after the fall, STNA #46 stated that on 03/15/14 at 12:30 A.M., while she was passing ice, she noticed that the alarm was on Resident #114 but was turned off and STNA #46 turned the alarm back on at that time. At 1:40 A.M. STNA #44 observed that the pull away tab alarm was attached to Resident #114, however it was turned off. STNA #46 turned the alarm on and left door open at that time. Observation of Resident #114 on 04/08/14 at 12:55 P.M. revealed the resident was sitting up in bed eating lunch. Her left arm was in a sling. The sensor alarm monitor box was noted to be on the right upper side rail. The alarm was observed to be unplugged and turned off. STNA #41 verified at the time of the observation that the sensor alarm was unplugged and turned off. Interview on 04/08/14 at 1:10 P.M. with STNA #41 revealed she thought the residents alarm was on after her bath this morning and maybe her husband had turned it off. STNA #41 stated that she doesn't work down this hall often so she was not sure why the alarm was off. Interview on 04/08/14 at 2:00 P.M. with LPN #45 per telephone verified that she was the nurse on duty caring for Resident #114 on 03/15/14. She stated that the husband came out into the hallway and alerted the staff that the resident had fallen. She stated that when she entered the room the resident was lying on her left side on the floor by her bed and stated that she had been getting up to go to the bathroom. LPN #45 stated that she was told by STNA #46 at the time of the fall that the alarm had been turned off and unplugged at 12:30 A.M. and that the STNA #46 stated she turned it back on. LPN #45 stated that she was unaware that the pull away alarm had been turned off earlier in the shift until after the resident was found on the floor. On 04/08/14 at 2:30 P.M., interview with STNA #44 per telephone revealed that on 03/15/14 she was late to work. She was told when she arrived, by STNA #46, that Resident #114's alarm was turned off around 12:30 A.M. while she was passing ice pitchers. She stated that she went around and checked all of her residents with alarms on. At the time the resident fell , she was in a room at the other end of the hall when she heard the resident's husband yelling for help in the hallway. When she entered the resident's room, the resident was on the floor by her bed with her walker on top of her and her alarm was off. Interview with STNA #46 on 04/08/14 at 2:09 P.M. revealed that she was working on 03/15/14 and verified that she was in Resident #114's room at 12:30 A.M. to pass ice pitchers. STNA #46 stated she discovered that the resident's pull away tab alarm was unplugged and turned off so she plugged it in and turned it on. STNA #46 verified that she did not report to the nurse that the alarm had been found off at 12:30 A.M., or that the 3-11 shift STNA's had stated that the resident's husband would turn the alarm off. Interview on 04/08/14 at 3:30 P.M. with the Director of Nursing (DON) verified that with the fall investigation, there was no determination as to how the alarm was turned off or unplugged prior to the residents fall on 03/15/14 which resulted in fractures. The DON verified there had been no interventions put in place to ensure that the sensor alarm remained functioning prior to the fall. Review of the facility policy titled , "Fall Reduction Policy", (revised June 2005) revealed that follow up investigations would be done to ascertain the cause of the incident to prevent risk of further occurrences. 2. Review of Resident #102's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 8. The resident was assessed as requiring extensive assistance of two staff for transfers and ambulation. Review of the Resident #102's plan of care, dated 01/17/13 with a recent update on 03/27/14, revealed the resident was at risk for potential fall related injuries due to arthritis and a history of falls with fractures The interventions included a perimeter mattress to her bed and on 03/07/14 a pressure pad alarm to her bed and chair. Review of the nurse's notes dated 03/07/14 at 2:05 P.M. revealed Resident #102 was found on the floor in the bathroom doorway. The resident had attempted to transfer herself and admitted to unclipping the personal pull away alarm and not using her call light. She stated," I thought I could do it but my knees would not hold me." She denied pain and sustained no injury. Review of the "Fall Risk" assessment dated [DATE] revealed that the resident was at high risk for falls and the plan was to change from a personal pull away alarm to a pressure pad alarm in her chair. Review of the monthly physician orders revealed on 03/28/14 revealed that the resident was to have a pressure pad alarm to her bed and chair to help prevent fall related injuries. Observation on 04/08/14 at 9:03 A.M. revealed Resident #102 was in a wheelchair eating breakfast in her room with a personal pull away alarm clipped to back of her shirt. At 11:00 A.M. on 04/08/14, the resident remained up in a wheelchair alone in her room with a personal pull away alarm clipped to her shirt. Continued observation at 12:52 P.M. revealed Resident #102 was in a wheelchair with a personal pull away alarm clipped to her shirt and eating in her room alone. At 5:00 P.M. on 04/08/14, Resident #102 was observed to be in a wheelchair with a personal pull away alarm clipped to the back of her shirt. State tested Nursing Aide (STNA) #42 verified that the resident had a personal pull away alarm on when in her wheelchair and recliner and a sensor alarm on when in bed. Observation on 04/09/14 at 9:00 A.M. revealed, Resident #102 was observed to be up in a wheelchair, and eating breakfast in her room alone. The personal pull away alarm was on the wheelchair, turned off and the clip was wrapped around the monitor box on the back of the resident's wheelchair and was not attached to the resident. Interview on 04/09/14 immediately following the observation with Licensed Practical Nurse (LPN) #40 came into the room and verified that the personal pull away alarm was not attached or turned on and that the resident was alone in the room. LPN #40 verified that the resident was to have a sensor pad alarm to her chair and not a personal pull away alarm as she had unclipped the alarm in the past and fell .