Every finding on record at Welsh Home the

Based on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit and choosing to remain in the facility. This affected two residents (#222 and #223) of three residents review of appropriate beneficiary notices. The facility census was 80. Findings include: 1. Resident #222 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic kidney disease, and dementia. Further review of the medical record revealed Resident #222 was discharged from skilled services while using her Medicare Part A benefit on 09/29/23 and chose to remain in the facility. Review of the notices given to Resident #222 revealed Resident #222 was given a notice of Medicare non-coverage (NOMNC) as required; however, the additional required skilled nursing advanced beneficiary notice (SNFABN) was not given to Resident #222. 2. Resident #223 was admitted to the facility 05/19/23 with diagnoses including dementia, mood disorder, and delirium. Review of the medical revealed Resident #223 was discharged from skilled services on 07/10/23 and chose to remain in the facility. Review of the notices given to Resident #223 revealed Resident #223 was given a NOMNC as required; however, the additional required SNFABN was not given to Resident #223. Interview with the Administrator on 01/02/24 at 4:15 P.M. verified no SNFABN was given to Residents #222 and #223 as required. Review of the undated facility policy titled The [NAME] Home NOMNC-ABN Procedure revealed In the event the patient is covered under traditional Medicare part A and stays at the facility after the last covered day social services will issue an ABN.

Based on interview, review of facility abuse policy and record review the facility failed to report timely to the Administrator/designee or the State Survey Agency after Resident #37 alleged she was physically and sexually abused on 03/23/21. This affected one resident (Resident #37) out of one resident reviewed for abuse. This had the potential to affect all 64 residents residing in the facility. Findings included: Review of medical record for Resident #37 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan for Resident #37 dated 03/01/21 revealed she had the potential to demonstrate verbally inappropriate behaviors related to mental and emotional illness. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medicare five-day Minimum Data Set (MDS) 3.0 dated 03/03/21 revealed Resident #37 had impaired cognition and she had delusions. Review of nursing note dated 03/23/21 at 12:40 A.M. and authored per Licensed Practical Nurse (LPN) #40 revealed Resident #37 came to the nursing desk and stated, I need to talk to you in my room please. LPN #40 revealed she went into Resident #37's room and Resident #37 started to cry and whimper and pulled up her shirt showing LPN #40 her right breast. Resident #37 stated A man came in here and smashed my boob down and now its flat and hanging down low, and he also fingered my down there (vagina) as she whispered the word vagina. LPN #40 revealed there was no noticeable change to her breast. LPN #40 revealed Resident #37 began to whimper and cry and stated, What have I done so wrong, I tell you when I find the man that has done this to me and he won't have any balls left, he better leave his hands off of me, because I'm not the one to be messed with, I'm completely happy with my husband. LPN #40 revealed she listened to the resident and expressed to her that staff would make frequent checks and that it was safe at the facility. The nursing note revealed staff was monitoring her room and she was currently resting quietly with eyes closed and call light in reach. The nursing note revealed no further assessments that LPN #40 completed on Resident #37 for signs of abuse except for the breast exam. The nursing note revealed no notification to the Administrator or designee, physician, or responsible party regarding the allegation of abuse or no details regarding an initiation of an investigation regarding the allegation of abuse. Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number # 2 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident.

Based on record review and interview the facility failed to develop a Hospice Care Plan for Hospice for Resident #44. This affected one of two residents reviewed for hospice (Resident #16 and Resident #44). This had the potential to affect all seven hospice residents in the facility (#16, #30, #36, #44, #45, #55, and #62). The facility census was 64. Findings Include: Medical record for Resident #44 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/15/21, revealed the resident had severely impaired cognition. The resident required the extensive assistance for bed mobility, locomotion, dressing, toilet use and personal hygiene. Limited assistance was needed for eating. The resident was totally dependence for transfers. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no hospice care plan had been developed. Interview on 04/22/21 at 11:41 with Assistant Director of Nursing (ADON) #70 verified there was no hospice care plan in the medical record.

Based on interview, review of facility abuse policy and record review the facility failed to thoroughly investigate when Resident #37 alleged she was physically and sexually abused on 03/23/21. This affected one resident (Resident #37) out of one resident reviewed for abuse. This had the potential to affect all 64 residents residing in the facility. Findings included: Review of medical record for Resident #37 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan for Resident #37 dated 03/01/21 revealed she had the potential to demonstrate verbally inappropriate behaviors related to mental and emotional illness. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medicare five-day Minimum Data Set (MDS) 3.0 dated 03/03/21 revealed Resident #37 had impaired cognition and she had delusions. Review of nursing note dated 03/23/21 at 12:40 A.M. and authored per Licensed Practical Nurse (LPN) #40 revealed Resident #37 came to the nursing desk and stated, I need to talk to you in my room please. LPN #40 revealed she went into Resident #37's room and Resident #37 started to cry and whimper and pulled up her shirt showing LPN #40 her right breast. Resident #37 stated A man came in here and smashed my boob down and now its flat and hanging down low, and he also fingered my down there (vagina) as she whispered the word vagina. LPN #40 revealed there was no noticeable change to her breast. LPN #40 revealed Resident #37 began to whimper and cry and stated, What have I done so wrong, I tell you when I find the man that has done this to me and he won't have any balls left, he better leave his hands off of me, because I'm not the one to be messed with, I'm completely happy with my husband. LPN #40 revealed she listened to the resident and expressed to her that staff would make frequent checks and that it was safe at the facility. The nursing note revealed staff was monitoring her room and she was currently resting quietly with eyes closed and call light in reach. The nursing note revealed no further assessments that LPN #40 completed on Resident #37 for signs of abuse except for the breast exam. The nursing note revealed no notification to the Administrator or designee, physician, or responsible party regarding the allegation of abuse or no details regarding an initiation of an investigation regarding the allegation of abuse. Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number # 2 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident.

Based on observation, interview, and record review the facility failed to ensure Resident #56's indwelling urinary catheter drainage bag and tubing were not on the floor and maintained below Resident #56's bladder to prevent urine back up into the bladder. This affected one resident (Resident #56) of six residents with indwelling urinary catheters. The facility also failed to ensure staff wore gloves when administering insulin to Resident #8. This affected one of one resident observed for subcutaneous injections. Facility census was 77. Findings include: 1. Record review for Resident #56 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].#56 had an indwelling urinary catheter to be maintained every shift due to chronic [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Review of Resident #56's care plan dated 09/25/18 revealed the potential for complications related to catheter use due to [DIAGNOSES REDACTED]. Intervention included position catheter bag and tubing below the level of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact. He required extensive assist of two person for toilet use, extensive assist of one person for locomotion on unit, and total dependence of two person assist with transfers. He had an indwelling urinary catheter. Observation on 02/26/19 at 9:17 A.M. revealed Resident #56 was sitting in his wheelchair with his indwelling catheter drainage bag and tubing touching the floor. Interview on 02/26/19 at 9:20 A.M. with Registered Nurse (RN) #600 verified Resident #56's indwelling urinary catheter bag and tubing was touching the floor. She indicated the wheelchair was low to the ground which caused the catheter bag and tubing to drag. Observation on 02/26/18 at 4:25 P.M. revealed Resident #56 sitting in his room in his wheelchair with his indwelling urinary catheter drainage bag on his lap. Resident #56 revealed staff unhooked his urinary catheter drainage bag and put the drainage bag on his lap. Resident #56 revealed that he had been waiting twenty minutes for staff to come back to lay him in bed. Interview on 02/26/18 at 4:28 P.M. with State tested Nursing Assistant (STNA) #603 verified the indwelling urinary catheter drainage bag was placed on Resident #56's lap. STNA #603 indicated she did not know who placed the drainage bag on his lap but that it should not have been placed on the resident's lap. STNA #603 said Resident #56 had returned from [MEDICAL TREATMENT] about twenty minutes ago and was waiting for staff to transfer him to his bed. Interview on 02/28/19 at 1:42 P.M. with the Director of Nursing verified that indwelling urinary catheter drainage bags should be maintained below the resident's bladder and the drainage bag or tubing should not touch the floor to prevent the risk of bladder infections. 2. Observation of a medication administration for Resident #8 by Licensed Practical Nurse (LPN) #201 on 02/27/19 at 11:22 A.M. revealed the nurse did not wear gloves while administering a subcutaneous injection of insulin to the resident. Interview with LPN #201 on 02/27/19 at 11:40 A.M. confirmed the above findings. LPN #201 confirmed she should have worn gloves when administering subcutaneous injections. Review of the facility infection control policy concerning glove-wearing dated 08/2009 revealed gloves were to be worn when it was likely the employee's hands would come in contact with body fluids or non-intact skin, as well as during all invasive procedures.

Based on observation, interview and record review the facility failed to ensure nutritional interventions recommended per the dietitian were implemented after Resident #55 and Resident #227 had significant weight loss. This affected two residents (Resident #55 and Resident #227) of three residents reviewed for nutritional status. Findings include: 1. Record review of Resident #55 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #55's weight record revealed an admission weight on 01/16/19 of 132.6 pounds. Review of the Nutritional assessment dated [DATE] revealed Resident #55 had a low body mass index and low [MEDICATION NAME] level (protein level). Dietitian #603 indicated Resident #55 needed additional calories and protein and recommended a Magic cup (nutritional supplement) with each meal. Review of physician order [REDACTED]. Review of Resident #55's care plan dated 01/17/19 revealed Resident #55 had a nutritional problem related to textured altered diet, illness, and infection related to low body mass index. Intervention included provide and serve supplements as ordered. Resident #55's subsequent weights were noted as: 01/19/19 - 132 pounds. 01/22/19 - 105 pounds indicating a significant weight loss of 20.45 percent. 01/22/19 a re-weigh of 105.2 pounds. 01/26/19 - 104.2 pounds. 01/28/19 - 103.8 pounds. 02/04/19 - 105.2 pounds. 02/05/19 - 100 pounds. 02/14/19 - 103.8 pounds. 02/20/19 - 107.8 pounds. Review of a 30- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had impaired cognition and required supervision with set up help only with eating. Observation on 02/26/19 at 11:57 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray when served. Observation on 02/27/19 at 11:58 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray. Interview with Resident #55 revealed that he had not received a Magic cup. Interview on 02/27/19 at 12:00 P.M. with State tested Nurse Aides (STNAs) #604 and #605 revealed they were currently assigned on the unit where Resident #55 resided and they gave Resident #55 his meal tray. They indicated Resident #55 did not receive a Magic cup with his meal. They also said Resident #55 had not received the Magic cup in awhile; they thought the Magic cup was discontinued when his thickened liquids were discontinued. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed Resident #55 was on a Regular diet and was to receive a Magic cup with his meals. Phone interview on 02/27/19 at 12:58 P.M. with Dietitian #603 verified she recommended Resident #55 receive a Magic cup with his meals due to weight loss. She was not aware that he had not been receiving his supplement as ordered. 2. Record review of Resident #227 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #227's weight record revealed an admission weight on 01/14/19 of 165 pounds. Review of Resident #227's care plan dated 01/15/19 revealed he had unplanned and unexpected weight loss related to acute illness, increased nutritional and calorie needs associated with fracture injury and decreased food intake. Interventions included giving supplements as ordered and alert dietitian if not consuming on a routine basis. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed decreased appetite with significant weight loss prior to admission in the last two to six months. Dietitian #604 added a Boost supplement. Review of the dietitian progress note dated 01/22/19 at 5:43 P.M. revealed Resident #227 expressed concern with recent weight loss and stated that his usual weight was 190 pounds. Resident #227 reported poor appetite. Resident #227 agreed to increase his Boost supplement to four times daily and was agreeable to have a peanut butter and jelly sandwich on each lunch and dinner tray for benefit of added calories. Review of a nursing note dated 01/23/19 at 2:03 P.M. revealed the dietitian recommended Boost supplement four times a day and a peanut butter and jelly on wheat bread per resident request for lunch and dinner. Resident #227's subsequent weights were: 01/28/19 - 157.4 pounds. 02/02/19 - 158.2 pounds. 02/12/19 - 150 pounds. 02/20/19 - 154.4 pounds. 02/26/19 - 153.6 pounds. 02/26/19 - 152.6 pounds (significant weight loss of 7.52 percent). Review of the 14- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #227 revealed he was cognitively impaired and required supervision with set up help only with eating. He had a height of 72 inches and a weight of 157 pounds with a weight loss noted that was not prescribed. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed history of significant weight loss with recent hip and rib fracture from fall. Dietitian #603 indicated Resident #227 was agreeable to supplements and a peanut butter and jelly sandwich for added calories due to weight loss. Observation on 02/26/19 at 12:02 P.M. revealed Resident #227's lunch tray did not include a peanut butter and jelly sandwich. Interview on 02/26/19 at 4:34 P.M. with State tested Nurse Aide (STNA) #607 revealed he worked on Resident #227's unit on second shift and Resident #227 did not receive a peanut butter jelly sandwich on his dinner trays unless he asked for it as an alternative to the main course. STNA #607 revealed that he was not aware Resident #227 was to receive a peanut butter jelly sandwich on his lunch and dinner trays. Observation on 02/27/19 at 11:54 P.M. revealed Resident #227 did not not receive a peanut butter and jelly sandwich on his lunch tray. Interview on 02/27/19 at 12:00 P.M. with STNAs #604 and #605 revealed they were currently assigned to the unit where Resident #227 resided. They stated Resident #227 did not get a peanut butter jelly sandwich with his lunch trays and they did not know that it was a dietitian recommendation to receive a peanut butter and jelly sandwich with his lunch and dinner trays. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed she had recommendations from the Dietitian that Resident #227 was on a Regular diet with no added salt and was to receive a peanut butter and jelly sandwich at lunch and dinner. Phone interview on 02/27/19 at 12:58 P.M. with Dietician #603 verified Resident #227 had a significant weight loss and that her recommendation was that Resident #227 was to receive a peanut butter and jelly sandwich on his lunch and dinner tray. She verified she was not aware he was not receiving the sandwiches.

Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (Resident #47) of one resident reviewed for pre admission screening and resident review (PASRR). The facility census was 77. Findings Include: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the psychiatric consult note for Resident #74 dated 02/21/18 revealed Resident #74 was given a [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#74's medical record. Review of both the electronic and hard charts revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new [DIAGNOSES REDACTED]. Social Service Designee #500 verified the appropriate state agency was not notified of the new diagnosis/decline in an interview on 02/28/19 at 11:32 A.M.

Based on observation, interview and record review the facility failed to ensure Resident #56's dignity was maintained when a urinary drainage collection bag was not covered. This affected one resident (Resident #56) of six residents with indwelling urinary catheters. The facility census was 77. Findings include: Record review for Resident #56 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].#56 had an indwelling urinary to be maintained every shift due to chronic [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Review of Resident #56's care plan dated 09/25/18 revealed the resident had the potential for complications related to urinary catheter use due to [DIAGNOSES REDACTED]. An intervention included position catheter bag away from the entrance from the room door or use bag cover. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 01/23/19 revealed Resident #56 was cognitively intact. He required extensive assist of two person for toilet use, extensive assist of one person for locomotion on unit, and total dependence of two person assist with transfers. He had an indwelling urinary catheter. Observation on 02/25/19 at 10:37 A.M. revealed Resident #56's indwelling urinary catheter drainage bag was hanging on the side of the bed facing the entrance to the room without a bag cover. From the hallway urine could be seen in the drainage bag. Observation on 02/26/19 at 9:17 A.M. revealed Resident #56 was sitting in a wheelchair by the nursing station with the indwelling urinary catheter drainage bag underneath the wheelchair without a bag cover and urine could be seen in the drainage bag. Interview on 02/26/19 at 9:20 A.M. with Registered Nurse #600 verified that Resident #56's urinary catheter drainage bag was not covered. Observation on 02/27/19 at 11:13 A.M. revealed Resident #56's indwelling urinary catheter drainage bag was positioned on the side of the bed towards the entrance of the room without a bag cover and from the hallway urine could be seen inside the bag. Interview on 02/27/19 at 11:13 A.M. with Licensed Practical Nurse #601 verified that Resident #56's catheter drainage bag was not covered and that from the hallway urine could be seen inside the drainage bag. Review of the undated facility policy Urinary Drainage Bag/ Urinary leg Drainage bag Cleansing During Alternating Use revealed the continuous drainage bag should be placed inside the drainage privacy bag to maintain dignity for continued socialization and mobility.

Based on record review and interview the facility failed to ensure Resident #74's medical record was maintained in a complete and accurate manner. This affected one resident (Resident #74) of three residents whose closed medical records [REDACTED] Findings include: Review of Resident #74's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating she was moderately cognitively impairment. Review of the nurse's notes dated 10/13/17 at 2:21 A.M. revealed the resident's bilateral lower extremities had [MEDICAL CONDITION]. The resident allowed the nurse to put the pillow back under her arm, and to elevate her bilateral lower extremities. The residents oxygen saturation level/pulse ox (POX) was documented to be 88%, her lungs were clear, but diminished. The resident had a moist, productive cough. A breathing treatment was given. The resident denied any pain or having any trouble breathing. She stated I just keep coughing up thick mucous in my tissue. Her right hand continued to be swollen, and in order to get a POX, the left splint needed to be opened up. At 8:11 A.M. the doctor was updated regarding the moist productive cough and nursing was awaiting response for further instruction. At 8:41 A.M. nursing received an order to obtain a chest x-ray. At 11:32 A.M. the physician was in the facility and initiated a new order to obtain a POX on every shift for three days, due to the resident's shortness of breath. The doctor was updated on the resident's POX of 82 % on oxygen and that the resident was leaning her head forward to catch her breath. The resident did not complain of shortness of breath though her lung sounds were diminished with a small amount of wheezing in the lower lobe. At 12:16 P.M. the doctor was in to see the resident. At this time he was updated on the residents POX of 82 % on 2-3 liters of oxygen. The resident's left hand was noted to be cold to the touch. The physician warmed up the residents hand with a warm wash cloth and obtained a POX of 82 % on oxygen. The resident was leaning her head forward and was attempting to catch her breath. She still did not complain of shortness of breath. Her lung sounds were diminished with a small amount of wheezing in lower lobe. The physician ordered a cervical collar to hold the residents head in a upright position. At 12:21 P.M. the physician was notified of the chest x-ray results. [MEDICATION NAME] (antibiotic) 400 mg once a day for seven days was ordered. At 1:45 P.M. the nurse was called down to resident's room because she had removed her cervical collar. At 2:10 P.M. the speech therapist was in the residents room performing a swallowing evaluation when she called the nurse to the residents room. Upon the nurses arrival to the room it was noted the resident had blood in her mouth. The therapist stated the resident was coughing up blood. The resident then coughed up a small amount of bright red blood. The resident allowed the therapist to replaced her cervical collar. At 2:25 P.M. a call was placed to the physician to report that the resident was coughing up blood. He ordered the resident to be sent to the hospital. A call was placed to ambulance for transport, there would be a 60 to 90 minutes wait. The resident's vitals signs were then taken, her blood pressure was 124/60, and POX was 68 % on oxygen. A call was placed to 911 for transport. The resident was transported to the hospital at 2:58 P.M. The resident passed away 10/14/17. During an interview on 01/15/18 at 2:38 P.M. with the director of nursing (DON), the DON was asked if there was a POX taken between 12:21 P.M. and 2:10 P.M. The DON stated she was not familiar with the case so she interviewed the nurse who stated the resident had swelling in the right hand and there was a splint for broken fingers on the left hand so they could not get a accurate POX. However, the resident was not showing any physical signs of the [MEDICAL CONDITION], the resident was alert and speaking. She stated they believed the readings were off due to the condition of the residents hands. However, none of this information had been documented in the nurse's notes or any where else in the residents chart.

Based on record review and interview the facility failed to ensure care plan interventions were in place and implemented as planned for Resident #20. This affected one resident (Resident #20) of 17 residents whose care plan interventions were reviewed. Findings include: Record review revealed Resident #20's most recent admission to the facility was on 09/25/17. The resident had [DIAGNOSES REDACTED]. This resident's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance from staff for most activities of daily living. Record review revealed the resident received [MEDICAL TREATMENT] treatments. Review of Resident #20's care plan for [MEDICAL CONDITION] revealed an intervention to monitor/document/report for signs/symptoms of acute failure related to oliguria (urine output less than 400 milliliters (ml) per 24 hours), and for output greater than 500 ml in 24 hours. Review of the resident's record revealed no evidence the resident's output was being monitored. Interview with Registered Nurse (RN) #61 on 01/05/18 at 9:50 A.M. revealed they do not monitor the resident's output. When asked how they monitor for signs/symptoms of oliguria or excessive output she stated that she would have to look into it and get back to this surveyor. Another intervention under this resident's [MEDICAL CONDITION] care plan revealed to monitor/document/report to the physician as needed signs/symptoms of [MEDICAL CONDITION] (accumulation of fluid in tissues of the body), and weight gain over two pounds a day. Review of the resident's record revealed no documentation regarding [MEDICAL CONDITION]. Her weight was monitored two times in November 2017, four times in December 2017 and once in January 2018. Interview with RN #61 on 01/05/18 at 9:50 A.M. verified the resident's weights were not being monitored daily. When asked about [MEDICAL CONDITION], she stated the staff document daily on her [MEDICAL CONDITION]. However, review of the progress notes and the resident's record did not show any documentation regarding [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 01/05/18 at 12:30 P.M. revealed when asked how staff were following these interventions when they do not monitor urine output, or weigh the resident daily, she stated she did not know. When asked about documenting the resident's [MEDICAL CONDITION], the DON verified no documentation was noted regarding the resident's [MEDICAL CONDITION]. Another intervention under the [MEDICAL CONDITION] care plan revealed the use of the medications [MEDICATION NAME] and Milk of Magnesium were contraindicated with [MEDICAL TREATMENT]. It further stated that these were not to be given. Review of this resident's Medication Administration Record [REDACTED]. Interview with the DON on 01/05/18 at 12:30 P.M. verified the resident did have an as needed order for Milk of Magnesia and [MEDICATION NAME]. She stated he resident had not received these medications at any time during November 2017, December 2017 or January 2018. The DON further stated when the resident was readmitted to the facility her previous orders automatically downloaded onto the MAR. When asked how she guaranteed the resident did not receive this medication if a nurse did not review the care plan and she stated she would not know. Record review also revealed the resident had a plan of care for potential for nutritional problem which revealed an intervention to provide supplements as ordered. Review of the dietary assessment, dated 12/05/17 revealed the dietician was going to start one ounce of liquacel (a dietary supplement) daily for up to 16 grams of protein related to the resident's assessed increased protein needs. Review of an e-mail sent to the DON and the MDS nurse revealed they were both aware of the need to start the resident on this supplement. Review of the resident's MAR indicated [REDACTED]. Interview with the RN #61 on 01/05/18 at 2:00 P.M. revealed she was not giving the resident liquacel and there was no order for the supplement written on the MAR. Interview with the DON on 01/05/18 at 2:30 P.M. verified there was an e-mail sent from the dietician regarding the liquacel. She stated she was out of town at the time. She did not know who was responsible but stated that a nurse was to contact the physician to obtain the order and this was not done.

Based on observation, record review and interview the facility failed to ensure medications were properly stored and labeled. This affected one resident (Resident #8) of 26 residents on the North Hall. The facility census was 68. Findings Include: Record review revealed Resident #8 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. This resident's Minimum Data Set 3.0 (MDS) assessment, dated 12/15/17 revealed Resident #8 had severe cognitive impairment. Her functional assessment revealed the resident required extensive assistance for all activities of daily living. On 01/03/18 observation of the resident's room revealed a cup on the resident's desk. Observation revealed a medication cup with two round reddish pink colored tablets in it. When the resident was asked about the medication, she was unable to state what they were, where they came from or if they were hers. Review of the resident's Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #60 on 01/03/18 at 10:00 A.M. verified there were medications in a medication cup left in the resident's room. Further interview revealed the LPN indicated she did not pass these medications to the resident this morning. She further stated they must have been from the previous shift.

Based on observation, interview and record review the facility did not ensure infection control was maintained during incontinence care. This affected 1 of 3 residents reviewed for incontinence. The facility census was 66. Findings include: Resident #66 had [DIAGNOSES REDACTED]. The resident's minimum data set assessment (MDS 3.0) with the assessment reference date of 07/01/17 revealed the resident required extensive assistance of two or more persons for toileting and transferring. Review of the resident's physician's orders [REDACTED]. On 09/21/17 at 3:52 P.M. a State tested Nurse Aide (STNA) #303 was observed knocking on Resident #66's door. STNA#303 explained to the surveyor that she was about to assist STNA #301 with care. Upon entering Resident #66's room, STNA #303 donned gloves without washing her hands. STNA#301 already had gloves applied and Resident #66 was sitting in her wheelchair with a sit to stand lift in front of her. At 3:55 P.M. STNA#301 and STNA#303 connected the lift pad to the hooks on the lift with the pad behind the resident. STNA#301 supported the resident while STNA#303 operated the lift using the electronic controller. While the resident was in a standing position, STNA#301 removed the wet brief from the resident and cleansed her perineal area. STNA#301 did not change her gloves or wash her hands prior to applying a clean brief, pulling the residents clean pants up, lowering her to the wheelchair, and removing the lift pad. Interview with STNA#301 at 4:00 P.M., confirmed she should have washed her hands and changed her gloves after providing incontinence care and before handling clean items. Interview with STNA#303 at the same time confirmed she should have washed her hands prior to donning glove in Resident #66's room. This deficiency was an incidental finding.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for two residents (Resident #50 and Resident #75). This affected two of 34 residents whose MDS assessments were reviewed. Findings included: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was placed on Hospice services on 04/23/16. Review of the MDS 3.0 assessment dated [DATE] revealed the prognosis for Resident #50 was not six months or less and Hospice services were not indicated. On 10/20/16 at 10:04 A.M., MDS Coordinator #5 verified the 09/21/16 MDS assessment was incorrect as Resident #50 had been on Hospice services since 04/23/16. 2. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of an MDS 3.0 assessment dated [DATE] revealed the resident needed only extensive assistance for transfers. Review of an MDS 3.0 assessment dated [DATE], revealed the resident had severe cognitive impairment, and was totally dependent on staff for transfers. Interview with Resident #75 and her husband on 10/18/16 at 2:00 P.M. revealed the resident needed assistance of two people to get up out of bed and to be transferred from the chair to the bed. Interview with MDS Coordinator #5 on 10/18/16 at 5:30 P.M. revealed she coded the assessments according to the State tested Nurse Aide (STNA) documentation regarding the way the resident was transferred. Interviews on 10/19/16 with STNA #83 at 2:30 P.M. and STNA #84 at 2:50 P.M., revealed Resident #75 required the assistance of two persons for transfers. On 10/19/16 at 12:00 P.M., the Director of Nursing and MDS Coordinator #5 verified Resident #75 required the extensive assist of two persons, and was not totally dependent on staff for transfers. They verfied the MDS 3.0 assessment dated [DATE] was coded incorrectly.

Based on observation, interview and record review, the facility failed to ensure medications were not left at the bedside for one resident, Resident #13. This could affect seven cognitively impaired and independently mobile residents on the North unit. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of the care plan dated 08/02/16 indicated the resident had alteration in thought processes due to short term memory loss. Review of a Social Service Note written 04/27/16 stated the resident was oriented with short term memory loss. She also has episodes of confusion. Observation of Resident #13 on 10/17/16 at 10:20 A.M. revealed she was finishing her breakfast. There were two small pale yellow pills on her breakfast tray next to an empty souffle cup. State tested Nurse Aide (STNA) #83 came into the room, scooped the pills into the souffle cup and placed the cup on the overbed table. Resident #13 said she wasn't she wasn't sure what the pills were. STNA #38 stated she had no idea what the pills were for. At that time Licensed Practical Nurse (LPN) #82 came down the hall. LPN #82 stated the pills were two aspirin that the resident had requested. LPN #82 then motioned to the plastic cup in her hand and stated she was just bringing the resident more water to take the pills with. LPN #82 verified she had left the pills with the resident to get the water. On 10/17/16 at 11:20 A.M. LPN #82 verified Resident #13 was cognitively impaired, and was not interviewable. Twenty-six residents resided on the North unit. Seven were cognitively impaired and independently mobile, Residents #16, #32, #40, #52, #54, #81 and #95.

Based on record review, policy review and interview, the facility failed to offer Resident #123, Resident #122, and Resident #90 pneumococcal immunizations. This affected three of five residents reviewed for immunizations. Findings include: 1. Review of the medical record revealed Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #123's nursing admission data dated 10/04/16 revealed the resident had not received the pneumococcal vaccination and the reason was not indicated. Review of Resident #123's medical record revealed the resident last received a pneumococcal immunization on 04/16/05, and had not been offered the vaccination upon admission to the facility. On 10/20/16 at 9:35 A.M., interview with the Director of Nursing (DON) revealed Resident #123's admission assessment should have included determination of pneumococcal status and the need for vaccination. The DON verified Resident #123 should have been offered a pneumococcal vaccination upon admission. 2. Review of the medical record revealed Resident #122 was admitted on [DATE] for aftercare following urogenital surgery. Resident #122's nursing admission data dated 10/05/16 revealed the resident had not received the pneumococcal vaccination and the reason was not indicated. Review of Resident #122's medical record revealed no evidence the resident had ever received a pneumococcal vaccination or was offered the pneumococcal vaccination upon admission. On 10/20/16 at 9:35 A.M., the DON verified Resident #122 had not been offered the pneumococcal vaccination until 10/19/16. 3. Review of the medical record revealed Resident #90 was admitted on [DATE] for orthopedic aftercare related to surgery of the left leg. Resident #90's nursing admission data dated 09/08/16 revealed the resident had not received the pneumococcal vaccination with a comment that the resident's son would find out the reason the vaccination was not received. Review of Resident #90's medical record revealed no evidence the facility followed up with the resident's son on Resident #90's pneumococcal history or when the resident last had the vaccination. On 10/20/16 at 9:35 A.M. the DON verified the facility did not follow up on Resident #90's pneumococcal vaccination history and the resident had not been offered the pneumococcal vaccination. Review of the facility Pneumococcal Vaccine policy (undated) revealed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident has already been vaccinated.

Based on observation, record review, policy review, and interview, the facility failed to ensure Resident #67 was offered routine dental care. This affected one of three residents reviewed for dental services. Findings include: Review of the medical record revealed Resident #67 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #67's Minimum Data Set 3.0 assessment dated [DATE] revealed the resident's cognition was intact. Review of Resident #67's medical record revealed the resident did not have a consent for dental treatment and had not had any routine dental care since admission. Resident #67's current comprehensive care plan did not include a plan of care for dental needs. Review of the facility dental scheduling report for 10/21/16 revealed Resident #67 was not on the upcoming list to see the dentist for routine dental care. Observation on 10/18/16 at 9:31 A.M. of Resident #67 revealed the resident was missing some of his upper teeth. Interview on 10/18/16 at 3:37 P.M. with the Administrator revealed four to six months ago the facility changed dental companies. The Administrator verified Resident #67 did not have a consent to receive or not receive dental care, and was not on the upcoming list for routine dental care. Review of the facility Dental Services policy (undated) revealed routine dental services are available to meet the resident's oral health services in accordance with the residents assessment and plan of care.

Based on observation, staff interview and record review, the facility failed to develop accurate and individualized plans of care for Residents #5 and #120. This affected two of 22 residents whose plans of care were reviewed. Findings include: 1. Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident could not be interviewed because he was rarely understood. He had short and long term memory impairment and was severely cognitively impaired. His behavioral symptoms included physical abuse toward others. He required the extensive to total assistance of one to two staff persons for activities of daily living, and was always incontinent of bowel and bladder. Review of the plan of care related to the use of [MEDICAL CONDITION] medications and non-compliance lacked interventions related to the use of an anti-psychotic medications prior to laboratory blood draws. Review of the physician's orders [REDACTED]. Review of the progress notes from 09/01/15 to December 2015 indicated Resident #5 refused, resisted and/or became combative with care and treatment on 20 occasions, including requiring as needed anti-psychotic medication prior to laboratory blood draws on 10/12/15 and 12/07/15. Interview with Licensed Practical Nurse (LPN) #77 on 12/09/15 at 2:34 P.M. indicated Resident #5 was a former boxer and was combative with care. She confirmed as needed anti-psychotic medications were used about a half hour prior to laboratory blood draws because of his past combativeness. Interview with Registered Nurse (RN) #86 on 12/10/15 at 1:20 P.M. verified the current care plan lacked individualized interventions related to non-compliance with laboratory blood draws. 2. Review of the clinical record revealed Resident #120, a female resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] indicated she was moderately cognitively impaired, had hallucinations, an indwelling urinary catheter and was always incontinent of bowel. Review of the plan of care for complications related to catheter use indicated an intervention was to report redness or [MEDICAL CONDITION] of the penis, glans or scrotum, skin breakdown involving the penile shaft or scrotum. Review of the plan of care related to urinary tract infection revealed the section for interventions was blank. There was no plan of care related to the ,[MEDICAL CONDITION]. Difficle. Review of the progress note dated 12/10/15 at 12:30 P.M. indicated it was a late entry from 12/08/15. The note indicated the physician wanted the antibiotic to continue until the stop date and he was aware the ,[MEDICAL CONDITION]. Difficle laboratory test was negative. Resident #120 was observed on 12/08/15 at 10:53 A.M. and 2:42 P.M. in her bed. A posting to see the nurse prior to entering room was on the door frame. A cart containing personal protective equipment was just outside her door. On 12/09/15 at 1:00 P.M. the posting and the personal protective equipment cart were gone. On 12/10/15 at 9:03 A.M. the posting and the cart were outside Resident #120's room again. Interview with LPN #87 on 12/08/15 at 2:52 P.M. indicated Resident #120 had isolation precautions because she was being treated for [REDACTED]. She stated they were waiting for fecal culture results to return to discontinue isolation. She stated to wear a gown and gloves to speak with the resident. Interview with LPN #88 on 12/09/15 at 2:48 P.M. confirmed Resident #120 was admitted from the hospital with [MEDICAL CONDITION] but found in her chart the test was negative. She stated the resident continued to have diarrhea so the intravenous antibiotic was continued. Interview with the Director of Nursing on 12/10/15 at 11:53 A.M. stated isolation precautions would remain until completion of the antibiotic. Interview with RN # 86 on 12/10/15 at 9:03 A.M. indicated she was unsure why the isolation cart had returned. Interview with RN #86 on 12/10/15 at 1:20 P.M. confirmed the plan of care was inaccurate and that Resident #120 was female. She also verified the plan of care for urinary tract infections lacked interventions and no immediate needs plan of care was developed related to her having the [MEDICAL CONDITION] infection.

Based on record review, policy review and interview, the facility failed to implement their abuse procedure by failing to investigate and report to the State Agency Resident #80's allegation of abuse. This affected one of two residents reviewed for abuse. Findings include: Review of the facility policy and procedure titled Abuse/Neglect of Residents (undated) revealed the definitions of the types of abuse, prevention of abuse, screening of new employees, training of staff, protection of the resident, and procedure for reporting and investigating allegations of abuse in the facility. The procedure included the prevention of abuse in the facility by requiring the employees to report allegations of abuse to the Administrator immediately. The facility would prevent further potential abuse while the investigations was conducted. Complaints of abuse would be investigated immediately. The state of Ohio would be notified as required by the regulations. The protection of the residents included to uphold the rights of the residents. The reporting of abuse guidelines included the staff were to immediately report allegations of abuse to the DON or the Administrator. Notify the Ombudsman and health department. The investigation included to use the facility incident report form, suspend the alleged perpetrator during the investigation, determine if abuse had occurred, the extent of the abuse and causative factors. The investigation would include staff and resident interviews. Report the results of the investigation to the resident and reporter of the allegation of abuse. Identify causative factors and evaluate the system of the facility and implement corrective action to improve the quality of service. Review of the medical record revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #80's nursing progress note dated 03/05/15 at 12:17 P.M. indicated Resident #80 refused five times to be washed up and have her clothing changed. The nursing note indicated Resident #80 was counseled by the nurse and Resident #80 stated she knew her rights. Review of Resident #80's Minimum Data Set (MDS) 3.0 assessments dated 05/15/15 and 11/25/15 indicated Resident #80 needed the assistance of one staff member for bathing, and her cognition was intact. An interview with Resident #80 on 12/08/15 at 11:00 A.M. revealed that approximately a year ago she was forced to endure a bed bath against her wishes. Resident #80 stated one unnamed state tested nurse aide (STNA) forced her to receive a bed bath in her room. Resident #80 was unable to provide their name but stated the STNA was a female and the resident would recognize her. Resident #80 stated she was fighting the whole time and screaming for someone to come to her aid. Resident #80 stated eventually another staff member (a different STNA) was walking by the room and came in to assist the STNA in forcing her to have a bed bath. Resident #80 stated she felt she was assaulted and they hurt her left shoulder and bruised her forearms. Resident #80 stated she reported the incident to the administrative staff (a male employee). Resident #80 did not know his name or title and he was one of the administrative staff. The administrative staff member told her He would take care of it. Resident #80 understood the facility would reassign the two STNAs to a different unit in the facility. The administrative staff member told her the two STNAs would no longer be assigned to care for her. Resident #80 stated she observed the two STNAs performing their duties and occasionally came in her room to remove her meal tray or perform minor tasks. Resident #80 stated she felt angry every time she thought of the assault. On 12/08/15 at 4:00 P.M. the Administrator was notified of Resident #80's allegation of abuse. The Administrator stated she was aware there was an incident regarding Resident #80's refusal to take a bath in March 2015. The Administrator stated the Director of Nursing (DON) had informed her Resident #80 had refused to take a bath and was very upset. The Administrator stated she personally did not interview Resident #80 about the incident and had depended on the DON to handle the situation. The Administrator stated the DON informed her that there was a personality conflict between the STNA assigned to care for Resident #80 and Resident #80. The DON informed her the STNA involved would no longer be assigned to care for Resident #80. An interview with the Administrator on 12/09/15 at 12:19 P.M. revealed she was unable to find documentation of the incident and investigation. The Administrator indicated the DON who was employed by the facility at the time of the incident was no longer employed by the facility. The Administrator stated the previous DON had not investigated the incident properly. The Administrator was unable to produce documentation there had been an investigation of Resident #80's allegations of abuse, and a Self Reported Incident form was not submitted to the State Agency. On 12/10/15 at 8:21 A.M., the Administrator verified the above findings.

Based on observations, record review and interviews, the facility failed to ensure Resident #5's wheelchair was sanitary and free of odors. This affected one of three residents reviewed for urinary incontinence. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment dated [DATE] indicated Resident #5 could not be interviewed because he was rarely understood. He required the extensive to total assistance of one to two staff persons for activities of daily living, and was always incontinent of bowel and bladder. On 12/09/15 at 9:34 A.M. a medicinal urine odor was present in Resident #5's room. On 12/09/15 at 2:26 P.M. Resident #5 was observed lying in a low bed with a mattress on the floor next to the bed. The top sheet was pulled over to the side exposing him in an incontinence undergarment and he had no lower legs. On 12/09/15 at 2:38 P.M. Licensed Practical Nurse (LPN) #77 accompanied the surveyor into Resident #5's room. LPN #77 put the sheet back over the resident. A slight odor was detected in the room. The surveyor requested to see the resident's wheelchair. LPN #77 opened the bathroom door and a foul pungent odor permeated the room. Resident #5's wheelchair was in the bathroom. A disposable bed pad was on top of the black custom molded seat. LPN #77 identified the odor as urine, felt the bed pad and the seat, and confirmed both were dry. She smelled the seat and stated the odor was in the seat of the wheelchair. Interview with Physical Therapy Assistant (PTA) #85 on 12/09/15 at 3:00 P.M. stated he had worked with Resident #5 in the past. He was aware of the strong urine odor that came from the seat and that the seat had been changed in the past because of the odor. He stated he would contact the wheelchair company to see if there was a cleanable waterproof seat for the wheelchair to help minimize the strong odor. Interview with the Director of Nursing on 12/09/15 at 3:43 P.M. indicated she was not aware of the urine odor in Resident #5's wheelchair. She stated staff would thoroughly clean the current cushion and would look into purchasing a cushion that could be cleaned. On 12/10/15 at 8:54 A.M. Resident #5 was observed in bed. The bathroom door was open and the strong urine odor remained. Interview with LPN #77 on 12/10/15 at 8:56 A.M. stated the night shift cleaned his cushion. LPN #77 entered the bathroom and confirmed the the wheelchair cushion did not smell any different than before it was cleaned.

Based on interview and record review, the facility failed to investigate and report Resident #80's allegation of abuse. This affected one of two residents reviewed for abuse. Findings include: Review of the medical record revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #80's nursing progress note dated 03/05/15 at 12:17 P.M. indicated Resident #80 refused five times to be washed up and have her clothing changed. The nursing note indicated Resident #80 was counseled by the nurse and Resident #80 stated she knew her rights. Review of Resident #80's Minimum Data Set (MDS) 3.0 assessments dated 05/15/15 and 11/25/15 indicated Resident #80 needed the assistance of one staff member for bathing, and her cognition was intact. An interview with Resident #80 on 12/08/15 at 11:00 A.M. revealed that approximately a year ago she was forced to endure a bed bath against her wishes. Resident #80 stated one unnamed state tested nurse aide (STNA) forced her to receive a bed bath in her room. Resident #80 was unable to provide their name but stated the STNA was a female and the resident would recognize her. Resident #80 stated she was fighting the whole time and screaming for someone to come to her aid. Resident #80 stated eventually another staff member (a different STNA) was walking by the room and came in to assist the STNA in forcing her to have a bed bath. Resident #80 stated she felt she was assaulted and they hurt her left shoulder and bruised her forearms. Resident #80 stated she reported the incident to the administrative staff (a male employee). Resident #80 did not know his name or title and he was one of the administrative staff. The administrative staff member told her He would take care of it. Resident #80 understood the facility would reassign the two STNAs to a different unit in the facility. The administrative staff member told her the two STNAs would no longer be assigned to care for her. Resident #80 stated she observed the two STNAs performing their duties and occasionally came in her room to remove her meal tray or perform minor tasks. Resident #80 stated she felt angry every time she thought of the assault. On 12/08/15 at 4:00 P.M. the Administrator was notified of Resident #80's allegation of abuse. The Administrator stated she was aware there was an incident regarding Resident #80's refusal to take a bath in March 2015. The Administrator stated the Director of Nursing (DON) had informed her Resident #80 had refused to take a bath and was very upset. The Administrator stated she personally did not interview Resident #80 about the incident and had depended on the DON to handle the situation. The Administrator stated the DON informed her that there was a personality conflict between the STNA assigned to care for Resident #80 and Resident #80. The DON informed her the STNA involved would no longer be assigned to care for Resident #80. An interview with the Administrator on 12/09/15 at 12:19 P.M. revealed she was unable to find documentation of the incident and investigation. The Administrator indicated the DON who was employed by the facility at the time of the incident was no longer employed by the facility. The Administrator stated the previous DON had not investigated the incident properly. The Administrator was unable to produce documentation there had been an investigation of Resident #80's allegations of abuse, and a Self Reported Incident form was not submitted to the State Agency. On 12/10/15 at 8:21 A.M., the Administrator verified the above findings.

Based on observation, record review and interview, the facility failed to provide an appropriate transfer of one resident (Resident #7) from a broken recliner chair out of five residents with accidents reviewed, resulting in a fractured right humerus. The facility census was 33. Findings include: Resident #7 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set 2.0 (MDS) assessment dated [DATE] revealed the resident to be alert and oriented and modified independent for decision making. The MDS revealed the resident to require an extensive assistance by two staff members for bed mobility, transferring and toileting. The resident was non-ambulatory, per her choice remained mostly in her room sitting up in a recliner and was 66 inches tall with a weight of 144 pounds. The resident was assessed as a high risk for falls from the above MDS and had a plan of care regarding her risk for falls dated 10/20/10 with interventions including the resident to be a two person assistance with transfers. During observation of Resident #7 on 05/05/11 at 9:30 A.M. the resident was seated in a recliner chair in the middle of her room. The chair was in a reclined position with her legs elevated and back and head bent forward from the reclining back of the chair trying to rest her head on a pillow on her chest. The resident was crying, did not speak but shook her head "yes" and "no" to the surveyor's questions. The resident shook her head "yes" that she was in pain and the surveyor notified the charge nurse who medicated the resident at this time. At 10:30 A.M. the surveyor revisited the resident. The resident verbalized that the pain was "little better" in a whispered voice. When asked about her broken arm, the resident stated "they pulled me out of the chair, hurt me". Nursing notes dated 04/16/11 at 3:30 P.M. revealed the resident was sitting in her recliner and complained of right arm discomfort. The resident was given an anti-pain medication (Tylenol) 650 milligrams (mg). At 4:00 P.M. on this same date, nursing notes revealed that the "resident again complained of right arm pain." The resident's arm was examined with no reddened or discolored areas noted on her skin, skin intact, range of motion is limited due to history of CVA with right side weakness. At 11:00 P.M. revealed the resident complained of right arm pain and was medicated again with Tylenol. Nursing notes dated 04/17/11 at 12:00 A.M. (one hour later) revealed the resident was crying. The resident stated the Tylenol did not help with the pain. The resident was medicated with a narcotic analgesic medication (Tramadol) at this time. At 4:27 A.M. the nursing notation revealed the resident to be awake requesting something to drink. The resident informed the nurse that "pain diminished but still present". At 5:57 A.M. the resident stating her right arm aches. The resident was offered pain medication but refused indicating "I don't want that." The resident was repositioned "with some success." At 6:00 A.M. the resident was now requesting the Tylenol medication which was given to the resident. At 6:31 A.M. the resident's arm was examined. No discoloration or irregularities noted to the skin. Range of motion "unable to assess due to right sided weakness from prior CVA" (had limited range of motion noted on 04/16/11). The resident stated that the "Tylenol helped a little." At 9:22 A.M. the resident was medicated again with the Tramadol for complaints of right upper arm pain. Nursing notes dated 04/18/11 at 8:00 A.M. revealed the resident sitting in her recliner in her room "still complaining of right arm pain." The nurse again medicated the resident and attempted range of motion to her arm with the resident crying out "with any movement to her right arm." Mild swelling was noted to the right hand fingers. The physician was finally called and notified regarding Resident #7's complaint of arm pain (three days after the beginning of the complaints of arm pain). An x-ray was ordered and completed with results per nursing notes dated 04/18/11 at 7:32 P.M., showing a fractured right shoulder. X-ray results dated 04/18/11 revealed a fracture at the proxima humerus of the right shoulder and was confirmed at an orthopedic appointment on 04/19/11. On 05/05/11 at 1:30 P.M. review of the facility investigation for the fractured right humerus for Resident #7 revealed statements from two state tested nursing assistants (STNAs) who had transferring the resident from her recliner chair on 04/16/11 at 2:00 P.M. (one hour prior to the onset of right arm pain). Both staff indicated the recliner chair to be broken with the bottom leg rest stuck in an upward position approximately six to eight inches. Both staff statements stated that "they decided to do a fireman transfer" of the resident from the recliner. They transferred the resident out of the recliner and placed her on her right side in the bed. At 2:00 P.M., during interview with the facility director of nursing (DON), administrator and MDS nurse, the administrator stated that the fireman transfer involves a staff member on each side of the resident with arms clasped together under the resident's buttocks and their other arms clasped together across the resident's back. She indicated that the staff put their arm under each of the residents arms (under arm pits of resident), clasp their hands together and on the count of three, lifted the resident out of the recliner. The administrator stated that she did not consider the fracture of the resident's arm to be an injury of unknown origin because she "knew it was caused from the transfer." At 2:30 P.M. the DON verified that both staff involved in the improper transfer of Resident #7 out of the broken recliner chair were disciplined. This deficiency substantiates Complaint Number OH 534.