Every finding on record at Westerville Post Acute

Based on observations, medical record review, staff and resident interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of one resident (#640) out of five residents observed for call light placement. The facility census was 89.Findings include: Review of the medical record for Resident #640 revealed an admission date of 01/24/22 with diagnoses of but not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease hyperlipidemia, morbid obesity, hypertension, major depressive disorder, Alzheimer's disease with late onset, dementia, chronic respiratory failure, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment, was dependent on a wheelchair for mobility, and required maximal to dependent assistance for activities of daily living (ADLs). Review of the care plan dated 09/03/25 for Resident #640 revealed a focus of fall risk characterized by impaired mobility and medication use with an intervention of call light accessible when in room.Observation on 05/20/26 at 8:14 A.M. revealed the call light was wrapped around the top rail of Resident #640's bed and Resident #640 was in her wheelchair.Interview on 05/20/26 at 8:14 A.M. with Resident #640 revealed she was looking for her call light, didn't know where it was, then looked on the bed rail and said over there.Interview on 05/20/26 at 8:14 A.M. with Registered Nurse (RN) #220 verified the call light was wrapped around the bed rail and out of Resident #640's reach.Interview on 05/21/26 at 7:31 A.M. CNA #485 stated Resident #640 does use her call light.Review of the facility policy Call Light Response dated 07/2024 revealed call lights are a method of notification for those in need of assistance, be it in the form of medical, social, or other. All employees are to ensure proper response time and service to call lights initiated.This deficiency represents non-compliance investigated under Complaint Number 3011104.

Based on interview, record review, and facility policy review, the facility failed to ensure dietary preferences were honored. This affected two residents (#605 and #630) of five residents reviewed for food preferences. The facility census was 89.Findings include:1.Review of the medical record for Resident #605 revealed an admission date of 01/05/26 with diagnoses of but not limited to hydronephrosis with renal and ureteral calculous obstruction, severe protein-calorie malnutrition, pressure ulcer to left buttock stage 3, diastolic heart failure, adult failure to thrive, hypertension, spastic hemiplegia affecting left nondominant side, cognitive communication deficit, and obstructive reflux uropathy.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status of 12 which indicated moderate cognitive impairment, was dependent on staff for all activities of daily living (ADLs), and required supervision for eating.Review of the care plan for Resident #605 revealed a focus of Resident #605 admitted with diagnoses of protein-calorie malnutrition. At risk for nutrition changes related to recent admission, recent hospitalization, chronic conditions, history of altered texture diet, missing teeth, history of abnormal nutrition related to labs, congestive hear failure, risk for fluid shifts, and advanced age greater than 65 with interventions to include provide diet per order, honor food preferences, encourage to eat and drink, and feed/assist with meals as needed.Review of diet order for Resident #605 revealed regular diet, regular texture, thin liquid consistency.Review of dietary interview dated 01/06/26 for Resident #605 revealed no preferences, likes, or dislikes where checked. Review of the meal tickets for breakfast, lunch, and dinner for Resident #605 had no preferences or dislikes listed.Interview on 05/21/26 at 8:27 A.M. with Dietary Director #865 revealed she does an interview with the residents at admission to discuss dietary preferences. Dietary Director #865 revealed she puts the residents' dislikes on the meal tickets unless the dislike list is too long. Dietary Director #865 stated there is an always available menu which residents can order from if they do not want what is on their tray or menu. Interview on 05/21/26 at 10:10 A.M. with Dietary Director #865 verified the dietary interview for Resident #605 did not have preferences, likes, or dislikes checked. Dietary Director #865 stated she did not do the dietary interview for Resident #605. Dietary Director #865 verified the meal ticket for breakfast, lunch, and dinner for Resident #605 did not have any dislikes on it.Interview on 05/21/26 at 10:46 A.M. with Resident #605 revealed she does not like much of the food at the facility. Resident #605 stated she did have a dietary interview when she admitted to the facility and told the person her food dislikes and likes. Resident #605 stated she did get things on her tray which she did not like. Resident #605 stated she did not know there was an always available- menu until just a few minutes ago when the Dietary Manager came to her room to ask about her preferences and told her about the always available menu. Resident #605 stated she liked grilled cheese and stated she would be ordering them. Interview on 05/21/26 at 10:18 A.M. Director of Nursing verified there were no preferences, likes, or dislikes on Resident #605's dietary interview or meal tickets for breakfast, lunch, and dinner.2. Review of the medical record for Resident #630 revealed an admission date of 09/24/25 with diagnoses of but not limited to chronic obstructive pulmonary disease, muscle weakness, type two diabetes, acute and chronic respiratory failure, hypertension, and major depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #630 had a BIMS of 15 which indicated no cognitive impairment, and required set up for her meals.Review of the care plan for Resident #630 revealed a focus of Resident #630 is at risk for malnutrition related to chronic condition, need for therapeutic diet, diabetic, chronic respiratory condition, congestive heart failure, fluid restriction, obesity, history of significant weight changes and advanced age with interventions to include food preferences per resident choice and observe for signs and symptoms of malnutrition as evidenced by emaciation, refusing meals, significant weight loss, significant abnormal lab values, signs and symptoms of dehydration, and report to physician as needed.Review of diet order for Resident #630 revealed consistent carbohydrate diet, cardiac diet, regular texture, thin liquid consistency.Review of dietary interview dated 09/26/25 revealed no preferences, likes, or dislikes were checked.Review of the meal tickets for breakfast, lunch, and dinner for Resident #630 revealed no preferences or dislikes listed.Interview on 05/20/26 at 3:00 P.M. with Resident #630 revealed the food at facility was terrible. Resident #630 stated she had a note which said she did not like chicken and she still gets it on her tray. Resident #630 stated no dietician interviewed her at admission.Interview on 05/21/26 at 10:10 A.M. with Dietary Director #865 verified the dietary interview for Resident #630 did not have preferences, likes, or dislikes checked. Dietary Director #865 stated she did not do the dietary interview for Resident #630. Dietary Director #865 verified the meal ticket for breakfast, lunch, and dinner for Resident #630 did not have any dislikes on it.Interview on 05/21/26 at 10:18 A.M. Director of Nursing verified there were no preferences, likes, or dislikes on Resident #630's dietary interview or meal tickets for breakfast, lunch, and dinner.Review of the facility policy, Food and Nutrition Services, dated 2001, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intakes and utilization.This deficiency represents non-compliance investigated under Complaint Number 3011104.

Based on observations, interviews, record review, the facility failed to follow infection control procedures during incontinence care. This affected one residents (#630) of the five residents reviewed for incontinence care. The facility census was 89.Findings include:Review of the medical record for Resident #630 revealed an admission date of 09/24/25 with diagnoses of but not limited to chronic obstructive pulmonary disease, muscle weakness, type two diabetes, acute and chronic respiratory failure, hypertension, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #630 had a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment and was dependent on staff for toileting hygiene.Review of the care plan for Resident #630 revealed a focus of resident is incontinent of bowel and bladder due to limited mobility, medication use, and overactive bladder wit interventions to include provide check and change incontinence management and observe for signs and symptoms of urinary tract infection and notify physician of abnormal findings.Observation on 05/20/26 at 1:57 P.M. to 2:09 P.M. revealed Certified Nursing Assistant (CNA) 3930 went into Resident #630's bathroom and washed her hands and put on gloves. Then CNA #930 carried two wash basins into the room and set them on a bedside table. Then CNA #930 moved Resident #630's bed up and put a plastic bag at the end of the bed. Then CNA #930 put wash clothes into each of the basins and placed a towel across Resident #630's abdomen. Then CNA 3930 performed incontinent care on Resident #630. Afterwards, CNA #930 put the trash and wash clothes into two separate bags and took the wash basins into Resident #630's bathroom and emptied them. While in the bathroom, CNA #930 removed her gloves and washed her hands.Interview on 05/20/26 at 2:11 P.M. CNA #930 verified she put her gloves on while gathering supplies and did not remove her gloves until after performing incontinent care for Resident #630.Review of the facility, Hand Hygiene policy dated 2001 revealed hand hygiene is indicated immediately before touching a resident.Review of the facility policy Perineal Care dated 2001 revealed the procedure included place the equipment on the bedside stand. Arrange the supplies so they can be easily reached, wash and dry your hands thoroughly, fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within easy reach. Fold the bedspread or blanket toward the foot of the bed. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. Raise the gown or lower pajamas. Avoid unnecessary exposure of the resident's body. Put on gloves. Ask the resident to bend his or her knees and put his or her feet on the mattress. Assist as necessary.This deficiency represents non-compliance investigated under Complaint Number 3011104.

Based on medical record review, staff interviews, pharmacist interview, and review of facility policy, the facility failed to have an adequate post discharge plan for medication administration when the facility did not ensure an adequate supply of medications were available for a resident at discharge. This affected one former resident (#95) out of three residents reviewed for discharge planning. The facility census was 91 residents. Findings Include:Review of a closed medical record revealed that former Resident #95 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, hypertension, malignant neoplasm of kidney, and atrial fibrillation.Review of Resident #95's Minimum Data Set (MDS) 3.0 assessment on 12/12/25 revealed that Brief Interview with Mental Status (BIMS) score of 15, indicative of intact cognitive status. Resident #95 was assessed as being on antidepressant, anticoagulant, antiplatelet and diuretic medications.Review of Resident #95's discharge summary initiated on 12/10/25, revealed Resident #95 was discharging to home in the community. Resident #95's primary care physician appointment was made for 12/18/25. The pharmacy, home health company, and durable medical equipment company were listed in the discharge summary. The summary indicated that Resident #95 was given a copy of his current medications and when they were last received. The discharge summary was signed by Resident #95 on 12/12/25.Review of Resident #95's progress notes dated 12/12/25 revealed that Resident #95 was discharging home from his dialysis appointment. Medications were sent with the resident. Resident #95 was educated on his upcoming appointments and medication schedule.Review of Resident #95's physician orders revealed that on his discharge date of 12/12/25, Resident #95's prescribed medications included: amlodipine besylate (a calcium channel blocker to treat high blood pressure), atorvastatin (a medication to treat high cholesterol), darbepoetin alfa injection solution (a man-made form of protein to help the body produce red blood cells), melatonin (a natural hormone and supplement that regulates the sleep-wake cycle), midodrine (a medication used to treat severe low blood pressure), mirtazapine (an antidepressant to treat major depressive disorder), pantoprazole (a proton pump inhibitor that decreases the amount of acid produced in the stomach), torsemide (a loop diuretic used to treat fluid retention and high blood pressure), warfarin sodium (an anticoagulant used to prevent and treat blood clots), metoprolol tartrate (a beta blocker medication used to treat high blood pressure), and Renvela (a phosphate binder used to control high phosphorus levels in people with chronic kidney disease). An interview with Family Member #530 on 05/04/26 at 9:22 A.M. revealed that Resident #95 did not have medications that were important for his health conditions for several days after discharge because the facility failed to call the medications into Resident #95's pharmacy upon discharge.An interview with Pharmacist #500 on 05/06/26 at 11:36 A.M. revealed that Nurse Practitioner #455 called in Resident #95's medications to the pharmacy on 12/16/25, four days after Resident #95 discharged from the facility.An interview with the Director of Nursing (DON) on 05/06/26 at 2:16 P.M. confirmed that the supply of medications given to Resident #95 was only sufficient to cover one additional day of medications, as the facility pharmacy only delivered one day of medication in advance. The nurse practitioner was responsible for ordering the medications into the pharmacy upon discharge. She stated if the resident had already been discharged out of the electronic medical record, the nurse practitioner would have to physically call the pharmacy to get the medications ordered for the resident.Review of the facility policy titled, Discharge Summary and Plan, dated March 2025, revealed that as part of the discharge summary, the nurse reconciles the pre-discharge medications with the resident's post-discharge medications. The final discharge plan of care shows what arrangements have been made for the resident regarding needed medical services. The discharge plan will meet the resident's health and safety needs.This represents noncompliance investigated under Complaint Number 2734219.

Based on review of resident medical records, resident interviews, staff interviews and review of facility policy, the facility failed to offer activities of interest to residents. This affected one resident (#95) out of four residents reviewed for activities. The facility census was 91 residents. Findings include:Review of a closed resident medical record revealed that Former Resident #95 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and depression. Review of Former Resident #95's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15, indicative of cognitively intact status. Resident #95 was assessed as having books, newspapers and magazines to read while in the facility as somewhat important to him. He was assessed as feeling that it was somewhat important for him to have music that he liked to listen to while he was in the facility. It was also somewhat important to him to do things in groups of people, to keep up with the news, to participate in religious services or practices, and to do his favorite activities. Review of Former Resident #95's activity assessment dated [DATE] revealed that it was somewhat important for him to have books, newspapers and magazines to read, to listen to music that he liked, to do things in groups of people, to keep up with the news, to participate in religious services and to do his favorite activities while he was in the facility. His other interests included fishing and skiing. It was noted that Former Resident #95 preferred in-room activities. Review of Former Resident #95's care plan dated 11/26/25 revealed that Resident #95 had a need for activities that were consistent with his abilities and interests. Enjoyable meaningful activities listed included, but were not limited to, music and one on one visits. A goal listed included for Former Resident #95 to continue to pursue independent activities of choice as well as group programs, while accepting one to one visits to promote socialization and mental stimulation, encouragement and prevent episodes of depression to the extent possible. Interventions included to assist Former Resident #95 to and from activity locations as needed, to assist with in-room activities as needed, to couple him with peers of similar interest, to encourage to attend activities of interest, providing assistance as needed, to provide activity materials like books, magazines, television, arts and crafts in accordance with interests, and to have room visits for socialization as needed. Review of activity logs for Former Resident #95 revealed that there were no documented one on one visits, and no group activities listed. Review of Former Resident #95's medical record revealed that there was no documentation of any activities offered or provided to Former Resident #95. An interview with Activity Director #379 on 05/05/26 at 11:53 A.M. confirmed that she did not have any evidence that activities were offered to Former Resident #95 and that she did not have activity logs available for Former Resident #95 for either one on one visits or group activities. Review of the facility policy titled, Activity Programs, revised June 2018, revealed that activities are offered based on the resident-centered assessment and the preferences of each resident. All activities are documented in the resident's medical record. This represents noncompliance investigated under Complaint Number 2734219.

Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure Resident #25 was free from a significant medication error when the physician was not notified of a high blood glucose per sliding scale order. This affected one resident (#25) of two residents reviewed for insulin management. The facility census was 91.Findings Include: Review of Resident #25's medical record revealed an admission date of 04/25/26 with diagnoses that included but were not limited to diabetes type one (DM), hypertension and chronic obstructive pulmonary disease. Review of Resident #25's functional abilities assessment dated [DATE] revealed he required assistance from staff with toileting, dressing and mobility.Review of Resident #25's physicians orders dated 04/25/26 revealed the following orders for insulin: Insulin Glargine Subcutaneous Solution 100 units per milliliter (ml) with instructions to inject 15 units subcutaneously one time a day; Insulin Lispro Injection Solution 100 units per ml with instructions to inject eight units three times a day for DM and to give with sliding scale; and Insulin Lispro Injection Solution 100 units per ml with instructions to inject as per sliding scale: if blood sugar 151-200 milligrams per deciliter (mg/dL) give one unit; 201-250 mg/dL give two units; 251-300 mg/dL give three units; 301-350 mg/dL give four units; 351-400 mg/dL give five units, and to NOTIFY MD [medical doctor] WHEN BS [blood sugar] IS ABOVE 400. There were no orders for a continuous glucose monitor.Review of Resident #25's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 14 indicating intact cognition.Observation of medication administration on 05/06/26 at 8:30 A.M. for Resident #25 revealed Licensed Practical Nurse (LPN) #143 stated the resident was due for his insulin and he used a glucose monitoring sensor and she would check the reading prior to giving insulin. Upon entering the room, LPN #143 asked the resident if he could check his monitor for a blood glucose reading, at that time the monitor read the word HI with no associated number reading. LPN #143 returned to her cart and drew up 13 units of Lispro. She returned to the resident who requested a manual blood sugar check. LPN #143 did not respond and gave the insulin. Interview on 05/06/26 at 8:40 A.M. with LPN #143 confirmed she did not take a manual glucose reading after Resident #25 requested to confirm accuracy. She also verified she had not contacted the physician of the HI blood glucose reading stating she would re-check his glucose reading in about 30 minutes.Review of Resident #25's medication administration record (MAR) dated 05/06/26 at 8:43 A.M. revealed LPN #143 documented a blood glucose reading of 388 mg/dL.Observation on 05/06/26 at 9:25 A.M. revealed Resident #25 had a blood glucose reading on his continuous monitor as HI. Resident #25 expressed at that time the nurses should take his blood glucose manually to check if his continuous glucose monitoring readings are accurate because sometimes they vary.Interview on 05/06/26 at 9:30 A.M. with the Director of Nursing (DON) confirmed Resident #25 received insulin for a high blood glucose reading and the physician was not notified. After surveyor intervention, the DON notified the nurse practitioner (NP) of the high blood sugar and LPN #143 was instructed to obtain a manual reading. Resident #25's blood sugar was 491 mg/dL and orders were received for five additional units and to monitor.Review of facility policy titled Insulin Administration dated March 2025 revealed the nurse will notify the provider of any discrepancies prior to administering insulin and the nurse must document the resident's blood glucose result, as ordered.This deficiency represents non-compliance investigated under Complaint Number 2747255.

Based on observation and interview, the facility failed to ensure that opened bulk medications were properly labeled with an open date or discard date to prevent the risk of use of contaminated or expired medications. This had the potential to affect all 32 residents in the 400 hall receiving medications. The facility census was 91.Findings Include: Observation on 05/05/26 at 7:45 A.M. of medication storage for the 400 hall nurses cart revealed the following opened and undated bulk medications: Milk of Magnesia 473 milliliter (ml) bottle that was half empty; Tylenol 325 milligram (mg) 100 count bottle that was half empty; Tylenol 500 mg 100 count bottle that was half empty; Active Liquid Protein 887 ml bottle that was half empty; Geri-Tussin 473 ml bottle that was half empty; and Alkums antacid tablets 150 count bottle that was half empty.Interview on 05/05/26 at 7:45 A.M. with Licensed Practical Nurse (LPN) #525 revealed opened bulk medication bottles once opened should be dated with the open date. LPN #525 also verified the above medications were not dated.

Based on record review, interview and facility policy review, the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #16) out of three residents reviewed for wound care. The facility census was 84. Findings include: Review of the medical record for Resident #16 revealed an admission date of 10/16/24 with diagnoses including mild cognitive impairment, borderline personality disorder, type II diabetes mellitus, non-pressure chronic ulcer of the right foot, paraplegia, chronic kidney disease, anxiety, depression and osteomyelitis of the vertebra. Review of the care plan dated 10/26/24 revealed Resident #16 has an alteration in skin integrity with an unstageable pressure injury (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) in the wound bed) to the right buttock and a deep tissue injury (DTI) (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) to the left heel. Interventions included administering medications per physician orders, documenting wound status weekly and as needed, elevating heels, monitoring wounds for signs or symptoms of infection, and completing treatments per order. Review of a physician order dated 07/03/25 revealed a left heel DTI with directions to apply Skin-Prep (forms a protective barrier) to the peri-wound, paint the DTI with Betadine (disinfectant), cover with an absorbent dressing, and wrap with Kerlix gauze. Dressing changes were to occur every shift and as needed for soiled or dislodged dressings. Review of a wound care provider progress report dated 07/17/25 revealed treatment orders for: Left midline heel: Paint the area with Betadine, cover with an absorbent pad dressing, and wrap with rolled gauze twice daily (BID) and as needed (PRN). Right medial gluteal fold: Cleanse with Dakin's solution (disinfectant), pat dry, apply medical-grade honey (antimicrobial to promote healing) and calcium alginate (dressing for wounds with moderate to heavy drainage), and cover with a foam dressing BID and PRN. Review of a physician order dated 07/18/25 revealed an unstageable right buttock pressure injury with directions to cleanse with Dakin's solution, pat dry, apply Medi-Honey, and cover with calcium alginate and a sacral foam dressing. The dressing was to be changed every shift and as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 07/18/25 revealed Resident #16 is cognitively intact, had impairments in both lower extremities, requires substantial to maximal assistance with bathing, and has one unstageable wound and one DTI. Review of the Braden Assessment (tool to predict the risk of pressure ulcers) completed 07/25/25 revealed Resident #16 had no sensory perception impairment, very moist skin, was chairfast, completely immobile, had adequate nutrition, and showed no apparent problem with friction or shear placing the resident at risk for pressure sores. Review of the Treatment Administration Record (TAR) for 07/26/25 through 07/31/25 revealed dressing changes to the left heel DTI and unstageable right buttock pressure injury were not marked as completed or refused on 07/26/25 or 07/27/25. Review of progress notes dated 07/26/25 through 07/27/25 revealed no documentation of refusal or completion of the left heel DTI or right buttock dressing changes for Resident #16. Resident #16 expressed concerns regarding missed wound care during the night shifts on 07/26/25 and 07/27/25. She stated that nursing staff neither offered nor provided the scheduled dressing changes, and she did not refuse the care. Interview conducted on 07/31/25 at 10:20 A.M. with the Director of Nursing (DON) confirmed Resident #16's medical record did not contain evidence the resident received the physician-ordered dressing changes on 07/26/25 and 07/27/25. The DON confirmed if a treatment was refused, it should be documented on the TAR and followed up with a progress note that included notification to the wound nurse and physician. The DON confirmed Licensed Practical Nurse (LPN) #118 was assigned to complete the dressing changes for Resident #16 on those dates. Interview conducted on 07/31/25 at 1:22 P.M. with LPN #118 confirmed if dressing changes were completed, they should be documented on the TAR. If refused, it should also be documented on the TAR with a corresponding progress note. Review of the facility's dry/clean dressing policy (undated) revealed that documentation should include the date and time the dressing was changed, the name and title of the person who changed the dressing, type of dressing and wound care provided, any problems or complaints, and if the resident refused treatment the reason for refusal, the explanation of risks and benefits, alternative options, and the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number 2566099.

2. Review of Resident #25's medical record revealed an admission date of 10/04/21 with diagnoses including epileptic seizures related to external causes, disease of esophagus, major depressive disorder, anxiety disorder, encephalopathy, dysphagia, psychotic disorder with delusions, personal history of traumatic brain injury, and other sexual dysfunction not due to a substance or known condition. Review of Resident #25's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. He had verbal behaviors directed towards others and rejection of care daily. Review of Resident #25's plan of care dated 04/15/24 revealed he required the use of psychotropic medications with potential for adverse reactions related to diagnoses. Interventions included adjusting room temperature and lighting, administering medications as ordered, assessing comfort levels as needed, encouraging appropriate mobility aides and safety devises, encouraging to verbalize feelings, evaluating effectiveness of medications, and keeping environmental noise to a minimum. Review of Resident #25's physician order dated 06/02/25 to 06/16/25 revealed an order for olanzapine 2.5 milligrams (mg) every six hours as needed for mood stabilizer. Review of Resident #25's physician order dated 6/11/25 to 06/24/25 revealed an order for Lorazepam one mg by mouth every eight hours as needed for anxiety. Review of Resident #25's Medication Administration Record (MAR) from 06/01/25 to 06/24/25 revealed Olanzapine was administered once on 06/02/25, 06/04/25, 06/10/25, and 06/12/25 and twice on 06/03/25. Lorazepam was administered on 06/17/25, 06/18/25, 06/19/25, 06/20/25, 06/22/25, 06/23/25, and 06/24/25. Review of Resident #25's progress notes revealed there was no description of behavior or justification for 'as needed' Olanzapine on 06/02/25, 06/03/25, 06/04/25, 06/10/25, and 06/12/25 or for 'as needed' Lorazepam on 06/17/25, 06/19/25, 06/20/25, 06/22/25, 06/23/25, and 06/24/25. Interview on 06/25/25 at 12:30 P.M. with Assistant Director of Nursing (ADON) #156 and the Director of Nursing (DON) verified there was no description of behaviors with the administration of as needed medications and should be. Based on staff interview and record review, the facility failed to have appropriate diagnoses to support the use of antipsychotic medication for Resident #22 and failed to adequately monitor behaviors prior to administering as-needed psychotropic medications for Resident #25. This affected two residents (Resident #22 and Resident #25) of five reviewed for antipsychotic medication administration. The facility census was 83. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 01/10/24 revealed Resident #22 requires use of psychotropic medications with potential for adverse reactions related to depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications per physician order and evaluating effectiveness and side effects for possible dose decrease or elimination of psychotropic drugs. Review of physician orders dated 01/19/25 revealed an order for olanzapine oral tablet 5 milligrams (mg) by mouth twice daily for agitation. Review of physician orders dated 05/10/25 revealed an order for olanzapine oral tablet 5 mg by mouth twice daily for major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. The resident was currently receiving antipsychotic, antianxiety, and antidepressant medications. Interview on 06/26/25 at 1:26 P.M. with Social Worker (SW) #195 confirmed olanzapine is not appropriate for treatment of major depressive disorder or agitation. Social Worker #195 stated the medication label for olanzapine indicates usage for bipolar disorder and schizophrenia, neither of which are active diagnoses for Resident #22. SW #195 confirmed bipolar which was listed as an active diagnosis was marked incorrectly on Resident #22 medical diagnoses. Review of the U.S. Food and Drug Administration (FDA) drug label for olanzapine revealed indications for treatment of schizophrenia, acute treatment of manic or mixed episodes associated with bipolar I disorder, and maintenance treatment of bipolar I disorder. Review of antipsychotic medication use policy dated 07/2022 revealed residents will only receive antipsychotic medications when necessary to treat specific condition for which they are indicated and effective.

Based on staff interview and record review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for PASARR. The facility census was 83. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 08/21/23 revealed Resident #22 was at risk for changes in mood related to diagnoses of depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications as ordered, allowing time to express feelings, and encouraging participation in preferred activities. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 is cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. Review of the Pre-admission Screening and Resident Review (PASARR) dated 06/20/23 listed the following mental health diagnoses for Resident #22: mood disorder, panic or other severe anxiety disorder, unspecified anxiety disorder, post-traumatic stress disorder, major depressive disorder, and insomnia. Diagnoses of borderline personality disorder, other specified personality disorder, and bipolar disorder were not included. Interview on 06/25/25 at 3:48 P.M with Social Worker #195 confirmed the PASARR submitted on 06/20/23 did not include borderline personality disorder or other specified personality disorder. The social worker stated bipolar disorder was listed in error and would be removed from the resident's active diagnosis list. Social Worker #195 acknowledged a new PASARR would need to be submitted to the state mental health authority with the correct diagnoses, including borderline personality disorder and other specified personality disorder.

Based on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR). The facility census was 83. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 08/21/23 documented Resident #22 was at risk for changes in mood related to diagnoses of depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications as ordered, allowing time to express feelings, and encouraging participation in preferred activities. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #22 was cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. Review of the Pre-admission Screening and Resident Review (PASARR) dated 06/20/23 listed the following mental health diagnoses: mood disorder, panic or other severe anxiety disorder, unspecified anxiety disorder, post-traumatic stress disorder, major depressive disorder, and insomnia. Diagnoses of borderline personality disorder and other specified personality disorder were not included. Interview on 06/25/25 at 3:48 P.M. with Social Worker #195 confirmed the resident's current diagnoses included borderline personality disorder and other specified personality disorder. The social worker stated bipolar disorder had been marked in error on the resident's diagnosis list and would be removed. Social Worker #195 acknowledged the PASARR submitted on 06/20/23 did not reflect all current and accurate diagnoses and stated a revised PASARR would need to be submitted to the state mental health authority.

Based on interview and record review the facility failed to hold a timely admission care conference for one resident. This affected one resident (#188) of three residents sampled for care planning. The facility census was 83. Findings include: Review of Resident #188's medical record revealed an admission date of 06/03/25 and diagnoses including chronic obstructive pulmonary disease, cerebral infarction, atrial fibrillation, major depressive disorder, anxiety disorder, adjustment disorder with depressed mood, polyneuropathy, hypertension, antisocial personality disorder, and insomnia. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #188 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Further review revealed the resident had daily verbal behaviors directed at others and rejected care daily. Review of Resident #188's physicians' orders revealed an order for two staff members to be in his room for any care or contact dated 06/04/25. Review of Resident #188's medical record revealed no evidence of an admission care conference being held with Resident #188. In an interview on 06/23/25 at 9:47 A.M. Resident #188 stated that he had not had a care conference meeting since being admitted to the facility. In an interview on 06/25/25 at 8:56 A.M. the Administrator confirmed an admission care conference had not yet been held with Resident #188. The Administrator stated the care conference had been scheduled. In an interview on 06/25/25 at 10:45 A.M. the Administrator revealed a care conference was scheduled with Resident #188 on 06/26/25 from 12:30 P.M. to 1:00 P.M. Review of the policy titled Care Planning - Interdisciplinary Team (revised 03/2022) revealed the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. further review revealed that if it was determined that participation of the resident or the resident's representative was not practicable an explanation would be documented in the record.

Based on observation, resident interview, staff interviews, personnel file reviews, record review and policy review, the facility failed to ensure activities were offered to meet the individualized needs of a resident. This affected one resident (#48) of one resident reviewed for activities. The facility census was 83. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. She needed substantial assistance for bathing and personal hygiene and was dependent on staff for toileting, lower body dressing and transfers. Review of the care plan dated 10/14/24 revealed Resident #48 was capable of pursuing independent and group activities, that the goal for Resident #48 was to participate in 3-5 activities a week. Interventions on the care plan included: Encourage attendance and participation in activities, Invite resident to attend scheduled activities and provide assistance/escort to activity functions. The care plan also noted that resident was at risk for psychosocial well being concerns and an intervention suggested to enhance her well being was for staff to encourage involvement in activities. Review of the Activities Assessment for Resident #48 dated 04/18/25 revealed Resident #48 rated the following activities as very important: having books, newspapers and magazines to read; listening to music; doing things with groups of people; going outside when weather is good; and being around animals. Interview on 06/23/25 at 10:01 A.M. with Resident #48 said she is dependent on staff to help her get up to go to activities and they haven't been taking her. She said they do not bring activities for her to do in her bed and specified, not even a book. Observation on 6/24/25 at 1:52 P.M. confirmed resident had an activity calendar posted in her room on the wall out of her reach. Interview on 06/24/25 at 1:53 P.M. with Resident #48 revealed she likes to work with pastels but hasn't had the opportunity since she arrived at the facility. She would like to do word search and finds, jumbles or freestyle art. She said that these were not provided for her. She said she hadn't been to a facility activity in months. Interview on 06/25/25 at 8:32 A.M. with Activities Assistant #148 confirmed that while she is a trained aide and could assist with getting Resident #48 to an activity, she could not recall the last activity that was offered to Resident #48. She said they deliver the calendars and the newsletters to the room. She said she knows the resident likes bingo and reads articles on her phone. Interview on 6/25/25 at 1:33 P.M. with Activities Director #188 confirmed she is new in the role and she could not find any written documentation of when activities were offered to Resident #48. She also was unable to locate any documents that confirmed Resident #148's attendance at an activity in past three months. Review of personnel files for previous activities director confirmed previous activities director was terminated on 03/20/25. Review of personnel file for current Activities Director #188 confirmed her enrollment in activities certification program was paid for on 06/25/25. Review of facility policy titled, Activities Evaluation noted activities assessment should be integrated into individualized care plan for residents and the activities are offered in a way that accommodates a resident's physical limitations.

Based on observation, interview, and record review revealed the facility failed to ensure a hand protector was in place for Resident #35 as ordered. This affected one resident (#35) of three residents reviewed for positioning and mobility. The facility census was 83. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting left side, type two diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. She had a range of motion impairment of upper and lower extremity on one side. Review of Resident #35's plan of care dated 10/29/24 revealed the resident required use of splinting palm protector of left hand. She was at risk for skin irritation and or breakdown contracture. Interventions included assessing splint or brace for defects, cleansing area of skin, and inspecting skin for irritation. Review of Resident #35's physician order dated 10/29/24 revealed an order for a hand splint palm protector to the left hand every shift. Observation on 06/24/25 at 10:45 A.M., 3:39 P.M., and 4:21 P.M., on 06/25/25 at 10:10 A.M., and on 06/26/25 at 7:49 A.M., 9:00 A.M., and 10:00 A.M. revealed Resident #35's palm protector was not in place. Interview on 06/26/25 at 10:05 A.M. Licensed Practical Nurse (LPN) #236 verified the protector was not in place, she searched the bedside table and was unable to find it. At 10:05 A.M. she reported she got a new palm protector to put in place. LPN #236 reported that the resident usually tolerates the splint well and does not refuse it.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a complete investigation was completed to determine root cause analysis when a resident sustained a fall and failed to ensure fall safety interventions were in place as per residents care plan. This affected three residents (#238, #3, and #79) of the six residents reviewed for accidents and falls. Facility census was 83. Findings include: 1. Review of the medical record for Resident #238 revealed an initial admission date of 08/30/2023, a re-entry date of 11/20/2024 and a discharge date of 12/03/2024. Diagnoses included non-traumatic intracerebral hemorrhage, dementia, and hypertension. Review of Resident #238's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating an severely impaired cognition for daily decision making abilities. Resident #238 was noted to display behaviors including rejection of care. Resident #238 was noted to be free of any impairment to his upper and lower extremities and was noted to be independent with all activities of daily living and mobility. Review of Resident #238's admission Fall Risk assessment dated [DATE] revealed a score of 8 indicating this resident was at a low fall risk. Review of Resident #238's annual Fall Risk assessment dated [DATE] revealed this assessment was incomplete. Review of the progress note dated 11/08/2024 at 9:15 A.M. revealed Patient states he fell last night and ever since he is unable to move his right leg. Upon assessment patient's right hip and leg noted with some redness, unable to do range of motion, patient also noted crying during assessment. He usually walks around the facility but unable to even sit up at this time. Nurse Practitioner instructed nursing to transfer patient to the hospital for further evaluation. Continued review of Resident #238's medical records revealed no evidence to support that a post fall investigation was completed or if this reported fall was reviewed. Interview on 06/26/2025 at 3:00 P.M. with Regional Nurse #252 confirmed Resident #238's annual Fall Risk Assessment was incomplete as well as confirming a fall investigation was not completed for the reported fall that was said to have occurred on 11/07/2024 reported by the the resident. Review of the facility policy titled Falls Clinical Policy, revised 03/2018 revealed For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the cause of the fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. 3. Review of the medical record for Resident #79 revealed an admission date of 05/28/25, with diagnoses including chronic respiratory failure, hypertension, dissection of the ascending aorta, cerebral infarction, history of transient ischemic attack, metabolic encephalopathy, hemiplegia, and hemiparesis. Review of the hospital Discharge summary, dated [DATE], revealed activity instructions indicating that a helmet should be used during resident transfers and when the resident was out of bed. Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 06/04/25, revealed Resident #79 was severely cognitively impaired and dependent on staff for all activities of daily living and ambulation. Observation on 06/23/25 at 9:21 A.M. revealed Resident #79 was seated in a recliner, engaged with staff, and wearing a protective head cap during the encounter. Review of the medical record on 06/23/25 showed no documentation specifying the requirement, frequency, or circumstances for wearing head protection. Observation on 06/24/25 at 7:32 A.M. revealed signage in Resident #79 ' s room, located behind the television, stating, STOP NO BRAIN FLAP ON LEFT SIDE. At that time, Resident #79 was lying in bed without the protective head cap. Interview on 06/26/25 at 2:11 P.M. with Registered Nurse #194 confirmed information about the indication and frequency for the use of the protective head covering should be documented either in the care plan or in physician orders. Interview on 06/26/25 at 2:14 P.M. with Assistant Director of Nursing (ADON) #146 confirmed that neither the care plan nor the physician's orders included documentation about the indication, frequency, or rationale for the use of the protective head cap. ADON #146 acknowledged that this information was only added after surveyors requested clarification, and that prior to the request, there was no system in place to ensure staff had consistent guidance on the use of head protection for Resident #79. This deficiency represents non-compliance investigated under Complaint Numbers OH00164069, OH00163718. 2. Review of Resident # 3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physicians orders dated 05/30/25 revealed no orders for fall interventions. Review of Resident #3's fall risk care plan dated 11/01/24 to 09/16/25 revealed fall interventions for a low bed, initiated on 02/03/25 and a fall mat to the right side of the bed when resident is in bed, initiated on 04/18/25. Observation on 06/23/25 at 10:20 A.M. revealed Resident # 3 in bed with the bed up in high position and fall mat folded up against the wall near her bed. Interview on 06/23/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) # 152 revealed Resident #3 was a fall risk and confirmed that the low bed with fall mat was not in place.

Based on interview, observation, and record review the facility failed to timely or accurately implement nutrition recommendations for Resident #13, #35, and #81. This affected three residents (#18, #35, #81) of seven residents reviewed for nutrition. The facility census was 83. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 09/25/21 with diagnoses including malignant neoplasm of mouth, dysphagia, protein-calorie malnutrition, adult failure to thrive, major depressive disorder (8/16/24), and unspecified psychosis. Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderately impaired cognition. Review of Resident #18's plan of care dated 03/24/25 revealed the resident had altered nutritional status as evidenced by impaired chewing ability, decreased intake of solids, refuses to eat puree and only drinks. The resident required tube feeding and supplement use. Her weight loss was unavoidable due to cancer status, refusal of tube feed, supplements, and meals. Interventions included administering medications as ordered, communicating with residents and family, diet as ordered, encouraging adequate fluid and oral intake, monitoring weight monthly and as needed, obtaining and monitoring lab work as ordered, providing supplements and tube feed as ordered, SLP as ordered. Review of Resident #18's physician order dated 03/28/25 to 05/22/25 revealed an order for Jevity 1.5 360 milliliters (ml) three times a day. Review of Resident #18's progress note dated 05/21/25 revealed the dietitian recommended increasing bolus feedings to four times a day. Review of Resident #18's physician order dated 05/22/25 to 06/13/25 revealed an order for Jevity 1.5 three times a day. Review of Resident #18's physician order dated 06/16/25 revealed an order for Jevity 1.5 bolus feeding four times a day 300 ml. Interview on 06/25/25 at 4:16 P.M. with Diet Technician #255 verified the recommendations from 05/21/25 were not put in place until 06/16/25. Interview on 06/26/25 at 2:04 P.M. with Dietitian #254 revealed ideally the facility would implement nutrition recommendations within 24 hours. She verified the tube feeding was not appropriately addressed in a timely manner and was not done correctly initially. 2. Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting left side, type two diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #35's plan of care dated 01/13/24 revealed the resident required tube feeding to assist the resident in maintaining or improving nutritional status related to dysphagia and history of poor intake. Interventions included alternate tube feeds with oral feeding as tolerated, check residual, maintain tube, monitor for complications, monitor for signs of aspiration Review of Resident #35's plan of care dated 04/04/25 revealed the resident had altered nutritional status as evidenced by need for mechanically altered diet with swallowing difficulty, need for assistance with meals. Interventions included administering medications as ordered, diet according to dietitian, feeding at meals, monitoring weight monthly, obtaining and monitoring lab work as ordered, tube feeding and flushes as ordered. Review of Resident #35's physician order dated 03/28/25 revealed an order for Glucerna 1.5, 80 ml an hour continuously starting at 8:00 P.M. and running until 720 mls have been infused. With the tube feed being turned off at 8:00 A.M. Review of Resident #35's progress note dated 03/28/25 revealed a recommendation to increase the residents tube feeding from 60 ml an hour to 80 ml an hour. Observation on 06/26/25 at 7:49 A.M. revealed Resident #35's tube feeding was running at 60 ml an hour. Interview on 06/26/25 at 7:55 A.M. with Licensed Practical Nurse (LPN) #236 verified the tube feed was running at 60 ml an hour as her tube feeding had been decreased to this rate. She reported this was what it was normally running at. Interview on 06/26/25 at 2:04 P.M. with Dietitian #254 revealed ideally the facility would implement nutrition recommendations within 24 hours. Dietitian #254 reported the 720 ml should have been removed from Resident #35's physician order since this indicated a tube feed rate of 60 ml an hour. 3. Review of the medical record for Resident #81 revealed an admission date of 04/19/25 with diagnoses including urinary tract infection, severe protein-calorie malnutrition, chronic kidney disease, and cognitive communication deficit. Review of the nutritional risk assessment dated [DATE] showed the resident was borderline underweight and required increased metabolic support for wound healing. Review of the admission Minimum Data Set (MDS) 3.0 completed on 04/26/25 showed the resident was severely cognitively impaired, required supervision or limited assistance with eating, and had a diagnosis of malnutrition. Review of a physician order dated 04/29/25 showed ProSource oral liquid nutritional supplement to be given 30 milliliters by mouth two times a day. Review of the care plan dated 05/02/25 revealed the resident had a diagnosis of protein-calorie malnutrition with interventions to allow time for meal consumption, assist with meals and fluids, encourage adequate nutrition and hydration, and provide diet, supplements, and vitamins/minerals as ordered by the physician. Review of the resident's weight history showed on 05/04/25, the resident weighed 122.8 pounds. On 06/20/25, the weight was documented as 110.2 pounds, reflecting a 10.26% loss over approximately six weeks. Review of the nutrition progress note dated 06/20/25 showed a recommendation to increase the ProSource supplement from two times a day to three times a day in response to the documented weight loss. Interview on 06/26/25 at 2:05 P.M. with Dietitian #254 confirmed the recommendation to increase ProSource oral liquid from two times a day to three times a day was made on 06/20/25 due to significant weight loss. The dietitian stated facility staff are expected to implement nutrition recommendations within 24 hours unless contraindicated or otherwise directed by the physician. Dietitian #254 confirmed the recommendation had not been implemented at the time of interview and was unaware of any documented reason for the delay.

Based on interview, policy review, and record review the facility failed to identify and make staff aware of trauma triggers for a resident with post-traumatic stress disorder and failed to provide consistent psychosocial intervention. This affected one resident (#45) of one sampled for mood and behavior. The facility census was 83. Findings include: Review of Resident #45's medical record revealed an admission date 12/07/23 and diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, hyperlipidemia, anemia, intervertebral disc replacement lumbar region, spinal stenosis, major depressive disorder, post-traumatic stress disorder, hypertension, and heart failure. Review of Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Review of Resident #45's physicians' orders revealed the resident was receiving the antidepressant medications Zoloft 150mg daily, trazodone 100 mg daily at bed time, and Wellbutrin 150mg daily. Review of Resident #45's care plan for trauma revealed resident #45 was a trauma survivor and experienced anxiety and fear related to her past trauma. Further review revealed the resident was to be provided psychiatric services as requested by the resident and as recommended by her psychiatric providers, consultation with pastoral care, social services, psychosocial and behavioral support as needed and was to be provided psychosocial support services. Further review of Resident #45's care plan revealed no mention of specific triggers that may cause re-traumatization of the resident. Review of Resident #45's medical record revealed a social service admission assessment dated [DATE] revealed the facility identified Resident #45 as a trauma survivor but did not identify Resident #45's specific triggers that may lead to re-traumatization. Review of Resident #45's medical record revealed a quarterly social history review dated 03/10/25 and a quarterly social history review dated 05/15/25 with no indication of Resident #45's specific triggers that may lead to re-traumatization revealed in either review. Review of Resident #45's psychiatric progress notes provided by the facility revealed the resident is a client of GuideStar Eldercare, LLC psychiatric services. Further review of Resident #45's psychiatric notes revealed notes for 01/30/25, 02/27/25, 04/04/25, 04/10/25, 04/30/25, 05/01/25, 05/02/25, 05/29/25 and 06/13/25. The notes contained no mention of Resident #45's specific triggers that may lead to re-traumatization. Review of Resident #45's medical record revealed no documentation of the resident requesting counseling services. In an interview on 06/26/25 at 9:32 A.M. Resident #45 stated her triggers are loud noises, arguing or the perception of arguing, someone moving too fast around her or someone appearing suddenly in front of her. In an interview on 06/26/25 at 1:30 P.M. the Administrator and Social Worker #195 confirmed the facility had not identified Resident #45's triggers and had not identified them on the resident's care plan so the facility staff would be aware of the resident's triggers. In an interview on 06/26/25 at 2:41 P.M. Resident #45 stated she had asked for counseling from several people but does not recall when she asked. Resident #45 stated she would like to get counseling for at least six months and longer if the counselor feels she should continue. Resident #45 stated that she has been a victim of abuse since her childhood. Resident #45 further stated that a couple of weeks ago a facility staff member appeared suddenly in front of her causing her to jump and her heart to race for just a short amount of time. She stated that she also has nightmares about her past trauma. Resident #45 stated she assumes she is not getting counseling because the facility thinks that she does not need it. In an interview on 06/26/25 at 3:20 P.M. Social Worker #195 stated GuideStar Eldercare, LLC psychiatric services, the facility's behavioral provider, saw Resident #45 once a week. Although she stated there was a gap of about a week and half when there was a change in the provider. Social Worker #195 stated Resident #45 would be seen by the psychiatric provider for 20 minutes to an hour depending upon the residents willingness. Social Worker #195 confirmed the psychiatric progress notes provided by the facility covered the past three months. Review of the policy titled Trauma Informed Care and Culturally Competent Care, revised 08/2022, revealed assessment of trauma survivors should include the identification of triggers and the care plan should identify and decrease exposure to triggers that may re-traumatize the resident.

Based on observation, interview, and facility policy review, this facility failed to ensure controlled substances were logged or signed out in the control substance log when that medication was administered. This affected one resident (Resident #44) of the four residents reviewed during medication administration observation. The facility census was 83. Findings include: During observation completed on 06/26/2025 at 12:45 P.M. of one of the facility's four medication carts, it was noted that not all controlled substance medications were logged when the medication was removed from it packet for administration. Resident #44 was noted to have a package housing 12 tablet of the controlled substance, Lacosamide (Vimpat) 50 milligrams (mg), give one tablet two times a day. Review of the controlled substance log book for this medication cart revealed the last tablet signed out was on 06/25/2025 leaving 13 tablets Interview on 06/26/2025 at 12:48 P.M. with Licensed Practical Nurse (LPN) #112 revealed she administered one of the Vimpat tablets this morning to Resident #44 but did not sign the medication out or log the medication in the controlled substance log book. LPN #112 confirmed when a controlled substance is administered, the administering nurse is required to sign the log book to help verify this medication was removed from the package and to help keep count of how many tablets have been administered and how many tables remain. Review of facility policy titled Controlled Substances, revision date of 11/2022 revealed The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: Records of personnel access and usage, medication administration records, declining inventory records, and destruction, waste and return to pharmacy records.

3. Review of Resident #3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physician orders dated 05/30/25 revealed orders for Aspirin Oral Tablet Chewable 81 MG; give 1 tablet by mouth one time a day for hypertension, Insulin Glargine Subcutaneous Solution 100 UNIT/ML; inject 12 unit subcutaneously at bedtime for type 2 diabetes, Hydrochlorothiazide Tablet 25 MG; give 1 tablet by mouth one time a day for hypertension and edema, Ramelteon Oral Tablet 8 MG; give 1 tablet by mouth at bedtime for Insomnia and Gabapentin Capsule 400 MG; give 1 capsule by mouth three times a day for nerve pain. Review of Pharmacy Medication reviews from May 2024 to May 2025 for Resident #3 revealed no reviews for the months of July 2024, August 2024, September 2024, December 2024 and March 2025. Interview on 06/25/25 at 2:00 P.M. with Regional Director of Clinical Services (RGCS) and Director of Nursing (DON) revealed that the facility identified that the documentation was missing in March 2025 and did a plan to correct it at that time. The deficient practice was corrected on 03/25/25 when the facility implemented the following corrective actions: On 03/25/25 the facility requested pharmacy recommendations and forwarded them to the physician for review of current residents. On 03/25/25 the DON reviewed all current residents, ensuring that no deviations from their normal baselines were noted. On 03/25/25 all licensed staff were re-educated on the importance of forwarding pharmacy recommendations to the residents' provider for review. Random audits were performed on 03/28/25, 04/04/25, 04/11/25 and 04/18/25 and revealed no issues. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review and policy review, the facility failed to provide evidence of medication regiment reviews and pharmacy recommendations for Residents #3, #6 and #48. This affected three residents (#3, #6, #48) of five residents reviewed for pharmacy recommendations. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/16/22. Pertinent diagnoses included: acute and chronic respiratory failure with hypoxia, dementia, bipolar disorder, insomnia, and long term (current) use of anticoagulants. Review of the care plan for Resident #6 dated 01/10/24 revealed Resident #6 required use of psychotropic medications with potential for adverse reactions related to Bipolar and associated mood disorder. An accompanying intervention recommendation stated that the resident (#6) should be monitored for effectiveness and side effects for possible decrease or elimination of the medication. Review of physician orders for Resident #06 revealed Resident #06 had order dated 06/01/23 for Sertraline HCI Tablet 100 milligrams (MG) to be given one time a day for depression related to bipolar disorder; an order dated 06/01/23 for trazodone HCI Oral Tablet 50 MG to be given one time a day for insomnia due to depression, an order dated 06/01/23 for Eliquis oral tablet 5 MG to prevent blood clots. Review of pharmacy documentation of review of medications for Resident #6 reveal no pharmacy recommendations or documentation of pharmacy review of medications for Resident #6 for December 2024 or March 2025. 2. Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, personal history of pulmonary embolism, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. She needed substantial assistance for bathing and personal hygiene and was dependent on staff for toileting, lower body dressing and transfers. Review of the care plan for Resident #48 dated 10/18/24 revealed Resident #48 required use of psychotropic medications with potential for adverse reactions related to anxiety, depression and schizophrenia. An accompanying intervention recommendation stated that the resident (#48) should be monitored for effectiveness and side effects of antidepressant medication. Review of the physician orders for Resident #48 revealed prescriptions including but not limited to: an order dated 04/11/25 for Ariprazole (antipsychotic) oral tablet 30 MG to be given one time a day for Schizoaffective Disorder; order dated 04/11/25 for Apixaban 2.5 MG to be given two times a day for blood clot; an order dated 4/11/25 Clonazepam tablet 1 MG to be given two times a day for anxiety. Review of the pharmacy recommendations and pharmacy documentation of no recommendations for the past 12 months for Resident #48 revealed absence of pharmacy documentation for Resident #48 for December 2024.

Based on resident interviews, staff interviews, record review, policy review and safety data sheet review, the facility failed to ensure Resident #38 was free from significant medication errors. This affected one resident (#38) of one resident reviewed for medication errors. The facility census was 83. Findings Include: Record review revealed Resident #38 was admitted to the facility on [DATE]. Pertinent diagnoses included: type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, acquired absence of right foot, acquired absence of left leg below knee, severe obesity and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #38 revealed he was cognitively intact. The functional assessment rated Resident #38 as independent on eating, hygiene, dressing and transfers, with supervision needed for showers/bathing. Review of Care Plan for Resident #38 dated 11/13/24 revealed Resident #38 was at risk for hyper/hypoglycemic reactions, abnormal lab values and diabetic ulcers due to his diabetes. Interventions for this focus suggested that medications should be given per physician order and that nursing should monitor for signs and symptoms of hypo/hyperglycemia (high/low blood sugar). Interview on 06/23/25 at 11:32 AM with Resident #38 who said nursing staff doesn't give his insulin to him in a timely manner. He said when he asks them they ignore him. He said he sometimes feels lightheaded. Review of physician's orders for Resident #38 revealed an order dated 11/04/24 for HumaLog Solution 100 unit/ml (fast acting insulin) to be injected subcutaneously before meals per sliding scale as follows: If blood sugar is 0 to 150, give 0 units. If blood sugar is 151 to 200, give 2 units. If blood sugar is 201 to 250, give 4 units. If blood sugar is 251 to 300, give 6 units. If blood sugar is 301 to 350, give 8 units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call provider. Additionally, there was a physician order dated 11/23/24 for Resident #38 for Lantus (long acting insulin) SoloStar Solution Pen Injector for 25 units to be injected subcutaneously one time per day. Resident #38 had physician order dated 01/27/25 for Basaglar (long acting) Kwikpen Solution Pen-Injector 100 unit/ML (Insulin Glargine) 30 units to be injected subcutaneously at bedtime for diabetes. Interview on 06/24/25 at 2:01 P.M. with Resident #38 shared he did not receive his medications the previous evening. He said he told the nurse and she just walked away. Review of Medication Administration Record (MAR) for Resident #38 for 06/23/25 appeared to confirm that Resident #38 did not receive his evening insulin medication (Basaglar), although the documentation indicated that he had refused the medication on the evening of 6/23/25. Further review revealed that the 6/22/25 scheduled 7:00 P.M. long acting insulin dose was documented as having been administered on 06/23/25 at 3:08 A.M. The documentation further indicated that on 06/23/25, less than five hours later, Resident #38 received his morning short acting insulin dose at 8:36 A.M. as well as his morning dose of long acting insulin at 8:39 A.M. Resident #38 had a recorded blood sugar of 214 at that time and he was administered 4 units of the short acting insulin. Per the MAR documentation, the resident was not available in the afternoon of 06/23/25 and there was no recorded blood sugar that day until 4:24 P.M. when the resident's blood sugar was 283 and he was administered 6 units of insulin. Interview on 06/24/25 at 3:02 PM with Registered Nurse (RN) #122 verified that the MAR indicated Resident #38 received his 6/22/25 evening dose of long acting insulin at 03/23/25 at 3:08 A.M. RN #122 said that if the medication is scheduled at bedtime you want to make sure you give it at the time the resident goes to bed. She said she does not look at previous evening's MAR and therefore would not know a resident received the bedtime dose in the early morning. She said Resident #38 does go out sometimes (in daytime) and that if he was gone at the time he should have received his insulin and he returned near dinner time, she would hold off on the dose. Interview on 06/24/25 at 4:40 PM with the Director of Nursing (DON) verified the MAR indicated Resident #38 received his 06/22/25 evening dose of insulin the following morning at 3:08 A.M. The DON said the bedtime administration of insulin could be variable if the resident goes to bed at different times. The DON said he was not concerned with the dose being administered so late because he said the blood sugar test would've caught any issues. Regarding the missed insulin dose on the evening of 06/23/25, he said that perhaps the resident was out of the building. Interview on 06/24/25 at 5:05 PM with Regional Director of Clinical Services #252 confirmed an order for bedtime medication administration should be given between the hours of 7:00 P.M. and 11:00 P.M. He verified the MAR record appeared to indicate the 06/22/5 evening dose of insulin was administered on 06/23/25 at 3:08 A.M. and confirmed that time was outside the accepted parameters. Interview on 06/25/25 at 9:10 A.M. with Resident #38 confirmed he did not leave the property on the evening of 06/22/25. He admitted he had been outside the dining room at the smoking area with other residents. He said he thought he came in around 10:00 or 11:00 P.M. He said he did not remember what time he received the 06/22/25 evening dose of insulin and said he did not refuse his insulin the evening of 06/23/25 and had not left the building that night either. Interview on 06/25/25 at 3:29 P.M. with the DON who said he spoke with the nurse who administered the insulin dose that was recorded at 3:08 A.M. on 6/23/25. He said that she relayed she was having internet troubles and had administered the dose earlier. He said she did not record the actual administration time on paper and he said there were no other residents who had late medication administration charted. Further review of the May and June 2025 MAR for Resident #38 revealed the evening administration of Basaglar was documented as being administered outside of the 7:00 P.M. to 11:00 P.M. time frame on the following dates: 05/10/25 at 1:31 A.M., 05/13/25 at 11:44 P.M., 05/15/25 at 5:39 A.M., 05/20/25 at 11:21 P.M., 05/23/25 at 11:31 P.M., 05/30/25 at 11:29 P.M., 06/06/25 at 11:51 P.M., and 06/09/25 at 11:28 P.M Review of facility policy titled, Administering Medications revised April 2019 stated medications are administrated in accordance with prescriber orders including any required time frame. Medication should be administered within one hour of prescribed time unless otherwise specified such as after meals. The policy stated that if resident is not in room or otherwise unavailable, the MAR may be flagged and the nurse will return to administer the dose. Review of the Safety Data Sheet for Bagaslar Insulin pen revised 07/2021 emphasized the importance of administering the medication at the same time every day. The safety data sheet stated that the median time to maximum effect of the medication is 12 hours. The data sheet warned that the risk for hypoglycemia is highest when the glucose lowering effect of the insulin is maximal and noted that changes in administration can increase risk. The safety data sheet also noted that symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes. This deficiency represents non-compliance investigated under Complaint Number OH00164069.

Based on medical record review, staff interviews, hospital record review, review of emergency medical services (EMS) run reports, review of prescribing information for NPH ,d+[DATE] Insulin, and facility policy review, the facility failed to ensure Resident #104's blood sugar levels were adequately monitored to prevent incidents of hypoglycemia. This resulted in Immediate Jeopardy on [DATE] when Resident #104, who had a history of hypoglycemia (low blood sugar), was ordered NPH insulin ,d+[DATE] (mixture of short and fast acting insulin) and Dapagliflozin propanediol (oral medication used to lower blood glucose level), and did not have routine blood sugar/glucose checks being completed, was found unresponsive with a low blood sugar of 39 milligrams/deciliter, required cardio-pulmonary resuscitation (CPR), and was admitted to the hospital for hypoglycemia, hypotension, unresponsiveness, fracture of the clavicle and fracture of the right second rib. This affected one (Resident #104) of three residents reviewed for blood sugar monitoring. The census was 102. On [DATE] at 11:31 A.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Clinical Service Manager (RCSM) #221 were notified Immediate Jeopardy began on [DATE], when Resident #104, who had a history of hypoglycemia and did not have routine blood sugar checks, was found unresponsive with a low blood sugar of 39 milligrams/deciliter, required CPR, and was admitted to the hospital for hypoglycemia, hypotension, unresponsiveness, fracture of the clavicle and fracture of the right second rib. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: As of [DATE], Resident #104 no longer resided at the facility. On [DATE], an Ad Hoc policy review was held with the Administrator, DON, RCSM #221, Chief Nursing Officer #224, Regional Director of Operations #222, [NAME] President of Clinical Services #223, and Medical Director #113 to review the system in place to ensure the care needs of all residents who have a diagnosis of diabetes were met. The Medical Director provided her preferred standards of practice for blood glucose monitoring of residents with a diagnosis of diabetes. The policy did not require any revisions at that time. Effective [DATE], for new admissions, the admitting nurse would verify all orders with either the Medical Director or the on-call physician. If the new admission resident had a diagnosis of diabetes and the admitting nurse was not able to speak directly to the Medical Director, and the on call physician did not prescribe any form of diabetic monitoring, then the DON or the nurse manager on call, would review all orders with the Medical Director or Nurse Practitioner to ensure the resident's needs were being met and they have appropriate blood glucose monitoring orders. On [DATE], an Ad Hoc Resident Council meeting was held with the Activities Director #157, Administrator, and 13 residents (#9, #19, #21, #27, #44, #63, #75, #84, #85, #87, #100, #101, #106) to review updated standards of practice provided by the Medical Director, the facility following physicians' orders, and signs and symptoms of hypo/hyperglycemia. The residents present (some of whom were not diabetic) provided no additional feedback. All residents in the facility had been invited to discuss the updated standards of practice and provide feedback. On [DATE], all staff were educated related to monitoring for signs and symptoms of hypo/hyperglycemia by the Director of Nursing/designee. The education was added to the new hire orientation agenda as of [DATE]. All staff were trained by [DATE]. On [DATE], the DON/designee educated all nurses on the Medical Director's preferred standards for diabetic residents as well as following physician orders by the Director of Nursing/Designee. Agency staff would be educated upon their arrival for their scheduled shift. On [DATE] from 1:30 P.M. to 2:39 P.M., a finger stick blood sugar was completed on all diabetic residents (#1, #2, #3, #4, #9, #10, #13, #14, #17, #31, #32, #34, #36, #43, #45, #47, #51, #52, #56, #59, #62, #64, #66, #68, #70, #72, #74, #78, #79, #80, #84, #85, #86, #92, #93, #94, #97, #102, #105 and #106). One resident (#49) refused the blood sugar check. The results were reported to the Medical Director/Nurse Practitioner and orders were received as indicated. All diabetic residents were assessed for signs and symptoms of hypoglycemia/hyperglycemia and their orders were reviewed by the Medical Director/Nurse Practitioner to ensure they had appropriate orders for blood glucose monitoring and blood glucose levels were being followed per physician orders. During this review, two residents (#99 and #105) were identified as receiving oral antihyperglycemic medication without orders for routine blood glucose monitoring. No new orders or changes were made at that time. Beginning [DATE], an ongoing audit would be completed by the Director of Nursing/Designee daily for four weeks, then randomly thereafter. The audit would include ensuring all residents with diabetes had appropriate orders for monitoring blood glucose, ensuring nursing staff follow physician's orders, and staff were aware to identify and report symptoms of hypo/hyperglycemia. New admissions would be included in the audit and would be audited to ensure the Medical Director was notified and reviewed the chart, there were appropriate orders for blood glucose monitoring, and that staff were following the orders received by the Medical Director related to diabetic monitoring. Interviews on [DATE] from 1:13 P.M. to 1:30 P.M., with Registered Nurse (RN) #110, RN #214, Licensed Practical Nurse (LPN) #128, State tested Nursing Assistant (STNA) #131, STNA #145, Dietary Cook #219, and Housekeeper #205 revealed the staff were knowledgeable of the signs/symptoms of hypo/hyperglycemia. Additionally, facility nurses were knowledgeable on the new admission/readmission process. On [DATE], the facility obtained physician orders for Resident #99 and Resident #105, who were diabetic and required medication to treat for routine blood glucose monitoring. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #104 revealed an initial admitted [DATE] and discharge to an acute care hospital on [DATE] with diagnoses including diabetes mellitus, alcohol dependence induced acute pancreatitis, alcohol abuse, heart failure, and long-term use of insulin. Resident #104 was also hospitalized from [DATE] to [DATE] and from [DATE] to [DATE]. Following the [DATE] hospitalization , the resident did not return to the facility. Review of an acute care hospital discharge summary, dated [DATE] (initial admission), revealed Resident #104 was discharged with an order for NPH insulin ,d+[DATE] (mixture of short and fast acting insulin) 100 units/milliliter (ml) with special instructions to administer eight units under the skin twice daily before meals. The order indicated vials should be rolled between palms of hands 10 times prior to each use and the insulin should be administered 30 to 40 minutes prior to the meal. Additionally, Resident #104 was discharge with an order for Dapagliflozin propanediol (oral medication used to lower blood glucose level) 10 milligrams (mg) by mouth daily for diabetes mellitus. Review of Resident #104's physician orders revealed an order, dated [DATE], for NPH insulin ,d+[DATE] 100 units/ml with special instructions to administer eight units subcutaneously twice daily for diabetes mellitus, administer 30 to 40 minutes before meals, and included the vial should be rolled between palms of hands (prior to drawing up the insulin). The NPH insulin remained an active order until [DATE] when the order was discontinued. Further review of Resident #104's physician orders revealed no orders for routine blood sugar/glucose monitoring from [DATE] to [DATE]. Review of Resident#104's physician orders revealed an order, dated [DATE] for Dapagliflozin propanediol 10 mg by mouth daily for diabetes mellitus. Further review revealed the medication remained an active order until [DATE] when Resident #104 was readmitted from an acute care hospitalization . Review of Resident #104's vital sign documentation revealed a blood glucose level of 290 mg/deciliter (dl) was obtained by LPN #156 on [DATE] at 5:52 P.M. Review of the progress note, dated [DATE] at 11:35 P.M., revealed Resident #104 was confused and was not responding, vital signs were taken and recorded. Resident #104's blood sugar was taken and it was very low (actual value not documented). The on-call physician service was notified and gave an order to send the resident to the local emergency department (ED). 911 was called and the resident was sent to the local hospital. Review of the emergency medical service (EMS) run sheet, dated [DATE], revealed the facility called EMS at 9:42 P.M. and EMS arrived on the scene at 9:47 P.M. Upon arrival to the facility Resident #104 was found in bed with possible hypoglycemia. Resident #104's blood glucose was 31 mg/dl. Resident #104 was confused and slow to respond with some combative behaviors. EMS established intravenous (IV) access and dextrose (a sterile solution of sugar and water given IV to raise blood glucose level) was administered. The resident began to regain mental status. The facility staff present were unsure of the resident's baseline mental status. EMS completed a recheck of the resident's blood glucose and it was 186 mg/dl. The resident was transported to the local ED for further evaluation due to the hypoglycemic episode. Review of the acute care hospital summary, dated [DATE], revealed Resident #104 was transported to the local ED via medics. The summary revealed when the medics arrived to the facility the resident's blood glucose level had dropped even more to 31 mg/dl. The medics administered dextrose to the resident which raised the resident's blood glucose to 122 mg/dl upon arrival to the ED. The summary indicated Resident #104 alerted the emergency room physician of poor oral intake. Resident #104's blood sugar again began to drop and was in the 70's at which time the resident was given Dextrose 50 (D50). The resident's urinalysis was consistent with a urinary tract infection (UTI) and the resident was placed on a course of Keflex following a round of IV Rocephin (antibiotic medication used to treat infections). The final diagnoses given following the ED visit was hypoglycemia and acute cystitis without hematuria. Review of the progress note, dated [DATE] at 4:07 A.M., revealed Resident #104 returned to the facility at 3:45 A.M. with her son and two paramedics. The resident's vital signs were taken and were stable. The resident was in bed sleeping with the call light within reach. Review of Physician #113's progress note, dated [DATE], revealed the physician documented Resident #104's medication regimen, noted blood glucose trends and labs were reviewed, and to continue current medications, monitor blood glucose daily and adjust regimen as needed. The physician also indicated to check Hemoglobin A1C (HgbA1c), lipids and basal metabolic panel periodically. The note indicated a HgbA1c (lab which indicates the average glucose level over the past few months) was ordered. Review of Resident #104's medical record revealed Resident #104's blood glucose level was obtained by RN #220 on [DATE] at 11:24 A.M. and was 149 mg/dl as well as on [DATE] at 5:31 P.M. and was 200 mg/dl. Further review of Resident #104's medical record revealed no documented evidence the resident's blood glucose was monitored routinely following the instance of hypoglycemia leading to a transfer to the emergency department on [DATE] after this date. Review of Resident #104's comprehensive Minimum Data Set assessment, dated [DATE], revealed Resident #104 had no cognitive deficit. The assessment indicated Resident #104 received daily insulin injections. Review of the medication pass note, dated [DATE] at 5:40 P.M., revealed Resident #104's blood glucose was obtained by RN #114 and was 100 mg/dl. Review of Resident #104's lab results, dated [DATE], revealed Resident #104's HgbA1c level was high at 7.7% (normal range of 5XXX,d+[DATE].5%). Review of Resident #104's plan of care, dated [DATE], revealed the resident was at risk for hyper/hypoglycemia reactions, abnormal lab values and diabetic ulcers related to diabetes. Interventions included to give medications per physician orders and monitor for signs/symptoms of hypo/hyperglycemia: change in mental status, fatigue, change in vision, change in vital signs and increased urination, and increase in hunger or thirst. Review of the medication pass note, dated [DATE] at 8:05 A.M., revealed Resident #104's blood glucose was obtained by RN #114 and was 81 mg/dl. Review of the progress note, dated [DATE] at 5:25 P.M., revealed Resident #104's blood sugar was low at 43 mg/dl. The resident was given orange juice, milk, oral glucose and Gvoke (a subcutaneous, prefilled syringe injection used to treat severe hypoglycemia) prefilled syringe (PFS) one mg/0.2 ml subcutaneously (SQ). The resident's blood sugar increased to 49 mg/dl and finally to 100 mg/dl. Once the resident's blood glucose level began to rise, the resident was observed eating with no signs/symptoms of hypoglycemia. The on-call physician was made aware, and a new order was given to hold Resident #104's insulin on [DATE] at 8:00 A.M. Review of the progress note, dated [DATE] at 6:26 P.M., revealed Resident #104's blood glucose was 184 mg/dl following the injection of Gvoke PFS one mg/0.2 ml. Review of an EMS run report, dated [DATE], revealed the facility called 911 at 11:08 P.M. and alerted EMS of the need for emergency services for hypoglycemia with cardiopulmonary resuscitation (CPR) in progress. Upon entry at 11:19 P.M., the facility staff were observed performing chest compressions with Resident #104 making grunting sounds. EMS ordered the staff to stop compressions and a pulse was immediately identified in Resident #104's neck. The resident was responding to painful stimuli and the facility staff reported they had been doing chest compressions for approximately 10 minutes. EMS administered Dextrose 10 via IV and Resident #104 responded and had a blood glucose level of 48 mg/dl at 11:21 P.M. The report documented the resident's blood glucose level was 237 mg/dl at 11:35 P.M. The resident was transported to the local acute care hospital. Review of the progress note, dated [DATE] at 11:45 P.M., revealed Resident #104 was found unresponsive with a blood sugar of 39 mg/dl. The resident was unable to tolerate oral glucose so a Glucagon (medication used to raise blood glucose) SQ was administered. The resident's blood sugar was rechecked and had gone down to 36 mg/dl. The resident remained unresponsive with no pulse or breathing. The staff initiated cardiopulmonary resuscitation (CPR), called 911 and continued CPR until 911 arrived and took over. The resident was transported to a local hospital. Review of the progress note, dated [DATE] at 4:28 A.M., revealed a follow-up call was placed to the local hospital and the resident was being admitted to the hospital. No diagnoses was documented for the admission as of this time. Review of Resident #104's February 2024 Medication Administration Order (MAR) revealed Resident #104's NPH ,d+[DATE] insulin was scheduled to be administered at 8:00 A.M. and 4:30 P.M. Staff documented Resident #104 received the insulin at 8:00 A.M. and 4:30 P.M. Review of the facility mealtimes revealed the dinner meal cart was scheduled to be brought to the 100 hallway, where Resident #104 resided, at 6:30 P.M. which was approximately two hours following the scheduled administration time of 4:30 P.M. for the NPH ,d+[DATE] insulin, even though the order indicated to administer the insulin ,d+[DATE] minutes prior to the meal. Review of Resident #104's re-admission acute care hospital discharge summary, dated [DATE], revealed the resident was admitted to the acute care hospital for hypoglycemia, hypotension, unresponsiveness, fractured clavicle and fractured right second rib. While at the acute care hospital, the resident's oral antihyperglycemic medication Dapaglifozin Propanediol 10 mg by mouth daily and NPH ,d+[DATE] insulin 100 units/ml were discontinued. The resident was ordered Glargine insulin 10 units subcutaneously daily at bedtime and Lispro Insulin 100 units/ml subcutaneously three times daily before meals per sliding scale as follows: ,d+[DATE] mg/dl administer two units, ,d+[DATE] mg/dl administer four units, ,d+[DATE] mg/dl administer six units, ,d+[DATE] mg/dl administer eight units, ,d+[DATE] mg/dl administer 10 units and call the physician if blood glucose level is less than 60 mg/dl or greater than 300 mg/dl. Interview on [DATE] at 11:50 A.M. with the DON revealed she was aware Resident #104 had no routine blood glucose level monitoring in place and would have expected to see physician orders for the resident's blood glucose level to be checked prior to administration of the insulin. Interview on [DATE] at 2:23 P.M., with Pharmacist #111, who was employed with the facility contracted pharmacy, revealed it was recommended with all insulin medications to routinely obtain a blood glucose level prior to the administration of the insulin, especially if the resident has had hypoglycemic episodes. Interview on [DATE] at 2:34 P.M. with Nurse Practitioner (NP) #112 revealed she does not verify the hospital admission orders and only Physician #113 can verify the orders coming from an acute care hospital. NP #112 revealed she reviewed Resident #104's blood glucose levels that were available in the electronic medical record. NP #112 revealed she spoke with Resident #104's family regarding Resident #104 not eating and requested the family to bring snacks to the facility for Resident #104. NP #112 revealed she thought Resident #104 had routine blood glucose level checks and verified the lack of physician orders for routine blood glucose level checks. Interview on [DATE] at 2:55 P.M. with Physician #113 revealed she was unaware Resident #104 did not have routine monitoring of blood glucose levels. Physician #113 revealed all residents admitted to the facility under her care with a diabetes mellitus diagnosis, regardless of whether they were on insulin or oral antihyperglycemic medication needed to have blood glucose monitoring. Physician #113 revealed diabetic residents should also have HgbA1c levels drawn periodically. Physician #113 verified Resident #104 should have had routine blood glucose monitoring in place with the use of the NPH ,d+[DATE] insulin and oral antihyperglycemic medication. Review of the Highlights of Prescribing Information, last revised [DATE], revealed NPH ,d+[DATE] is an insulin indicated to improve glycemic control in adults with diabetes mellitus. Individualize and adjust dosage based on metabolic needs, blood glucose monitoring and glycemia control goal. Hypoglycemia may be life-threatening. Monitor blood glucose and increase monitoring frequency with changes to insulin dosage, use of glucose lowering medications, meal pattern changes, physical activity, patients with hypoglycemia unawareness and acute illness. Further review revealed the NPH ,d+[DATE] insulin mean peak of lowering the blood glucose happens with one to five hours. Review of the facility policy titled, Blood Glucose Testing, dated [DATE], revealed the purpose of blood glucose testing was to monitor blood glucose control and assess for acute changes. Review of the facility policy titled, Preparation and General Guidelines, last revised [DATE], revealed medications were to be administered within 60 minutes of the scheduled time, except before, with or after meal orders, which were administered based on mealtimes. This deficiency represents non-compliance investigated under Master Complaint Number OH00152110.

Based on closed medical record review, review of a facility self-reported incident (SRI) and investigation, review of a police report, review of emergency medical service (EMS) report, review of the hospital reports, review of the facility's Abuse/Neglect policy and procedure, and interviews with the police, family, and staff, the facility failed to ensure Resident #109, who was admitted to the facility for abdominal surgical wound care was free from a situation of neglect when facility staff failed to provide appropriate and timely wound treatment, care, and services. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and medical emergency on 02/03/04 when Resident #109 and her family identified delayed and improper wound care resulting in the family's call to local police for a welfare check. Upon police arrival (on 02/03/04 beginning at approximately 12:00 P.M.) the resident's call light was activated for staff assistance and police identified significant concerns with the resident's care and overall condition which included the resident's use of blankets/towels for wound care. Upon initial investigation by police, Licensed Practical Nurse (LPN) #301 and Activities Director #405 (the facility manager on duty) indicated the facility had received two new admissions and were short-staffed resulting in Resident #109 having to wait for care. In addition, LPN #301 indicated the facility did not have the proper dressing supplies to care for the wound. Police contacted Emergency Medical Services (EMS) and the resident was subsequently transferred to the hospital with the facility documenting Resident #109 was an urgent transfer (to the hospital) because the welfare and needs of the resident could not be met in the facility. Upon arrival to the hospital on 02/03/24, Resident #109 was assessed to require abdominal surgical wound care and was assessed to have additional areas of skin impairment. Resident #109 reported facility staff did not assist her with going to the bathroom or provide care for the bodily fluids that were draining. The hospital noted the facility's inability to properly care for and manage the resident's wound care placed Resident #109 at risk for recurrent wound infections, severe sepsis, and increased Resident #109's morbidity and mortality. As a result of the incident, there was an open police investigation with possible criminal charges being pursued. This affected one resident (#109) of three residents reviewed for abuse and neglect. The facility census was 104. On 02/16/24 at 9:51 A.M., the Administrator, Director of Nursing (DON), Clinical Service Manager #505, and Clinical Service Manager #400 were notified Immediate Jeopardy began on 02/03/24 when Resident #109 was transferred to the hospital due to a lack of timely and necessary wound care identified by Resident #109, who was alert and oriented, and the resident's family. The resident was admitted to the hospital with worsening of an abdominal surgical wound. The lack of timely and necessary wound care placed the resident at risk of infection, severe sepsis, complications for healing, and increased Resident #109's morbidity and mortality. The Immediate Jeopardy was removed on 02/16/24 when the facility implemented the following corrective actions: On 02/03/24, Resident #109 was transferred to the hospital and did not return to the facility. On 02/16/24 at 3:30 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting and Immediate Jeopardy (IJ) Review was held with the Administrator, Regional Clinical Services Managers #505, and Medical Director #600 to review the facility polices for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, and Completion of Wound Care. No policy changes were made as a result of the review. On 02/16/24 at 3:30 P.M., the Chief Clinical Nursing Officer #506 and Regional Clinical Services Manager #505 educated the Administrator and DON on Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, and Completion of Wound Care policies. On 02/16/24, the Administrator and DON educated administrative staff, which included ADON #306, ADON #196, Human Resources Director #600, Licensed Social Worker (LSW) #222, Admission Director #601, Business Office Manager #288, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #187, MDS LPN #322, Dietary Manager #602, Maintenance Director #603, Housekeeping Manager #604, Activities Director #405, Central Supply/Scheduler #605, and Medical Records #606, on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, including how to identify and prevent situations of neglect, identification of change in condition, including how to timely identify situations when care cannot be or is not provided to residents in the facility to know when to seek medical attention, and completion of wound care per orders. On 02/16/24, ADON #306, ADON #196, Human Resources Director #600, Licensed Social Worker (LSW) #222, Admission Director #601, Business Office Manager #288, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #187, MDS LPN #322, Dietary Manager #602, Maintenance Director #603, Housekeeping Manager #604, Activities Director #405, Central Supply/Scheduler #605, and Medical Records #606 educated all direct care staff on policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. The facility implemented a plan for any remaining staff not educated to be removed from the schedule after 02/16/24, pending completion of the mandatory education. Education completed included 27 nurses, 47 state tested nursing aides (STNA), one activity staff, 23 therapy, 12 environmental services staff (housekeeping, laundry, and maintenance), and 12 dietary staff. On 02/16/24, the Administrator, DON, and Regional Clinical Services Manager #505 educated all licensed nurses on the facility policies for Change in Condition and Completion of Wound Care. For residents admitted after hours/weekends, staff would notify the clinical on-call manager to double check that treatments were in place and supplies were available and the resident was placed on the list to be seen by the wound certified nurse practitioner (CNP) on the next visit. A wound nurse practitioner from Wound Care Consultants visited the facility every Thursday. When a nurse identified a new skin issue with a resident, the nurse must complete necessary assessments, and contact the facility wound nurse, Assistant Director of Nursing (ADON) #306. If the wound nurse was not in the facility, the nurse would call the on-call clinical nurse manager, and the resident's physician to receive necessary orders. An on-call clinical manager is always available. On 02/16/24, Central Supply #605 and the Administrator were educated by Chief Clinical Officer #506, on the ordering process, the ability to have deliveries STAT/same day, how to contact vendors as needed for supplies, and keeping stock in house and available to clinical staff. If all efforts to obtain wound supplies fail, the nursing staff would notify the resident's physician to review current orders and provide new orders as needed based on availability of supplies. On 02/16/24, the DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 completed head-to-toe body assessments on all 106 current residents to ensure no evidence of negligence in care resulting in skin impairments had occurred. The head-to-toe assessments included recently admitted Residents #15, #99, and #104. The appropriately assigned clinician was made aware of any change of conditions. On 02/16/24, DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 interviewed all 106 current residents regarding adequate care and treatment and if they felt safe in the facility. On 02/16/24, DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 reviewed all 106 current residents to ensure all residents remained at their psychosocial baseline. The assessment included observation for changes in mood or behaviors, and discussion with the LSW #222 regarding any new changes. On 02/16/24, the Administrator completed an audit of all wound care supplies in the facility to ensure adequate supplies were onsite to provide the necessary care for Residents #16, #18, #28, #30, #33, #34, #44, #51, #58, #67, #75, #84, #92 #113, and #115 (those residents with current wound care orders). On 02/16/24, Staffing Agency #500 was made aware of the neglect allegations involving LPN #401. LPN #401 was placed on the Do Not Return list. On 02/16/24, the SRI that was filed on 02/05/24 related to the incident with Resident #109 was updated to reflect additional interviews regarding staff involved in the resident's care. The Administrator submitted an addendum to the SRI upon review of the police report on 02/16/24. Beginning 02/16/24, an ongoing audit would be completed by the DON/Designee daily for four weeks, then randomly thereafter. Audits would include ensuring all wound care was provided per physician's order, timely identification of changes in condition, ensuring adequate supplies were available to provide necessary care, and ensuring identification and prevention of situations of neglect for all residents. Although the Immediate Jeopardy was removed on 02/16/24, 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 still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #109 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. Resident #109 had diagnoses including surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of hospital wound documentation dated 01/29/24 at 12:55 P.M. (from the resident's hospitalization prior to admission) revealed Resident #109 had wounds located on midline abdomen incision/fistula and left lower quadrant end colostomy. The wound measured 20.5 centimeters (cm) long, 16 cm wide, and 4.5 cm deep. There was a moderate amount of yellow drainage. The wound was pink, moist with a scant amount of yellow slough, and the stoma was pink and moist. The peri wound was pink and painful. Resident #109's skin and wound were to be cleansed gently with Dial soap and water (no bath wipes) and dried thoroughly. Cavilon (breathable, waterproof moisture barrier) skin prep was to be applied to peri wound. Eakin Horizontal and Vertical wound pouches (flexible pouches designed to offer skin protection and contain drainage from wounds, fistulas and difficult stoma sites) should be cut slightly larger than wound opening. Pre-warm pouches prior to application and seal one side of each pouch edge together to form one pouch. Barrier ring strips were to be applied to skin creases to create a flat pouching surface. Apply the wound pouches over the midline fistula and colostomy and apply pink tape to the pouch edges. Hold the pouch in place with hands for two to three minutes to warm it up after application to ensure a good seal. The pouch was to be emptied when a third to half full. The pouch should be checked every four hours and document output. Pouches need to be changed when leaking and do not reinforce. The pouches should be changed every seven days or as needed for leakage. Resident #109 to continue care as described above at discharge. The discharge instructions included a phone number for any ongoing problems or concerns Monday through Friday from 8:00 A.M. to 4:30 P.M. If there were questions or concerns during evening, weekends, or holidays another phone number and instructions were provided to reach an on-call doctor for Trauma/Acute Care surgery. Review of the nursing note dated 02/01/24 at 9:13 P.M. revealed Resident #109 was admitted to the facility. Resident #109 was alert and able to make her needs known. The note indicated the dressing to the resident's abdominal fistula was intact and loose yellow drainage was observed in the drain bag. The nursing note dated 02/02/24 at 11:18 A.M. revealed a 24-hour skin assessment was completed for Resident #109. Resident #109 had a significant surgical trauma to abdomen extending into right and left abdominal quadrants. The wound measured 20 cm long, 17 cm wide, and five cm deep. A previous ostomy opening, and small fistula were noted to left lower quadrant. Resident #109 had Eakin drainage pouch ordered for treatment. The note indicated the pouch was dislodged and was replaced by the nurse. No other skin alterations were noted. Review of Nurse Practitioner's (NP) #502 note dated 02/02/24 at 2:37 P.M. revealed Resident #109 was being seen per the request of a nurse for dressing change assistance. Resident #109 was lying in bed with dressing to wound dislodged. NP #502 gave a one-time order for Oxycodone (opioid for moderate to severe pain) five milligrams (mg) to be administered now (02/02/24). Resident #109 was educated on the importance of pain management as well as the relation of dressing changes if necessary. Resident #109's nurse and ADON #306 were at the bedside for assistance. Resident #109 tolerated the dressing change. The nursing note dated 02/02/24 at 3:25 P.M. revealed Resident #109's drain pouch was dislodged. NP #502 assisted with the pouch replacement and wrote updated orders to border wound with a foam dressing prior to applying drainage pouch and for the dressing to be changed only by NP. The note included the nurse could reinforce as needed for dislodgement and/or leaking. Review of a physician's order dated 02/02/24 at 4:40 P.M. revealed a NP was the only one to complete dressing changes for Resident #109. The wound was to be cleansed only with normal saline and patted dry. CeraRing Barrier ring (to help prevent leakage and infused with Cereamide [waxy lipid molecules] to protect the skin) cut in half to left lower border of abdominal surgical incision. Silicone foam to be cut to fit the excoriated skin surrounding the abdominal surgical incision to create an occlusive dressing every Thursday and as needed for wound care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the staff assessment for Resident #109 reflected the resident's short-term and long-term memory were intact. Resident #109 was independent with cognitive skills for daily decision making. Resident #109 had an ostomy and was occasionally incontinent of urine. Resident #109 required substantial/maximal assistance from staff with toileting hygiene, and partial/moderate assistance from staff to roll left and right. Resident #109 had a surgical wound. The nursing note dated 02/03/24 at 8:45 A.M. revealed Resident #109's wound pouch was loose at the bottom and a small bowel movement was noted. The nurse applied a new bandage to the bottom of the wound pouch. No leakage of bowel movement was noted from the wound pouch after the new bandages were applied. The nursing note dated 02/03/24 at 10:00 A.M. revealed a medium amount of stool was noted in Resident #109's wound pouch. The nurse removed the stool from the wound pouch. No pain or discomfort was noted. The nursing note dated 02/03/24 at 10:11 A.M. (created on 02/14/24 at 10:23 A.M.) revealed Resident #109 was given a Notice of Transfer and Bed Hold upon being sent to the hospital. Resident #109 was transferred because the welfare and needs of Resident #109 could not be met in the facility. The transfer was urgent because an emergency existed in which Resident #109's urgent medical needs necessitated an immediate transfer. The nursing note dated 02/03/24 at 4:19 P.M. revealed Resident #109 had been given scheduled medications and bandages had been applied to the bottom of wound pouch. Resident #109 had given as needed pain medication for discomfort and pain of the wound. Resident #109 decided to call EMS without notifying staff. EMS transported Resident #109 to the hospital. Review of the e-Interact situation, background, assessment, recommendation (SBAR) summary for providers dated 02/03/24 at 6:25 P.M. revealed Resident #109 had a change in condition to skin wound/ulcer. Resident #109's wound continued to be complicated due to size, fistula leaking stool into the wound bed, and compromised peri-wound. All wound complications were present upon admission. Primary care provider recommendations were to reinforce dressing and continue to monitor. Review of the medical record from 02/01/24 to 02/03/24 revealed Resident #109 did not have any behaviors including any rejection of care or non-compliance with care. Review of the case report summary from the local (Westerville) police reflecting an incident that occurred on 02/03/24 from 3:00 A.M. to 12:11 P.M. revealed a family member asked for a well-being check for Resident #109. The family member reported Resident #109 had been in their own filth for over seven hours and staff were not providing care. Resident #109 reported they had been denied assistance with an open wound. Three officers arrived at the facility and advised the receptionist they were there to speak to Resident #109. The receptionist seemed to be frustrated and began walking down the hall. While walking to Resident #109's room, it was noted Resident #109's call light was one of only two lights activated in the hallway. The officers were asked to stand outside Resident #109's door. An officer overheard staff ask Resident #109 if they had called the police. Resident #109 stated a family member called because Resident #109 was being neglected. An employee came out of Resident #109's room and told the officer not to enter because they needed to get a blanket to cover Resident #109. Upon entering Resident #109's room, Resident #109 was observed lying flat on her back with multiple blankets covering their waist and midsection. Resident #109 stated she had been admitted to the facility on [DATE] and had been lying in their own filth for 10 hours and had been asking for help. Resident #109 stated the nurse had been in to give medications multiple times but never cleaned the abdominal wound. Resident #109 stated multiple people had entered the room and told Resident #109 to wait to get help. Resident #109 showed two officers the wound and condition Resident #109 had been left in. The wound was covered by a blanket soaked in bodily fluids from the wound. The open wound began near Resident #109's belly button and went to Resident #109's ribcage. The skin surrounding the opening was bright pink in color, spreading outward from the wound. The fluid appeared to be yellow in color and smelled like feces. A lump of feces about the size of a grapefruit with the consistency of cottage cheese was sitting on Resident #109's lower stomach and the inside of the wound and was not contained in the medical bag that was in place. While talking with Resident #109, a male employee looked in the room and asked if anything was needed. It was later discovered the male employee was Resident #109's nurse. The nurse was LPN #401, who worked as a travel nurse. Resident #109 also advised the officers a similar incident was reported on Thursday/Friday. Two officers went out of Resident #109's room to talk to LPN #401. LPN #401 stated they did not neglect Resident #109 for 10 hours as Resident #109 claimed. LPN #401 indicated he was working 7:00 A.M. to 7:00 P.M. LPN #401 stated Resident #109's medical treatment required a specific medical bag and the hospital had only provided the facility with three bags when Resident #109 was admitted . LPN #401 stated they did not have any more medical bags and because it was the weekend, more bags could not be obtained from the pharmacy. LPN #401 was asked if it would be beneficial for Resident #109 to be transported to a hospital due to the facilities inability to properly care for Resident #109. LPN #401 stated he could not request Resident #109 be transported to the hospital without a supervisor's approval. LPN #401 stated he had been in contact with Resident #109's doctor and NP. LPN #401 stated Resident #109's current condition was due to a surgery the resident had. LPN #401 also stated because there had been two unexpected new admissions and the facility was short staffed, LPN #401 told Resident #109 she would have to wait until someone was available to clean her. LPN #401 claimed Resident #109's current condition did not reach the level to be considered an emergency that required transportation to the hospital. One of the officers on scene recommended medics be dispatched to the scene to evaluate Resident #109. Medics and the Battalion Chief were dispatched to the scene. While waiting for the medics, the acting manager (Activities Director #405) of the facility came to talk to the officers. Activities Director #405 explained Resident #109 was told to wait because there were two new admissions the nurse was busy with. LPN #401 was standing next to Activities Director #405 and stated they had been in to see Resident #109 to deliver medications to ease Resident #109's pain. LPN #401 also stated on 02/02/24, he had been with the doctor and NP (actually was NP and ADON #306) to learn how to properly care for Resident #109's wound without the use of the specific bags sent from the hospital. Medics arrived on scene and were advised of the situation with Resident #109. The medics entered Resident #109's room and shortly afterwards one medic exited the room and advised the officers and staff that Resident #109 was being transported to the hospital. The medic also advised staff that a formal complaint would be filed. LPN #401 and Activities Director #405 went about their business within the facility. The Battalion Chief arrived on the scene and went to Resident #109's room to investigate. The Battalion Chief spoke with staff (redacted) about the state Resident #109 was in and any statements the staff wanted to make. Staff (redacted) claimed Resident #109 was disoriented. A contact at the Attorney General's (AG) Office was contacted on 02/03/24 at 1:30 P.M. The police were advised to complete their investigation and the special agent at the AG office would assist where possible. An officer spoke with Resident #109 on the telephone after Resident #109 was transported to the hospital. Resident #109 stated the hospital staff were appalled at her medical state and pictures were taken to document Resident #109's condition. Resident #109 reported she had an infection she was currently being treated for. Resident #109 stated she wanted to press charges for neglect. The report also provided a summary of notable points and times from body worn camera footage on 02/03/23 as follows: At 12:14 P.M., the call light for Resident #109's room was on/illuminated. At 12:16 P.M., Resident #109 stated a call had also been placed (to police) on Thursday (02/01/24) asking for assistance. At 12:18 P.M., Resident #109 stated she was constantly told by staff they would be back. Resident #109 believed she had not been tended to since 3:30 A.M. At 12:23 P.M., Resident #109 was asked some basic questions to help gauge awareness (date, time, location, etc). Resident #109 answered all questions correctly without any apparent issues. At 12:26 P.M., Resident #109 was asked about any prior issues at the facility. Resident #109 reported on the day of admission (02/01/24) she needed cleaned up from the trip from the hospital and had been at the facility for hours without anything being done. At 12:33 P.M., medics were called with a request for the Battalion Chief to also come to the facility. At 12:38 P.M., Resident #109 stated feces had been on her open wound for nine hours. At 12:39 P.M., Resident #109 was asked if she had notified anyone during the nine hours. Resident #109 held up the nurse call button and said that she did constantly. At 12:40 P.M., a medic came in, took one look at Resident #109's opened wound area and said they needed to get Resident #109 to the hospital. From 12:48 P.M. to 12:49 P.M., Activities Director #405 was overheard telling other officers and Battalion Chief that Resident #109 was confused. This officer reported Resident #109 had been asked questions related to awareness and Resident #109 had answered correctly. Review of the EMS report dated 02/03/24 revealed at 12:39 P.M., EMS arrived at Resident #109's bedside. Resident #109 was alert and oriented times four and had bowel/stomach contents spilling from seal around abdomen surgery area. The area was red and warm, and appeared possibly infected. Resident #109 stated she had been resting in spilled contents for approximately nine hours and staff would not help remedy the situation. EMS transported Resident #109 to the hospital at 12:53 P.M. Review of the hospital records dated 02/03/24 revealed Resident #109 had an extensive history of abdominal surgeries, multiple colostomy revisions, fistulous tracks, and perforation. Resident #109 was discharged from the hospital to a facility on 02/01/24. Resident #109 stated she had been lying in their own feces and drainage from the wound for the past five days. The police were called to the facility. Resident #109 had a complicated abdominal surgical history now with a recurrent postoperative wound infection. It appeared the outpatient facilities were unable to care for this complex wound. It was likely in the best interest of Resident #109 to remain hospitalized until her wound could be appropriately cared for at an outpatient facility. The inability of the skilled facility to provide adequate wound care, placed Resident #109 at risk for recurrent wound infections, severe sepsis and increased Resident #109's morbidity and mortality. Resident #109's abdominal wall inferior to the wound looked significantly erythematous (redness) likely secondary to irritation and cellulitis from succus (fluid secretions) and feculent (waste) output. A computed tomography (CT) scan of abdomen/pelvis on 02/03/24 at 5:26 P.M. compared to the previous CT on 01/13/24, revealed the abdominal wound had worsened. Review of photos taken at the hospital revealed Resident #109's skin was very red from the bottom of the wound to the mons pubis. An additional photo showed redness to Resident #109's upper right thigh and a white dried substance to Resident #109's right groin. Another photo revealed Resident #109's buttocks were reddened. A photo showed Resident #109's left heel was dry, cracked and reddened. A photo also revealed a reddened area under Resident #109's left breast. Review of the emergency department notes by a Licensed Social Worker (LSW) dated 02/03/24 at 4:07 P.M. revealed the LSW spoke with Resident #109 about concerns for neglect at the skilled facility. Resident #109 reported she was placed in skilled facility from 02/01/24 to 02/03/24. Resident #109 reported she was unable to ambulate or toilet without assistance. Resident #109 reported lying in bed for about 12 hours on 02/02/24 with a call light on asking for assistance to go to the bathroom and have the wound cleaned. Resident #109 reported when no one showed up to help, Resident #109 used blankets, pillows, and sheets to clean the wounds. Resident #109 reported lying in feces and urine for long periods of time. Resident #109 had contact with a family member. On 02/03/24, Resident #109's family called the police and Resident #109 was transported to the hospital. This case had been reported to the police, adult protective services, department of health, and hospital case management given Resident #109 was covered in feces for four days. Review of the facility self-reported incident (SRI), tracking number 243820 dated 02/05/24 revealed there was an allegation of neglect that occurred on 02/03/24 at 10:00 A.M. when Resident #109's family/friend called 911. Police officers arrived on 02/03/24 around 12:00 P.M. and asked to speak with Resident #109. Officer #542 spoke with Resident #109 and facility staff. The SRI included Officer #542 was aggressive toward LPN #401 and raised her (actually a male officer) voice at LPN #401 in the hallway, asking what was going on with Resident #109 and that they were taking Resident #109 to the hospital. The facility documented in the SRI that officers and EMS did not explain to anyone what was going on and what the complaint was about. On 02/03/24, the DON called the police department to find out what was going on and why Officer #542 yelled at LPN #401. The DON called on 02/05/24 and was given a report number. LPN #401 stated Resident #109 was putting tissue paper onto her wound and was taking the dressing off. LPN #401 and State tested Nursing Assistant (STNA) #184 stated they were in the resident's room multiple times for the day helping and educating Resident #109 not to mess with the wound. Review of the written statement by STNA #184 dated 02/03/24 revealed they received report at 7:00 A.M. Resident #109 was sleeping when the report was given. Resident #109 refused breakfast and lunch. Resident #109 was encouraged to eat breakfast but stated she was not hungry. Resident #109's call light was on and STNA #184 found soiled linens with feces on the floor. STNA #184 picked up the soiled linens and gave Resident #109 new linens. Housekeeping cleaned the floor. Resident #109's call light was on, and Resident #109 stated she wanted the nurse. STNA #184 notified LPN #401. Later, STNA #184 saw three police officers asking for Resident #109. Resident #109 refused care when the officers came in the room and said she did not want to be cleaned or touched. A written statement by LPN #401 dated 02/03/24 (no time) revealed Resident #109 was given morning medications and the resident's wound was assessed. The wound bandage was loose at the bottom and LPN #401 applied new bandages to the bottom of the wound. Resident #109 was using tissue and other random linen for self-care of the wound. LPN #401 educated Resident #109 about infection by using tissue and linen sheets inside of wound. Resident #109 was educated about using call light. The call light came on and STNA #184 answered the call light. STNA #184 notified LPN #401 that Resident #109 would like to speak to LPN #401. LPN #401 told STNA #184 he would be there as soon as possible. STNA #184 and housekeeping were in Resident #109's room. LPN #401 went into Resident #109's room and the bandage was loose at bottom. LPN #401 applied a new seal on the bandage. Resident #109 requested a pain pill for discomfort and pain. Resident #109 was given as needed pain medication. STNA #184 notified LPN #401 that police officers were in Resident #109's room regarding concerns that Resident #109 expressed to them. LPN #401 communicated with officers regarding concerns and reassured officers Resident #109 had been cared for and was given a pain pill. EMS decided to take Resident #109 to the hospital. Officer #542 was verbally aggressive and pointed finger in LPN #401's face upon questions about Resident #109. Review of the plan of care dated 02/09/24 revealed Resident #109 had alteration in skin integrity related to surgical abdominal wound. Interventions included checking dressing every shift for placement during the provision of routine care and services, observing placement of dressing as appropriate, and surgical wound to be kept clean and dry. Interview on 02/14/24 at 12:16 P.M. with Resident #109's son revealed Resident #109 had been hospitalized from 02/03/24 until 02/13/24 and then discharged to a specialty hospital for ongoing care. Resident #109's son stated he arrived at the hospital on 02/03/24 and hospital staff were taking pictures of Resident #109 showing the concerns with the condition Resident #109 was in when she arrived at the hospital. < [TRUNCATED]

Based on observation, record review, review of hospital records, and interview, the facility failed to timely identify and assess symptoms of a urinary tract infection (UTI), accurately collect a sample of urine for testing, and notify the physician of contaminated urine specimens for Resident #24. Additionally, the facility failed to remove Resident #52's indwelling urinary catheter following the collection of a 24-hour urine. Actual harm occurred beginning on 07/04/23 when the facility failed to identify symptoms of UTI, treat the UTI with the appropriate antibiotics, and notify the physician of multiple contaminated urine samples causing Resident #24 to sustain a significant decline in condition. On 08/04/23 the resident was transferred to an acute care hospital for confusion and suicide attempt and was found to have a UTI. The resident was hospitalized for nine days and required intravenous (IV) antibiotics to treat the urinary tract infection. This affected two residents (#24 and #52) of two residents reviewed for UTI and/or indwelling catheter use. The facility census was 92. Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admitted [DATE] with the most recent re-admission of 08/12/23. Resident #24 had diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, Alzheimer's disease, dementia, bipolar disorder, psychosis, osteoarthritis, obstructive sleep apnea, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, mood disorder, hypertension, major depressive disorder, benign prostatic hyperplasia, allergic rhinitis, insomnia, retention of urine, and cerebrovascular accident (CVA). Review of the plan of care dated 02/06/19 revealed the resident had a suprapubic urinary catheter due to disease process and obstructive uropathy. Interventions included catheter care, change catheter per physician order, change urinary collection bag as needed, maintain dignity bag to catheter, maintain drainage bag below bladder level, report to physician signs of urinary tract infection (UTI), secure catheter with securement device, wears pads/briefs as needed, report any changes in amount, color or odor to urine and administer medications per physician's orders. Review of the resident's progress note dated 07/04/23 revealed the resident's spouse reported the resident's urine was dark in color. On assessment by the staff nurse the resident's urine was found to be amber in color with a foul odor. A new physician's order was obtained for a urinalysis/culture & sensitivity (UA/C&S). Review of the medical record revealed the resident's urine was collected on 07/05/23 and was sent to the facility's contracted lab on 07/06/23. The results of the UA/C&S returned on 07/09/23 with the bacteria Escherichia coli (E-coli) greater than 100,000, Providencia stuartii greater than 100,000 and Pseudomonas aeruginosa greater than 100,000. The resident was treated with the antibiotic, Augmentin 500 milligrams (mg) by mouth twice daily for five days. Further review of the UA/C&S revealed the antibiotic, Augmentin was only sensitive to the E-coli. Review of the progress note dated 07/18/23 revealed the resident's wife reported the resident had increased confusion/hallucinations and a new order was obtained for a UA/C&S. Review of the progress note dated 07/24/23 revealed the resident's wife was at the facility and asked Director of Nursing (DON) #225 to review the UA/C&S results with her which showed the urine was contaminated. The Nurse Practitioner (NP) was notified at that time of the contaminated urine and a new order was obtained for another UA/C&S. On 07/31/23 the NP saw the resident and reviewed the resident's UA/C&S results and started the antibiotic Cipro 500 mg by mouth twice daily for seven days; however, the UA/C&S again showed the urine was contaminated. Review of the progress note dated 08/04/23 at 12:40 P.M. revealed the resident's family wanted the resident transferred to a local emergency department (ED) for an evaluation due to an acute change in mental status. Review of the medical record revealed no documented evidence staff had identified the change in the resident's condition until it was brought to their attention by family (on 08/04/23). Further record review revealed a lack of comprehensive monitoring/assessment of the resident's urinary status during the time period between 07/04/23 and 08/04/23. Review of the acute care hospital history and physical dated 08/04/23 revealed the resident was transferred to the acute care hospital for confusion and suicide attempt and was found to have a UTI. The resident was treated in the hospital with intravenous (IV) antibiotics for nine days. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had displayed hallucinations and delusions, however had displayed no behaviors. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, toileting, dressing and bathing. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. On 10/02/23 at 3:28 P.M., an interview with the resident's wife revealed the resident was sick the entire month of July 2023 due to a UTI. She revealed he had a temperature, and the physician ordered a UA/C&S. She said he had two urines come back contaminated and the contracted lab failed to pick up his urine over the holiday weekend. She revealed the facility did not repeat the urine testing until she requested. She revealed the resident continued to become more confused and had increased hallucinations to the point he took his scissors and held them to his throat and stated he wanted to kill himself. She revealed the resident spent nine days in the hospital on intravenous (IV) antibiotics to treat the UTI the facility failed to treat properly. On 10/04/23 at 11:09 A.M., an interview with DON #225 verified the lack of care causing the resident's hospitalization related to the UTI. A request was made during the onsite survey to review the facility policy and procedure related to change in condition; however, no policy was provided. 2. Review of the medical record for Resident #52 revealed an initial admitted [DATE] with the most recent re-admission of 07/24/23. Resident #52 had diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the admission assessment and baseline care plan dated 07/24/23 revealed the resident was incontinent of urine. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, and toilet use. The assessment indicated the resident was always incontinent of bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the use of the indwelling urinary catheter. Review of the physician's orders revealed no orders for the use of the indwelling urinary catheter. Review of the medical record revealed no evidence the resident had an indwelling urinary catheter or reason for the indwelling urinary catheter. Review of the resident's discontinued physician orders identified an order dated 08/23/23 to place foley catheter to begin 24-hour urine collection (on 08/23/23). On 10/02/23 at 11:12 A.M., observation of Resident #52 revealed the resident had an indwelling urinary catheter. Further observation revealed the resident's indwelling urinary catheter collection bag was purple in color. On 10/03/23 at 3:35 P.M., an interview with DON #225 verified the resident currently had an indwelling urinary catheter. DON #225 revealed the catheter should have been removed following the collection of the 24 hour urine (on 08/24/23).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the National Weather Forecast, review of an investigation report, observations, staff and family interviews, and review of facility policies on Missing Person Locator and Insight Clinical, the facility failed to appropriately respond to an alarming door and provide adequate supervision to ensure one cognitively impaired resident, assessed to be at high risk for elopement from the facility and with exit seeking behaviors (Resident #3), did not elope from the facility. This resulted in Immediate Jeopardy when Resident #3 was placed at risk for serious harm and injury when the resident exited the facility through a door near the therapy room without staff knowledge. Resident #3 walked 4.9 miles to his old house where he was banging on the neighbor's door. This affected one of four residents (Residents #3, #31, #34, and #74) reviewed for elopement. The facility identified four current residents, Residents #3, #31, #34, and #74 to be at risk for elopement. The facility census was 90. On 12/07/21 at 3:30 P.M., the Administrator was notified Immediate Jeopardy began on 11/13/21 around 1:30 P.M., when Resident #3 exited the facility through a sliding door activating a door alarm which State tested Nursing Assistant (STNA) #100 and Licensed Practical Nurse (LPN) #500 turned off without initiating a resident search. Resident #3 then exited another door to the outside. Resident #3 was found 4.9 miles away from the facility when a neighbor called the facility. The ambient air temperature outside was 41 degrees Fahrenheit (F) on 11/13/21. The facility resided on a four-lane road. At the time of discovery, Resident #3 was found to have minor scrapes and bruises to his right last three fingers and back of the hand. The Immediate Jeopardy was removed, and the deficient practice corrected on 11/15/21 when the facility implemented the following corrective actions: · On 11/13/21 at 3:44 P.M., a missing person drill was conducted. All remaining residents were accounted for. · On 11/13/21 at 4:05 P.M., alert charting was initiated for Resident #3. · On 11/13/21 at 4:05 P.M., Resident #3 was placed on continuous one-to-one staff supervision. Resident #3 would remain on one-to-one supervision indefinitely until Resident #3 no longer resided at the facility or had a significant change of condition and no longer required one-to-one supervision. · On 11/13/21 at 4:15 P.M., a complete physical assessment of Resident #3 was conducted by LPN #500. Minor bruises were noted. Additionally, there was a small scratch on the right index finger, and two small scratches on the top of the hand above the pinky and ring finger as well as a small abrasion noted to the dorsal surface of Resident #3's hand and back of hand. A Secure Care Bracelet (wanderguard) was noted on Resident #3's left ankle and was checked upon re-entrance to the facility by the Director of Nursing (DON). Resident #3's wanderguard was functional. · On 11/13/21 at 4:30 P.M., an investigation was initiated which included interviewing employees in the facility. · On 11/13/21 at 5:00 P.M. the wanderguard monitoring box was evaluated and was found to be working properly. · On 11/13/21 at 6:08 P.M., door system functions were checked by the Administrator and DON on 100 percent of exit doors to the outside with no functional concerns identified. · On 11/13/21 at 7:30 P.M., three residents were identified as at risk for exit seeking behaviors. The three residents wanderguards were assessed by the DON for placement and function, and all were functioning appropriately. · On 11/13/21 at 7:30 P.M., the DON reviewed the three Center Watch Binders, and all of the information was accurate and correct. The facility had three binders. One was on the back unit nurses' station, one was on the front unit nurses' station, and one was at the reception area. The binders included the face sheet, picture, and general description of those residents identified to be at risk for elopement. · On 11/13/21 at 7:40 P.M., an ad hoc quality assessment and assurance (QAA) meeting was held to review the investigation process. · On 11/13/21 at 7:40 P.M., Resident #3's responsible party was updated on Resident #3's status. · On 11/13/21 at 7:45 P.M., the DON updated exit seeking assessments as needed and reviewed the plan of care for residents identified as exit seekers. · On 11/13/21 at 9:15 P.M., all door codes were changed by Maintenance Director #400. · On 11/13/21, Resident #3's care plan was reviewed and updated to include one-to-one supervision. Additionally, a new behavior/elopement risk assessment was completed for Resident #3. · On 11/13/21, staff education was initiated. The education included door code use and the missing person protocol. Education was completed on 11/16/21 by the DON and/or Administrator. All full-time, part-time, as needed, or agency staff were educated prior to working any shift after 11/13/21. · On 11/13/21, the DON/designee began conducting random door alarm drills and checks two times a daily for seven days to ensure appropriate function and response. Random audits would continue one time per week for an additional two weeks. · On 11/13/21, STNA #100 and LPN #500 were placed on suspension pending an investigation. STNA #100 was re-educated on elopement and the door alarm policy and procedures, and received a corrective action. LPN #500 was re-educated on elopement and door alarm policy and procedures, and received a final written warning. · On 11/14/21, a missing person drill was conducted. · On 11/14/21, the Administrator/designee initiated a QAPI audit tool daily for seven days to ensure all component of the Exit Seeking Guidelines were in place for those residents identified as an elopement risk. Random audits would continue one time per week for two additional weeks. · On 11/15/21, the DON and Licensed Social Worker re-assessed residents in the facility who were not identified as at risk for exit seeking for current risk, and assessments were completed as needed and plans of care were reviewed and/or revised as needed. One additional resident (#26) was identified as at risk for elopement. Center Watch Binders and The Center Watch Board were updated as needed. · On 11/15/21, a missing person drill was conducted and would continue to be conducted at increased frequencies. · Resident #3 continued to have his wanderguard checked every shift for placement and every day for function until Resident #3 no longer requires a wanderguard. · All newly admitted residents were evaluated for elopement risk during the admission evaluation, after a change of condition, and quarterly. Any newly admitted resident identified as at risk for elopement had interventions put into place upon admission. · Exterior exit doors continued to be locked at all hours of the day. · All concerns or trends from monitoring would be forward to QAA for review/resolution. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two with diabetic polyneuropathy, attention and concentration deficit, dementia, disorientation, and [CONDITION(S)] stage four. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/15/21, revealed Resident #3 had moderate cognitive impairment. The assessment revealed Resident #3 had behaviors of wandering during one to three days in the lookback period. Resident #3 required supervision for bed mobility, transfers, eating, toileting, and personal hygiene. He required extensive assistance with one person assist for dressing and bathing. Review of Resident #3's nursing note dated 11/11/21 at 6:46 P.M. revealed Resident #3 was talking about going home earlier in the shift and walking towards the front door. Resident #3 was re-directed back to the floor by the dietary manager. Resident #3 was able to speak with a family member over the phone. Staff was to assist as needed and redirect as needed. Review of the Behavioral Symptom assessment dated [DATE] revealed Resident #3 was high risk for exit seeking. The assessment further revealed Resident #3 was noted to exhibit exit seeking behaviors in an attempt to go home. Staff attempted to redirect Resident #3 and after several attempts, Resident #3 returned to his room. The assessment further revealed a wanderguard was placed on Resident #3. Review of the plan of care dated 11/09/21 revealed on 11/12/21 it was initiated into the care plan that Resident #3 was at risk for behavior symptoms related to exit seeking behaviors. Interventions included one to one supervision initiated on 11/13/21, redirect patient by offering activities of choice initiated on 11/13/21, use consistent approaches when giving care initiated on 11/12/21, and wander guard put into place for exit seeking behaviors initiated on 11/12/21. Review of Resident #3's physician order dated 11/12/21 revealed an order for an alert bracelet to the left ankle, check functioning on night shift, and check placement every shift. Review of Resident #3's nursing note dated 11/12/21 at 11:37 A.M., revealed Resident #3 was ambulating throughout the building, attempting to leave the building, and stating he was going home. Resident #3 was not easily redirected and continued to push through the door. Staff were eventually able to redirect Resident #3 with calling his niece. The niece stated Resident #3 had attempted to leave another rehab facility twice but was redirected. The niece revealed she was okay with placement of the wanderguard bracelet to alert staff when Resident #3 was exit seeking. The nurse practitioner was notified, and new orders were received. Review of Resident #3's nursing note dated 11/13/21 at 3:00 P.M. revealed Resident #3 was last seen at 1:30 P.M. by the nurse, eating lunch in his room. The nurse continued to pass 2:00 P.M. medications and after the medication pass assisted another nurse on the 200 halls with intravenous therapy and later took her lunch break. Review of Resident #3's nursing note dated 11/13/21 at 4:30 P.M. revealed Resident #3 returned to the facility via staff. Upon arrival a head-to-toe assessment was completed. Resident #3 was noted to have minor bruises to his right last three fingers and the back of the hand. Review of Resident #3's nursing note dated 11/13/21 at 7:47 P.M. revealed the nurse validated the wanderguard was on Resident #3's left ankle and was functioning properly. Review of the National Weather Service Report for the day of 11/13/21 revealed the temperature outside was 41 degrees F. Review of the investigation report dated 11/13/21 revealed an investigation took place from 11/13/21 through 11/19/21. On 11/13/21 at approximately 2:55 P.M., the facility received a phone call from Resident #3's niece reporting Resident #3 was at his old home. STNA #100 was the employee who answered the phone call from Resident #3's niece. STNA #100 immediately reported the information to the Manger on Duty, Dietary Manager #200. Dietary Manager #200 took over the phone conversation. The niece informed Dietary Manager #200 she received a phone call from Resident #3's previous neighbor reporting Resident #3 was banging on his front door. Dietary Manager #200 instructed STNA #100 to call 911. 911 was called at 3:00 P.M. The local police department was notified Resident #3 had left the facility and was at his previous home. The local police department transferred the call to the city police department as Resident #3's location was within the city police departments jurisdiction. Dietary Manager #200 and Central Supply #300 drove the facility van to Resident #3's old home and met him there. About five minutes after their arrival, the city police department showed up. The neighbor came out and told Central Supply #300 that Resident #3 was with him. Resident #3 told Dietary Manger #200 that he just wanted to go home. Resident #3 agreed to get in the van and come back to the facility. Dietary Manager #200 observed Resident #3 wearing black pants, grey long sleeve zip up sweater, t-shirt under the sweater, white shoes, and a black ball cap. The neighbor asked Resident #3 if he was cold and Resident #3 reported he was okay. Dietary Manager #200 observed some scratches on Resident #3's right hand and a small cut on his bottom lip. Resident #3 told Dietary Manager #200 that he fell when he was walking home. Resident #3 returned back to the facility at approximately 4:10 P.M. Upon arrival back to the facility, Resident #3 was immediately assessed by the charge nurse. A head-to-toe skin assessment was completed. The findings of the assessment included a small scratch on the right index finger, and two small scratches on the top of the hand above the pinky and ring finger. The scratches were cleaned with normal saline and did not require bandages. Resident #3's home was approximately 4.9 miles from the facility. The temperature at the time of Resident #3's elopement was 41 degrees F. According to staff interviews, Resident #3 was last seen in his room at approximately 1:30 P.M. by the STNA. The facility implemented an immediate plan of action in order to protect Resident #3 and like residents. Resident #3 was assessed for injury with only minor scrapes and bruises to his right hand. Like residents were identified as those residents at risk for exit seeking behavior. Staff education was immediately implemented. The facility door alarm and missing resident drills were completed and would continue at an increased rate. Monitoring would continue at that time. Review of Resident #3's nursing note dated 11/14/21 at 3:55 P.M. revealed Resident #3 was standing at the doorway asking to go home. Resident #3 was advised that it was cold and snowing so he needed to stay inside. Resident #3 replied Okay and went back to his bed and sat down. Review of Resident #3's nursing note dated 11/15/21 at 1:10 A.M. revealed Resident #3 continued on one-to-one supervision with no issues. No exit seeking behaviors were noted during the shift. Review of Resident #3's nurse practitioner note dated 11/15/21 revealed Resident #3 had a bruise to his right hand and was status post an elopement from the facility on 11/13/21. Resident #3 was reported with bruising present when he returned to the facility. Resident #3 reported no pain. Resident #3 stated he fell when he went home on Saturday and put his hands out to break his fall. Resident #3 had minor bruising noted to the last three fingers with a small abrasion noted to the dorsal surface of his hand with a scab in place. Resident #3 reported he was ready to go home, and he went. Resident #3 was noted to have a wanderguard present to his left ankle upon exam. Resident #3 was alert and oriented to self and place. Review of the care conference note dated 11/16/21 revealed the Interdisciplinary Team met with Resident #3's niece/Power of Attorney (POA). The note revealed Resident #3 was being discharged from services on 11/17/21 due to walking ad lib and completing Activities of Daily Living. The note further revealed Resident #3's recall time was 30 seconds to one minute and Resident #3 required 24-hour support at home. The note further revealed staff discussed Resident #3's recent elopement and the interventions in place for safety including wander guard placement and one-to-one supervision. The Social Worker was assisting in Long Term Care placement as it was understood Resident #3 was not safe alone in his home and needed 24-hour supervision. Interview on 12/07/21 at 9:00 A.M. with STNA #101 revealed she was working the day Resident #3 eloped from the building. STNA #101 stated she was assisting a resident with care at the end of the 100 hallway and did not hear the door alarms. The interview further revealed Resident #3 wanders to the nurse's station throughout the day and wants to leave. STNA #101 stated the closed double doors which lead to the front lobby deter Resident #3 from leaving. STNA #101 reported there was a lot of family coming in and out of the building on the day Resident #3 eloped and she was unsure how Resident #3 eloped from the building. Observations of Resident #3 on 12/07/21 revealed the following: · At 9:00 A.M., Resident #3 was in his room. Resident #3 was wearing tan pants, a black shirt, and white shoes with a wander guard bracelet on his left ankle. Resident #3 had a one-to-one staff sitting in his room. · At 10:50 A.M., Resident #3 was in his room. Resident #3's one-to-one staff was present. · At 11:00 A.M., Resident #3 was at the front double doors leading to the lobby in front of the nurse's station and Resident #3's one-to-one staff member was standing approximately ten feet away from Resident #3. · At 11:15 A.M., Resident #3 was standing at the nurse's station with Resident #3's one-to-one staff nearby. · At 2:26 P.M., Resident #3 was sitting in the front lobby with his one-to-one staff. · At 2:55 P.M., Resident #3 was standing in front of the exit doors with staff attempting to re-direct Resident #3 from the door. · At 3:30 P.M., Resident #3 was standing at the front door and staff were attempting to re-direct Resident #3 from the door. · At 4:30 P.M., Resident #3 was in the television room visiting with family. Interview and observation with Maintenance #400 on 12/07/21 at 9:30 A.M. of the facility exit doors revealed all doors were tested and all doors alarmed/sounded at the nurse's station. Numerous staff answered the door testing. Maintenance #400 stated the doors were checked daily and weekly for function and there were no issues or concerns. Interview on 12/07/21 at 11:00 A.M. with STNA #104 revealed she did not work the night Resident #3 eloped from the facility. STNA #104 verified Resident #3 was standing at the nurse's station near the front door. STNA #104 reported this was typical behavior, but once Resident #3 placed his jacket on then he was going to try to leave. Interview on 12/07/21 at 11:15 A.M. with the Administrator revealed on 11/13/21 before 3:00 P.M., the facility received a call from Resident #3's niece reported she received a call from Resident #3's neighbor informing her that Resident #3 was at the neighbor's house banging on the door. The police were notified and two facility staff went to Resident #3's home to bring him back to the facility. When the staff arrived, Resident #3 was inside the neighbor's home. The interview revealed the staff waited until the city police arrived onsite. After city police arrived onsite, Resident #3 willingly got into the facility van and returned to the facility. The Administrator stated she reviewed the medication administration records for Resident #3 and he received his medication on 11/13/21 at 1:30 P.M. from the nurse. The aide working the unit stated she saw Resident #3 around 1:30 P.M. to 1:45 P.M. in his room. The Administrator and the DON started the investigation immediately and began interviewing all staff. An STNA reported she was working on the 200-hallway and responded to a door alarm around 1:30 P.M. to 1:45 P.M. near the therapy sliding doors. The interview further revealed when the STNA came around the corner, the nurse was already at the door. The nurse reported she came out of a room and the door alarm was sounding but the nurse did not know the code to turn off the door alarm and did not know why the alarm was going off. The STNA put in the code to shut the alarm off. The STNA did not check the area because the nurse was the first on the scene. Both the STNA and the nurse were placed on suspension pending an investigation. The STNA was re-educated on elopement and the door alarm policy and procedures, and received a corrective action. The nurse was re-educated on elopement and door alarm policy and procedures, and received a final written warning. Once Resident #3 came back to the facility, Resident #3 was placed on one-to-one staffing. Resident #3's niece gave approval for the one-to-one staffing. Additionally, all doors were validated to be in working order. Resident #3 and all like residents' wander guard bracelets were verified to be in working order. The maintenance director changed all of the door codes. The facility was not aware Resident #3 was an elopement risk upon admission. Resident #3's hospital paperwork did not identify Resident #3 as being an elopement risk. When Resident #3 started to display exit seeking behaviors, the facility obtained consent from Resident #3's niece and placed a wanderguard on Resident #3. In the first seven days, the facility completed two missing person drills a day as well as door checks. Staff education was initiated immediate and all staff including agency could not work until they received education. Interview on 12/07/21 at 2:00 P.M. with Resident #3's niece revealed she called the facility on 11/13/21 around 3:00 P.M. to notify them she received a call from Resident #3's neighbor that Resident #3 was there knocking on the neighbor's door. The neighbor let him in his home. Resident #3's niece was told by the neighbor that Resident #3 walked to his home. Resident #3 had some scratches on him. The niece revealed Resident #3 was at a different facility and attempted to go out the facility doors on two different occasions but was able to be re-directed. She stated she did not notify the facility of this behavior at the time of admission but did notify them the day before Resident #3's elopement which was when the wanderguard was placed on Resident #3. Review of facility policy titled Missing Patients dated revealed the Missing Patient Response Plan was intended to provide guidelines for patient accountability, searching for missing patients and communicating with outside agencies. This plan supplements the most current clinical services information regarding missing patients. Use the Missing Patient Action Table and Missing Patient Locator Form to document all actions taken during the search. The Missing Patient Location form step one revealed whenever a staff member discovers a patient missing or hears an alarm that may indicate a patient had left the center, the staff member immediately conducts an initial interior or simultaneous external search of the immediate area to locate the patient. Review of the facility policy titled Insight Clinical dated 08/2021 revealed residents were evaluated upon admission for a history of or risk factors for wandering and/or exit seeking. Interview the patient and family or responsible party about patient's specific history, triggers, and interventions attempted in the past. Interventions that may be considered include structured activity programming, patient room placement in relation to egress doors, personal security bracelet, and safe wandering interventions. When unsafe wandering or elopement risk had been identified a Behavioral Symptoms User-Defined Assessment ([NAME]) would be completed. The personal security bracelet serves as an alert to the patient of safe boundary limits and as an alert to staff if patient was close to an alarmed door. A physician order would be obtained and education to family and resident prior to application. Bracelet placement would be validated every shift and functioning of the sensor every day. Exit doors and stairwells doors were alarmed. Door alarms were checked for functionality per manufacturer's guidelines. Staff response drill would be conducted monthly, encompassing each shift as needed. Findings would be documented and submitted to the Safety and or QAPI Committee for review and follow-up as needed. This deficiency substantiates Self-Reported Incident, Control Number OH 687.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's policy and procedure, review of the facility's Coronavirus (COVID-19) timeline, review of daily resident census reports, record review, and staff interview, the facility failed to perform adequate contact tracing to properly identify, quarantine, and appropriately test residents with exposure to staff members who had tested positive for COVID-19. The facility failed to implement effective and recommended infection control practices, including appropriate use of a designated COVID unit, implement appropriate quarantine procedures, and ensure staff used appropriate personal protective equipment (PPE) to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on [DATE] when the facility dismantled the dedicated COVID-19 unit while there were still two positive COVID-19 residents residing on the unit. Residents #9 and #10 were moved to the end of the hall and the facility no longer had dedicated staff providing care for those residents that were COVID-19 positive. In addition, the facility failed to provide contact tracing after five employees tested COVID-19 positive on [DATE], [DATE], [DATE], [DATE], and [DATE]. This affected 23 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #23, #50, #54, #55, #61, #62, #71, and #79). The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facilities failure to control the spread of Covid-19. The facility census was 87. On [DATE] at 10:02 A.M. the Administrator was notified Immediate Jeopardy began on [DATE] when the facility dismantled the dedicated COVID-19 unit while there were still two positive COVID-19 residents (Residents #9 and #10) residing on the unit. Observations on [DATE] also revealed PPE gowns were not being used for the residents under droplet, airborne precautions (quarantine status) on the 200 unit. Additional observations also revealed Resident #1 and #2 were under droplet, airborne precautions after the ordered time had expired; and, Resident #5, #6, and #7 did not have any signage on their doors indicating they were under droplet, airborne precautions. Review of medical records revealed Residents #12 and #14 were not tested during the whole house COVID-19 testing but continued to share rooms with a roommate (Residents #13, #15) resulting in these residents testing positive for COVID-19. The facility also failed to provide contact tracing after five employees tested positive on [DATE], [DATE], [DATE], [DATE], and [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · On [DATE] the COVID 19 Isolation Unit was re-opened. On this date, Residents #14, #23, #50, #54, #55, #61, #62, and #71 were moved to the isolation unit. · On [DATE] the Central Supply Clerk ensured isolation carts were placed and stocked with PPE, including gowns and gloves, in the hallway of resident rooms that required quarantine. · On [DATE] the facility took immediate action through Quality Assessment Performance Improvement upon identification of the issue and notified the medical director. · On [DATE] four facility staff that have tested positive and are currently on quarantine were contacted for contact tracing information by the Staffing Coordinator. Contact tracing was completed by the Staffing Coordinator. · On [DATE] the facility COVID-19 Focused Rounds Tool was completed by the Quality Assurance Coordinator to ensure compliance with infection control practices. This tool is completed daily during COVID-19 outbreak and includes observations made to determine if the facility COVID-19 Prevention Plan is in place and if general standard precautions are being implemented. When the facility is not experiencing an outbreak, this tool is completed weekly. · On [DATE] specified areas (quarantine area) for newly admitted residents and readmission of residents has been identified and placed on a floor map for education. The quarantine unit is located at the terminal end of the 200 hallway. Dedicated staff members will be assigned to specific areas of the facility. Staff members that work the COVID-19 positive area will only work that unit for that day. Once the staff member works the COVID-19 positive area that day, they will not be allowed to work any other unit that day. This will be completed by the facility Administrator. · Beginning [DATE] placement of residents who require isolation precautions will be reviewed by the Director of Nursing or Quality Assurance Consultant. · On [DATE] dedicated staffing for residents requiring isolation (COVID unit and quarantine unit) to be implemented with appropriate PPE available. Staffing will be reviewed by the Administrator, Director of Nursing or Infection Preventionist during the daily staffing meeting. · Beginning [DATE] immediate education of 100% of facility staff on COVID 19 infection control practices in specified isolation areas will begin by the Quality Assurance Consultant, Director of Nursing and/or Infection Preventionist. Education will be completed by [DATE] at 5:00PM. Education will include, but not limited to appropriate use of PPE, identification of areas of the facility with specific isolation practices, and facility staff members will not be allowed to work until the education is completed. As of [DATE] at 4:00 P.M., 101 of 128 employees have received in-service education. Per Administrator, no staff will be permitted to work until they have received the in-service education. · On [DATE] the Administrator will be educated on the contact tracing process for positive employees by the Quality Assurance Consultant. If needed, identified residents will be tested for COVID-19. There were no identified residents that required contact tracing based on the facility investigation. · On [DATE] the Administrator and DON will be educated on the dedicated unit for COVID-19 positive residents and a dedicated space for quarantined residents by the Quality Assurance Consultant. · On [DATE] the Infection Preventionist and DON will be educated on ensuring the facility COVID-19 tracking tool is filled out accurately and completely to monitor progression of COVID-19 positive residents by the Quality Assurance Consultant. This tool is used to track the following: resident's name, room number, admitted with lab confirmation and diagnosis, date of onset of symptoms, date of test, in house acquired or community acquired, isolation off unit, symptomatic, asymptomatic, discharge and location of discharge, expired, projected recovery date, and recovery date. · On [DATE] residents requiring quarantine will be placed in the appropriate area as identified on the floor map per isolation needs. This will be completed by facility managers. · On [DATE] therapy employee (Therapist #201) observed without appropriate PPE was removed from care and educated on PPE use by the Quality Assurance Coordinator. Moving forward employees will not be permitted to provide care without receiving PPE education. · Beginning [DATE] random observations of staff will occur utilizing the competency: PPE (Donning and Doffing) audit tool. These observations continue to be completed by the Director of Nursing, Infection Preventionist, Unit Manager or Quality Assurance Consultant. · Beginning [DATE] employees who work on the COVID Airborne Isolation Unit (CA I U) will be educated by the Quality Assurance Consultant, Director of Nursing or Unit Manager as it relates to entering and exiting the CAI U. This education was initiated on [DATE] by the Quality Assurance Consultant and will be completed on [DATE]. Employees will not be permitted to work on the CAIU unit until this education is completed. · Beginning [DATE] random weekly audits will be conducted using the COVID-19 FOCUSED ROUNDS TOOL to ensure compliance as it relates to: COVID-19 Prevention Plan, General Standard Precautions, Transmission Based Precautions, Infection Surveillance and Staff Screening and Monitoring. These audits will be completed by the Director of Nursing, Infection Preventionist or Quality Assurance Consultant. · Beginning [DATE] facility staffing meeting minutes will be reviewed daily to ensure dedicated nursing, therapy, and housekeeping staff are scheduled on the COVID-19 unit and for quarantined residents. · On [DATE], [DATE], [DATE], and [DATE] the facility QAPI committee met through Ad Hoc or full QAPI and shall monitor weekly (beginning [DATE]) for 4 weeks to review any trends and findings, issues or concerns and develop plan of action for follow up and resolution. · On [DATE] onsite observations of the facility revealed staff were appropriately wearing and removing PPE, hand hygiene was in place, and residents requiring quarantine were residing on the appropriate unit. · On [DATE] from 4:47 P.M. to 5:01 P.M., three staff members (an STNA, a nurse supervisor LPN, and a dietary aide) were interviewed and found to be knowledgeable of the facility's COVID -19 practices and general infection control practices. The staff confirmed they received recent education at the facility that included: appropriate use of PPE, admission and readmission policy and procedures, areas of the facility where isolation and quarantined residents would be placed, and hand hygiene. Although the Immediate Jeopardy was removed on [DATE], 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 still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes.We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). 1. A tour of the facility on [DATE] from 2:05 P.M. to 3:00 P.M. revealed there were no personal protective equipment (PPE) carts on the 200 hall. Personal Protective Equipment (PPE) is specialized clothing or equipment worn by an employee that provides protection against infectious materials. An observation on the 200-hall revealed Residents #1, #2, #3, and #4 had a STOP sign on their doors. The sign on the door had STOP, N95 mask, gloves, and face shield. No staff were observed wearing gowns on the 200-hall. STOP signs were posted on the doors of those residents that had been admitted within the last 14 days and were under droplet, airborne precautions/quarantine status. Interview on [DATE] at 2:15 P.M. with the Administrator verified there were no PPE carts outside of the rooms on the 200-hall. The Administrator stated the STOP signs on the door stated a N95 mask, gloves, and face shield were required. The Administrator verified that gowns were not listed as required PPE. The Administrator verified no gowns were worn for residents under droplet, airborne precautions. The Administrator stated, if a resident was under investigation (exposed or showing symptoms of COVID-19), the staff would wear a gown in addition to the N95 mask and face shield or goggles. Interview on [DATE] at 2:25 P.M. with State tested Nursing Assistant (STNA) #105 revealed the STOP signs on the door showed what PPE was required. STNA #105 verified gowns were not on the list of required PPE. The STNA stated a N95 mask and face shield or googles were worn all day. Gloves were changed between residents, but gowns were not worn for residents under droplet, airborne precautions. STNA #105 verified the same PPE was required for those under droplet, airborne precautions and those that were not. On [DATE] at 3:59 P.M. an email response from Registered Nurse (RN) #200 from the local health department (LHD) revealed there was frequent communication with the Administrator regarding new cases. RN #200 wrote she was told residents who were under droplet, airborne precautions were being placed on the appropriate transmission-based precautions and staff were wearing masks, gowns, gloves, and face protection while caring for those residents. 2. a. Observations on [DATE] from 2:10 P.M. through 2:50 P.M. revealed Resident #1 had a STOP sign on the door which indicated the resident was under droplet, airborne precautions. Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of physician order dated [DATE] revealed Resident #1 was to be on airborne isolation for 14 days with an end date of [DATE]. b. Observations on [DATE] at 2:10 P.M. through 2:50 P.M. revealed Resident #2 had a STOP sign on the door which indicated the resident was under droplet, airborne precautions. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician order dated [DATE] revealed Resident #2 was to be in airborne isolation for 14 days with an end date of [DATE]. c. Observations on [DATE] at 2:10 P.M. through 2:50 P.M. revealed Resident #5 did not have a STOP sign on the door to indicate the resident was under droplet, airborne precautions. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of progress note dated [DATE] at 10:56 A.M. revealed Resident #5 was on airborne isolation. A physician order dated [DATE] revealed Resident #5 was to be in airborne isolation for 14 days with an end date of [DATE]. d. Observations on [DATE] at 2:10 P.M. through 2:50 P.M. revealed Resident #6 did not have a STOP sign on the door to indicate the resident was under droplet, airborne precautions. Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of progress note dated [DATE] at 11:27 A.M. revealed Resident #6 was on airborne isolation. A physician order dated [DATE] revealed Resident #6 was to be in airborne isolation for 14 days with an end date of [DATE]. e. Observations on [DATE] at 2:10 P.M. through 2:50 P.M. revealed Resident #7 did not have a STOP sign on the door to indicate the resident was under droplet, airborne precautions. Review of Resident #7's medical record revealed an admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order dated [DATE] revealed Resident #7 was to be in airborne isolation for 14 days with an end date of [DATE]. Interview on [DATE] at 11:41 A.M. with the Administrator verified Residents #1 and #2 still had STOP signs on their doors on [DATE] and they should not have. The Administrator also verified Residents #5, #6, and #7 did not have STOP signs on their doors on [DATE] and they should have. The Administrator stated an audit had been completed of the facility since [DATE] to ensure STOP signs were located on the doors of those residents that were under droplet, airborne precautions and STOP signs were removed from any residents' doors who were no longer under droplet, airborne precautions. f. Observation on [DATE] at 8:35 A.M. revealed Therapist #201 entered Resident #5's room. A STOP sign was on the door which indicated the resident was on droplet, airborne precautions and another sign was posted next to it that indicated the appropriate PPE to be used, including gown and gloves. Therapist #201 was observed looking at the resident's door and then entered the room without putting on a gown or gloves. The therapist was wearing an N95 mask, goggles, and face shield. Therapist #201 walked over to the resident's bedside and touched the resident's arm. The interim Director of Nursing (DON), also observed Therapist #201 in Resident #5's room without appropriate PPE on. The DON knocked on the door and informed Therapist #201 that she needed to put on a gown and gloves before entering the resident's room. Therapist #201 came out of the resident's room and put on a gown and gloves. Therapist #201 did not use any hand hygiene prior to putting on the clean gloves. Therapist #201 re-entered the room. Interview with the interim DON on [DATE] at 8:40 A.M. confirmed the therapist entered a room without appropriate PPE on and did not use any hand hygiene before putting on clean gloves. The DON confirmed Resident #5 was under droplet, airborne precautions. 3.a. Review of Resident #12's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's census report revealed the resident had resided on Unit 4, in room [ROOM NUMBER]-B from [DATE] through [DATE]. Review of Resident #12's progress notes revealed the resident was not tested for COVID-19 on [DATE] due to being at [MEDICAL TREATMENT]. The facility had completed 400 hall (the hall the resident resided on) COVID-19 testing on [DATE]. The resident continued to share a room with Resident #13. Resident #12 was tested later, on [DATE] and received a COVID-19 positive result on [DATE]. There was no evidence the facility increased monitoring of Resident #12, placed the resident in quarantine, or notified the physician regarding the resident's refusal to be tested . Review of Resident #13's medical record revealed an admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's census report revealed the resident resided on Unit 4, in room [ROOM NUMBER]-A from [DATE] through [DATE]. Review of Resident #13's progress notes revealed the resident was tested for COVID-19 on [DATE] and received a negative result. On [DATE] at 10:41 A.M., a nurse practitioner (NP) progress note revealed Resident #13 was evaluated for any signs or symptoms associated with COVID-19 due to exposure to his roommate (Resident #12) who had tested positive for COVID-19. Review of the laboratory results dated [DATE] revealed Resident #13 tested positive for COVID-19. Review of an email from the Administrator on [DATE] at 9:44 A.M. revealed the facility did not do anything different for those residents who refused COVID-19 testing. The facility continued respiratory assessments and encouraged residents to stay in their rooms. Interview on [DATE] at 11:41 A.M. with the Administrator revealed Resident #12 was at [MEDICAL TREATMENT] when the facility testing for COVID-19 on the 400-hall was completed on [DATE]. The Administrator verified Resident #12 and #13 continued to share a room until Resident #12 tested positive for COVID-19 on [DATE]. The Administrator confirmed the residents were not separated, neither resident was placed under droplet, airborne precautions or had increased monitoring when Resident #12 was not tested on [DATE]. The Administrator also verified Resident #13 tested positive for COVID-19 on [DATE]. 4. Review of Resident #14's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's census report revealed the resident resided on Unit 3, in room [ROOM NUMBER]-B, from [DATE] through [DATE]. Review of the resident's progress notes revealed Resident #14 refused to be tested for COVID-19 on [DATE]. The resident later agreed to be tested on [DATE]. The resident continued to share a room with Resident #15. Review of the laboratory results dated [DATE] confirmed Resident #14 tested positive for COVID-19. Review of Resident #15's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's census report revealed the resident resided on Unit 3, in room [ROOM NUMBER]-A, from [DATE] through [DATE]. Resident #15 was tested for COVID-19 on [DATE] and received a negative result. Resident #15 continued to share a room with Resident #14 until [DATE]. The resident's progress notes revealed the resident was tested again on [DATE] and received a COVID-19 positive result on [DATE]. Review of an email from the Administrator on [DATE] at 9:44 A.M. revealed the facility did not do anything different for those residents who refused COVID-19 testing. The facility continued respiratory assessments and encouraged residents to stay in their rooms. Interview on [DATE] at 11:41 A.M. with the Administrator confirmed Resident #14 refused to be tested on [DATE] but later agreed to be tested on [DATE]. The Administrator confirmed Resident #15 tested negative for COVID-19 on [DATE]. The Administrator confirmed Resident #14 and Resident #15 continued to share a room after Resident #14 refused to be tested . The residents were not separated, neither resident was placed under droplet, airborne precautions or had increased monitoring after Resident #14 refused to be tested on [DATE]. Resident #14 was confirmed to be COVID-19 positive on [DATE]. Resident #15 was confirmed to be COVID-19 positive on [DATE]. 5. Review of the facility Employee Log and COVID-19 timeline revealed the following: a. STNA #108 worked with residents on [DATE] and tested positive for COVID-19 on [DATE]. b. LPN #106 worked with residents on [DATE] and tested positive for COVID-19 on [DATE]. c. LPN #107 worked with residents on [DATE] and tested positive for COVID-19 on [DATE]. d. Housekeeping Supervisor #109 worked at the facility and was in contact with residents on [DATE] and tested positive for COVID-19 on [DATE]. e. STNA #111 worked with residents on [DATE], [DATE], [DATE], and [DATE]. STNA #111 tested positive for COVID-19 on [DATE]. Review of facility contact tracing documentation, dated [DATE], revealed the facility completed contact tracing of STNA #111 to include those residents this staff member had contact with when she worked on [DATE], [DATE], [DATE], and [DATE]. These residents were monitored for signs and symptoms of COVID-19 but were not tested . The contact tracing and monitoring of residents was not completed until nine (9) days after STNA #111 tested positive for COVID-19. Review of CDC guidance revealed the facility should have performed expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility. A single case of COVID-19 infection in any health care provider (HCP) or a nursing home onset infection of a resident should be considered an outbreak. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions such as isolation, cohorting, and use of PPE to prevent infection transmission. There was no evidence the facility completed these actions. Interview on [DATE] at 2:05 P.M. with the Administrator revealed she was not sure if any contact tracing had been completed by the local health department. The Administrator verified the facility had not completed any contact tracing after staff, who had worked with residents, tested positive for COVID-19. Review of an email response from the Administrator on [DATE] at 12:12 P.M. stated, Contact tracing was not necessary due to the fact we (facility) tested 100% of the population of the residents (minus the 3 patient refusals that were asymptomatic) and our employees wear appropriate PPE in a clinical setting. Review of an email response from the Administrator on [DATE] at 4:14 P.M. verified the facility had concluded no residents needed to be tested after exposure to STNA #111 who tested positive for COVID-19. The conclusion was based on no signs and symptoms. 6. Review of the medical record revealed Resident #9 was admitted as COVID-19 positive on [DATE] with additional [DIAGNOSES REDACTED]. A physician order dated [DATE] revealed Resident #9 was to be on airborne isolation. Review of a Nurse Practitioner (NP) note dated [DATE] at 11:48 A.M. revealed Resident #9 was an [AGE] year-old male recently hospitalized as COVID-19 positive with bilateral pneumonitis. Due to COVID-19 infection, Resident #9 remained on the respiratory care unit. Review of the medical record revealed Resident #10 was admitted as COVID-19 positive on [DATE] and discharged on [DATE]. Resident #10 had additional [DIAGNOSES REDACTED]. A physician order dated [DATE] revealed Resident #10 was to be on airborne isolation. Review of a NP note dated [DATE] at 2:28 P.M. revealed Resident #10 was a [AGE] year-old female who was admitted to the hospital with [REDACTED]. Due to COVID-19 infection, Resident #10 remained on the respiratory care unit. Review of the facility COVID-19 timeline sent by the Administrator on [DATE] at 2:35 P.M. revealed the COVID Airborne Isolation Unit (CAIU) was reinitiated on [DATE] but was later confirmed to be reinitiated on [DATE]. Interview on [DATE] at 2:05 A.M. with the Administrator verified the COVID-19 unit was reinitiated on [DATE] after there were seven residents who tested positive for COVID-19 on the 300-hall. Review of an email from the Administrator on [DATE] at 4:49 P.M. confirmed the CAIU was first set up on [DATE], taken down on [DATE], and then put back up on [DATE]. Interview on [DATE] at 11:41 A.M. with the Administrator revealed Resident #9 and #10 (residents were COVID-19 positive) were moved to the end of the COVID-19 hall and the barrier was removed. The Administrator verified there was not dedicated staff to provide care for Residents #9 and #10. The staff changed their PPE in the shower room between Resident #9 and #10, and those at the other end of the hall. 7. Interviews on [DATE] at 8:55 A.M. and 9:10 A.M. with Registered Nurse (RN) #202 and STNA #203, on the CAIU, revealed the process changed over the weekend on how the staff exited the CAIU at the end of a shift. RN #202 and STNA #202 stated instead of exiting the facility at the end of the hallway, taking off their PPE, placing it in a covered trashcan outside, and then going directly to their cars, the staff were now taking off their dirty PPE in the same room that had been converted into a nurse's station and breakroom. The staff use the room to chart, eat, and store personal belongings. RN #202 and STNA #203 confirmed there was no covered trash can or bio-hazard bags to place dirty PPE in. The nurse stated they use a small, uncovered office trash can with a regular trash bag in it. Staff used the bathroom in the room to wash their hands after taking off their PPE. Goggles or face shields were wiped down with bleach wipes, allowed to air dry, and then placed in paper bags to reuse. Interview on [DATE] at 9:10 A.M. with STNA #203 revealed the aide did not feel comfortable and did not feel it was appropriate to take off dirty PPE in the same room where the staff ate, charted, and stored personal belongings. Interview on [DATE] at 3:56 P.M. with the interim DON confirmed staff had been using the room that was converted into a nurse's station and breakroom to take off dirty PPE. The DON stated the staff were not supposed to be using that room as the dirty room and should have been using the room across the hallway as the dirty room. The nurse's station/breakroom room should be a clean room and should be used to put on clean PPE before going on to the COVID unit. The DON confirmed there was not a covered trash can or any biohazard bags being used for dirty PPE. The DON stated a large covered trash can with trash bag had been placed on the unit now. Review of the facility policy, Hand Hygiene updated ,[DATE], stated, When to wash hands or use an alcohol-based hand rub: before applying and after removing gloves and after having direct contact with patient's intact skin (e.g., when taking pulse or blood pressure and turning a patient) if hands are not visibly contaminated. Review of the facility Practice Guidelines: Transmission-Based Precautions dated ,[DATE] revealed standard precautions required a gown to be worn that was appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and resident care activities when contact with blood, body fluids, secretions or excretions was anticipated. The soiled gown was to be removed promptly before leaving the residents room. Droplet precautions included standard precautions and gloves, mask, and goggles if there was a likelihood of exposure during care. Review of Preparing for COVID-19 in Nursing Homes dated [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed a plan needed created for managing new admissions and readmissions whose COVID-19 status was unknown. Healthcare personnel should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Review of Key Strategies for Long-term Care Facilities provide by the LHD revealed COVID-19 Prevention & Control Measures for Long-Term Care Facilities (named county) Public Health from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html if COVID-19 was identified in the facility, all residents should be restricted to their rooms and health care providers should wear all recommended PPE for care of all residents (regardless of symptoms) on the affected unit (or facility-wide depending on the situation). This included: an N95 or higher-level respirator (or facemask if a respirator is not available), eye protectio (TRUNCATED)

Based on review of a closed medical record, a facility Self-Reported Incident (SRI), a local law enforcement report, facility policy and procedures, and interviews with staff, law enforcement and and outside laboratory provider, the facility failed to ensure one resident, (Resident #40), was free from sexual abuse by a staff member. This resulted in Immediate Jeopardy and psychosocial harm when State tested Nursing Assistant (STNA) #99 sent sexually explicit text messages from his personal cell phone to Resident #40's personal cell phone. This affected one of four residents reviewed for sexual abuse. The facility census was 115. On 10/24/19 at 3:48 P.M., the Licensed Nursing Home Administrator (LNHA), Interim Director of Nursing (DON) #116, Director of Operations #110, and Clinical Consultant #112 were notified that Immediate Jeopardy began on 10/01/19 at 12:30 P.M., when Resident #40 shared with Medical Records Clerk (MRC) #101 she was receiving inappropriate text messages from STNA #99. The text messages included a video to Resident #40's personal cell phone of two people having sex. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating, Can I (expletive) you in the (expletive) tonight? When recounting the incident Resident #40 became tearful and was afraid of retaliation. The Immediate Jeopardy was removed on 10/27/19 when the facility implemented the following corrective actions: · On 10/01/19 at 12:55 P.M., the LNHA notified the local police department of the allegation of sexual abuse. · On 10/01/19 at 3:10 P.M., the Social Worker offered counseling services to Resident #40 and she declined. The resident was also offered transport to the local hospital for an evaluation and she declined. · On 10/01/19 at 4:10 P.M., the LNHA submitted an SRI to the State Agency regarding the sexual abuse allegation. · On 10/01/19 at 8:45 P.M., Human Resource Director (HRD) #102 suspended STNA #99 via telephone. · On 10/03/19 female department managers completed interviews with female residents to ensure they had not received inappropriate text messages or were inappropriately touched from any staff members. No concerns were noted. · On 10/10/19 Interim DON #116 and HRD #102 terminated STNA #99. · On 10/12/19 at 12:00 [NAME]M., interviews were completed by Department Managers with all current staff members to ensure no staff member had engaged in sending text messages to residents. No concerns were noted. · On 10/24/19 the Nurse Aide Registry was notified of the termination of STNA #99. · On 10/25/19 at 8:00 [NAME]M., the Divisional Director of Clinical Services educated the department managers on the Patient Protection Practice Guide. · On 10/25/19 the Senior Administrator educated the LNHA and Interim DON #116 on the Patient Protection Practice Guide, the facility process for completing a thorough investigation, and the State Agency reporting guidelines. · On 10/27/19 by 3:00 P.M., all facility staff were educated by the Department Managers on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. Any employee who has not completed the education will be removed from the working schedule until said education is completed. · Beginning on 10/28/19 the Director of Operations #110 and/or the Quality Assurance Consultant will monitor daily for 14 days to ensure investigations are initiated, thoroughly investigated, reported to the State Agency timely, and resolved. · Beginning 10/28/19, utilizing the Resident Interview Questionnaire, Department Managers will interview five residents daily for 14 days to ensure residents are not being abused. · Beginning 10/28/19, utilizing the Staff Interview Questionnaire, Department Managers will interview five employees daily, for 14 days to ensure staff can verbalize the facilities abuse policy. · On 10/28/19 from 1:12 P.M., to 1:20 P.M., interviews with Licensed Practical Nurse (LPN) #125, State tested Nursing Assistants (STNAs) #128, STNA #130 verified they had received education on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. They all were knowledgeable and knew who to report any allegation of abuse to. Although the Immediate Jeopardy was removed, the deficiency remained 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 were monitoring to ensure continued compliance. Findings include: Closed medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #40 had no cognitive deficits. On 09/17/19 Resident #40 was discharged to a local hotel. The resident returned to the facility on [DATE] and then again was discharged to the hospital for a surgical procedure on 10/07/19 and did not return to the facility. Review of the SRI (# 2) submitted to the State Agency by the LNHA on 10/01/19 at 4:10 P.M., revealed Resident #40 shared with MRC #101 she was receiving inappropriate texts from an employee. The resident at this time would not share who she was receiving the text messages from. The local police department was contacted, and a police report was filed. The only witness statements provided by the facility on 10/23/19 as part of the investigation for the SRI were from MRC #101, Resident #40, and STNA #99. Review of the witness statement dated 10/01/19 completed by MRC #101 revealed on 10/01/19 Resident #40 came to her and stated she was scared to come back to the facility when she had returned to the facility on [DATE], however, she did so because she had nowhere else to go. Resident #40 revealed she felt like an employee was sexually harassing her. At this time the resident would not provide a name of the alleged perpetrator because the employee had friends and family who resided in the facility, and she was worried about retaliation. The witness statement further revealed Resident #40 reported the employee had done things with her and he would text her and send her pictures of sexual positions and asked her for sexual favors. Resident #40 also reported to MRC #101 a phlebotomist had come in her room one time to draw blood and caught her and the employee in a very compromising position. Review of the local police detective's statement dated 10/02/19 at 2:18 P.M., revealed Resident #40 reported she had been receiving obscene texts from an employee of the facility. The text shared by Resident #40 revealed a picture of a couple having sex and a link to a porn site. The text also revealed the employee wanted to sodomize her. Resident #40 reported she had sex with the employee at the facility because he threatened her, and she was scared of him. Resident #40 reported to law enforcement the sex was not consensual. Resident #40 would not reveal the employee's name at the time, because she was afraid of what he would do to her. The resident reported the last time she had sex with the employee was around 09/12/19. The resident could not remember how many times she had sex with the employee, however, she said it was a handful of times. Review of the witness statement dated 10/02/19 completed by HRD #102 revealed the HRD was asked to be present during the interview with the LNHA and Resident #40. The statement revealed Resident #40 named the employee who had been sending her texts of a sexual nature to her personal cell phone as STNA #99. Resident #40 revealed she had been texting with STNA #99 for a while and wanted to share what was recently sent by the STNA to her. The witness statement included copies of the text messages which revealed STNA #99 sent a video to Resident #40 of two people having sex with an offensive title. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating he wanted to sodomize her. Resident #40 revealed she was not comfortable with the context of the texts STNA #99 was sending her. Resident #40 revealed there was more than texting that had been going on between them and she felt intimidated by STNA #99. She was afraid the STNA would have her kicked out of the facility if she did not comply with what he wanted her to do. Review of STNA #99's statement completed by Interim DON #116 dated 10/03/19 at 1:30 P.M., revealed STNA #99 confirmed he had shared nasty text messages with Resident #40. The STNA confirmed they had been texting for a few weeks, however he stated he never acted on any of the texts. STNA #99 denied ever having sex or any type of intimacy with Resident #40. STNA #99 denied he ever threatened her. The STNA admitted his texts were inappropriate, however he said he never had sexual relations with her (Resident #40). Review of the Employee Warning notice dated 10/10/19 revealed STNA #99 was terminated from employment due to it being confirmed the STNA did engage in texting with Resident #40 which was inappropriate and obscene. Review of an investigation completed by the outside company who provided laboratory services to the facility dated 10/23/19 revealed Phlebotomist #145 was interviewed on 10/23/19 and reported she went to the facility to draw Resident #40's blood several months ago, around (MONTH) 2019. The phlebotomist knocked on Resident #40's door and when she entered the room it was dark, so she turned the light on. Phlebotomist #145 indicated she observed Resident #40 in bed and STNA #99 sitting on the bed with his hands under the blanket. The phlebotomist revealed Resident #40 did have a top on and STNA #99 was clothed. Phlebotomist #145 indicated the resident and the STNA seemed surprised. The phlebotomist revealed she felt uneasy because it seemed odd to her an STNA was alone with the resident in a dark room. Phlebotomist #145 asked Resident #40 if it was okay that she drew her blood and the resident said it was. STNA #99 remained in the room during the blood draw. Phlebotomist #145 revealed neither the resident or STNA #99 appeared to be in distress or she would have reported it to the facility staff. Review of the facility lab draws revealed Phlebotomist #145 drew Resident #40's blood on 03/19/19. On 10/23/19 at 1:30 P.M., telephone interview with Police Detective #500 confirmed he was the detective who came to the facility on [DATE] to interview Resident #40. He confirmed Resident #40 alleged she and STNA #99 had sex a handful of times, however it was not consensual as she was afraid if she didn't comply the STNA would do something to her. Detective #500 stated the investigation was ongoing at this time. On 10/23/19 at 10:19 [NAME]M. and at 2:00 P.M. interview with the LNHA and Interim DON #116 confirmed an SRI was immediately submitted when Resident #40 reported she was receiving text messages from an employee of the facility. The LNHA confirmed he became aware on 10/10/19 Resident #40 told Police Detective #500 she had sex with STNA #99, and it was never consensual. He also confirmed Resident #40 reported to MRC #101 on 10/01/19 STNA #99 asked her to do sexual things and threatened her. He also was aware she reported a phlebotomist walked into her room and found her and STNA #99 in a compromising position. The LNHA confirmed he was aware and did not investigate the allegations of Resident #40 being threatened or forced to have sexual contact with STNA #99. The LNHA confirmed he did not follow-up with the phlebotomist at that time. On 10/24/19 at 2:00 P.M. interview with Human Resource Director (HRD) #140 of the Laboratory Company confirmed it was Phlebotomist #145 who found Resident #40 and STNA #99 in a compromising position and the phlebotomist did not report it to her, or to any staff member of the facility. On 10/28/19 at 1:50 P.M., interview with MRC #101 confirmed Resident #40 came to her office on 10/01/19 and reported she was receiving inappropriate texts from an employee. She confirmed what she wrote in her witness statement dated 10/01/19. MRC #101 revealed on 10/26/19 she visited Resident #40 at the new facility she now resided at, and the resident revealed she was still fearful of STNA #99. Review of the facility policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual Abuse is non-consensual sexual contact of any type. The Administrator is responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Review of the facility policy titled, Procedures for Patient/Resident and Customer Relations (undated), revealed all employees should keep their relationships with patients/residents on a professional level. This deficiency substantiates allegations contained in Complaint Number OH 709.

Based on review of a closed medical record, a facility Self-Reported Incident (SRI), a local law enforcement report, facility policy and procedures, and interviews with staff, law enforcement and an outside laboratory provider, the facility failed to implement their abuse policy to ensure one resident, (Resident #40), was free from sexual abuse by a staff member. This resulted in Immediate Jeopardy and psychosocial harm when State tested Nursing Assistant (STNA) #99 sent sexually explicit text messages from his personal cell phone to Resident #40's personal cell phone. The facility further failed to implement their abuse policy when an allegation was reported by Resident #40 alleging STNA #99 had physical sexual contact with her against her will and the facility failed to report and investigate the allegation. This affected one of four residents reviewed for sexual abuse. The facility census was 115. On 10/24/19 at 3:48 P.M., the licensed nursing home administrator (LNHA), Interim Director of Nursing (DON) #116, Director of Operations #110, and Clinical Consultant #112 were notified that Immediate Jeopardy began on 10/01/19 at 12:30 P.M., when Resident #40 shared with Medical Records Clerk (MRC) #101 she was receiving inappropriate text messages from STNA #99. The text messages included a video to Resident #40's personal cell phone of two people having sex. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating, Can I (expletive) you in the (expletive) tonight? When recounting the incident Resident #40 became tearful and was afraid of retaliation. The Immediate Jeopardy was removed on 10/27/19 when the facility implemented the following corrective actions: · On 10/01/19 at 12:55 P.M., the LNHA notified the local police department of the allegation of sexual abuse. · On 10/01/19 at 3:10 P.M., the Social Worker offered counseling services to Resident #40 and she declined. The resident was also offered transport to the local hospital for an evaluation and she declined. · On 10/01/19 at 4:10 P.M., the LNHA submitted an SRI to the State Agency regarding the sexual abuse allegation. · On 10/01/19 at 8:45 P.M., Human Resource Director (HRD) #102 suspended STNA #99 via telephone. · On 10/10/19 Interim DON #116 and HRD #102 terminated STNA #99. · On 10/12/19 at 12:00 [NAME]M., interviews were completed by Department Managers with all current staff members to ensure no staff member had engaged in sending text messages to residents. No concerns were noted. · On 10/24/19 the Nurse Aide Registry was notified of the termination of STNA #99. · On 10/25/19 at 8:00 [NAME]M., the Divisional Director of Clinical Services educated the department managers on the Patient Protection Practice Guide. · On 10/25/19 the Senior Administrator educated the LNHA and Interim DON #116 on the Patient Protection Practice Guide, the facility process for completing a thorough investigation, and the State Agency reporting guidelines. · On 10/25/19 the Facility Quality Assurance Performance (QAPI) re-opened SRI # 2 and the facility's internal investigation. · On 10/25/19 at 6:00 [NAME]M., the DON and Unit Managers initiated skin evaluations on all current residents with completion on 10/27/19 at 12:00 P.M. There were no negative findings. · On 10/26/19 at 9:15 [NAME]M., the Medical Records Clerk (MRC) #101 and Unit Manager #200 went to the facility where Resident #40 now resides and re-interviewed the resident regarding the alleged non-consensual vagina, anal, and oral sex between her and STNA #99. At 11:30 [NAME]M., the local police department arrived to the facility and were given a copy of Resident #40's statement. · On 10/27/19 the internal investigation was completed by the LNHA related to Resident #40 and findings included the investigation of alleged vagina, anal, and oral sex between Resident #40 and STNA #99 were inconclusive. In addition STNA #99 will not be permitted on company property. If noted to be on company property, the police will be notified immediately. The investigation is ongoing with the police department at this time. · On 10/27/19 by 3:00 P.M., all facility staff were educated by the Department Managers on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. Any employee who has not completed the education will be removed from the working schedule until said education is completed. · Beginning on 10/28/19 the Director of Operations #110 and/or the Quality Assurance Consultant will monitor daily for 14 days to ensure investigations are initiated, thoroughly investigated, reported to the State Agency timely, and resolved. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Resident Interview Questionnaire, Department Managers will interview five residents daily for 14 days to ensure residents are not being abused. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Staff Interview Questionnaire, Department Managers will interview five employees daily, for 14 days to ensure staff can verbalize the facilities abuse policy. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · On 10/28/19 from 1:12 P.M., to 1:20 P.M., interviews with Licensed Practical Nurse (LPN) #125, State tested Nursing Assistants (STNAs) #128, STNA #130 verified they had received education on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. They all were knowledgeable and knew who to report any allegation of abuse to. Although the Immediate Jeopardy was removed, the deficiency remained 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 were monitoring to ensure continued compliance. Findings include: Closed medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #40 had no cognitive deficits. On 09/17/19 Resident #40 was discharged to a local hotel. The resident returned to the facility on [DATE] and then again was discharged to the hospital for a surgical procedure on 10/07/19 and did not return to the facility. Review of the SRI (# 2) submitted to the State Agency by the LNHA on 10/01/19 at 4:10 P.M., revealed Resident #40 shared with MRC #101 she was receiving inappropriate texts from an employee. The resident at this time would not share who she was receiving the text messages from. The local police department was contacted, and a police report was filed. The only witness statements provided by the facility on 10/23/19 as part of the investigation for the SRI were from MRC #101, Resident #40, and STNA #99. Review of the witness statement dated 10/01/19 completed by MRC #101 revealed on 10/01/19 Resident #40 came to her and stated she was scared to come back to the facility when she had returned to the facility on [DATE], however, she did so because she had nowhere else to go. Resident #40 revealed she felt like an employee was sexually harassing her. At this time the resident would not provide a name of the alleged perpetrator because the employee had friends and family who resided in the facility, and she was worried about retaliation. The witness statement further revealed Resident #40 reported the employee had done things with her and he would text her and send her pictures of sexual positions and asked her for sexual favors. Resident #40 also reported to MRC #101 a phlebotomist had come in her room one time to draw blood and caught her and the employee in a very compromising position. Review of the local police detective's statement dated 10/02/19 at 2:18 P.M., revealed Resident #40 reported she had been receiving obscene texts from an employee of the facility. The text shared by Resident #40 revealed a picture of a couple having sex and a link to a pornographic site. The text also revealed the employee wanted to sodomize her. Resident #40 reported she had sex with the employee at the facility because he threatened her, and she was scared of him. Resident #40 reported to law enforcement the sex was not consensual. Resident #40 would not reveal the employee's name at the time, because she was afraid of what he would do to her. The resident reported the last time she had sex with the employee was around 09/12/19. The resident could not remember how many times she had sex with the employee, however, she said it was a handful of times. Review of the witness statement dated 10/02/19 completed by HRD #102 revealed the HRD was asked to be present during the interview with the LNHA and Resident #40. The statement revealed Resident #40 named the employee who had been sending her texts of a sexual nature to her personal cell phone as STNA #99. Resident #40 revealed she had been texting with STNA #99 for a while and wanted to share what was recently sent by the STNA to her. The witness statement included copies of the text messages which revealed STNA #99 sent a video to Resident #40 of two people having sex with an offensive title. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating he wanted to sodomize her. Resident #40 revealed she was not comfortable with the context of the texts STNA #99 was sending her. Resident #40 revealed there was more than texting that had been going on between them and she felt intimidated by STNA #99. She was afraid the STNA would have her kicked out of the facility if she did not comply with what he wanted her to do. Review of STNA #99's statement completed by Interim DON #116 dated 10/03/19 at 1:30 P.M., revealed STNA #99 confirmed he had shared nasty text messages with Resident #40. The STNA confirmed they had been texting for a few weeks, however he stated he never acted on any of the texts. STNA #99 denied ever having sex or any type of intimacy with Resident #40. STNA #99 denied he ever threatened her. The STNA admitted his texts were inappropriate, however he said he never had sexual relations with her (Resident #40). Review of the Employee Warning notice dated 10/10/19 revealed STNA #99 was terminated from employment due to it being confirmed the STNA did engage in texting with Resident #40 which was inappropriate and obscene. Review of an investigation completed by the outside company who provided laboratory services to the facility dated 10/23/19 revealed Phlebotomist #145 was interviewed on 10/23/19 and reported she went to the facility to draw Resident #40's blood several months ago, around (MONTH) 2019. The phlebotomist knocked on Resident #40's door and when she entered the room it was dark, so she turned the light on. Phlebotomist #145 indicated she observed Resident #40 in bed and STNA #99 sitting on the bed with his hands under the blanket. The phlebotomist revealed Resident #40 did have a top on and STNA #99 was clothed. Phlebotomist #145 indicated the resident and the STNA seemed surprised. The phlebotomist revealed she felt uneasy because it seemed odd to her an STNA was alone with the resident in a dark room. Phlebotomist #145 asked Resident #40 if it was okay that she drew her blood and the resident said it was. STNA #99 remained in the room during the blood draw. Phlebotomist #145 revealed neither the resident or STNA #99 appeared to be in distress or she would have reported it to the facility staff. Review of the facility lab draws revealed Phlebotomist #145 drew Resident #40's blood on 03/19/19. On 10/23/19 at 1:30 P.M., telephone interview with Police Detective #500 confirmed he was the detective who came to the facility on [DATE] to interview Resident #40. He confirmed Resident #40 alleged she and STNA #99 had sex a handful of times, however it was not consensual as she was afraid if she didn't comply the STNA would do something to her. Detective #500 stated the investigation was ongoing at this time. On 10/23/19 at 10:19 [NAME]M. and at 2:00 P.M. interview with the LNHA and Interim DON #116 confirmed an SRI was immediately submitted when Resident #40 reported she was receiving text messages from an employee of the facility. The LNHA confirmed he became aware on 10/10/19 when the police department provided him with a copy of his report that Resident #40 told Police Detective #500 she had sex with STNA #99, and it was never consensual. He also confirmed Resident #40 reported to MRC #101 on 10/01/19 STNA #99 asked her to do sexual things and threatened her. He also was aware she reported a phlebotomist walked into her room and found her and STNA #99 in a compromising position. The LNHA confirmed he was aware and did not investigate the allegations of Resident #40 being threatened or forced to have sexual contact with STNA #99. The LNHA confirmed he did not follow-up with the phlebotomist at that time. On 10/24/19 at 2:00 P.M. interview with Human Resource Director (HRD) #140 of the Laboratory Company confirmed it was Phlebotomist #145 who found Resident #40 and STNA #99 in a compromising position and the phlebotomist did not report it to her, or to any staff member of the facility. On 10/28/19 at 1:50 P.M., interview with MRC #101 confirmed Resident #40 came to her office on 10/01/19 and reported she was receiving inappropriate texts from an employee. She confirmed what she wrote in her witness statement dated 10/01/19. MRC #101 revealed on 10/26/19 she visited Resident #40 at the new facility she now resided at, and the resident revealed she was still fearful of STNA #99. Review of the facility policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual Abuse is non-consensual sexual contact of any type. The Administrator is responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Review of the facility policy titled, Procedures for Patient/Resident and Customer Relations (undated), revealed all employees should keep their relationships with patients/residents on a professional level. This deficiency substantiates allegations contained in Complaint Number OH 709.

Based on review of a closed medical record, a facility Self-Reported Incident (SRI), a local law enforcement report, facility policy and procedures, and interviews with staff, law enforcement and an outside laboratory provider, the facility failed to ensure all allegations of staff to resident sexual abuse were reported to the Stage Agency for one resident (Resident #40). This resulted in Immediate Jeopardy and psychosocial harm when Resident #40 alleged State tested Nursing Assistant (STNA) #99 had physical sexual contact with her against her will and the facility failed to report it. This affected one of four residents reviewed for sexual abuse. The facility census was 115. On 10/24/19 at 3:48 P.M., the licensed nursing home administrator (LNHA), Interim Director of Nursing (DON) #116, Director of Operations #110, and Clinical Consultant #112 were notified that Immediate Jeopardy began on 10/10/19 when the LNHA received a copy of the police report which revealed Resident #40 alleged her and STNA #99 had sex a handful of times. When recounting the incident Resident #40 became tearful and was afraid of retaliation. The Immediate Jeopardy was removed on 10/27/19 when the facility implemented the following corrective actions: · On 10/10/19 Interim DON #116 and Human Resource Director (HRD) #102 terminated STNA #99. · On 10/24/19 the Nurse Aide Registry was notified of the termination of STNA #99. · On 10/25/19 at 8:00 [NAME]M., the Divisional Director of Clinical Services educated the department managers on the Patient Protection Practice Guide. · On 10/25/19 the Senior Administrator educated the LNHA and Interim DON #116 on the Patient Protection Practice Guide, the facility process for completing a thorough investigation, and the State Agency reporting guidelines. · On 10/25/19 the facility's Quality Assurance Performance Improvement (QAPI) re-opened SRI # 2 and the facility's internal investigation. · On 10/25/19 at 6:00 [NAME]M., the DON and unit managers initiated skin evaluations on all residents with completion on 10/27/19 at 12:00 P.M. There were no negative findings. · On 10/26/19 at 9:15 [NAME]M., Medical Records Clerk (MRC) #101 and Unit Manager #200 went to the facility where Resident #40 now resides and re-interviewed the resident regarding the alleged non-consensual vagina, anal, and oral sex between her and STNA #99. At 11:30 [NAME]M., the local police department arrived to the facility and were given a copy of Resident #40's statement. · On 10/27/19 the internal investigation was completed by the LNHA related to Resident #40 and findings included the investigation of alleged vaginal, anal, and oral sex between Resident #40 and STNA #99 were inconclusive. In addition STNA #99 will not be permitted on company property. If noted to be on company property, the police will be notified immediately. The investigation is ongoing with the police department at this time. · On 10/27/19 by 3:00 P.M., all facility staff were educated by the Department Managers on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. Any employee who has not completed the education will be removed from the working schedule until said education is completed. · Beginning on 10/28/19 the Director of Operations #110 and/or the Quality Assurance Consultant will monitor daily for 14 days to ensure investigations are initiated, thoroughly investigated, reported to the State Agency timely, and resolved. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Resident Interview Questionnaire, Department Managers will interview five residents daily for 14 days to ensure residents are not being abused. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Staff Interview Questionnaire, Department Managers will interview five employees daily, for 14 days to ensure staff can verbalize the facilities abuse policy. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · On 10/28/19 from 1:12 P.M., to 1:20 P.M., interviews with Licensed Practical Nurse (LPN) #125, STNA #128, and STNA #130 verified they had received education on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. They all were knowledgeable and knew who to report any allegation of abuse to. Although the Immediate Jeopardy was removed, the deficiency remained 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 were monitoring to ensure continued compliance. Findings include: Closed medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #40 had no cognitive deficits. On 09/17/19 Resident #40 was discharged to a local hotel. The resident returned to the facility on [DATE] and then again was discharged to the hospital for a surgical procedure on 10/07/19 and did not return to the facility. Review of the SRI (# 2) submitted to the State Agency by the LNHA on 10/01/19 at 4:10 P.M., revealed Resident #40 shared with MRC #101 she was receiving inappropriate texts from an employee. The resident at this time would not share who she was receiving the text messages from. The local police department was contacted, and a police report was filed. The only witness statements provided by the facility on 10/23/19 as part of the investigation for the SRI were from MRC #101, Resident #40, and STNA #99. Review of the witness statement dated 10/01/19 completed by MRC #101 revealed on 10/01/19 Resident #40 came to her and stated she was scared to come back to the facility when she had returned to the facility on [DATE], however, she did so because she had nowhere else to go. Resident #40 revealed she felt like an employee was sexually harassing her. At this time the resident would not provide a name of the alleged perpetrator because the employee had friends and family who resided in the facility, and she was worried about retaliation. The witness statement further revealed Resident #40 reported the employee had done things with her and he would text her and send her pictures of sexual positions and asked her for sexual favors. Resident #40 also reported to MRC #101 a phlebotomist had come in her room one time to draw blood and caught her and the employee in a very compromising position. Review of the local police detective's statement dated 10/02/19 at 2:18 P.M., revealed Resident #40 reported she had been receiving obscene texts from an employee of the facility. The text shared by Resident #40 revealed a picture of a couple having sex and a link to a pornographic site. The text also revealed the employee wanted to sodomize her. Resident #40 reported she had sex with the employee at the facility because he threatened her, and she was scared of him. Resident #40 reported to law enforcement the sex was not consensual. Resident #40 would not reveal the employee's name at the time, because she was afraid of what he would do to her. The resident reported the last time she had sex with the employee was around 09/12/19. The resident could not remember how many times she had sex with the employee, however, she said it was a handful of times. Review of the witness statement dated 10/02/19 completed by HRD #102 revealed the HRD was asked to be present during the interview with the LNHA and Resident #40. The statement revealed Resident #40 named the employee who had been sending her texts of a sexual nature to her personal cell phone as STNA #99. Resident #40 revealed she had been texting with STNA #99 for a while and wanted to share what was recently sent by the STNA to her. The witness statement included copies of the text messages which revealed STNA #99 sent a video to Resident #40 of two people having sex with an offensive title. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating he wanted to sodomize her. Resident #40 revealed she was not comfortable with the context of the texts STNA #99 was sending her. Resident #40 revealed there was more than texting that had been going on between them and she felt intimidated by STNA #99. She was afraid the STNA would have her kicked out of the facility if she did not comply with what he wanted her to do. Review of STNA #99's statement completed by Interim DON #116 dated 10/03/19 at 1:30 P.M., revealed STNA #99 confirmed he had shared nasty text messages with Resident #40. The STNA confirmed they had been texting for a few weeks, however he stated he never acted on any of the texts. STNA #99 denied ever having sex or any type of intimacy with Resident #40. STNA #99 denied he ever threatened her. The STNA admitted his texts were inappropriate, however he said he never had sexual relations with her (Resident #40). Review of the Employee Warning notice dated 10/10/19 revealed STNA #99 was terminated from employment due to it being confirmed the STNA did engage in texting with Resident #40 which was inappropriate and obscene. Review of an investigation completed by the outside company who provided laboratory services to the facility dated 10/23/19 revealed Phlebotomist #145 was interviewed on 10/23/19 and reported she went to the facility to draw Resident #40's blood several months ago, around (MONTH) 2019. The phlebotomist knocked on Resident #40's door and when she entered the room it was dark, so she turned the light on. Phlebotomist #145 indicated she observed Resident #40 in bed and STNA #99 sitting on the bed with his hands under the blanket. The phlebotomist revealed Resident #40 did have a top on and STNA #99 was clothed. Phlebotomist #145 indicated the resident and the STNA seemed surprised. The phlebotomist revealed she felt uneasy because it seemed odd to her an STNA was alone with the resident in a dark room. Phlebotomist #145 asked Resident #40 if it was okay that she drew her blood and the resident said it was. STNA #99 remained in the room during the blood draw. Phlebotomist #145 revealed neither the resident or STNA #99 appeared to be in distress or she would have reported it to the facility staff. Review of the facility lab draws revealed Phlebotomist #145 drew Resident #40's blood on 03/19/19. On 10/23/19 at 1:30 P.M., telephone interview with Police Detective #500 confirmed he was the detective who came to the facility on [DATE] to interview Resident #40. He confirmed Resident #40 alleged she and STNA #99 had sex a handful of times, however it was not consensual as she was afraid if she didn't comply the STNA would do something to her. Detective #500 stated the investigation was ongoing at this time. On 10/23/19 at 10:19 [NAME]M. and at 2:00 P.M. interview with the LNHA and Interim DON #116 confirmed an SRI was immediately submitted when Resident #40 reported she was receiving text messages from an employee of the facility. The LNHA confirmed he became aware on 10/10/19 when the police department provided him with a copy of the report that Resident #40 told Police Detective #500 she had sex with STNA #99, and it was never consensual. He also confirmed Resident #40 reported to MRC #101 on 10/01/19 STNA #99 asked her to do sexual things and threatened her. He also was aware she reported a phlebotomist walked into her room and found her and STNA #99 in a compromising position. The LNHA confirmed he was aware and did not investigate the allegations of Resident #40 being threatened or forced to have sexual contact with STNA #99. The LNHA confirmed he did not follow-up with the phlebotomist at that time. On 10/24/19 at 2:00 P.M. interview with Human Resource Director (HRD) #140 of the Laboratory Company confirmed it was Phlebotomist #145 who found Resident #40 and STNA #99 in a compromising position and the phlebotomist did not report it to her, or to any staff member of the facility. On 10/28/19 at 1:50 P.M., interview with MRC #101 confirmed Resident #40 came to her office on 10/01/19 and reported she was receiving inappropriate texts from an employee. She confirmed what she wrote in her witness statement dated 10/01/19. MRC #101 revealed on 10/26/19 she visited Resident #40 at the new facility she now resided at, and the resident revealed she was still fearful of STNA #99. Review of the facility policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual Abuse is non-consensual sexual contact of any type. The Administrator is responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Review of the facility policy titled, Procedures for Patient/Resident and Customer Relations (undated), revealed all employees should keep their relationships with patients/residents on a professional level. This deficiency substantiates allegations contained in Complaint Number OH 709.

Based on review of a closed medical record, a facility Self-Reported Incident (SRI), a local law enforcement report, facility policy and procedures, and interviews with staff, law enforcement and an outside laboratory provider, the facility failed to ensure all allegations of staff to resident sexual abuse were thoroughly investigated for one resident (Resident #40). This resulted in Immediate Jeopardy and psychosocial harm when Resident #40 alleged State tested Nurse Aide (STNA) #99 had physical sexual contact with her against her will and the facility failed to initiate an investigation into the allegation. This affected one of four residents reviewed for sexual abuse. The facility census was 115. On 10/24/19 at 3:48 P.M., the licensed nursing home administrator (LNHA), Interim Director of Nursing (DON) #116, Director of Operations #110, and Clinical Consultant #112 were notified that Immediate Jeopardy began on 10/10/19 when the LNHA received a copy of the police report which revealed Resident #40 alleged her and STNA #99 had sex a handful of times. When recounting the incident Resident #40 became tearful and was afraid of retaliation. The Immediate Jeopardy was removed on 10/27/19 when the facility implemented the following corrective actions: · On 10/10/19 Interim DON #116 and HRD #102 terminated STNA #99. · On 10/24/19 the Nurse Aide Registry was notified of the termination of STNA #99. · On 10/25/19 at 8:00 [NAME]M., the Divisional Director of Clinical Services educated the department managers on the Patient Protection Practice Guide. · On 10/25/19 the Senior Administrator educated the LNHA and Interim DON #116 on the Patient Protection Practice Guide, the facility process for completing a thorough investigation, and the State Agency reporting guidelines. · On 10/25/19 the Facility Assurance Performance Improvement (QAPI) re-opened SRI # 2 and the facilities internal investigation. · On 10/25/19 at 6:00 [NAME]M., the DON and Unit Managers initiated skin evaluations on current residents with completion on 10/27/19 at 12:00 P.M. There were no negative findings. · On 10/26/19 at 9:15 [NAME]M., Medical Records Clerk (MRC) #101 and Unit Manager #200 went to the facility where Resident #40 now resides and re-interviewed the resident regarding the alleged non-consensual vagina, anal, and oral sex between her and STNA #99. At 11:30 [NAME]M., the local police department arrived to the facility and were given a copy of Resident #40's statement. · On 10/27/19 the internal investigation was completed by the LNHA related to Resident #40 and findings included the investigation of alleged vaginal, anal, and oral sex between the resident and STNA #99 were inconclusive. In addition STNA #99 will not be permitted on company property. If noted to be on company property, the police will be notified immediately. The investigation is ongoing with the police department at this time. · On 10/27/19 by 3:00 P.M., all facility staff were educated by the Department Managers on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. Any employee who has not completed the education will be removed from the working schedule until said education is completed. · Beginning on 10/28/19 the Director of Operations #110 and/or the Quality Assurance Consultant will monitor daily for 14 days to ensure investigations are initiated, thoroughly investigated, reported to the State Agency timely, and resolved. Trends and findings will be reviewed by the QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Resident Interview Questionnaire, Department Managers will interview five residents daily for 14 days to ensure residents are not being abused. Trends and findings will be reviewed by the facility QAPI committee to determine ongoing monitoring frequency. · Beginning 10/28/19, utilizing the Staff Interview Questionnaire, Department Managers will interview five employees daily, for 14 days to ensure staff can verbalize the facilities abuse policy. Then randomly interview two employees once a week for four weeks, and then two employees once a month for six months. · On 10/28/19 from 1:12 P.M., to 1:20 P.M., interviews with Licensed Practical Nurse (LPN) #125, STNA #128 and STNA #130 verified they had received education on the Patient Protection Practice Guide, Reporting Guidelines, Cell Phone Usage in the facility while in patient care areas. They all were knowledgeable and knew who to report any allegation of abuse to. Although the Immediate Jeopardy was removed, the deficiency remained 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 were monitoring to ensure continued compliance. Findings include: Closed medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #40 had no cognitive deficits. On 09/17/19 Resident #40 was discharged to a local hotel. The resident returned to the facility on [DATE] and then again was discharged to the hospital for a surgical procedure on 10/07/19 and did not return to the facility. Review of the SRI (# 2) submitted to the State Agency by the LNHA on 10/01/19 at 4:10 P.M., revealed Resident #40 shared with MRC #101 she was receiving inappropriate texts from an employee. The resident at this time would not share who she was receiving the text messages from. The local police department was contacted, and a police report was filed. The only witness statements provided by the facility on 10/23/19 as part of the investigation for the SRI were from MRC #101, Resident #40, and STNA #99. Review of the witness statement dated 10/01/19 completed by MRC #101 revealed on 10/01/19 Resident #40 came to her and stated she was scared to come back to the facility when she had returned to the facility on [DATE], however, she did so because she had nowhere else to go. Resident #40 revealed she felt like an employee was sexually harassing her. At this time the resident would not provide a name of the alleged perpetrator because the employee had friends and family who resided in the facility, and she was worried about retaliation. The witness statement further revealed Resident #40 reported the employee had done things with her and he would text her and send her pictures of sexual positions and asked her for sexual favors. Resident #40 also reported to MRC #101 a phlebotomist had come in her room one time to draw blood and observed her and the employee in a compromising position. Review of the local police detective's statement dated 10/02/19 at 2:18 P.M., revealed Resident #40 reported she had been receiving obscene texts from an employee of the facility. The text shared by Resident #40 revealed a picture of a couple having sex and a link to a porn site. The text also revealed the employee wanted to sodomize her. Resident #40 reported she had sex with the employee at the facility because he threatened her, and she was scared of him. Resident #40 reported to law enforcement the sex was not consensual. Resident #40 would not reveal the employee's name at the time, because she was afraid of what he would do to her. The resident reported the last time she had sex with the employee was around 09/12/19. The resident could not remember how many times she had sex with the employee, however, she said it was a handful of times. Review of the witness statement dated 10/02/19 completed by HRD #102 revealed the HRD was asked to be present during the interview with the LNHA and Resident #40. The statement revealed Resident #40 named the employee who had been sending her texts of a sexual nature to her personal cell phone as STNA #99. Resident #40 revealed she had been texting with STNA #99 for a while and wanted to share what was recently sent by the STNA to her. The witness statement included copies of the text messages which revealed STNA #99 sent a video to Resident #40 of two people having sex with an offensive title. Resident #40 replied to the text stating it was disgusting and she didn't like things like that. STNA #99 sent another text to Resident #40 stating he wanted to sodomize her. Resident #40 revealed she was not comfortable with the context of the texts STNA #99 was sending her. Resident #40 revealed there was more than texting that had been going on between them and she felt intimidated by STNA #99. She was afraid the STNA would have her kicked out of the facility if she did not comply with what he wanted her to do. Review of STNA #99's statement completed by Interim DON #116 dated 10/03/19 at 1:30 P.M., revealed STNA #99 confirmed he had shared nasty text messages with Resident #40. The STNA confirmed they had been texting for a few weeks, however he stated he never acted on any of the texts. STNA #99 denied ever having sex or any type of intimacy with Resident #40. STNA #99 denied he ever threatened her. The STNA admitted his texts were inappropriate, however he said he never had sexual relations with her (Resident #40). Review of the Employee Warning notice dated 10/10/19 revealed STNA #99 was terminated from employment due to it being confirmed the STNA did engage in texting with Resident #40 which was inappropriate and obscene. Review of an investigation completed by the outside company who provided laboratory services to the facility dated 10/23/19 revealed Phlebotomist #145 was interviewed on 10/23/19 and reported she went to the facility to draw Resident #40's blood several months ago, around (MONTH) 2019. The phlebotomist knocked on Resident #40's door and when she entered the room it was dark, so she turned the light on. Phlebotomist #145 indicated she observed Resident #40 in bed and STNA #99 sitting on the bed with his hands under the blanket. The phlebotomist revealed Resident #40 did have a top on and STNA #99 was clothed. Phlebotomist #145 indicated the resident and the STNA seemed surprised. The phlebotomist revealed she felt uneasy because it seemed odd to her an STNA was alone with the resident in a dark room. Phlebotomist #145 asked Resident #40 if it was okay that she drew her blood and the resident said it was. STNA #99 remained in the room during the blood draw. Phlebotomist #145 revealed neither the resident or STNA #99 appeared to be in distress or she would have reported it to the facility staff. Review of the facility lab draws revealed Phlebotomist #145 drew Resident #40's blood on 03/19/19. On 10/23/19 at 1:30 P.M., telephone interview with Police Detective #500 confirmed he was the detective who came to the facility on [DATE] to interview Resident #40. He confirmed Resident #40 alleged she and STNA #99 had sex a handful of times, however it was not consensual as she was afraid if she didn't comply the STNA would do something to her. Detective #500 stated the investigation was ongoing at this time. On 10/23/19 at 10:19 [NAME]M. and at 2:00 P.M. interview with the LNHA and Interim DON #116 confirmed an SRI was immediately submitted when Resident #40 reported she was receiving text messages from an employee of the facility. The LNHA confirmed he became aware on 10/10/19 when the police department provided him with a copy of his report that Resident #40 alleged sexual contact by STNA #99 and an investigation into the allegation was not completed. Resident #40 told Police Detective #500 she had sex with STNA #99, and it was never consensual. The LNHA also confirmed Resident #40 reported to MRC #101 on 10/01/19 STNA #99 asked her to do sexual things and threatened her. He also was aware she reported a phlebotomist walked into her room and found her and STNA #99 in a compromising position. The LNHA confirmed he was aware and did not investigate the allegations of Resident #40 being threatened or forced to have sexual contact with STNA #99. The LNHA confirmed he did not follow-up with the phlebotomist at that time. On 10/24/19 at 2:00 P.M. interview with Human Resource Director (HRD) #140 of the Laboratory Company confirmed it was Phlebotomist #145 who found Resident #40 and STNA #99 in a compromising position and the phlebotomist did not report it to her, or to any staff member of the facility. On 10/28/19 at 1:50 P.M., interview with MRC #101 confirmed Resident #40 came to her office on 10/01/19 and reported she was receiving inappropriate texts from an employee. She confirmed what she wrote in her witness statement dated 10/01/19. MRC #101 revealed on 10/26/19 she visited Resident #40 at the new facility she now resided at, and the resident revealed she was still fearful of STNA #99. Review of the facility policy titled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual Abuse is non-consensual sexual contact of any type. The Administrator is responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Review of the facility policy titled, Procedures for Patient/Resident and Customer Relations (undated), revealed all employees should keep their relationships with patients/residents on a professional level. This deficiency substantiates allegations contained in Complaint Number OH 709.

Based on observation, staff interview, clinical record review, review of emergency room records, pharmacy records and the facility's policy on emergency pharmacy services, the facility failed to ensure medications were administered as ordered, resulting in significant medication errors, which required hospitalization due to [MEDICAL CONDITION] embolism for Resident #104, and increased shortness of breath with an increase in oxygen requirement for Resident #13. This resulted in Immediate Jeopardy for two (Resident #13 and Resident #104) of eleven residents reviewed for medication administration. The facility census was 103. On 01/08/15 at 2:47 P.M., the Administrator, Regional Nurse Consultant #5, and Performance Improvement Consultant #6 were notified that Immediate Jeopardy began on 12/12/14 at 9:00 A.M. when Resident #104 did not receive her scheduled anticoagulant, [MEDICATION NAME], ordered by the physician daily for a history of [MEDICAL CONDITION] embolism (a blood clot in the lung). Resident #104 last received the anticoagulant medication on 12/11/14 at 11:39 A.M. while in the hospital. Subsequently, on 12/13/14 at approximately 6:30 A.M., Resident #104 called 911 because she was having chest pain and staff failed to respond to her call light in a timely manner. The resident was admitted to the hospital and diagnosed with [REDACTED]. The resident was hospitalized for [REDACTED]. The Immediate Jeopardy continued on 01/02/15 at 6:00 A.M. when Resident #13 did not receive his scheduled [MEDICATION NAME], a diuretic medication prescribed for [MEDICAL CONDITION] or his [MEDICATION NAME], a medication for chronic obstructive [MEDICAL CONDITION] disorder. On 01/02/15 at 10:00 A.M. during an interview with Resident #13, the resident was observed wearing a nasal cannula (which delivers oxygen) and was observed to be very short of breath. The resident could not speak well due to the shortness of breath and was in tears. When assessed by Certified Nurse Practitioner (CNP) #7 that afternoon, the resident was assessed to be very short of breath with abdominal breathing noted, and not wearing any oxygen. Vital signs were not obtained at any time on 01/02/15 and no documentation of an assessment was completed. The [MEDICATION NAME] was not administered on 01/02/15 until 4:00 P.M., despite the medication being available in the facility contingency supply (SureMed system). The [MEDICATION NAME] medication was not administered on 01/02/15 until 6:00 P.M. The physician order was for [MEDICATION NAME] to be administered once daily in the morning and the [MEDICATION NAME] was ordered to be administered twice daily. The Immediate Jeopardy was removed on 01/11/15 when the facility implemented the following corrective actions: ? On 01/08/15, Resident #13 was reassessed for adverse effects of missing his medications and his medications were reconciled to ensure all medications ordered were available in the facility. The attending physician was notified of all medication doses missed. ? On 01/08/15, the facility reconciled all resident physician orders to ensure all medications were available in the facility. Any identified missed doses were reported to the attending physicians. ? On 01/08/15, the Administrator, Assistant Director of Nursing Services (ADNS) #26, and Directors of Care Delivery (DCDs) #24 and #25 were educated by the Divisional Performance Improvement Consultant #27 on the process for obtaining medications as ordered per facility policy. ? On 01/08/15, the facility Administrator, ADNS #26, and DCDs #24 and #25 began education of all nursing staff on the process for obtaining medications as ordered per facility policy. By 01/10/15, 35 of 44 nurses had been educated. All remaining nurses were to be educated prior to working. ? On 01/08/15, the facility converted from a Med Dispense (SureMed) system to an Emergency Drug Kit (EDK). An EDK is a system to provide certain medications for residents when the pharmacy is unable to ship medication or one is needed emergently. ? On 01/08/15, the "Receipt of Interim/Stat/Emergency Deliveries" policy was revised. ? On 01/09/15, interviews with Licensed Practical Nurse (LPN) #13 at 2:30 P.M., Registered Nurse (RN) #14 at 2:35 P.M., LPN #15 at 2:50 P.M., and LPN #17 at 3:09 P.M., and LPN #16 at 3:11 P.M. revealed they were not able to articulate the updated policy. ? On 01/10/15, the facility re-educated nursing staff and handed out the updated policy on laminated cards for the nurses to use as reference. ? On 01/10/15, interviews with LPN #18 at 5:17 P.M., RN #19 at 5:20 P.M., LPN #20 at 5:24 P.M., LPN #21 at 5:26 P.M., RN #12 at 5:28 P.M., LPN #22 at 5:30 P.M., and LPN #23 at 5:40 P.M. revealed all were knowledgeable regarding the revised facility policy on obtaining medications when unavailable. Although the Immediate Jeopardy was removed when the facility established systems to ensure residents received medications as ordered, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as not all nursing staff had been educated on the updated policy. Findings include: 1. Review of the clinical record for Resident #104 revealed the resident was admitted to the facility on [DATE] at 7:30 P.M. with [DIAGNOSES REDACTED]. Review of the hospital transfer paperwork, dated 12/08/14, revealed Resident #104 had primary [MEDICAL CONDITION] with metastases to her lungs, liver, and bone with spinal cord compression resulting in [MEDICAL CONDITION]. She had a [MEDICAL CONDITION] embolism in the lower lobe of her right lung. Review of the hospital discharge paperwork, dated 12/11/14, revealed Resident #104 received the following medications, prior to her discharge from the hospital: [MEDICATION NAME] on 12/11/14 at 11:39 A.M., [MEDICATION NAME] on 12/11/14 at 4:41 P.M., a [MEDICATION NAME] on 12/10/14 at 12:41 P.M., and [MEDICATION NAME] had not been given. Review of the Patient Admission Screen, dated 12/12/14 at 12:16 A.M. revealed Resident #104 had no signs or symptoms of [MEDICAL CONDITION], was alert and oriented times three and had modified independence in decision making. The resident was assessed to be dependent on staff for bed mobility, bathing, dressing, toileting, and transferring. She had pain present at a four of ten related to a breast biopsy. She was assessed as alert and oriented with appropriate verbal responses. Review of the physician orders, dated 12/11/14 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED].M. as scheduled on the Medication Administration Record [REDACTED]. The associated nursing note by LPN #11, dated 12/12/14 at 9:20 A.M. revealed the medication was not in the SureMed and was to arrive from pharmacy. The nursing notes were silent as to physician notification or any further actions related to the anticoagulant. Further review of the MAR indicated [REDACTED].M., any of her two scheduled doses of [MEDICATION NAME], and did not receive any breakthrough pain medication until 12/12/14 at 9:50 P.M. despite complaints of pain noted. Resident #104 had a physician order for [REDACTED]. Review of the nursing notes revealed on 12/12/14 at 6:57 P.M., [MEDICATION NAME], a medication given for nausea, was administered and was ineffective. On 12/12/14 at 10:18 P.M., LPN #10 wrote Resident #104 complained of nausea, vomiting and pain so medications were given for each. LPN #10 wrote she spoke to Resident #104 ' s sister in regard to the resident ' s concerns of vomiting and lack of response to her call light. On 12/13/14 at 6:58 A.M., LPN #10 wrote that the resident was alert and oriented times two and was physically and verbally aggressive towards the staff. The note revealed the resident called 911 related to chest pain and when the medics arrived the LPN told them the resident did not complain of chest pain and was having behavioral issues. LPN #10 wrote she notified the physician and sister. She wrote the sister told her the resident wanted to leave the facility and was going to call 911 to get kicked out. Review of the emergency room documentation, dated 12/13/14, revealed the resident was admitted to the emergency room at 6:49 A.M., complaining of upper chest and abdominal pain that had started at 1:00 A.M. The resident rated the pain a five out of ten with ten being the worst pain. The resident also complained of shortness of breath. Resident #104 was assessed as alert and oriented, with sound judgment and appropriate, calm, and cooperative behaviors. The documentation revealed the facility confirmed to the hospital the resident had a history of [REDACTED]. A computed tomography (CT) scan revealed multiple [MEDICAL CONDITION] embolisms. Review of Resident #104's hospital Discharge Summary, dated 12/18/14, revealed the resident was in the hospital from 12/13/14 through 12/18/14 due to a [MEDICAL CONDITION] embolism. The discharge summary revealed the resident was diagnosed with [REDACTED]. Her [DIAGNOSES REDACTED]. On 01/08/15 at 10:40 A.M., an interview with Resident #104's sister revealed Resident #104 had to call 911 herself on 12/13/14 when no staff would respond to her call light and she was experiencing chest pain. She revealed the hospital had explained that a second blood clot had formed in Resident #104's left lung, as a result of not receiving her anticoagulant [MEDICATION NAME] in the facility. Resident #104's sister revealed she had been aware the [MEDICATION NAME] had not been given and had spoken to two separate nurses at the facility, each of whom told her they were waiting on the medication to drop ship from the pharmacy. She revealed she never told the nurse who called her on 12/13/14 that her sister was trying to get kicked out or that she was making anything up. She revealed her sister had called her multiple times in the days she was at the facility panicked that no staff were responding to her call light and she was in pain and vomiting, so the sister had to call the desk and ask staff to go assist Resident #104. On 01/08/15 at 11:03 A.M., an interview with the Administrator and the Director of Nursing (DON) confirmed Resident #104 did not receive her anticoagulant medication [MEDICATION NAME] and they were unsure why she did not. The Administrator and DON also confirmed the resident did not receive her [MEDICATION NAME] as ordered, and no pain medication was documented as administered until 12/12/14 at 9:50 P.M. when the resident had a pain score of nine out of ten (with ten being the worst pain). On 01/08/15 at 2:15 P.M., an interview with Director of Pharmacy Services #4 revealed the pharmacy received the order for [MEDICATION NAME] on 12/12/14 and the medication was shipped out at 1:00 P.M. to the facility and should have arrived there that afternoon. On 01/09/15 at 12:56 P.M., an interview with LPN #11 revealed she worked with Resident #104 on 12/12/14. She revealed she did not administer the [MEDICATION NAME] to Resident #104 as ordered. She had called the pharmacy to drop ship the medication but was unsure when it arrived, although she revealed she saw it the next day she worked, still in the pharmacy tote bag. LPN #11 revealed she did not notify the physician of the missed anticoagulant as she was busy and forgot. She revealed she did not remember why she did not administer the other medications and stated the SureMed system was acting up during that time, freezing and showing that no [MEDICATION NAME] was available, and she had problems obtaining pain medications as well for Resident #104. She revealed she did not remember administering any pain medications other than Tylenol when she could not obtain the [MEDICATION NAME] from the SureMed. LPN #11 revealed Resident #104 was crying in pain due to her wound sites and that Resident #104's family had called in concerned because of her pain level and lack of anticoagulant administration. On 01/09/15 at 2:45 P.M., an interview with LPN #10 revealed she worked the night Resident #104 was admitted and the morning she was discharged . LPN #10 revealed Resident #104 did complain her call lights were not being answered and her sister had called in regarding that. LPN #10 revealed she was not told in report Resident #104 had not received the [MEDICATION NAME] or [MEDICATION NAME], but she knew that one of those had not been administered because Resident #104's sister had called and was very upset the medication had been missed. LPN #10 revealed Resident #104 was not happy about being in the facility and wanted to leave, so she repeatedly called 911. She revealed she had behaviors since admission and described the behaviors as talking to herself and being demanding and had never complained of pain. She confirmed she did not document any behaviors prior to 12/13/14 at 6:58 A.M. and that she had administered medication for pain that same evening when the resident rated her pain at a nine of ten. LPN #10 also confirmed she did not document any other 911 calls made by Resident #104. On 01/09/15 at 3:30 P.M., an interview with Physician #8 revealed he was the physician for Resident #104, but had not seen the resident during her stay at the facility. Physician #8 revealed he only remembered being called regarding this resident when she was sent out to the hospital the morning of 12/13/14. Physician #8 revealed missing any medication such as an anticoagulant was always a concern even though it had a long half-life. He revealed her pain would have been an issue if he had known she was unable to receive her medications. Physician #8 revealed that Resident #104 had been seen by palliative care while in the hospital and her pain had been difficult to control. He revealed the [MEDICATION NAME] was for breakthrough pain and he could have easily switched it to something the facility had available if he had been notified. 2. Review of the clinical record for Resident #13 revealed the resident was admitted on [DATE] at 6:05 P.M. with [DIAGNOSES REDACTED]. Review of the hospital documentation revealed Resident #13 had been hospitalized for [REDACTED]. Transfer orders included a nasal cannula to deliver two to four liters of oxygen with a goal oxygen saturation of 92% or greater. The last dose of [MEDICATION NAME] was administered on 12/31/14 at 4:22 P.M., the last dose of [MEDICATION NAME] was administered on 01/01/15 at 7:16 A.M., and the last dose of [MEDICATION NAME] was administered on 01/01/15 at 10:13 A.M. Review of the Patient Admission Screen, dated 01/01/15 at 6:05 P.M. revealed Resident #13 showed no signs or symptoms of [MEDICAL CONDITION] and displayed modified independence in decision making. The resident was assessed as displaying shortness of breath and on oxygen therapy. Review of the physician orders revealed orders for [MEDICATION NAME], a diuretic prescribed for [MEDICAL CONDITION], daily every morning, [MEDICATION NAME], an anticoagulant, daily, and [MEDICATION NAME], a medication for [MEDICAL CONDITION], twice a day. Review of the MAR indicated [REDACTED].M. on 01/02/15 and did not receive the ordered [MEDICATION NAME] or [MEDICATION NAME] at 9:00 A.M. on 01/02/15. Review of the nursing notes revealed on 01/02/15 at 7:15 A.M., the facility was still waiting for medications to arrive from pharmacy for Resident #13. A nursing note by RN #12 revealed she called pharmacy on 01/02/15 at 7:45 A.M. and left a message for them to drop ship all medications. At 10:21 A.M. on 01/02/15, a nursing note revealed RN #12 had spoken to pharmacy and they would drop ship all medications not available in the emergency drug kit (EDK). At 4:00 P.M. on 01/02/15, a nursing note revealed the [MEDICATION NAME] was given. Review of the vital signs for Resident #13 revealed vital signs were taken on admission on 01/01/15 at 9:00 P.M. and not again until 01/03/15. On 01/02/15 at 9:55 A.M., an interview with RN #12 revealed she was the nurse for Resident #13. She revealed not all of his medications were available, including his [MEDICATION NAME] and [MEDICATION NAME], but that she had called pharmacy for them to drop ship those medications. She revealed it usually takes a few hours for a drop shipment to arrive. On 01/02/15 at 10:05 A.M., an interview with Resident #13 revealed he had received some of his medications but not all of them. Observation of Resident #13 revealed he was sitting with the head of the bed at a 60 degree angle, had a nasal cannula for oxygen delivery in place, and was showing signs of labored breathing. Resident #13 was laboring so much that he could not speak well, had tears in his eyes, and was straining to get out words. RN #12 confirmed his labored breathing when notified. Review of the admission note from CNP #7 on 01/02/15 at 2:10 P.M. revealed Resident #13 was admitted to the facility after a hospitalization for influenza A and on hospital discharge, the physician had been trying to adjust his [MEDICATION NAME] to achieve an international normalized ratio (INR) between 2.5 and 3.5. This measures how long it takes the blood to clot. On admission to the facility his INR was sub-therapeutic at 1.8. CNP #7's assessment revealed Resident #13 displayed shortness of breath and dyspnea, or labored breathing, on room air. He was assessed as displaying abdominal breathing and having scattered rhonchi (abnormal breath sounds). CNP #7 noted the resident was anxious. In conclusion, CNP #7 revealed Resident #13 was very short of breath upon assessment without oxygen and her plan was to maintain supplemental oxygen. A nasal cannula was re-applied to Resident #13. Review of a drop ship delivery confirmation revealed the [MEDICATION NAME] and [MEDICATION NAME] were delivered to the facility on [DATE] at 11:00 A.M. Review of the SureMed drug transactions revealed on 01/02/15 the SureMed had [MEDICATION NAME] available to be pulled and given for Resident #13. On 01/04/15 at 11:33 A.M., an interview with the Administrator and DON revealed the facility completed an investigation into the missed medications for Resident #13 and found that medications including [MEDICATION NAME], for high blood pressure, [MEDICATION NAME], for pain, and Potassium, for low potassium were not administered on 01/01/15 at night as ordered and so a medication error was recorded. They explained the nurse had tried to access some of the medications from the SureMed overnight on 01/01/15 but the screen was blank and medications were unable to be accessed. In addition, the DON revealed the pharmacy was late with the drop shipments that day, although she was unsure why. On 01/09/15 at 1:55 P.M., an interview with CNP #7 revealed she saw Resident #13 on the afternoon on 01/02/15 so she could complete an admission assessment. She revealed he had been very sick with influenza A and [MEDICAL CONDITION] and was short of breath on assessment. She revealed she had not been notified by nursing that Resident #13 had been short of breath on admission and on assessment the morning of 01/02/15. CNP #7 revealed she was not notified Resident #13 had not received a number of his medications including his [MEDICATION NAME] and [MEDICATION NAME]. She explained the [MEDICATION NAME] was a maintenance medication for [MEDICAL CONDITION] and the [MEDICATION NAME] was for the resident's [MEDICAL CONDITION], and missing that may have contributed to his shortness of breath. On 01/09/15 at 1:34 P.M., an interview with Medical Director #28 revealed he was unaware of any issues the facility had been having with accessing medications from the pharmacy. He was aware the facility had issues with pain management and was working on that issue. He revealed if medication doses had to be missed, his expectation would be the nurse call the physician for instructions, as he was not familiar with that resident. The Medical Director revealed the missed doses of [MEDICATION NAME] and [MEDICATION NAME] had a high potential of adverse effects in a patient such as Resident #13 who had [DIAGNOSES REDACTED]. On 01/12/15 at 12:06 P.M., an interview with Physician #9 revealed he was the physician responsible for Resident #13, but he had not actually seen or assessed the resident since admission. He revealed he was notified on 01/02/15 that a number of his residents in the facility had medications that were not available and would be four to eight hours late. He could not specifically remember if he was notified that Resident #13's [MEDICATION NAME] and [MEDICATION NAME] were not available, and he was not notified of Resident #13's shortness of breath or any other issues or concerns with Resident #13 since admission. Review of the facility policy "Medication Shortages/Unavailable Medications", dated 12/01/07 and last revised on 01/01/13, revealed if a medication was unavailable in the facility for a resident, the nurse should contact pharmacy for the medication to be sent in the next available delivery. If that delivery would cause a delay or missed dose for the resident, the nurse should obtain the medication from the emergency medication supply. If the medication is not in the emergency medication supply, the nurse should arrange the medication to be drop shipped. If the shortage is discovered after normal pharmacy hours, the nurse should call and ask to speak with the on-call pharmacist. If emergency delivery is unavailable, the nurse should call the physician. If unable to obtain an order related to the medication from the physician, the nurse should call the nursing supervisor and Medical Director to notify them of the shortage and obtain orders or directions. If a missed dose is unavoidable, the nurse should document the missed dose and a description of the circumstances of the medication shortage, the pharmacy's response upon notification, and the actions taken. This deficiency substantiates Master Complaint Number OH 349 and Complaint Number OH 308.

Based on observation, record review, and interview, the facility failed to provide adequate pain management for three residents. This resulted in harm for Resident #104, who complained of pain on admission and was not administered pain medication for 10 hours after admission when her pain had reached a level eight out of ten. This resulted in harm for Resident #91, whose pain medications were decreased and her pain level reached a level of ten out of ten, which she described as "intolerable", causing her to not sleep or eat. This also resulted in harm for Resident #33, whose pain medications were not available following admission which resulted in increased pain and also required the resident's spouse to obtain the medication from an outside pharmacy for the resident. This affected three residents (Resident #104, Resident #91 and Resident #33) of three residents reviewed for pain. The facility identified 67 residents on a pain management program. Findings include: 1. Review of the clinical record for Resident #104 revealed the resident was admitted to the facility on [DATE] at 7:30 P.M. with [DIAGNOSES REDACTED]. Review of the hospital transfer paperwork, dated 12/08/14, revealed Resident #104 had primary [MEDICAL CONDITION] with metastases to her lungs, liver, and bone with spinal cord compression resulting in [MEDICAL CONDITION]. She had a [MEDICAL CONDITION] embolism in the lower lobe of her right lung. Review of the hospital discharge paperwork, dated 12/11/14, revealed Resident #104 received the following medications for pain, prior to her discharge from the hospital: 10 milligrams (mg) [MEDICATION NAME] on 12/11/14 at 4:41 P.M. and a [MEDICATION NAME] on 12/10/14 at 12:41 P.M. Review of the Patient Admission Screen, dated 12/12/14 at 12:16 A.M. revealed Resident #104 had no signs or symptoms of [MEDICAL CONDITION], was alert and oriented times three and had modified independence in decision making. The resident was assessed to be dependent on staff for bed mobility, bathing, dressing, toileting, and transferring. She had pain present and rated the pain with a score of four out of ten related to a breast biopsy. She was assessed as alert and oriented with appropriate verbal responses. Review of the physician orders revealed an order for [REDACTED]. Review of the pain level summary for Resident #104 revealed her pain level was assessed only three times. On 12/11/14 at 23:58 her pain level was a four out of ten. On 12/12/14 at 3:35 P.M. her pain level was a nine out of ten. On 12/12/14 at 9:50 P.M., her pain level was an eight out of ten. Review of the Medication Administration Record [REDACTED].M., Licensed Practical Nurse (LPN) #11 administered a [MEDICATION NAME] for a pain score of nine of ten. On 12/12/14 at 9:50 P.M., LPN #10 administered [MEDICATION NAME] for a pain level of eight of ten. Review of the nursing notes revealed on 12/12/14 at 5:45 P.M., Resident #104 complained of pain at an eight of ten and was repositioned, which was not effective. The MAR indicated [REDACTED]. A nursing note on 12/12/14 at 10:18 P.M. revealed Resident #104 complained on pain and was medicated by LPN #10, yet a nursing note on 12/13/14 at 6:58 A.M. by LPN #10 revealed the resident did not complain of pain during her shift. Review of the pharmacy drop ship receipt revealed LPN #10 received and signed for Resident #104's [MEDICATION NAME]. Review of the SureMed dispense charge report for Resident #104 revealed LPN #11 removed 2 tablets of [MEDICATION NAME] 10 mg on 12/12/14 at 12:51 P.M. and 2 more tablets at 3:47 P.M. On 01/09/15 at 12:56 P.M., an interview with LPN #11 revealed she remembered Resident #104 and had experienced problems obtaining her pain medications from the SureMed, as the medications had not been drop shipped by pharmacy. She revealed she had an authorization to pull the [MEDICATION NAME] but the SureMed was not working properly and she could not obtain the medication. LPN #11 revealed she administered Tylenol to the resident because when she called pharmacy for help, they told her there was nothing else they could authorize her to pull out. She recalled that she could not remember the resident's exact pain level, although the resident was crying in pain, which was located at her breast biopsy sites, and the resident's family members had been calling into the facility because Resident #104 was calling them complaining of pain. On 01/09/15 at 2:45 P.M., an interview with LPN #10 revealed she remembered Resident #104 and was her nurse on admission on 12/11/14 and discharge on 12/13/14. She confirmed Resident #104 did complain of pain on admission and was not given any medication for breakthrough pain. She revealed Resident #104 never complained of pain, however confirmed that she administered [MEDICATION NAME] on 12/12/14 at 9:50 P.M. for Resident #104 due to a pain rating on eight of ten. On 01/09/15 at 3:30 P.M., an interview with Physician #8 revealed he was not notified the facility was having difficulty obtaining Resident #104's [MEDICATION NAME]. He revealed he would have been very concerned with her pain level and that prior to being admitted to the facility, she was seen by the palliative care team at the [MEDICAL CONDITION] Hospital for pain management. Physician #8 revealed the team had noted her pain was difficult to control and had prescribed the [MEDICATION NAME] for breakthrough pain. Physician #8 revealed if he had been notified of the problem, he could have easily written to switch the pain medication to something the facility had readily available. 2. Review of the clinical record for Resident #91 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, completed 12/10/14, revealed Resident #91 was cognitively intact with no signs or symptoms of [MEDICAL CONDITION], and displaying no verbal or physical behaviors or rejection of care. She was assessed as receiving pain medications and non-pharmacological interventions to treat pain, having pain present constantly, with the worse rating a nine of ten, which made it hard to sleep and limited day to day activities. Review of the Pain Evaluation, dated 12/04/14, revealed Resident #91 had pain for longer than six months of intermittent duration that occurred frequently in both feet. Her current pain level was a seven out of ten, with a two being her goal. She described her pain as aching, gnawing, and exacerbated by position changes and sleeping. Medications helped to alleviate her pain and the pain negatively affected her activities of daily living, standing, and her depression. The assessment revealed her current pain regimen of two [MEDICATION NAME] 5/325 mg tablets every four hours was effective. Review of the plan of care related to pain, dated 12/04/14, revealed the resident's pain was due to bilateral heel pressure ulcers and the goals were to reduce episodes of breakthrough pain and to keep pain manageable at a level of five. Interventions included, but were not limited to, administer medications per physician order and to notify the physician if the pain frequency or intensity is worsening or if current [MEDICATION NAME] regimen had become ineffective. Review of the physician orders revealed on 12/31/14, Certified Nurse Practitioner (CNP) #7 ordered a renewal for [MEDICATION NAME] 5/325 mg (a medication prescribed for moderate to moderately-severe pain) two tablets every four hours for pain, and to awaken the resident at night for the medication. A physician order by Physician #9, dated 01/01/15, revealed he decreased Resident #91's pain medication to one tablet of [MEDICATION NAME] 5/325 mg every four hours, with a notation to discontinue [MEDICATION NAME] 2 tablets every four hours. Review of the Pain Level Summary for Resident #91 revealed prior to 01/03/14 the resident's pain scores ranged from two to five. On 10/03/15 at 8:02 A.M., 12:02 P.M., and 4:22 P.M. her pain scores were at a seven. On 01/03/15 at 8:49 P.M. and 11:32 P.M., and on 01/04/15 at 4:07 A.M., Resident #91's pain level was a ten of ten. Review of CNP #7's progress note dated 12/30/14 at 1:26 P.M. revealed Resident #91 had sharp, throbbing pain to both legs. Review of the nursing notes revealed on 01/04/15 at 12:05 A.M., LPN #28 revealed the resident was alert and voiced concerns regarding her pain medication being decreased. LPN #28 attempted to call the physician without success and noted she would try again tomorrow. No other nursing notes revealed Resident #91 complained of her pain increasing or of physician notification regarding increased pain. On 01/05/15 at 2:38 P.M., an interview with Resident #91 revealed she was not happy her pain medications had been decreased. She revealed she suffered from chronic pain, and shortly after her medication decrease, her pain began to increase. She reported it was now intolerable, and she was unable to sleep or do much else. Resident #91 revealed that she saw the physician that day regarding her pain, although she had been asking to see him for the past few days. She reported the physician told her the nursing staff did not tell him she was asking for him. During the interview, the resident was displaying signs of pain such as facial grimacing, and reported her pain at a nine out of ten. On 01/09/15 at 1:55 P.M., an interview with CNP #7 revealed she was not aware why Physician #9 decreased Resident #91's [MEDICATION NAME] on 01/01/15, as she did not feel a decrease was warranted when she wrote to renew the order on 12/31/14. CNP #7 revealed she was not notified that Resident #91 wanted to speak to someone regarding her pain, although she was aware the resident was not happy with the decrease, and she was not notified regarding the increased pain scores or that the [MEDICATION NAME] regimen was becoming ineffective for the resident. On 01/09/15 at 4:04 P.M., an interview with LPN #28 revealed that when she received report on 01/03/15 from RN #14, he reported that Resident #91's pain had been increasing and he had attempted to notify the physician without success. LPN #28 revealed she too had called the physician without success, and had passed it on for the oncoming nurse the morning of 01/04/15. She revealed she did not notify anyone when Resident #91 had three pain scores of ten out of ten. LPN #28 revealed Resident #91 would fall asleep at times, but woke up between each medication dose. On 01/12/15 at 12:06 P.M., an interview with Physician #9 revealed he wrote the order to decrease Resident #91's pain medication, although it was a miscommunication or misunderstanding. He revealed he was in the facility and was approached by a nurse who told him Resident #91 needed a renewal prescription. Physician #9 revealed he wrote the order but was unsure of the dose the resident received. He revealed he was not notified regarding the resident requesting to speak with him, of the increased pain scores, or that the decrease in dosage had made the pain regimen ineffective. Physician #9 revealed Resident #91 had chronic pain. 3. Review of the clinical record for Resident #33 revealed the resident was admitted to the facility on [DATE] at 3:00 P.M. with [DIAGNOSES REDACTED]. Review of the Patient Admission Screen, dated 01/01/15 at 4:00 P.M., revealed Resident #33 was independent in his decision making with no signs or symptoms of [MEDICAL CONDITION], was in pain and had received pain medications as needed. He was assessed as having surgical incisions to both knees. Review of the Pain Evaluation, dated 01/01/15 at 8:55 P.M., revealed Resident #33 had a bilateral partial knee replacement. The pain was described as intermittent in both knees. At the time of the assessment, Resident #33 rated his pain at a five out of ten, with his goal a two. The pain was described as a throbbing tightness that worsened with increased activity, position changes, and walking. Medications, repositioning, and resting helped to alleviate the pain. The evaluation noted Resident #33's prescribed [MEDICATION NAME] 5/325 mg (prescribed for moderate to moderately-severe pain) was effective and that Resident #33 wanted to be proactive with the pain medication prior to increasing his activity levels. Review of the Pain Level Summary revealed Resident #33 had a pain score of five on 01/01/15 at 8:15 P.M. and 9:08 P.M., a three on 01/02/15 at 2:05 A.M., and a six on 01/02/15 at 6:06 A.M. and 8:52 A.M. Review of the physician admission orders [REDACTED]. On 01/02/15 at 9:00 A.M., the physician ordered those medications to be given every four hours as needed for pain. Review of the MAR indicated [REDACTED].M. for a pain score of five, one [MEDICATION NAME] tablet on 01/02/15 at 2:05 A.M. for a pain score of three and two [MEDICATION NAME] tablets on 01/02/15 at 6:06 A.M. for a pain score of six. On 01/02/15 at 8:50 A.M., an interview with Resident #33 revealed he had bilateral partial knee replacements. He revealed he had received pain medication prior to leaving the hospital on [DATE] around 2:00 P.M. Resident #33 revealed that on 01/01/15, after admission, facility staff informed him they were having difficulty with the computer that gave them access to the pain medications, so he would not get his [MEDICATION NAME] on time. Resident #33 explained that he then called his wife, who drove to the facility to get his prescription and had it filled at a local pharmacy so he could receive his medications. He revealed that because of this his medications were late and his pain increased to a seven or eight out of ten, making it difficult for him to sleep, and as a result the physician had ordered his medications for every four hours. On 01/02/15 at 9:42 A.M., an interview with LPN #17 revealed that Resident #33's wife had to come in last night and filled his prescription for [MEDICATION NAME] at a local pharmacy, as the SureMed was acting up and staff were unable to obtain the needed medications for Resident #33. LPN #17 confirmed staff did not notify the physician when the medication was unable to be accessed, and a nursing manager was not notified of the issues with the SureMed. On 01/05/14 at 11:33 A.M., an interview with the Administrator and Director of Nursing revealed they had been unaware of issues with the SureMed. They confirmed that Resident #33's wife had to fill his [MEDICATION NAME] prescription because the medication was unable to be accessed by facility staff. The Administrator revealed the facility had no policy specifically to pain management. Review of the facility policy "Medication Administration: Medication Pass" , dated 03/10, revealed no mention of pain medication administration. This deficiency substantiates Complaint Number OH 308 and is an example of continued noncompliance from the annual survey of 10/30/14.

Based on record review and staff interview the facility failed to ensure adequate monitoring of Resident #105's blood pressure when administering an anti-hypertensive medication. This resulted in harm for Resident #105 when her medication was administered without knowledge of her blood pressure, and she suffered a hypotensive, non-responsive episode three hours following the scheduled time for the administration of the medication which required intravenous fluids, oxygen administration, and hospitalization . This affected one resident (Resident #105) of three residents reviewed for hospitalization . The facility identified 44 residents receiving anti-hypertensive medications. Findings include: Review of the clinical record for Resident #105 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the list of Resident #105's home medication did not include [MEDICATION NAME] or any medications to regulate blood pressure. Review of the Medication Administration Record [REDACTED].M. Review of the blood pressure records revealed Resident #105's blood pressure was obtained on admission and was 160/76 on 12/16/14 at 8:00 P.M. On 12/17/14 at 10:06 A.M. her blood pressure was 171/75. Resident #105 did not have her blood pressure checked on the morning of 12/18/14 until 12:28 P.M., at which time it was 68/42. Review of the nursing notes, dated 12/18/14 and written at 3:16 P.M., revealed Licensed Practical Nurse (LPN) #23 had been called into Resident #105's room by the physical therapist to check on the resident. Resident #105 could not be aroused, her blood pressure was 68/42 and her oxygen saturation was low at 86%. The resident required an oxygen mask and an intravenous (IV) line with fluids initiated. However the resident still could not be aroused. LPN #23 notified the family, who requested Resident #105 be sent to the emergency room at that time. Prior to the medics arriving, Resident #105 was able to be aroused but was not oriented to time and place. Review of the progress note by Certified Nurse Practitioner (CNP) #7, dated 12/18/14 at 7:34 P.M. revealed Resident #105 had been seen by therapy and had a very low blood pressure so was laid back down and a nurse was called. Upon arrival of the nurse, the resident was difficult to arouse, with a very low blood pressure, irregular respirations, and low oxygen saturations. CNP #7 assessed Resident #105 as having shortness of breath, non-responsive to sternal rub and verbal stimulus but responsive only to painful stimulus, and having flaccid extremities. CNP #7 assessed Resident #105 as alert and oriented times zero. Resident #105 was assessed as having a hypotensive episode requiring IV fluids and the plan was to discontinue the [MEDICATION NAME]. Resident #105's blood pressure post-IV fluids was 103/55. On 01/07/15 at 12:30 P.M., an interview with the Director of Nursing revealed she was not employed with the facility at the time of the incident and was unsure why a blood pressure was not checked prior to administering an anti-hypertensive new to Resident #105. She revealed there was no order to check the blood pressure and the facility did not have a policy on monitoring vital signs when giving anti-hypertensive medications. On 01/09/15 at 1:15 P.M., an interview with LPN #23 revealed she remembered Resident #105. She revealed she did not know the [MEDICATION NAME] was a new medication for Resident #105 and that she normally checked vital signs on every resident prior to morning medication pass to ensure they should be given medications that regulate heart rate or blood pressure. She could not say why there were no vital signs documented for Resident #105 on the morning of 12/18/14 prior to administering the [MEDICATION NAME]. LPN #23 remembered that a physical therapist had come to get her to assess Resident #105 on 12/18/14 because of a low blood pressure. When she arrived in the room, Resident #105 was laying down and could not be aroused, so she went and got her nursing manager and CNP #7, who was in the building at the time. She revealed the resident required an IV, IV fluids, oxygen, and hospitalization . Review of the manufacturer instructions for [MEDICATION NAME], last revised 12/14, revealed the recommended initial dose was 10 mg once a day, to be adjusted according to blood pressure response. The response can be evaluated by measuring blood pressure just prior to administering the medication to determine if the medication is controlling the blood pressure. This deficiency was an incidental finding during the investigation of Master Complaint Number OH 349 and is an example of continued noncompliance from the annual survey of 10/30/14.

Based on review of a facility self-reported incident (SRI), medical record review, staff interview, review of a police report, review of the Phlebotomist Daily Mileage Sheet and review of the facility abuse policy, the facility failed to protect Resident #91 from sexual abuse. This resulted in Immediate Jeopardy for one resident (#91) who was sexually assaulted by Laboratory Technician (LT) #1. This affected one of sixteen sampled residents whose laboratory values/blood draws were obtained on 05/07/13, 05/08/13 and 05/09/13. The facility census was 90. The Administrator was notified that Immediate Jeopardy began on 05/08/13 when Resident #91 was sexually assaulted by LT#1 during a visit to obtain blood for laboratory (lab) sampling. On 05/08/13, Resident #91 had orders for several lab values to be obtained. LT #1 drew the blood work. When he was finished drawing Resident #91's blood, LT #1 closed the door and drew the curtains around Resident #91's bed. LT #1 then lifted Resident #91's shirt and placed his penis between her breasts. LT#1 placed his hands on Resident #91's breast and ejaculated. LT #1 also asked the resident to perform oral sexual acts. The Immediate Jeopardy was removed on 05/10/13 at 8:30 P.M. when the facility implemented the following corrective actions: ? On 05/10/13, (no time identified) the facility verified that LT #1 was immediately suspended when the laboratory was notified of the allegation of sexual abuse. LT#1 would not be returning to this facility. ? On 05/10/13, the facility requested only female LT's would provide laboratory services for the facility. ? On 05/10/13, (no time identified) the laboratory provided confirmation that all employees that provide service to the facility had pre-employment background checks verified as clear and all abuse and neglect training was current. Review of an email sent to the Administrator dated 07/17/13 revealed the laboratory Abuse Training was completed in conjunction with an elderly abuse video "In their own words" put on by the United States Department of Justice. According to the documentation, there was open class time for questions and review of steps for reporting abuse and patient safety. The education was conducted by a certified teacher/adult education instructor through the State of Ohio. ? On 05/10/13, the facility implemented a QA&A Audit Tool: Lab Tracking-Privileged Work Document. This tracking identified the resident's room number, resident name, lab test ordered and date to be obtained, lab test obtained as ordered, date and time lab results received, results within normal limits, critical or panic results, date and time of physician notification of abnormal lab results, new physician order, if no new orders received for panic or critical lab values, physician justification documentation in progress notes, family or responsible party notified of abnormal result, lab technician initials and nurse initials. ? On 05/10/13, the facility interviewed the other 11 alert and oriented residents (Residents #67, #75, #76, #92, #94, #95, #96, #97, #99, #100 and #101) who had lab values drawn from 05/07/13 through 05/09/13 and with whom LT #1 had contact. No concerns were voiced by the residents. The facility provided documentation of head to toe assessments for residents not able to be interviewed (Residents #80, #89, #93 and #98) with no signs of abuse identified. ? On 05/10/13 at 8:30 P.M., all 179 employees: four Activity personnel, 11 Administrative staff, 10 housekeeping staff, two laundry staff, one medical record personnel, one medical supply staff member, 14 occupational therapy (OT) staff, 15 physical therapy (PT) staff, three social service personnel, nine speech therapy (ST) staff members, 54 State tested nurse aides (STNA's), 19 registered nurses (RN's), 24 Licensed Practical Nurses (LPN) and 12 dietary staff members were re-educated regarding Responding to Suspected Abuse/Neglect or Injury/Change in condition of unknown origin. ? Review of a letter dated 01/01/13 from the mobile X-ray company contracted by the facility revealed a background policy was instituted in 1997 and since that time their hiring practices have included drug screens and criminal background checks on all employees. All employees have also been trained in HIPPA, Standard of Conduct Compliance, Elder Care, Infection Control, and the OSHA Blood-borne Pathogen Standards. On 07/31/13 at 3:30 P.M. review of the QA&A Audit Tool dated 07/01/13 was reviewed and was being completed as directed on a daily basis. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level Two (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until 07/31/13 when it was corrected. ? On 07/31/13 at 3:30 P.M. review of the QA&A Audit Tool dated 07/01/13 was reviewed and was being completed as directed on a daily basis. ? On 07/31/13 from 2:35 P.M. to 4:00 P.M., interviews conducted with Physical Therapy Aide (PTA) #101, LPNs #201 and #202, RNs #203 and #204, STNAs #205 and #206 revealed all were knowledgeable of the facility's abuse policy and procedures as well as not allowing outside male medical persons to be with female residents without facility staff present. Findings include: Review of Resident #91's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/13, revealed Resident #91 was cognitively intact. Review of the facility's Self-Reported Incident (SRI), dated 05/10/13, revealed Resident #91 alleged a sexual assault occurred on 05/08/13 when LT #1 was inappropriate with her after drawing her blood. The facility's investigation was incomplete at that time due to an ongoing investigation. The report reflected the police, the physician, family and the laboratory were immediately notified of the allegation when the facility became aware on 05/10/13. The police immediately began their investigation. There was no evidence the facility submitted additional information after the initial SRI dated 05/10/13. Review of the documentation provided by the Administrator revealed the Director of Nursing (DON) spoke with Resident #91's sister who stated she was personally notified by her sister of the sexual abuse allegation on 05/08/13; however, the time was not specified, and no facility staff were notified. The facility was not made aware of the situation until 05/10/13 at 11:15 A.M., when the resident and her case worker notified the Administrator. On 07/24/13 at 4:30 P.M., interview with the Administrator regarding the SRI involving Resident #91 revealed the resident made a sexual abuse allegation against LT #1 on 05/10/13 during a visit with her psychological services counselor, who then reported it to the facility. The allegation was reported to the Police Department, where the investigation remains ongoing. Review of the Police Prosecutor Summary, dated 06/11/13, revealed that on the morning of 05/08/13 LT #1 admitted he was in Resident #91's room to draw blood. He lifted Resident #91's shirt without her consent, placed his penis in between her breasts, and "also used his hand and her hand to stroke his penis". In addition, he repeatedly asked Resident #91 to place his penis in her mouth, to which she repeatedly said "No". LT #1 also admitted to "ejaculating on (Resident #91's) right breast", using a Kleenex to clean himself up and then leaving the room. Resident #91 reported this incident lasted five to ten minutes and, after the incident, LT #1 "put his index finger up to his lips as though he was telling her not to say anything and then said something along the lines of her being his favorite patient". The report revealed Resident #91's history of a prior rape in 1978 and abusive relationship, and that Resident #91 stated "she in no way consented to any sexual contact" with LT #1. Upon contacting LT #1's regional manager, it was discovered that since his employment began in March 2013 he had one complaint lodged in regards to him touching a female patient. The report also revealed, during an interview with the Administrator, it was discovered that, although there was a sign-in book at the facility, not everyone signed in, and LT #1 had not signed in the day the sexual abuse occurred. Review of a copy of the Phlebotomist Daily Mileage Sheet dated 05/08/13 revealed LT #1 was in the facility between 8:25 A.M. and 10:35 A.M. According to interview of the Administrator on 07/26/13 at 10:00 A.M., none of the nursing staff observed LT #1 while in the building. During interview of staff on 07/31/13 from 2:40 P.M. until 4:00 P.M., LPN #202, who was assigned as Resident #91's nurse on 05/08/13, revealed she knew the resident very well. She stated they joked a lot together. LPN #202 was passing pills when LT #1 drew Resident #91's blood. LPN #202 stated she "saw him go in and come out" out of the resident's room. She stated she went in to administer pills after LT #1 left. LPN #202 stated "we joked as usual". She detected nothing unusual. LPN #202 stated Resident #91 and her roommate usually kept their door closed. She stated she didn't know LT #1 but had seen him at the facility before. He was not the usual lab technician; it was usually a female technician. On 07/31/13, at 2:50 P.M., interview with Receptionist #1 verified she usually worked Monday-Friday 8:30 A.M., until 4:00 P.M. She showed the surveyor the sign-in book on her desk. There were several names in it. Receptionist #1 stated people that are visiting with a resident usually sign the book. She stated medical people usually don't sign the book; hey go to the nursing station and pick up the order. The timeline initiated by the facility on 05/10/13 revealed at 11:15 A.M., the Administrator was notified via the resident and her case worker regarding the allegation of sexual abuse. From 11:15 A.M. until 11:40 A.M., Resident #91 was interviewed by the Administrator. After the interview, a sitter was assigned to be with Resident #91. The police department was notified at 12:20 P.M. and arrived at the facility immediately. At 12:45 P.M., the Assistant Director of Nursing Service (ADNS) notified the Medical Director, the laboratory at 12:50 P.M., the resident's sister at 1:00 P.M., and the Attending Physician at 1:10 P.M., of the allegation regarding sexual abuse. At 2:20 P.M., the police detective exited the facility. At 6:30 P.M., the resident's psychiatrist interviewed the resident. At 8:30 P.M., body audits and interviews with other residents were completed. Sixteen residents were either assessed or interviewed regarding any concerns with any LT's. Resident #13, upon return to the facility from [MEDICAL TREATMENT], refused to be assessed. Review of a progress note dated 05/10/13, from physician (MD) #15 revealed that since the sexual abuse, Resident #91 had been anxious and depressed, had been isolating herself and had worsening depression. MD #15 ordered a new antidepressant, [MEDICATION NAME], to start at that time. Resident #91 had been receiving Klonopin 0.5 mg as needed for increased anxiety. Review of the [MEDICAL CONDITION] Medication Use form, dated 05/14/13, revealed there was an overall status change in Resident #91, defined as a decline in behavior, noted to be uncontrolled depression. Review of the Social Service note, dated 05/15/13 at 11:48 A.M., revealed Resident #91 was having anxiety attacks, followed by smaller scale attacks. Review of Mental Health Progress Notes, dated 05/15/13, revealed Resident #91 had just recently returned from an inpatient hospital on [DATE]. The resident was admitted to the hospital due to chest pain, alleged sexual assault by a medical person, and that she "continues to exhibit depressive and anxious symptoms, as well as panic (related to) recent allegations". Review of Mental Health Progress Notes, dated 05/21/13, revealed Resident #91 "continues to focus on her allegations of sexual assault and continues to exhibit depressive and anxious symptoms". Review of Mental Health Progress Notes, dated 05/28/13, revealed Resident #91 "continues to exhibit depressive and anxious symptoms, as well as panic about the assault". Review of a letter from Resident #91's clinical psychologist, dated 06/04/13, revealed Resident #91 was "again traumatized and unable to rationally and reasonably give consent to the approach by (LT #1)". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 07/25/13 and 07/26/13, medical records were reviewed for the remaining 11 alert and oriented residents (Residents #67, #75, #76, #92, #94, #95, #96, #97, #99, #100 and #101) and the four non-interviewable residents (Resident #80, #89, #93 and #98). No concerns were identified. On 07/31/13 at 2:35 P.M., interview with Physical Therapy Aide (PTA) #101 who worked dayshift, verified the facility had presented an in-service recently (couldn't remember date) regarding abuse and answered interview questions appropriately. On 07/31/13 from 2:40 P.M. until 4:00 P.M., interviews were conducted with direct care staff. Four of seven licensed staff, LPN's #201 and #202 and RN's (RN #203 and #204, who worked dayshift on 05/08/13) were knowledgeable regarding the facility's abuse policy and verified that every staff member had been in-serviced following the incident of sexual abuse. The staff verified that not only were male LTs not to service the facility but any male person from an outside agency was to have a staff member present. Interviews with STNA's #205 and #206, who worked dayshift on 05/08/13, verified they were recently in-serviced regarding abuse. Both STNA's were knowledgeable in regard to what to do if they suspected abuse. STNA #205 stated she knew Resident #91 had 1:1 care. (She was unable to recall exact days). STNA #205 stated during the in-service they were told to not let male outside medical people do anything with a female resident without observation. Review of the facility policy, Patient Protection: Abuse, Neglect and Misappropriation Prevention (dated November 2011), noted that "it is essential that center practices help prevent abuse, (and) possible reoccurrence". The policy further stated that if the alleged abuser is not an employee, "Measures are taken to provide a safe, secure environment for the patient" and actions to be taken may include visitor restrictions.