Every finding on record at Westmoreland Place

Based on facility staffing schedules and staff interview, this facility failed to ensure the facility had Registered Nurse (RN) coverage for eight consecutive hours for four days out of the last two months. This had the potential to affect all 84 residents currently residing at this facility. Findings include:Review of the daily staffing posted numbers revealed on 05/10/2026, 05/17/2026, 06/27/2026, and 06/28/2026 the facility did not have a Registered Nurse scheduled for the day shift or night shift. Interview 07/20/2026 at 12:55 P.M. with the Director of Nursing (DON) confirmed the facility did not have the required RN coverage on 05/10/2026, 05/17/2026, and 06/27/2026, and 06/28/2026 as required. The DON confirmed the facility did use staffing agencies for fill open shifts including for RN coverage, but a staffing agency had not been used for the above dates.

Based on observation, interview and facility policy review, the facility failed to ensure food was stored appropriately. This had the potential to affect all residents. The facility census was 84.Findings include: Observation and interview on 07/13/2026 at 8:54 A.M. to 9:30 A.M. with the Dietary Manager (DM) #301 in the kitchen reveaeld all the floors throughout the entire kitchen area were dirty, the freezer had a half of box of cookies opened and undated on the shelf and there was one bag of chicken opened and undated on the shelf. Observation of the refrigerator revealed 13 rotten cucumbers on a tray uncovered and ready for use. The DM #301 confirmed the freezer had a half a box of cookies opened and undated on the shelf and one bag of chicken opened and undated on the shelf. The DM #301 confirmed the refrigerator had 13 rotten cucumbers on a tray uncovered and ready for use. The DM #301 further confirmed the floors are dirty in the entire kitchen area. Review of the policy titled, Food Receiving and Storage, dated 11/2022, revealed foods shall be received and stored in a manner that complies with safe food handling practices. Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. All foods in the refrigerator or freezer are covered, labeled and dated.

Based on observation, interview and policy review, the facility failed to ensure the kitchen was free from flies. This had the potential to affect all residents. The facility census was 84.Findings include:Observation and interview on 07/13/2026 at 8:54 A.M. to 9:30 A.M. with the Dietary Manager (DM) #301 revealed there were many flies in the kitchen and the air conditioning unit in the kitchen is in the window with a small opening to the outside. The DM #301 confirmed many flies throughout the entire kitchen area, including storage and preparation areas.Interview on 07/14/26 at 10:54 A.M. with Dietician #412 stated flies are bad, observed multiple flies on the preparation table area during tray preparation for residents meal.Interview on 07/14/26 at 11:05 A.M. with [NAME] #200 while preparing a tray the [NAME] #200 swatted a fly away and stated the flies are a problem in the kitchen.Interview on 07/14/26 at 11:53 A.M. with the Dietician #412 stated the flies in the kitchen are an infestation.Interview on 07/15/26 at 8:46 A.M. with the Maintenance Director (MD) #226 revealed they were unaware of the opening where the air conditioning unit is in the window and flies are getting in.Review of the policy titled, Food Receiving and Storage, dated 11/2022 revealed foods shall be received and stored in a manner that complies with safe handling practices. Review of the policy titled, Pest Control, undated revealed the facility shall maintain an effective, ongoing pest control program to ensure the nursing home environment remains free from insects, rodents, and other pests in order to protect the health, safety, and well-being of residents, staff and visitors. The program shall include routine monitoring, inspection, and corrective actions to ensure the environment remains pest free. Cracks, gaps and penetrations shall be sealed as identified through routine inspection.

Based on interview and staff record review, the facility failed to ensure the required annual training was completed for three Certified Nurse Aides (CNA) (#242, #221, #413). Further, the facility failed to ensure the additional training for the care of the cognitively impaired was completed for three CNA's (#239, #414, #277). This had the potential to affect all residents. The facility census was 84.Findings include:Review of the staff record for CNA #242 revealed a hire date of 01/30/13 and no documentation of the annual training for CNA #242 was completed. Review of the staff record for CNA #221 revealed a hire date of 05/24/24 and no documentation of the annual training for CNA #241 was completed. Review of the staff record for CNA #413 revealed a hire date of 08/25/23 and no documentation of the annual training for CNA #413 was completed. Review of the staff record for CNA #239 revealed a hire date of 10/31/25 and no documentation of the training for the care of the cognitively impaired for CNA #239 was completed. Review of the staff record for CNA #414 revealed a hire date of 04/24/26 and no documentation of the training for the care of the cognitively impaired for CNA #414 was completed. Review of the staff record for CNA #277 revealed a hire date of 08/20/25 and no documentation of the training for the care of the cognitively impaired for CNA #277 was completed. Interview on 07/20/26 at 2:45 P.M. with the Administrator verified there is no documented annual trainings and for CNA's (#242, #221, #413) and no documented training for the care of the cognitively impaired for CNA's (#239, #414, #277).

Based on staff interview and record reviews, the facility failed to ensure care conferences were completed quarterly for Resident #11. This affected one of one resident investigated for care conferences. The facility identified 32 other residents that had not had a care conference completed in the second quarter of 2026 (Residents #2, #6, #7, #9, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #44, and #98). The facility census was 84.Review of Resident #11's medical record revealed the resident was admitted [DATE] with intact cognition and had diagnoses that included fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease. Review of Resident #11's most recent care conference notes revealed a care conference was held on 10/13/25 and 01/16/26. Care conference notes for both conferences revealed the resident was not in attendance at the care conference.Review of care conference list received from Administrator revealed Resident #11's next care conference was scheduled for 07/17/26, along with scheduled dates for other residents who did not have a care conference in the second quarter of 2026. Interview on 7/16/26 at 12:46 P.M. with Licensed Social Worker (LSW) #406 confirmed no care conference was completed since 01/16/26 for Resident #11. LSW #406 confirmed that the facility had no social worker for a short time and many second quarter care conferences were not scheduled because of no staff in the social services position. Review of facility policy titled Participation in Care Conferences dated 02/10/25 revealed each long-term, resident will have a care conference with the IDT scheduled quarterly, annually, and with any significant changes.

Based on observation, staff interview, and record review, the facility failed to ensure medications were stored appropriately and that medication carts were free from expired medications. This affected the following 49 residents receiving medications from the three medication carts observed: Residents #3, #4, #6, #7, #8, #10, #11, #12, #14, #16, #19, #23, #25, #28, #29, #30, #31, #32, #33, #35, #37, #38, #39, #40, #41, #44, #45, #48, #50, #54, #55, #57, #59, #60, #61, #62, #63, #64, #67, #68, #69, #70, #71, #72, #75, #84, #85, #88, and #97. Facility also failed to ensure prescription medication was not left at the bedside for Resident #50. This had the potential to affect seven residents (#3, #24, #35, #37, #47, #84, and #88) who the facility identified as cognitively impaired and mobile. Facility census was 84. Findings include: 1.Observation on 07/15/26 at 7:39 A.M. of the first-floor medication cart serving residents in rooms 103 to 112 revealed the following: one unidentified small white round pill laying loosely in the bottom of the medication drawer. Interview at the time of observation with Licensed Practical Nurse (LPN) #203 confirmed the pill was laying loose in the bottom of the drawer. LPN #203 stated they could not identify what kind of pill it was. Observation on 07/15/26 at 8:08 A.M. of the first-floor medication cart serving residents in rooms 113-126 revealed the following: one unidentified round orange pill, one unidentified broken pink pill, one unidentified oblong white pill, one unidentified white round pill, and one unidentified pink and white oblong capsule. Further observation revealed two bottles of Iron 325/65 mg tablets with a best by date of 06/26. Interview at the time of observation with Registered Nurse (RN) #409 confirmed the loose pills in the medication drawers and the two bottles of expired pills. RN #409 confirmed they could not identify the loose pills. RN #409 stated they did not administer the expired Iron tablets to any residents that day. Observation on 07/15/26 at 8:17 A.M. of the second-floor medication cart serving residents in rooms 209A-226 revealed the following: one unidentified oblong white pill loose in drawer and one bottle of Guaifenesin (expectorant ) 400 mg immediate release tablets with an expiration date of 12/2024. Further observation revealed the expired bottle of Guaifenesin was opened and labeled with an opening date of 06/26/26. Interview at the time of observation with LPN #255 confirmed the loose pill in the medication drawer and the expired bottle of medication. LPN #255 confirmed they were unable to identify the loose medication. LPN #255 confirmed they had not administered the expired Guaifenesin to any resident that day. Interview on 07/15/26 at 8:32 A.M. with the Director of Nursing #232 revealed the expectation is nurses should be checking the medication carts daily for expired medications and loose pills and the facility should be doing weekly audits of the medication carts to ensure proper storage of medications. 2.Review of the medical record for Resident #50 revealed an admission date of 04/24/19. Diagnoses included unspecified dementia, anoxic brain injury, ataxia, vascular disease, epilepsy, schizoaffective disorder, Parkinson's disease, unspecified psychosis and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 11. Review of the physician orders from admission through 07/20/26 revealed Resident #50 had no past or current orders for Bacitracin Zinc (topical antibiotic) ointment or Nystatin (antifungal) powder. Observation on 07/13/26 at 11:00 A.M. found a tube of Bacitracin Zinc ointment and a full container of Nystatin powder sitting on residents nightstand in his room. The Bacitracin Zinc ointment had no date and the Nystatin powder stated it was filled on 06/30/26. Interview on 07/13/26 at 11:12 A.M. with Licensed Practical Nurse (LPN) #299 confirmed Resident #50 had Bacitracin Zinc ointment (undated) and Nystatin powder (dated 06/30/26) unsecured and located on the bedside table. The LPN confirmed Resident #50 had no orders for either treatment medication in the electronic medical record. Review of the facility policy titled Medication Labeling and Storage dated 2001, revealed the facility shall store all medications and biologicals in locked compartments and only authorized personnel shall have access to keys. Medications and biologicals shall be stored in the packaging containers in which they were received from the issuing pharmacy and the nursing staff was responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. If medications are discontinued or outdated facility shall contact the dispensing pharmacy for instructions or shall destroy these items. This deficiency represents non-compliance investigated under Complaint Number 2799087.

Based on review of the resident council meeting minutes, residents interviews, staff interviews and review of the facility policy, the facility failed to ensure resident and family concerns were addressed in a timely manner. This affected 10 Resident (#7, #9, #20, #25, #32, #43, #45, #68, #69, and #82). Facility census was 84. Findings include: Review of the Resident council meeting minutes dated 07/24/25 revealed concerns that a resident room was not cleaned except when one specific housekeeping staff person was on the scheduled response with a plan to educate the staff to remind the resident when their room is being cleaned to step out. The residents reported they were not getting enough snacks in the evening and also revealed aides were only giving snacks to certain residents and not everyone with the response to add more snacks to the cart and talk to the dietary manager about snack issues. They voiced concern of staff being on their phones when in the hallway with a plan to educate staff on the cell phone policies.Review of the Resident council meeting minutes dated 08/28/25 revealed concerns related to cooking too much or too little and not providing sauces on meal trays with a plan to cook food for the correct amount of time and to place sauces on trays. The residents reported concerns related to a problem with an aide and requesting she not work on a certain floor, aides being on their phones and sitting in the dining room on their phones and being rude and sleeping during their shift and not answering call lights with a response educate staff. Review of the Resident council meeting minutes dated 09/25/25 revealed a concern the peanut butter and jelly sandwiches do not have enough filling and revealed it was mostly just bread, a response/ plan to educate the staff to add more filling. Review of the Resident council meeting minutes dated 10/23/25 revealed a resident report that night staff treat residents like they were inmates, poor communication at shift changes, residents being left for 45 minutes in the shower, aides taking personal calls in front of residents, not giving medications on time and giving inaccurate medications. The facility responses included educating staff (including agency staff) on customer service, communication, activity of daily living, and the cell phone policy and the facility fired an agency nurse for issues with medication administration. Review of the Resident council meeting minutes dated 11/20/25 revealed a request for air fresheners for resident bathrooms with a response that residents cannot have any chemicals. They reported food was overcooked and wanted some menu changes with response for adjusted cooking times and menu changes to occur. Residents also reported they have to remind agency staff when they did not get all their medications and reports of staff not treating residents with respect with a plan to educate staff on medication pass in the electronic record and on customer service.Review of the Resident council meeting minutes dated 12/18/25 revealed a resident concern related to not getting medications as ordered with response to educate staff on medication administration. Residents also reported staff were grumpy and loud with a plan to educate staff on customer service. Review of the Resident council meeting minutes dated 01/22/26 revealed concerns that laundry was slow to be returned with response the facility no longer had a second shift laundry staff member. They also voiced two residents requested copies of their medical records with the response one of the two residents were provided a release of information form. It did not include any mention about the second resident's request. They voiced concern of staff (nurses and aides) were vaping in the building with a response to educate staff about vapes and instruction to residents to tell manager specific names of nursing aides they can be addressed separately. Review of the Resident council meeting minutes dated 02/26/26 revealed concerns that a resident room was not cleaned on the weekend with response they attempted twice and the resident was speaking with his counselor. The residents requested seasoning on their food with the response to put salt and pepper packs on trays. They voiced concern of a specific staff member vaping at the nursing station with a response to speak with the specific staff member and educate her about facility policy. The residents brought up concern regarding having enough staffing and having two aides at night but only one during the day with a response that staffing was based on facility need. Review of the Resident council meeting minutes dated 03/26/26 revealed concerns that residents were not getting salt and pepper with a plan to have staff put the seasoning on meal trays. They voiced concern of a specific staff member being rude to residents and staff asked for an accurate name as they had no staff by the name provided. They reported concerns related to a resident requesting medication at 2:00 P.M. and the nurse said she was busy and was on her phone. The facility responded, stating staff can administer medications from 1:00 P.M. to 3:00 P.M. to meet the guidelines and informed him the staff may use phones for work-related reasons or may have been on break. The residents reported staff (aides) have been on their phones and not answering call lights with a response for staff to be educated about phones cane call lights. Review of the Resident council meeting minutes dated 04/23/26 revealed concerns from the previous meeting were not resolved, including residents not getting condiments with meals with a plan to educate the staff again. They discussed the peanut butter, and jelly sandwiches had no peanut butter and jelly with a plan to instruct staff to add more filling. Residents also requested different items on the snack cart and were instructed they would try when the budget allowed. The residents reported they were seeing staff vaping in the building with a plan to remind staff to vape outside in designated smoking areas. Review of the Resident council meeting minutes dated 06/25/26 revealed concerns that a resident room was not cleaned and the resident was having to empty his own trash with a response for the housekeeping manager to check the room after it is cleaned to make sure it was done.Interview on 07/15/26 at 11:04 A.M. with the Administrator revealed the facility responses are documented on the resident council meeting minutes and confirmed she was not aware of any additional documentation or evidence of follow up including training sign in sheets or audits. The meeting minutes were reviewed and the Administrator confirmed they lacked detail of follow up to address the concerns. She acknowledged residents requesting air fresheners and were told no as residents could not have access to chemicals, but confirmed the facility had no documentation asking why they wanted air fresheners or looking into a cleanliness issue. She also confirmed an incidence of two residents requesting access to their medical records and it was documented, only one was given information. She confirmed facility should address concerns, so they are not brought up month after month. Interview and observation on 07/15/26 at 12:30 P.M. with Residents #25, #32 and #69 revealed concerns related to the facility not addressing resident concerns. They reported they bring up some of the same items over and over again and reported the facility management does not do enough to fix issues and reported it felt they were being brushed off. They confirmed issues related to staffing, smoking, cell phone use, snacks and peanut butter and jelly sandwiches, medication administration and housekeeping issues are regular issues that remain ongoing. Resident #69 had [NAME] a Peanut butter and jelly sandwich to the meeting and jelly was only seen in one corner of the sandwich and had barely any peanut butter on it. Interview on 07/15/26 at 2:00 P.M. with Activity Director #270 confirmed the previous administrator did not encourage documentation and follow up of resident concerns and did not want her to document concerns on the meeting minutes. She confirmed facility had a lack of follow up and revealed she provides an update to each department head of the issues brought up and they can provide her with information on their follow up. She confirmed the same items are repeated over and over again including concerns related to staff treatment of residents (being rude), concerns related to the amount of staff, staff vaping inside the facility, staff being on their phones, food being cooked properly, snacks not being provided, condiments and seasoning not being provided, and the peanut butter and jelly sandwiches having minimal filling. The activity director acknowledged they stated education for just about every complaint and also acknowledged if staff were educated and it was still happening; they should be trying other interventions including auditing and checking on staff and residents frequently. The activity director confirmed facility did not have a process to fix resident concerns. Review of the facility policy titled, Resident Concerns and Grievance Management Policy dated 09/30/25 revealed the facility shall establish a process to identify, document, investigate, track and resolve resident concerns and grievances and concerns. The process should include documentation of the concern, assigning follow-up, and documentation of resolution and maintain records for survey readiness. This deficiency represents non-compliance investigated under Complaint Number 2983546 and 2709514.

Based on observations and interview, the facility failed to ensure a homelike environment for four residents (#13, #35, #47, and #81) of six reviewed for environment. Facility census was 84. Findings include : 1. Interview and observation on 07/09/26 at 10:18 A.M. with Housekeeping Supervisor #266 confirmed the air conditioner (ac) window unit for Resident #35 had holes to the outside surrounding the unit and were not secured except with duct tape. She also confirmed their was a board covering the rest of the window that was also duct taped to the window sill. She confirmed it was not homelike to have a board and window ac unit duct taped to the wall. Observation on 07/09/26 at 10:22 A.M. revealed Resident #81 was sleeping in her room. Her window unit was secured with a board and duct tape. Observation on 07/09/26 at 10:27 A.M. revealed Resident #47's window ac unit was held in with duct tape. Interview and observation 07/09/26 at 12:05 P.M. with Maintenance Director #226 confirmed the facility had window ac units in place that were not fully sealed. He confirmed the board placed on the other part of the window was a piece of vinyl and confirmed they were held by duct tape or masking tape to hold it in place and confirmed you could see outside. He acknowledged this was not homelike to have window units held by duct tape with holes to the outside. Interview on 07/09/26 at 4:00 P.M. with Regional Support #404 acknowledged ac units installed with duct tape with unsealed areas was not a homelike environment. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included anxiety, raynaud's syndrome, thoracic aortic aneurysm, major depressive disorder and alzheimer's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had severely impaired cognition, and partial assistance with toileting and bathing. Interview and observation on 07/13/26 at 10:49 A.M. in Resident #13's room with Resident #13 revealed a large area approximately three foot by three foot next to Resident #13's bed had paint chipped off from the head of the bed to the foot of the bed. Resident #13 stated the area that has paint chipped off looks nasty and bothers her. Interview on 07/13/2026 10:50 AM with Licensed Practical Nurse (LPN) #220 confirmed the large area, approximately three foot by three foot next to Resident #13's bed had paint chipped off from the head of the bed to the foot of the bed. Interview on 07/15/26 at 7:57 A.M. with the Administrator confirmed the area with chipped paint in Resident #13's room. This deficiency represents non-compliance investigated under Complaint Number 3073628, 2686126 and 2983546.

Based on observations, interview, and review of the medical record, the facility failed to ensure residents were properly assessed and interventions were put in place when residents were moved from the secured memory care unit to an unsecured unit. This affected three Resident (#35, #47 and #81) of three reviewed for elopement risk. Facility census was 84.Findings include1. Review of the medical record for Resident #47 revealed an admission date of 06/20/26. Diagnoses included unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease.Review of the Physician order dated 06/20/26 to 07/04/26 revealed an order for the resident to reside on the secure unit.Review of the dementia assessment dated [DATE] revealed resident was disoriented to time and place with her immediate memory intact. The resident was unable to recall most events, receptiveness and had great resistance to care giving.Review of facility progress notes for Resident #47 from 06/24/26 through 07/10/26 reveaeld a note dated 06/24/26 at 8:49 P.M. that documented the resident used a wheelchair. Review of progress note dated 07/01/26 at 4:19 P.M. revealed resident's family was contacted and informed her of the resident's room move due to facility need. Review of note dated 07/04/26 revealed the door alarm was activated when Resident #47 attempted to exit through the secured door. The resident appeared exit seeking and required staff redirection away from the exit. 15-minute checks were initiated. The progress note dated 07/06/26 at 3:17 P.M.from an Interdisciplinary team (IDT) fall note revealed resident was ambulatory with assist. Review of the progress note dated 07/06/26 at 5:26 P.M. revealed resident was attempting to get on the elevator. The nurse was able to redirect without incident and the on call nurse and nurse practitioner were made aware. Another note dated 07/06/26 at 5:58 P.M.revealed facility staff located resident on the floor next to her wheelchair by the doorway on her buttock with her back against the door. Notes dated 07/09/26 and 07/10/26 stated resident was monitored on 15 minute checks. Review of two progress notes dated 07/10/26, one entered as a late entry at 5:48 P.M. and a second entered at 9:30 P.M. revealed resident had an elopement assessment and scored a one 1 solely on a documented history of exit seeking behaviors. Resident was assessed and was no longer demonstrating exit seeking behaviors.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively impaired, with a Brief Interview of Mental statud (BIMS) score of 4. Resident was also noted to be dependent with transfers and mobility and used a manual wheelchair.Review of the elopement assessment dated [DATE] revealed resident scored a one which meant she was at risk. The assessment indicated resident verbalized desire to go home or stayed near an exit door and had been recently admitted or re-admitted and was not accepting of the situation. Resident had no elopement assessments in the medical record after 07/01/26.Review of the care plan on 07/15/26 revealed no mention of resident's history of residing on a locked, secured unit and then being moved to an unsecured unit. There also was no entry related to wandering or exit seeking behaviors.Interview on 07/09/26 at 10:26 A.M. with Registered Nurse #292 (RN) and Licensed Practical Nurse #413 (LPN) revealed Resident #47 wandered. They reported concern related to her being taken off a locked memory care unit to a non-locked area with no new interventions. They reported she had pressed on doors until they alarmed and had attempted to go down the elevator. They confirmed she was unable to state her intent and was unable to explain what she was doing or where she was going.Interview on 07/09/26 at 1:20 P.M. with the Director of Nursing (DON) revealed facility completed elopement assessments on residents before they were removed from the locked memory care unit and placed on the unsecured unit. The medical record and assessments were reviewed and she was unable to explain without a change in the risk assessments, why Resident #47 was moved to an unsecured unit. The DON revealed she was unaware Resident #47 was still assessed to be at risk for elopement and was unaware of any interventions put in place when residents moved on 07/02/26 to ensure safety.Interview on 07/09/26 at 2:32 P.M. with Physician #500 revealed he was aware of the need to move residents. He revealed he would expect the staff to properly assess all the residents and determine needs for a safe transfer and ensure proper interventions were in place to ensure the safety of all the residents as they all have memory deficits. He confirmed he was not aware of residents on the non-locked areas having wandering behaviors.Interview on 07/09/26 at 2:59 P.M. with the DON confirmed Resident #47 did not exit seek when she was on the secured unit due to being in a wheelchair she would be unable to wander and move. The DON reported she was unaware of the notes and staff statements that the residents had been exit seeking and wandering. She also confirmed facility had no documentation of updated assessments and decision-making to move a resident off the secured memory care unit to an unsecured area and what interventions were needed.Interview on 07/09/26 at 4:00 P.M. with Regional Support #404 revealed the team assessed and discussed each resident and confirmed none of the updated information was documented in the medical record including discussions and interventions. She confirmed Resident #47 was in a tilt in space chair that would limit some mobility but acknowledged notes stating she had wandering attempts. She also confirmed a resident who used a wheelchair was not a disqualifier for needing a secured unit or interventions in place for safety from wandering.Interview attempted on 07/13/26 at 2:10 P.M. with Resident #47 revealed resident was unable to respond to any questions and was providing non sensical answers, even to simple yes and no questions.Observation on 07/14/26 at 9:59 A.M. revealed Resident #47 was actively wandering. Observation and interview on 07/15/26 from 9:04 A.M. to 9:30 A.M. revealed Resident #47 was being wheeled in her wheelchair down the hall by Certified Nursing Aide (CNA) #403. CNA reported the resident had wandered and was pushing on the exit doors. She reported frustration with residents being confused an unsecured with no new interventions to ensure their safety.Observation on 07/16/26 at 9:00 A.M. revealed Resident #47 was in her wheelchair and was moving around the unit without staff assistance. Resident was able to move her wheelchair by self propelling by her feet. The resident was going between the exit door and the dining area and was observed to push on the exit door causing the alarm to activate.2. Review of the medical record for Resident #35 revealed an admission date of 06/09/25. Diagnoses included polyneuropathy, respiratory failure, hypoxia, Alzheimer's, dementia with behaviors, atrial fibrillation and heart disease.Review of the elopement assessment dated [DATE] revealed resident scored a four, which meant he was at risk. The assessment indicated resident had a history of elopement or attempted elopement, had a history of attempting to leave without informing staff, verbalized desire to go home or stayed near an exit door, had wandering behavior that was aimless and non-goal directed.Review of progress notes dated 05/31/26 through 07/09/26 revealed a note dated 05/31/26 resident was wheelchair bound at baseline. Provider note dated 06/02/26 at 3:37 P.M. revealed the resident had Alzheimer's disease and wandering and exit seeking behavior. Review of the progress note on 07/09/26 revealed an elopement assessment note that stated in last 90 days resident had exhibited none of these behaviors and had not attempted to exit the facility or verbalize a desire to go home. The interdisciplinary team discussed residents risk of elopement and found resident to be at no risk based in current actions and behaviors.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired, with a BIMS of 00. Resident was also noted to require substantial maximum assist for mobility.Review of the behavior assessment dated [DATE] revealed resident had poor safety awareness and wandering and would benefit from a behavior unit.Review of the dementia assessment dated [DATE] revealed resident was unable to recall most recent events, had purposeful wandering, sleep disturbances and was unable to complete two-step instructions.Review of the elopement assessment dated [DATE] revealed resident scored a zero. The assessment indicated resident had no current or history of wandering or exit seeking behaviors.Review of the elopement assessment dated [DATE] revealed resident scored a zero. The assessment indicated resident had no current or history of wandering or exit seeking behaviors.Review of the care plan on 07/15/26 revealed no mention of the resident's history of being on a locked, secured unit and moving to an unsecured unit nor did the care plan document wandering or exit seeking behaviors.Interview on 07/09/26 at 10:26 A.M. with Registered Nurse #292 (RN) and Licensed Practical Nurse #413 (LPN) revealed Resident #35 wandered. They reported concern related to him being taken off a locked memory care unit to a non-locked area with no new interventions. They reported he had pressed on doors until they alarmed. They confirmed he was unable to state his intent and was unable to explain what he was doing or where he was going.Interview on 07/09/26 at 1:20 P.M. with the Director of Nursing (DON) revealed facility completed elopement assessments on residents before they were removed from the locked memory care unit and placed on the unsecured unit. The medical record and assessments were reviewed and she was unable to explain about the change in the risk assessments from a score of four to a score of zero. The DON revealed she was unaware Resident #35 was still wandering and was unaware of any interventions put in place when residents moved on 07/02/26 to ensure safety.Interview on 07/09/26 at 2:32 P.M. with Physician #500 revealed he was aware of the need to move residents. He revealed he would expect the staff to properly assess all the residents and determine needs for a safe transfer and ensure proper interventions were in place to ensure the safety of all the residents as they all have memory deficits. He confirmed he was not aware of residents on the non-locked areas having wondering behaviors.Interview on 07/09/26 at 2:59 P.M. with the DON reported Resident #35 did not wander and reported she was not aware of staff reports of wandering. She also confirmed facility had no documentation of the decision-making to move a resident off the secured memory care unit to an unsecured area and what interventions were needed.Interview on 07/09/26 at 4:00 P.M. with Regional Support #404 revealed the team assessed and discussed each resident and confirmed none of the updated information was documented in the medical record including discussions and interventions.Interview attempted on 07/13/26 at 2:40 P.M. with Resident #35 revealed resident was unable to respond to any questions and was provided non-sensical answers, even to simple yes and no questions.Observation on 07/14/26 at 10:05 A.M. revealed Resident #35 was actively wandering. Observation on 07/15/26 at 8:40 A.M. revealed Resident #35 was observed pressing on exit door while sitting in his wheelchair. He was seen scooting back and forth from one end of the hall to the other most of the morning.Interview on 07/15/26 at 9:30 A.M. with Certified Nursing Aide (CNA) #403 confirmed Resident #35 was wandering pushing on the exit doors. She reported frustration with residents being confused and on an unsecured with no new interventions to keep them safe. She confirmed the facility had only closed a sliding glass door that was unlocked as an intervention.3. Review of the medical record for Resident #81 revealed an admission date of 06/20/25. Diagnoses included unspecified dementia without behaviors, heart disease, kidney disease and weakness.Review of the physician order dated 06/21/25 to 07/04/26 revealed an order for the resident to reside on the secure unit.Review progress notes dated 06/18/26 from the Nurse Practitioner revealed resident was an elopement risk. The note stated she was mobile with use of her walker. Note dated 07/01/26 revealed the family was contacted to inform them of a room move due to facility needs.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively impaired, the BIMS was not completed as resident was rarely if ever understood.Review of the behavior assessment dated [DATE] revealed resident had poor safety awareness and wandering behavior.Review of the dementia assessment dated [DATE] revealed resident was unable to recall most events, had purposeless wandering and was unable to complete two step instructions. The assessment also stated resident was only able to speak one word and was unable to feed herself or complete simple tasks. The assessment revealed resident scored a seven for very severe cognitive decline and late dementia.Review of the elopement assessment dated [DATE] revealed resident scored a one which meant she was at risk. The assessment indicated resident verbalized desire to go home or stayed near an exit door and wandered. It stated the resident wandered aimlessly or non-goal directed.Observations on 07/09/26 at 10:45 A.M. revealed resident remained in her room and was not observed outside of her room.Interview on 07/09/26 at 1:20 P.M. with the Director of Nursing (DON) revealed facility completed elopement assessments on residents before they were removed from the locked memory care unit and placed on the unsecured unit. The medical record and assessments were reviewed and she was unable to explain without a change in the risk assessments, why Resident #81 was moved to an unsecured unit. The DON revealed she was unaware Resident #81 was still assessed to be at risk for elopement and was unaware of any interventions put in place when residents moved to an unsecured area on 07/02/26 to ensure safety.Interview on 07/09/26 at 2:32 P.M. with Physician #500 revealed he was aware of the need to move residents. He revealed he would expect the staff to properly assess all the residents and determine needs for a safe transfer and ensure proper interventions were in place to ensure the safety of all the residents as they all have memory deficits. He confirmed he was not aware of residents on the non-locked areas having wondering behaviors.Interview on 07/09/26 at 2:59 P.M. with the DON confirmed Resident #81 did not exit seek and was dependent with activities of daily living. She also acknowledged notes in the record stating she was a one-person assist and had been wandering. The DON reported she was unaware of these notes and documentation in the medical record. She also confirmed facility had no documentation of updated assessments or decision-making to move a resident off the secured memory care unit to an unsecured area and what interventions were needed.Interview on 07/09/26 at 4:00 P.M. with Regional Support #404 revealed the team assessed and discussed each resident and confirmed none of the updated information was documented in the medical record including discussions and interventions.Observations on 07/13/26 at 2:10 P.M. and 07/14/26 at 11:00 A.M. revealed resident remained in her room and was not observed outside of her room. This deficiency represents non-compliance investigated under Complaint Number 3073628.

Based on staff interview and record review, the facility failed to complete an advance directive form in a timely manner for Resident #11. This affected one of one resident investigated for advanced directives. The facility census was 84.Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE] with intact cognition and had diagnoses that included fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease. Review of Resident #11's physicians orders revealed the following active order revised on 01/12/26: Advanced directive Do not Resuscitate Comfort Care Assist (DNRCCA). Review of Resident #11's most recent care plan revealed the following focus area: Resident's code status is DNRCCA initiated 10/16/25. Review of Resident #11's DNR order form revealed the following sections completed: resident information, required signature of physician, Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA), and name of supervising physician or collaborating physician. Review of the DNR order form revealed no date of physician signature and no box checked for which DNR type was ordered. Interview on 07/15/26 at 12:58 P.M. with the Administrator confirmed the DNR order form for Resident #11 was incomplete. The Administrator confirmed the DNR order form should be dated and one of the DNR choice boxes (DNRCC or DNRCCA) should be checked on the form. Review of the facility policy titled Advanced Directives revised September 2022 stated the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance withs state law and facility policy.

Based on record review, interview, and policy review, the facility failed to ensure a resident was free from physical restraints. This affected one resident (#94) of three residents reviewed for restraints. The facility census was 84.Findings include:Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] and discharged on 06/05/26. Diagnoses included alzheimer's disease with late onset, mood disorder, disorientation, and unspecified dementia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had severely impaired cognition, and required substantial assistance with bathing and toileting the assessment coded bed rails and alrams were utilized in the care of Resident #94.Review of the provider orders and care plan for Resident #94 revealed no orders or interventions for side rails.Interview on 07/15/26 at 8:09 A.M. with Certified Nursing Assistant (CNA) #242 revealed side rails were used for Resident #94 on a daily basis. Interview on 07/15/26 at 8:23 A.M. with CNA #244 revealed side rails were used for Resident #94 on a daily basis. Interview on 07/16/26 at 8:17 A.M. with Assistant Director of Nursing (ADON) #302 revealed she was not sure if side rails were used for Resident #94 but would think they would use side rails for Resident #94.Interview on 07/20/26 at 9:46 A.M. with the Director of Nursing (DON) confirmed siderails were not documented as utilized in Resident #94's medical record. Review of the policy titled, Physical Restraint Use, undated, revealed Residents have the right to be free from physical restraints. This deficiency represents non-compliance investigated under Complaint Number 2799087.

Based on observation, staff interview, and record review, the facility failed to ensure a medication error rate of less than five percent. This affected two of six residents observed for medication administration (Resident #62 and #72). The facility census was 84.Findings include:Observation of medication pass at the facility on 07/15/26 and 07/16/26 reveaeld 30 opportunities were observed with two errors being made by facility staff. The total medication error rate was 6.67 %.1.Review of Resident #62's medical record revealed the resident was admitted on [DATE] and had diagnoses that included chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, and acute kidney failure. Review of the medical record revealed intact cognition. Observation on 07/16/26 at 8:09 A.M with Registered Nurse (RN) #408 revealed the nurse preparing Resident #62's Fluticasone Salmeterol Aerosol Inhalation (corticosteroid )Inhaler for administration. Observation revealed RN #408 hand the inhaler to Resident #62. Resident #62 proceeded to inhale two puffs of the inhaler and then give the inhaler back to RN #408. Interview with RN #408 at the time of the observation confirmed the physician's order for the inhaler was for one puff inhaled orally. RN #408 stated that she did not notice that Resident #62 took two puffs of the inhaler during the medication administration. Review of Resident #62's physician's orders revealed the following active order with a start date of 04/03/26: Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 500-50 MCG/ACT (Fluticasone-Salmeterol) 1 puff inhale orally every 12 hours for COPD. Review of the policy titled Administering Medications revised April 2019 revealed medications are administered in accordance with prescriber's orders, including any required time frame. 2.Review of Resident #72's medical record revealed the resident was admitted [DATE] and had diagnoses that included Type II Diabetes Mellitus, respiratory failure, and chronic kidney disease. Review of the medical record revealed intact cognition. Observation on 07/15/26 at 7:32 A.M. with Licensed Practical Nurse (LPN) #203 revealed the LPN put one 20 mg Omeprazole (proton pump inhibitor) Oral Capsule Delayed Release in a medicine cup with multiple other prescribed pills for Resident #72. The LPN preceded to crush all medications together and put the crushed mixture into a small cup of applesauce. The LPN then administered all crushed medications to resident. Interview with LPN #203 at time of medication administration confirmed that delayed release omeprazole was crushed and administered to the resident. LPN #203 stated that the resident took their medication crushed every day and tolerated the crushed medications well. Review of Resident #72's physician's orders revealed the following active order with a start dated of 11/03/24: Omeprazole Oral Capsule Delayed Release 20 MG. Review of Specialty RX (pharmcay) Do Not Crush Drug Guide (undated) revealed the drugs listed should not be chewed or crushed; they should be swallowed whole. Further review of the drug guide revealed Omeprazole cap/tab was on the do not crush list. Review of facility policy titled Crushing Medications revised 04/2018 revealed the nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long acting or enteric coated medications.) This deficiency represents non-compliance investigated under Complaint Number 2799087.

Based on record review, and interview, the facility failed to ensure the resident representative was notified of a fall. This affected one resident (#93) of three residents reviewed for accidents. The facility census was 84.Findings include:Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] and discharged on 01/30/26. Diagnoses included altered mental status, repeated falls, chronic obstructive pulmonary disease, and dementia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had moderately impaired cognition, and substantial assistance with toileting and bathing.Review of the progress note for Resident #93 dated 01/23/2026 at 2:10 P.M. revealed the nurse walked down hallway and patient was crouched down towards the floor, nurse went into patient's room and assisted patient to one knee. Patient was exhibiting agitation and confusion, nurse got other nurse to come assist in transferring patient back into bed. Patient was placed into bed, hospice was notified, fall mats were placed on both sides of patient's bed, bed was put in lowest position and checks on patient are being made more frequently. The Director of Nursing (DON) was notified, will continue to monitor.Interview on 07/16/26 at 8:17 A.M. with the Assistant Director of Nursing (ADON) #302 confirmed the resident representative for Resident #93 was not notified of the Resident #93 fall on 01/23/26.Interview on 07/20/26 at 9:46 A.M. with the Director of Nursing (DON) confirmed there was no documentation of the resident representative being notified of a fall on 01/23/26 for Resident #93.This deficiency represents non-compliance investigated under Complaint Number 2737390 and 2709514.

Based on observations, interview, review of the medical record, and review of the facility policy, facility failed to ensure timely communication and care for a resident receiving hospice services. This affected one resident (#35) of one reviewed for hospice services. Facility census was 84.Findings include:Review of the medical record for Resident #35 revealed an admission date of 06/09/25. Diagnoses included polyneuropathy, respiratory failure, hypoxia, Alzheimer's, dementia with behaviors, atrial fibrillation and heart disease.Review of the care plan dated 02/20/26 revealed resident was at risk of developing clinically unavoidable declines secondary to having a terminal prognosis of Alzheimer's disease for which the resident received hospice services. The interventions included follow the hospice plan of care and notify hospice for any changes in condition or significant declines and work cooperatively with the hospice team.Review of the Physician order dated 06/05/26 revealed an order a right arm and hand X-ray including humerous, forearm and hand for pain and decreased mobility.Review facility progress notes from 05/31/26 through 06/07/26 revealed a note dated 05/31/26 revealed the resident was found by staff on the floor in his room and sustained an injury of bleeding to the right elbow and a skin tear to the right hand finger. Progress note dated 06/01/26 revealed the resident had a bruise/hematoma and skin tear to the right elbow and bruising to the back of the hand. Note dated 06/01/26 revealed hospice and family were notified of the fall. Progress note dated 06/02/26 revealed resident had bruising to the right hand. Review of the progress note dated 06/02/26 revealed Resident #35's daughter voiced concern about resident's right hand which was injured during the fall. The note stated resident had significant bruising and edema and the resident was unable to follow commands for an assessment due to a Brief Interview of Mental Status (BIMS) of 00. The residents daughter was requesting an X-ray and had questions about splinting his hand. The nurse reported she would contact hospice regarding her concerns. The nurse checked in with hospice and they stated a nurse would be onsite to evaluate and another note after the hospice visit stating no new orders were given by hospice. Note dated 06/03/26 revealed resident had a bruise/hematoma and edema to the right hand. Note dated 06/05/26 revealed the staff spoke with hospice about an X-ray for the right hand. The nurse informed hospice resident was expressing pain by withdrawing from touch, facial grimacing and groaning out in pain. The hospice stated they would call back about doing the X-ray. A second note dated 06/05/26 stated staff were awaiting hospice sending a fax with the new X-ray order. Note dated 06/06/26 and revealed the residents daughter voiced a desire to have an X-ray of the right hand. The daughter was instructed by this nurse to contact hospice directly as they are his primary provider. The family contacted hospice and the X-ray was ordered. Note dated 06/07/26 revealed the X-ray results were obtained and found resident had a complete fracture through the base of the proximal phalanx of the fourth digit on the right hand. Staff also spoke with hospice and they ordered a splint.Review of hospice progress note dated 06/06/26 revealed the hospice nurse came and assessed the resident and an X-ray was ordered for the right upper extremity and identified a fracture of the finger. The note reported the nurse had informed the facility of their responsibilities with care and communication with hospice team after a delay in getting an X-ray for the resident.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired, with a Brief Interview of Mental Status (BIMS) of 00. Resident was also noted to be substantial maximum assist for mobility.Review of the hospice contract dated 01/03/24 revealed hospice was responsible for managing the terminal diagnosis and the facility was responsible for all other care. Interview on 07/15/26 at 9:13 A.M. with Licensed Practical Nurse (LPN) #255 revealed she was working when Resident #35's daughter asked about getting an X-ray of his hand. The LPN #255 reported resident's hand was bruised and swollen. The LPN #255 revealed she reached out to hospice and they were planning to send a nurse out for an assessment. She also reported she was working a few days later when the family asked again about an X-ray and reported she contacted the facility medical provider and was instructed to have family reach out directly to hospice for an X-ray order as they were the primary provider for resident. She also revealed resident was visibly in pain and was administered as needed pain meds. Interview on 07/15/26 4:10 P.M. with Hospice Executive Director ([NAME]) #417 confirmed they were the provider for Resident #35. She also acknowledged from the hospice note on 06/06/26 visit where the hospice nurse educated facility staff about the contract/agreement and about hospice and facility responsibilities. She confirmed facility could have ordered the X-ray and also confirmed if the facility had concerns they need to make those known as hospice can only order the X-ray if they assess and find a reason. Review of facility policy titled Hospice Program, dated 07/2017 revealed responsibilities of hospice included providing medical management of the terminal illness and the responsibilities of the facility included communicating with the hospice provider.

Based on interview, record review and policy review, the facility failed to report an allegation of resident to resident abuse to the state agency. This affected one resident (#56) of three residents reviewed for abuse. The facility census was 84.Findings include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact, and required partial assistance with toileting and bathing. Review of the progress notes for Resident #56 dated 1/7/2026 at 9:05 P.M. revealed this resident was in room and scooted bedside commode next to closet door picked her shoe up and was banging on the closet door with her shoe, when asked what was wrong the resident stated that her roommate has tried to kill her all day and hit and kicked her in the ribs resident was checked for injuries, resident has no red marks or bruises resident was redirected and reorientated, resident still says that her roommate is working for a company that is trying to get to her resident was reinsured that she is safe here and is now resting comfortably in bed.Interview on 07/13/2026 2:15 P.M. with Resident #56 revealed she was beat up in January 2026 by her roommate. Resident #56 stated her roommate was moved out the next day. Interview on 07/20/26 at 9:39 A.M. with the Administrator confirmed an investigation was not completed and not reported to the state agency for Resident #56's allegation of abuse in January 2026.Review of the policy titled, Abuse, dated 01/22/25, revealed possible indicators of abuse include, but are not limited to resident, staff or family report of abuse. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency and to all other required agencies within specific timeframes.

Based on interview, record review and policy review, the facility failed to ensure discharge planning was in place. This affected one resident (#56) of three residents reviewed for discharge. The facility census was 84.Findings include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact, and required partial assistance with toileting and bathing. Review of the Care Conference dated 04/07/26 for Resident #56 revealed the resident was short term with plans for discharge to an Assisted Living.Interview on 07/13/2026 at 2:15 PM with Resident #56 revealed Resident #56 could not recall the last care conference but wants to discharge and the social worker is not assisting with discharge plans. Interview on 07/15/26 at 12:59 P.M. with the Interim Social Service Director (SSD) #406 revealed there have been no updates or follow up to Resident #56's discharge plan since Resident #56's care conference held on 04/07/26 due to the previous Social Worker stopped working at the facility. Review of the policy titled, Discharge Planning, dated 07/28/25, revealed this facility is committed to ensuring that all resident discharges are conducted in a safe, person-centered, and compliant manner in accordance with CMS regulations. Discharges will be planned collaboratively with the resident, their representative, and the interdisciplinary team, with a focus on continuity of care, resident rights, and regulatory compliance. Update goals and services based on resident progress and needs.

Based on medical record review, staff interview and facility policy review, this facility failed to notify the ombudsman of resident discharge. This affected two residents (#2 and #92) of the three residents reviewed for discharge process. The facility census was 84. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 04/03/2026 and a discharge date of 04/22/2026. Diagnosis included generalized anxiety, Thoracic (T) T11-T12 wedge compression fracture, and major depressive disorder. Review of nursing progress notes dated 04/15/2026 revealed Resident #2 was admitted to a local hospital and was set to discharge to another skilled nursing facility to be closer to family. Interview on 07/16/2026 at 10:39 A.M. with the Administrator confirmed the Ombudsman had not been notified of Resident #2's discharge from the facility as required. 2.Review of the medical record for Resident #92 revealed an admission date of 04/30/2026 and a discharge date of 05/04/2026. Diagnosis included dementia, emphysema, and atrial fibrillation. Review of a nursing progress note dated 05/04/2026 revealed Resident #92 was discharging home from the facility with family. Interview on 07/16/2026 at 10:39 A.M. with the Administrator confirmed the Ombudsman had not been notified of Resident #2's discharge from the facility as required. Review of facility provided documented titled Notification to Ombudsman of Resident Discharge, revised 07/23/2025 revealed that Nursing facilities are requires to notify the Office of the State Long-Term Care Ombudsman (SLTCO) of resident discharge. To complete the notification, the Ombudsman request facilities submit this completed form along with a copy of discharge notice to SLTCO.

Based on medical record review, staff interview, review of residents Pre-admission Screening and Resident Review (PASARR) assessment and facility policy review, this facility failed to ensure the appropriate, State-designated authority was notified of an individuals newly identified or diagnosed intellectual disability or mental disorder. This affected two residents (#4 and #7) of the three residents reviewed for appropriate PASARR assessments. The facility census was 84. Findings include: Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnoses that included generalized anxiety disorder, depression, and bipolar disorder. Review of physician's orders revealed the following active orders: Mirtazapine (antidepressant) Oral Tablet 7.5 MG with a start date of 01/30/26 and Duloxetine HCL(antidepressant) Oral Capsule Delayed Release Sprinkle 30 MG with a start date of 01/31/26. Review of Resident #4's Preadmission Screening and Resident Review Identification Screen (PASRR) dated 01/08/26 revealed in Section E: Indications of Serious mental Illness Question 1: Does the individual have a diagnosis of any of the mental disorders below that only Panic or other Severe Anxiety Disorders is checked. No option is checked to reflect Resident #4's diagnosis of depression or bipolar disorder. Further review revealed in Section E Question 6: In the past six months has the individual been prescribed any psychotropic medications, the answer checked is No. Review of the PASRR revealed it does not document the antidepressants prescribed in the resident's orders. Review of the Preadmission Screening and Resident Review Result Notice dated 01/08/26 revealed the resident had no indications of serious mental illness and/or developmental disability. Interview on 07/16/26 at 1:46 P.M. with Licensed Social Worker (LSW) #406 confirmed that if a new mental health diagnosis is added to the resdient's medical record and not reflected on the current PASRR, then a new PASRR should be completed. LSW #406 also confirmed a new PASRR should be completed if the resident has a new prescription for antidepressant medication not reflected on the current PASRR. LSW #406 confirmed Resident #4's PASRR was not completed accurately or updated with changes to her condition. Review of the facility policy titled PASRR dated 04/01/2023 revealed 1, Facilities will use QDM guidelines for PASRR for all new admissions and continued stays at facility.

Based on observations, interview, and review of the medical record, the facility failed to ensure a care plan was in place for wandering for two residents (#35 and #47) and a care plan for toenail was in place for one resident (#81). This affected three Resident (#35, #47 and #81) of 24 reviewed for the initial sample. Facility census was 84.Findings include:1. Review of the medical record for Resident #47 revealed an admission date of 06/20/26. Diagnoses included unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively impaired, with a BIMS of 4. Resident was also noted to be dependent with transfers and mobility and used a manual wheelchair.Review of the physician order dated 06/20/26 to 07/04/26 revealed an order for the resident to reside on the secure unit.Review of the dementia assessment dated [DATE] revealed resident was disoriented to time and place with her immediate memory intact. The resident was unable to recall most events, and had great resistance to care giving.Review progress notes dated 06/24/26 at 8:49 P.M. revealed the resident used a wheelchair. Review of the elopement assessment dated [DATE] revealed resident scored a one which meant she was at risk. The assessment indicated resident verbalized desire to go home or stayed near an exit door and documented the resident been recently admitted or re-admitted and was not accepting of the situation. Resident had no elopement assessments in the medical record after 07/01/26.Review of progress note dated 07/02/26 revealed resident's family was contacted and informed of the resident's room move due to facility need. Review of progress note dated 07/04/26 at 6:30 P.M. revealed the door alarm was activated when Resident #47 attempted to exit through the secured door. The resident appeared exit seeking and required staff redirection away from the exit. 15-minute checks were initiated.Review of the progress note dated 07/06/26 from an Interdisciplinary Team (IDT) fall note revealed resident was ambulatory with assist.Review of the progress note dated 07/06/26 at 5:26 P.M. revealed resident was attempting to get on the elevator. The nurse was able to redirect without incident and the on call nurse and nurse practitioner were made aware. Another note dated 07/06/26 revealed facility staff located resident on the floor next to her wheelchair by the doorway on her buttock with her back against the door.Review of progress notes dated 07/09/26 and 07/10/26 stated resident was monitored on 15 minute checks. Review of two progress notes dated 07/10/26, one entered as a late entry and a second entered at 9:30 P.M. revealed the resident had an elopement assessment and scored a one 1 solely on a documented history of exit seeking behaviors. Resident was assessed and was no longer demonstrating exit seeking behaviors.Review of the care plan on 07/15/26 revealed no mention of resident having a history of residing on a secured locked unit and no entry related to wandering or exit seeking behaviors.Interview on 07/09/26 at 10:26 A.M. with Registered Nurse #292 (RN) and Licensed Practical Nurse #413 (LPN) revealed Resident #47 wandered. They reported concern related to her being taken off a locked memory care unit to a non-locked area with no new interventions. They reported she had pressed on doors until they alarmed and had attempted to go down the elevator. They confirmed she was unable to state her intent and was unable to explain what she was doing or where she was going.Interview attempted on 07/13/26 at 2:10 P.M. with Resident #47 revealed resident was unable to respond to any questions and was providing non sensical answers, even to simple yes and no questions.Observation on 07/14/26 at 9:59 A.M. revealed Resident #47 was actively wandering on the unit. Observation and interview on 07/15/26 from 9:04 A.M. to 9:30 A.M. revealed Resident #47 was being wheeled in her wheelchair down the hall by Certified Nursing Aide (CNA) #403. CNA reported the resident had wandered and was pushing on the exit doors. She reported frustration with residents being confused and unsecured with no new interventions to ensure their safety.Observation on 07/16/26 at 9:00 A.M. revealed Resident #47 was in her wheelchair and was moving around the unit without staff assistance. Resident was able to move her wheelchair by self propelling by her feet. The resident was going between the exit door and the dining area and was observed to push on the exit door causing the alarm to activate.Interview on 07/16/26 at 10:00 A.M. with MDS Coordinator #214 confirmed Resident #47's care plan included no mention of her wandering or exit seeking.2. Review of the medical record for Resident #35 revealed an admission date of 06/09/25. Diagnoses included polyneuropathy, respiratory failure, hypoxia, Alzheimer's, dementia with behaviors, atrial fibrillation and heart disease.Review of the elopement assessment dated [DATE] revealed resident scored a four which meant he was at risk. The assessment indicated resident had a history of elopement or attempted elopement, had a history of attempting to leave without informing staff, verbalized desire to go home or stayed near an exit door, had wandering behavior that was aimless and non-goal directed.Review of progress notes dated 05/31/26 at 11:41 A.M. revealed resident was wheelchair bound at baseline. Review of the provider note dated 06/02/26 at 3:37 P.M. revealed the resident had Alzheimer's disease and wandering and exit seeking behavior.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired, with a BIMS of 00. Resident was also noted to be substantial maximum assist for mobility.Review of the behavior assessment dated [DATE] revealed resident had poor safety awareness and wandering and would benefit from a behavior unit.Review of the dementia assessment dated [DATE] revealed resident was unable to recall most recent events, had purposeful wandering, sleep disturbances and was unable to complete two-step instructions.Review of the elopement assessment dated [DATE] at 1:27 P.M. revealed resident scored a zero. The assessment indicated resident had no current or history of wandering or exit seeking behaviors.Review of the elopement assessment dated [DATE] at 6:03 P.M. revealed resident scored a zero. The assessment indicated resident had no current or history of wandering or exit seeking behaviors. Review of the progress note on 07/09/26 at 6:00P.M. revealed an elopement assessment note that stated in last 90 days resident had exhibited none of these behaviors and had not attempted to exit the facility or verbalize a desire to go home. The interdisciplinary team discussed residents risk of elopement and found resident to be at no risk based in current actions and behaviors.Interview on 07/09/26 at 10:26 A.M. with Registered Nurse #292 (RN) and Licensed Practical Nurse #413 (LPN) revealed Resident #35 wandered.Observation on 07/14/26 at 10:05 A.M. revealed Resident #35 was actively wandering. Review of the care plan on 07/15/26 revealed no mention of resident's history of residing on a secured locked unit and no entry related to wandering or exit seeking behaviors.Observation on 07/15/26 at 8:40 A.M. revealed Resident #35 was observed pressing on exit door while sitting in his wheelchair. He was observed scooting back and forth from one end of the hall to the other most of the morning.Interview on 07/15/26 at 9:30 A.M. with Certified Nursing Aide (CNA) #403 confirmed Resident #35 was wandering pushing on the exit doors. She reported frustration with residents being confused an unsecured with no new interventions to keep them safe. She confirmed the facility had only closed a sliding glass door that was unlocked as an intervention.Interview on 07/16/26 at 12:35 P.M. with the Director of Nursing (DON) and a visiting DON #402 reviewed the care plan and confirmed it did not contain any language related to elopement or wandering.3. Review of the medical record for Resident #81 revealed an admission date of 06/20/25. Diagnoses included unspecified dementia without behaviors, heart disease, kidney disease and weakness.Review of podiatry note dated 06/16/25 revealed the resident's nails were trimmed this date. The note recommended professional treatment and follow-up.Review of the plan of care dated 04/19/26 revealed resident had an activity of daily living self care performance deficit with interventions for finger nail care to check the length and trim and clean on bath day and as necessary. The care plan made no mention of toenails or podiatry services.Review progress notes dated 06/18/26 from the Nurse Practitioner revealed a recommendation for resident to see podiatry for toenail trimming.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively impaired, the BIMS was not completed as resident was rarely if ever understood. The Resident was noted to be dependent with hygiene care.Observation and interview on 07/16/26 at 8:28 A.M. with Certified Nursing Aide (CNA) #290 revealed they removed Resident #81's socks to observe her toes. Residents toenails were over a half an inch past the nail bed. CNA #290 confirmed Resident #81's toenails were very long and reported all facility residents require podiatry to trim toenails. She revealed she was unsure if staff could trim toenails or not.Interview on 0/16/26 at 10:00 A.M. with MDS coordinator #214 confirmed the care plan did not mention toenails or podiatry care.

Based on observation, interview, record review and policy review, the facility failed to ensure one resident (#3), of nine residents the facility identified as needing maximal assistance with eating, receive assistance with eating. Further, the facility failed to ensure toenail care was provided for one resident, (#81) of three residents reviewed for Activities of Daily Living (ADL). The facility census was 84. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, dementia, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had moderately impaired cognition, and required substantial assistance with toileting and bathing. Review of the provider orders for Resident #3 dated 02/18/26 revealed feeding restrictions, resident needs max assist feeding with each meal for nutrition. Review of the provider orders for Resident #3 dated 03/25/26 revealed feeding order, nurse to ensure that resident is fed by staff for all meals with meals for to ensure proper nutrition. Observation on 07/16/26 at 7:54 A.M. in Resident #3's room of Resident #3 lying in bed with bedside table placed across the bed with the breakfast tray on it, Resident #3 was holding the plate in his lap and spilling food on his blanket and lap. Interview and observation on 07/16/26 at 8:00 A.M with Certified Nursing Assistant (CNA) #290 confirmed meal trays were being passed to resident rooms around 7:30 A.M. CNA #290 Resident #3's plate and fork was in Resident #3's lap with spilling food. Interview on 07/16/26 at 8:02 A.M. with CNA #407 confirmed CNA #407 passed Resident #3's tray around 7:30 A.M. and was not sure if he needed assistance with eating or not so CNA #407 confirmed the tray was set up for Resident #3 on his bedside table so Resident #3 could start eating while the trays were passed to the other residents. Interview on 07/16/26 at 8:05 A.M. with the Director of Nursing (DON) stated Resident #3 can feed himself but sometimes requires hands on or queuing. Interview on 07/16/26 at 8:17 A.M. with the Assistant Director of Nursing (ADON) #302 confirmed Resident #3 needs to be fed for all meals. The ADON #302 confirmed the order for Resident #3 to be fed for all meals. Interview on 07/20/26 at 9:46 A.M. with the DON confirmed the order for max assist for all meals for Resident #3 and staff need to be with Resident #3 to provide max assist with meals. Review of the policy titled, Activities of Daily Living (ADL), Supporting, dated 2001, revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with dining. 2. Review of the medical record for Resident #81 revealed an admission date of 06/20/25. Diagnoses included unspecified dementia without behaviors, heart disease, kidney disease and weakness. Review of podiatry note dated 06/16/25 revealed the resident's nails were trimmed this date. The note recommended professional treatment and follow-up. Review of the plan of care dated 04/19/26 revealed resident had an activity of daily living self care performance deficit with interventions for finger nail care to check the length and trim and clean on bath day and as necessary. The care plan made no mention of toenails or podiatry services. Review progress notes dated 06/18/26 from the Nurse Practitioner revealed a recommendation for resident to see podiatry for toenail trimming. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively impaired, and the Brief Interview of Mental Status (BIMS) was not completed as resident was rarely if ever understood. The Resident was noted to be dependent with hygiene care. Observation and interview on 07/16/26 at 8:28 A.M. with Certified Nursing Aide (CNA) #290 revealed they removed Resident #81's socks to observe her toes. Residents toenails were over a half an inch past the nail bed. CNA #290 confirmed Resident #81's toenails were very long and reported all facility residents require podiatry to trim toenails. She revealed she was unsure if staff could trim toenails or not. Interviews on 0/16/26 at 10:00 A.M. and 10:10 A.M. with MDS coordinator #214 confirmed the staff should be able to trim toenails but would need to double check. A second interview confirmed the aides were not trained to complete any nail care and nursing should be trimming toenails and monitoring if the need trimmed by podiatry. Interview on 01/16/26 at 10:30 A.M. with the Administrator confirmed the last podiatry visit was 06/2025 and confirmed staff was unable to locate any notes in the past year. Review of facility policy titled, Activities of Daily Living dated 03/2018 revealed residents shall be provided with care treatment and services as appropriate. Residents who were unable to carry out activities of daily living shall received services to maintain good hygiene care. Review of facility policy titled, Clinical Services-Podiatry dated 07/01/26 revealed residents should have access to podiatry care and services and should have documented nots and treatments in the medical record. This deficiency represents non-compliance investigated under Complaint Numbers 2726588, 3073628, 2684291, 2983546, 2709514 and 2686126.

Based on record reviews, interviews, and review of facility policies, the facility failed to prevent the decline of a pressure ulcer for one resident (Resident #43). Actual harm occurred when a pressure ulcer located on the coccyx of Resident #43 was not accurately assessed and treated timely resulting in a wound decline and infection requiring the resident's admission to the hospital for treatment. This affected one resident (#43) of the seven residents with pressure ulcers. The facility census was 109. Findings include: Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22, revealed the resident was assessed to require extensive assistance from one staff member for bed mobility and extensive assistance from two staff members for transfers and toileting. This resident was assessed to have had an area of pressure present. The stage of the pressure ulcer and presence upon admission were not indicated on the assessment. The resident was assessed to have a surgical wound. Review of the care plan, dated 03/16/22, revealed Resident #43 had an area of pressure located on the coccyx which was present upon admission. Interventions included to administer treatments as ordered by the physician and monitor for effectiveness and to assess/record/monitor wound healing, measure the length, width, and depth where possible and to assess and document the status of wound perimeter, wound bed, and healing process. Report improvements and declines to the physician. Review of the facility Health Admit/Readmit Review, dated 03/03/22 and locked on 03/25/22, revealed this resident had a red non-blanchable area to the coccyx and wounds to the bilateral sides of the back from stents being removed. No measurements of the size of wounds were documented. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change every day. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Health Skin Review assessment, dated 03/10/22, revealed this resident had a pressure area to the sacrum when admitted to the facility and treatment was in place. No measurements of the size of the wounds or description of the wounds were documented. Review of the facility Health Skin Review assessment, dated 03/12/22, revealed this resident had a pressure ulcer to the coccyx which was worsening as it was observed to have black eschar (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). The resident was documented to be educated on turning and repositioning and declined stating he could not turn due to his left hip hurting. No measurement of the size of the wounds were documented. Review of the facility Health Skin Review assessment, dated 03/13/22, revealed this resident continued with a pressure ulcer to the coccyx and the resident continued to be educated by staff on the need to turn and reposition or the wound would continue to deteriorate, and the resident verbalized understanding. No measurements or description of the wounds were documented. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Health Weekly Wound Review assessment, dated 03/16/22, revealed this resident was documented to have a stage four pressure ulcer to the coccyx measuring 10.0 centimeters (cm) long by 7.0 cm wide. The wound bed consisted of necrotic tissue and there was a moderate amount of serosanguinous drainage with no odor present. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Health Weekly Wound Review assessment, dated 03/23/22, revealed this resident was documented to have a stage four (full thickness tissue loss with exposed bone, tendon, or muscle. Eschar may be present) pressure ulcer to the coccyx measuring 9.0 cm long by 8.0 cm wide. The wound bed was documented to have slough and a heavy/copious amount of purulent drainage which contained a strong/foul odor. Review of the progress notes, dated 03/03/22 through 03/23/22, revealed no documentation of the size, location, or description of the resident's area of pressure to the coccyx or surgical wounds to bilateral sides of the back. Review of the progress note, dated 03/23/22, revealed the resident was sent to the emergency room and was admitted to the hospital due to ulcer of the coccyx. Interview with the Director of Nursing (DON) on 04/01/22 at 2:50 P.M. verified there was no documentation of the measurements or description of the pressure ulcer to Resident #43's coccyx until 03/16/22. The DON verified available documentation of the pressure ulcer to the coccyx of Resident #43 indicated the wound had declined and become infected between 03/03/22 and 03/16/22 with no change in treatment orders to the area. The DON verified weekly assessments including size and description of the residents wound should have been documented in the resident's medical record. The DON verified there was no care plan or interventions implemented for the pressure ulcer until 03/16/22. The DON verified Resident #43 was sent to the hospital and admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 04/2018, revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue. This deficiency substantiated Complaint Number OH 308.

Based on medical record review, staff interview, interview with wound consultant, and policy review, the facility failed to ensure one resident (#117) received adequate care, monitoring and treatment to prevent the development of pressure ulcers. This resulted in actual harm when Resident #117 was found to have an avoidable unstageable pressure areas to the left lateral foot, right lateral malleolus and right heel. In addition Resident #117 was also found to have a suspected deep tissue injury on the right lateral foot. This affected one resident (#117) of three reviewed for pressure ulcers. The facility census was 116. Findings Include: Review of the medical record revealed Resident #117 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #117 had moderate cognitive impairment. The resident was totally dependent on two persons for assistance with bed mobility, transfers, dressing and toilet use. The resident was at risk for developing pressure ulcers and was admitted with one Stage III pressure ulcer. No other skin issues were identified. The resident was to have a pressure reducing device for the bed mattress, a cushion for the chair, and nutrition/hydration interventions to manage skin problems. Resident #117 was 72 inches tall and weighed 144 pounds upon admission. Review of the pressure ulcer risk assessment dated [DATE] indicated the resident was at low risk for development of pressure ulcer. No other pressure ulcer risk assessment was available for review. Review of the plan of care dated 01/19/21 identified Resident #117 had a pressure ulcer upon admission related to history of pressure ulcers. The goals included the pressure ulcer would show signs of healing and the resident would have intact skin. Interventions included administer treatment as ordered, assess/record/monitor wound healing every shift, follow facility policy/protocols for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care dated 01/29/21 revealed the resident was at risk for impairment of skin integrity related to altered skin turgor, pressure ulcer present. Interventions included keep skin clean and dry, consult nurse practitioner for evaluation and treatment as indicated, ensure adequate hydration, monitor vital signs as needed, measure area per facility protocol, monitor for pain, monitor use of skin protective devises assessing condition of skin over bony prominence's for breakdown, and treatment as ordered. Review of the nurses notes dated from 12/06/20 through 02/08/21 revealed weekly measurements for a Stage III pressure ulcer to the left gluteus which was present on admission. The progress note on 01/25/21 indicated a wound to the left gluteus measuring 1.0 centimeter (cm) by 2.4 cm by 0.1 cm. An order was received to change the treatment to silver alginate covered by a foam dressing and to change daily and as needed until healed. Review of the progress note dated 02/01/21 revealed the wound nurse was in the facility to see Resident #117. The wound to the left gluteus was noted to have yellow slough and measured 1.0 cm by 2.2 cm by 0.1 cm. The progress note also indicated new areas to the left outer aspect of the foot that measured 0.8 cm by 1.2 cm by 0.1 cm and was covered with eschar. A wound to the right outer ankle was also noted covered with eschar and measured 1.0 cm by 1.3 cm by 0.1 cm. The right lateral foot was noted to have a deep tissue injuring measuring 1.0 cm by 1.5 cm by 0 cm. An order was received to treat the areas of the foot and to remove the footboard from the bed. Review of the wound care progress note dated 02/01/21 revealed Nurse Practitioner #359 documented the area to the left lateral foot was an unstageable pressure ulcer measuring 0.7 cm by 1.2 cm by 0.1 cm with no tunneling or undermining notes. The wound bed was described as 100% eschar (necrotic tissue); the wound to the right lateral foot was documented as an unstageable pressure ulcer measuring 1.2 cm by 1.2 cm by 0.1 cm with 100% eschar (necrotic tissue); the wound to the right lateral foot was noted to measure 1.0 cm by 1.5 cm by 0 cm and a suspected deep tissue injury pressure ulcer. The area to the right heel was documented as an unstageable pressure ulcer measuring 1.0 cm by 1.5 cm by 0.1 cm with moderate serous exudate noted and 100% eschar (slough). Interventions identified included barrier cream every shift, pressure reducing mattress, offload heels, positioning pillows, pressure reducing cushion for the chair and to reposition every two hours. Review of the physician orders dated 12/08/20 included pad and protect the coccyx with foam dressing, change daily and as needed and cleanse would to left gluteus with normal saline, pat dry. Apply calcium alginate to wound bed and cover with foam dress change daily and as needed. On 01/18/21 the physician ordered to apply skin protective cream to bilateral buttocks every shift and after each incontinence episode. On 01/26/21 the dressing to the left gluteus was changed to cleanse with normal saline, pat dry and apply silver alginate to wound bed and cover with a foam dressing daily and as needed. On 01/31/21 a physician order was noted to cleanse wound to the outside right lateral foot and right heel with normal saline, apply santyl and wet gauze and cover with foam dressing to be changed daily and as needed. On 02/03/21 the physician ordered to cleanse wound to outside right lateral foot and right heel with normal saline, apply santyl and wet gauze and cover with foam dressing and change daily; pad and protect right lateral foot with foam dressing to be changed three times weekly until healed; cleanse area to the right outer ankle and the right heel with normal saline, pat dry, place calcium alginate to the wound bed and cover with foam dressing and change three times weekly and as needed; cleanse the left foot wound with normal saline, pat dry and apply calcium alginate to the wound bed, cover with foam dressing and change three times weekly and as needed. The physician had also ordered weekly skin assessments. Review of the treatment administration record (TAR) dated December 2020 indicated the treatment to the left gluteus was not documented as completed on 12/09/20, 12/10/20, 12/14/20, 12/19/20, 12/23/20 and 12/25/2020. Review of the TAR dated January 2021 indicated the daily treatment to the left gluteus was not documented as completed on 01/02/21, 01/03/21, 01/06/21, 01/12/21, 01/13/21, 01/18/21, 01/20/21, and 01/25/21. The dressing was changed from calcium alginate to silver alginate on 01/26/21. Registered Nurse (RN) #226 confirmed on 03/03/21 at 10:15 A.M. the TAR had not indicated the dressing change had been completed. Review of the TAR dated February 2021 indicated the treatment to the right outer ankle and the right heel three times weekly and as needed started 02/01/21. The TAR indicated the dressing change was not documented as completed on 02/03/21 or 02/08/21. The TAR indicated the treatment to the left gluteus was not documented as completed on 02/03/21, 02/04/21 and 02/08/21. The treatment to the left foot ordered three times weekly and as needed indicated the treatment was not documented as completed on 02/03/21 and 02/08/21. The treatment to the right lateral foot ordered three times weekly was not documented as completed on 02/03/21 and 02/08/21. RN #226 confirmed on 03/03/21 at 10:15 A.M. the TAR had not indicated the dressing changes had been completed. Interview on 03/02/21 at 1:03 P.M., the Director of Nursing (DON) reported all residents were to have weekly skin assessments and documented in medical record. The DON stated the State tested Nursing Assistant (STNA)s completed a skin check with showers/bathing and if they noticed any changes, they would be reported to the nurse. The DON reported all treatments were to be recorded on the TAR, and all residents were to have a completed skin assessment weekly. The DON confirmed the TAR lacked documentation of completed treatments and the shower sheets where the skin checks would be documented had not indicated any concerns with Resident #117's lower extremities. Interview on 03/02/21 at 1:20 P.M., the RN #226 reported Resident #117 had an area to the left buttock they were treating which was present on admission. RN #226 reported the nurse called her on 01/31/21 and reported areas to the lower extremity and toes. RN #226 reported she felt the areas to the feet were due to the resident pressing his feet against the footboard because he was 72 inches and was tall for the bed. RN #226 reported she instructed the nurse to notify the physician for treatment orders and the skin nurse (Nurse Practitioner #359) was scheduled to see Resident #117 on 02/01/21 and would assess the areas at that time. RN #226 reported she had maintenance remove the footboard on 02/01/21. RN #226 reported the facility had the extra long beds, however they normally just remove the footboard when any concerns with a resident's height, however this had not been done for Resident #117. Interview on 03/03/21 at 7:43 A.M., RN #337 reported she had cared for Resident #117 and could remember his pressure areas. RN #337 stated Resident #117 had an area to the gluteus they were treating upon admission and then developed areas to both feet/ankles which were due to the boots he had been wearing. RN #337 reported she could not recall any schedule for when the boots would be applied or removed, however he had them on during the 12 hour day shift. RN #337 reported she could not recall removing the boots to assess Resident #117 skin condition. Follow-up interview on 03/03/21 at 1:05 P.M., RN #226 confirmed Resident #117 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #226 reported any resident with any type of a device to prevent skin pressure should have a physician order and treatment record indicating the devices were applied properly. Interview on 03/04/21 at 7:48 A.M., the STNA #221 revealed she had taken care of Resident #117 a little over one week ago and he had no other skin breakdown except on his bottom which had been there since he arrived. She further reported she had not seen any boots on the resident at all, and she had not applied any boots. Interview on 03/16/21 at 1:31 P.M., the Advanced Practice Nurse (APN) #800 who was the Director of Clinical Operations for the wound company where Nurse Practitioner #359 used to work verified the wounds were documented by the former employee Nurse Practitioner #359 as pressure areas. Review of the facility policy titled Dressings, dated 09/2013, indicated all treatments would be ordered by a physician. This deficiency substantiates allegations in Complaint Number OH 100.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], review of the guidance from the Centers for Disease Control (CDC) and Prevention website related to preparing for Coronavirus Disease 2019 (COVID-19) and responding to COVID-19 for nursing homes and health care facilities and healthcare personnel, review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos and Letters, surveyor observations, record reviews, staff interviews, review of the facilities COVID-19 Timeline, floor plan for the facilities dedicated COVID-19 units and list of staff who tested positive, and review of the facility's policy for COVID-19 Prevention and Control, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 including: ensuring residents were cohorted correctly in accordance with CDC Guidelines; ensuring staff infected with COVID-19 only provided care to residents infected with COVID-19; and ensuring appropriate Personal Protective Equipment (PPE) was used with residents infected with COVID-19. This resulted in Immediate Jeopardy for 32 residents (#111, #128, #142, #152, #153, #157, #160, #162, #163, #172, #176, #177, #179, #182, #184, #186, #188, #189, #193, #202, #208, #213, #214, #216, #221, #222, #224, #227, #238, #240, #241, and #243) who were negative for COVID-19 and remained on the dedicated COVID-19 units. Subsequent testing concluded 27 (#111, #128, #142, #152, #153, #160, #162, #172, #176, #177, #179, #182, #189, #193, #202, #208, #213, #214, #216, #221, #222, #224, #227, #238, #240, #241, and #243) of the 31 residents tested positive, who were previously negative, and the remaining four residents (#163, #184, #186, and #188) who tested negative, continued to remain on the designated COVID-19 unit. Two of the residents who continued to test negative for COVID-19 (#157 and #184) continued to reside on the designated COVID-19 unit and remained cohorted in a room with a COVID-19 positive resident. Additionally, the facility allowed 10 staff members, who tested positive for COVID-19, to work with residents who tested negative for COVID-19 during the time period they were considered infectious. The lack of effective infection control practices related to COVID-19 placed 31 residents (#111, #128, #142, #152, #153, #160, #162, #163, #172, #176, #177, #179, #182, #184, #186, #188, #189, #193, #202, #208, #213, #214, #216, #221, #222, #224, #227, #238, #240, #241, and #243) residing in the facility's COVID-19 units, in Immediate Jeopardy and the potential risk for serious life-threatening harm, negative health complications and/or death related to the facility's failed infection control practices. The facility census was 125. On [DATE] at 5:10 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when the facility created a designated COVID-19 unit and failed to move residents in accordance with the latest CDC guidelines dated [DATE] by allowing residents who tested negative for COVID-19 to remain on the dedicated COVID-19 unit. The facility allowed two COVID-19 negative residents to cohort in the same room with COVID-19 positive residents. Additionally, the facility shared staff between COVID-19 positive and COVID-19 negative residents and staff reused PPE between COVID-19 positive and COVID-19 negative residents. The staff who had tested positive for COVID-19 and were asymptomatic were allowed to work on the dedicated COVID-19 unit and provided care for both COVID-19 positive and COVID-19 negative residents during the same shift while utilizing the same PPE. Staff working in the facility reused their N95 masks for five consecutive shifts and without allowing a rest period in between uses. The facility's failure to effectively implement infection control practices likely contributed to the COVID-19 outbreak that spread throughout the facility infecting 32 residents with COVID-19, four (Residents #238, #239, #240 and #241) of which expired and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy was removed on [DATE] at 4:00 P.M. when the facility made room changes based on the residents' COVID-19 status, updated the facility practice pertaining to PPE when caring for quarantined residents, and began developing a COVID-19 policy specifically for cohorting residents, and implemented the following corrective actions: · On [DATE], the facility ordered 400 N95 masks. The estimated delivery date was [DATE]. · On [DATE], all 18 residents on the 3 West Unit met the CDC criteria to discontinue transmission-based precautions after being quarantined for 10 days. The 3 West Unit was no longer considered a COVID-19 Unit. · On [DATE], only three residents (#125, #175, and #177) on the 2 West Unit were still considered COVID-19 positive and have been moved and were isolated on the same unit. There was a plastic barrier placed on the 2 West Unit to separate the isolated residents from the other residents remaining on the unit. Designated staff was implemented on the COVID-19 unit. · On [DATE], the DON was in-serviced by Corporate Nurse #700 regarding no residents who were positive for COVID-19 will be cohorted with non-infected residents. The DON was also in-serviced on COVID-19 positive residents that should have dedicated staff members who do not work with non-infected residents to prevent the spread of infection. The designated staffing on the COVID-19 unit will follow the CDC guidelines. This included allowing staff who tested positive for COVID-19 and were asymptomatic to work with residents who tested positive for COVID-19. · On [DATE], all 155 staff were in-serviced by the DON and/or designee regarding no residents who were positive for COVID-19 will be cohorted with non-infected residents, and to follow CMS, CDC, State and local guidelines to prevent and control the spread of the COVID-19 for the resident population by using proper mask rest periods, utilizing designated COVID-19 staffing, and proper PPE usage. · Starting on [DATE], the DON or designee will complete a daily audit to ensure there were no residents with COVID-19 being cohorted with non-infected residents. This will occur daily for four weeks. Then three times weekly for two weeks, and once weekly for an additional two weeks. An audit was completed on [DATE] to ensure no like residents were being cohorted with COVID-19 infected residents. · Starting on [DATE], the DON or designee will audit new COVID-19 infections in the facility daily. · Starting on [DATE], the DON implemented that infection control will be added to the facility's Quality Assurance and Performance Improvement (QAPI) agenda and will be reviewed on a quarterly basis and as needed. · Beginning on [DATE], the staff received the additional N95 masks so they can have 72 hours of rest between uses. Staff will keep each mask in a separate brown bag and date the bag with the last use date in the staging area by the facility entrance. The staff started using the new masks on [DATE] per CDC guidelines. · On [DATE], the facility implemented a designated quarantine unit and three residents (#125, #175, and #177) were moved to this designated quarantine unit. · On [DATE], all staff were educated via VoiceFriend (an electronic communication to all staff) of mask availability and guidelines for proper usage of mask including the amount of uses for each individual mask and acceptable amount time between uses. · Observation on [DATE] at 3:30 P.M., revealed the facility staff prepared brown paper bags for the storage of N95 masks for staff. There were three paper bags for each staff member labeled with their names. · Interview with the Administrator on [DATE] at 3:40 P.M. revealed the facility had received a supply of N95 masks on [DATE]. He stated staff would begin utilizing the N95 masks per the CDC guidance by allowing them to rest for 72 hours in a paper bag after being worn and would not wear the masks beyond five uses. He stated all staff had been in-serviced via text message on [DATE] regarding the new mask usage and the utilization of the new COVID-19 unit. · Observation on [DATE] from 3:40 P.M. to 4:00 P.M. revealed the original COVID-19 units on 2 West and 3 West had been resolved. A new COVID-19 unit had been constructed on 2 West by blocking off four rooms with a plastic barrier. Three residents (#125, #175, and #177) remained in private rooms on the new COVID-19 unit due to continued infection with COVID-19. There was one Licensed Practical Nurse (LPN) and one State tested Nurse Aide (STNA) working with only the residents who were positive for COVID-19. The staff were observed to utilize a break room on the COVID-19 unit and were to exit via the stairwell leading to the outside. · Interviews with LPN #522, STNA #417, and STNA #419 on [DATE] from 4:00 P.M. to 4:15 P.M. confirmed they were all in-serviced on the appropriate use of N95 masks and the new COVID-19 unit. No concerns were identified, and all staff interviewed were knowledgeable on how to utilize N95 masks and isolation of residents diagnosed with COVID-19. · Interview with the DON on [DATE] at 4:20 P.M. revealed she had been in-serviced by the facilities corporate nurse regarding appropriate isolation for residents diagnosed with COVID-19, designated staffing and the correct way to utilize N95 masks. Although the Immediate Jeopardy was removed on [DATE] at 4:00 P.M., the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,d+[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) Review of the facilities COVID-19 Timeline revealed 2 West had become a dedicated COVID-19 unit on [DATE] after three residents (#198, #239, and #242) who resided on the unit had tested positive for COVID-19 and 3 West had become a dedicated COVID-19 unit on [DATE] after five residents (#159, #178, #211, #212, and #213) tested positive for COVID-19. After creating the designated COVID-19 units, 32 residents (#111, #128, #142, #152, #153, #157 #160, #162, #163, #172, #176, #177, #179, #182, #184, #186, #188, #189, #193, #202, #208, #213, #214, #216, #221, #222, #224, #227, #238, #240, #241, and #243) who had never tested positive for COVID-19 were allowed to remain on the dedicated COVID-19 units. Twenty-seven of the 32 residents tested positive for COVID-19 after remaining on the designated COVID-19 units. Four residents (#163, #184, #186, and #188) continued to reside on the dedicated COVID-19 units despite never testing positive for COVID-19. 1a) Resident #227 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1b) Resident #176 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1c) Resident #238 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. Resident #238 expired in the facility on [DATE]. 1d) Resident #142 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1e) Resident #240 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. Resident #240 expired in the facility on [DATE]. 1f) Resident #243 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1g) Resident #128 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1h) Resident #111 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1i) Resident #152 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1j) Resident #182 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1k) Resident #241 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. Resident #241 expired in the facility on [DATE]. 1l) Resident #222 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1m) Resident #208 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1n) Resident #162 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1o) Resident #193 remained on the 2 West COVID-unit on [DATE] and tested positive for COVID-19 on [DATE]. 1p) Resident #189 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1q) Resident #202 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1r) Resident #153 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1s) Resident #216 remained on the 3 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1t) Resident #224 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1u) Resident #214 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1v) Resident #172 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1w) Resident #179 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1x) Resident #213 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1y) Resident #160 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1z) Resident #221 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1aa) Resident #177 remained on the 2 West COVID-19 unit on [DATE] and tested positive for COVID-19 on [DATE]. 1bb) Resident #163 remained on the 3 West COVID-19 unit on [DATE] and continued to test negative for COVID-19. 1cc) Resident #184 remained on the 2 West COVID-19 unit on [DATE] and continued to test negative for COVID-19. 1dd) Resident #186 remained on the 3 West COVID-19 unit on [DATE] and continued to test negative for COVID-19. 1ee) Resident #188 remained on the 2 West COVID-19 unit on [DATE] and continued to test negative for COVID-19. 2) Review of the floor plan for the facilities dedicated COVID-19 units located on 2 West and 3 West, dated [DATE], revealed they were labeled with residents and their COVID-19 status by the DON. The floor plan revealed two residents (#157 and #184) resided on the dedicated COVID-19 units and were cohorted in a room with a COVID-19 positive resident. Record review for Resident #157 revealed the resident resided on a non-COVID unit until the resident was transferred to the 2 West COVID-19 unit on [DATE]. He remained on the 2 West COVID-19 unit from [DATE] to [DATE]. Review of the facilities COVID-19 Timeline revealed Resident #157 had tested positive for COVID-19 on [DATE]. The facility resumed testing the resident for COVID-19 on [DATE]. Between [DATE] and [DATE], the resident continued to test negative for COVID-19. Resident #157 was cohorted from [DATE] to [DATE] with Resident #172, who tested positive for COVID on [DATE]. Resident #157 was asymptomatic from [DATE] to [DATE]. Record review for Resident #184 revealed the resident resided on the 2 West COVID-19 unit from [DATE] to [DATE]. Review of the facilities COVID-19 Timeline revealed the resident had never tested positive for COVID-19. Resident #184 was cohorted from [DATE] to [DATE] with Resident #213 who tested positive for COVID-19 on [DATE]. 3) Review of the facilities list of staff who tested positive revealed ten staff members worked when they tested positive and were asymptomatic. These ten staff members worked on the COVID-19 unit and worked with both positive COVID-19 residents and negative COVID-19 residents. 3a) State tested Nurses Aide (STNA) #419 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #419 worked on the 2 West COVID-19 unit on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3b) Licensed Practical Nurse (LPN) #576 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed LPN #576 worked on the 3 West COVID-19 unit on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3c) LPN #591 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed LPN #591 worked on the 3 West COVID-19 unit on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3d) STNA #472 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #472 worked on the 3 West COVID-19 unit on [DATE], [DATE], [DATE], and [DATE]. 3e) Housekeeping Aide (HA) #587 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed HA #587 worked on the 3 West COVID-19 unit on [DATE], [DATE], and [DATE]. 3f) STNA #440 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #440 worked on both the 2 West and 3 West COVID-19 units on [DATE]. The STNA worked on the 3 West COVID-19 unit on [DATE], [DATE], [DATE], and [DATE] and worked on both the 2 West and 3 West COVID-19 unit on [DATE]. The STNA worked the 3 West COVID-19 unit on [DATE] and worked the 2 West COVID-19 unit on [DATE] and [DATE]. 3g) STNA #574 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #574 worked on the 3 West COVID-19 unit on [DATE]. 3h) STNA #598 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #598 worked on the 2 West COVID-19 unit on [DATE]. 3i) STNA #600 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed STNA #600 worked on the 3 West COVID-19 unit on [DATE], [DATE], [DATE] and worked on both the 2 West and 3 West COVID-19 units on [DATE]. 3j) HA #466 tested positive for COVID-19 on [DATE]. Review of the facility's list of staff who worked while positive for COVID-19 revealed HA #466 worked on the 2 West COVID-19 unit on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview with the Administrator and DON on [DATE] at 3:00 P.M. verified 2 West had been designated as a COVID-19 unit on [DATE] and 3 West had been designated as a COVID-19 unit on [DATE]. They verified the residents who had tested negative for COVID-19 were not removed from the designated COVID-19 units as they had possible exposure to the virus and the facility did not want to move them to another area and jeopardize other residents by possibly spreading the virus. They stated Resident #157 was moved to the COVID-19 unit despite testing negative for COVID-19 due to his roommate testing positive for COVID-19 and they presumed he was positive as well. They stated staff who had current infections with COVID-19 and were asymptomatic were allowed to work only on the COVID-19 unit until their infection period had resolved. They verified the staff worked on the COVID-19 unit and worked with both the COVID-19 positive and COVID-19 negative residents that resided on the unit. They presumed that all the residents who had been on the COVID-19 unit were exposed and would eventually test positive. They verified the staff in the facility were reusing their N95 masks for five consecutive shifts and would then dispose of them. They stated they were unaware of any recommendations to allow a 72 hour rest period between N95 uses. Observation of the 3 West designated COVID-19 unit on [DATE] from 3:40 P.M. to 4:00 P.M. revealed STNAs #402 and #592 working on the unit. The staff were observed to be providing care for both the COVID-19 positive and COVID-19 negative residents. Staff were observed to wear the same N95 mask and eye protection to care for both COVID-19 positive and COVID-19 negative residents without changing or cleaning the N95 mask or eye protection. Observation of the 2 West designated COVID-19 unit on [DATE] from 4:00 P.M. to 4:20 P.M. revealed LPN #527 and STNAs #419 and #440 working on the unit. The staff were observed to be providing care for both the COVID-19 positive and COVID-19 negative residents. Staff were observed to wear the same N95 mask and eye protection to care for both COVID-19 positive and negative residents without changing or cleaning the N95 mask or eye protection. Interview with LPN #527 on [DATE] at 4:00 P.M. revealed she only worked on the COVID-19 unit. She verified staff working on the unit provide care for both COVID-19 positive and COVID-19 negative residents during their shift. She stated staff reuse their N95 for five consecutive shifts then dispose of them. Interview with STNA #419 on [DATE] at 4:10 P.M. revealed she provided care to COVID-19 positive residents and COVID-19 negative residents who resided on the unit during her shift. She verified staff wear N95 masks for five consecutive shifts then dispose of them. Interview with STNA #440 on [DATE] at 4:13 P.M. revealed she provided care to COVID-19 positive and COVID-19 negative residents who resided on the unit during her shift. She verified staff wear N95 masks for five consecutive shifts then dispose of them. Interview with LPN #426 on [DATE] at 2:30 P.M. revealed she was the infection control designee for the facility. She verified 2 West became a designated COVID-19 unit on [DATE] and 3 West became a designated COVID-19 unit on [DATE]. She verified the residents who tested negative for COVID-19 remained on the units due to possible exposure. She stated Resident #157 was moved to the 2 West COVID-19 unit due to his roommate testing positive. She stated staff who tested positive for COVID-19 and were asymptomatic could work only on the COVID-19 units. She stated staff reused the same N95 respirator mask for five consecutive shifts then dispose of it. She stated she was unaware of any recommendations to allow N95 masks to rest for 72 hours between uses. She stated the facility had not identified an area in which to create a COVID-19 unit on at the beginning of the pandemic. Interview with the Administrator on [DATE] at 1:50 P.M. revealed he had ordered a supply of N95 masks that were supposed to be delivered on [DATE] but had not arrived yet. He stated he did not have any documentation of any attempts to contact the local health department or other agencies regarding obtaining additional PPE supplies. Attempts to interview the Local Health Department and the facility's Medical Director during the survey were unsuccessful. Review of the facility's policy titled COVID-19 Prevention and Control, revised [DATE], revealed in situations of staffing shortages, CDC staff shortage mitigation procedures may be instituted that supersede other guidance in the policy. Residents with suspected or confirmed COVID-19 will be placed in a designated room or area for COVID-19. The Infection Preventionist and MD will assess the risks associated with other resident placement options. Further review of the policy lacked evidence the facility had a plan to manage a surge of positive COVID-19 cases in the facility that was in compliance with the CDC guidance. Review of the CDC website COVID-19 guidelines titled, Infection Control for Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), dated [DATE], revealed he facility should have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive) and have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the CDC website COVID-19 guidelines titled, Responding to COVID-19, dated [DATE], revealed responding to residents newly infected with [CONDITION(S)]-CoV-2 includes ensuring the resident was isolated and cared for using all recommended COVID-19 PPE. The resident should be placed in a single room if possible pending results of [CONDITION(S)]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. Review of the CDC website N95 guidelines titled, Strategies for Optimizing N95 Respirator Supplies (https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html), updated [DATE], revealed N95 masks should not be used more than five consecutive uses and the amount of time in between uses should exceed the 72 hour expected survival time for [CONDITION(S)]-CoV-2 (the virus that causes COVID-19). Review of the CDC guidance titled, Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated [DATE], revealed when staffing shortages are occurring, healthcare facilities and employers may need to implement crisis capacity strategies to continue to provide patient care. When there are no longer enough staff to provide safe patient care and the shortages continue despite other mitigation strategies, the last resort is to allow healthcare professional (HCP) with confirmed [CONDITION(S)]-CoV-2 infection to provide direct care only for patients with confirmed [CONDITION(S)]-COV-2 infection, preferably in a cohort setting. Review of the CMS letter titled, COVID-19 Long-Term Care Facility Guidance (https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf), dated [DATE], revealed facilities should also refer to CDC's guidance to long-term care facilities on COVID-19 and also use the guidance on conservation of PPE when unable to follow the long-term care facility guidance. To avoid transmission within long-term care facilities, facilities should use separate teams for COVID-19 positive residents to the best of their ability, and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status. This deficiency substantiates Complaint Number OH 747 and is an example of continued noncompliance from the survey dated [DATE].

Based on medical record review, self-reported incident (SRI) review, resident and staff interview, and review of facility's abuse policy, the facility failed to ensure Resident #27 was free from sexual abuse from Resident #1. Actual harm occurred when Resident #1 sexually assaulted Resident #27 resulting in vaginal injury. This affected one (Resident #27) of four residents reviewed for abuse (#20, #27, #46 and #50). The facility census was 114. Findings include: Medical record review revealed Resident #27 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact, required limited assistance with toileting and was continent of bowel and bladder. Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident's cognition was intact, his ability to hear was intact and did not wear hearing aides, independent with bed mobility, required limited assistance with transferring and had a urinary catheter in place. Review of the social service progress notes dated 08/11/17 revealed Resident #1 requested that Resident #27 be moved into his room. The social worker talked to both residents who agreed to be roommates. Education was provided to both on the importance of keeping doors closed if any sexual activity was going on. Both requested only one bed be kept in the room. Residents #1 and #27 participated in a consensual sexual relationship. Review of an undated witness statement by Licensed Practical Nurse (LPN) #205 revealed on 08/27/17 at 4:45 P.M., Resident #27 kept falling asleep in the dining room and vital signs were taken and her oxygen level was low. Staff took her back into her room and she began shaking like she was nervous or scared. The resident stated she did not want to get back into bed because she was afraid her roommate would do what he had done to her prior to dinner. The resident stated she was asleep and was awakened by her leg feeling like it was getting pulled out of socket and Resident #1 was doing things to her that she didn't consent to because she was asleep. The resident asked Resident #1 to quit but he continued until he finished himself. Further interview on 08/27/17 between 7:15 P.M. and 7:20 P.M. revealed the resident told the LPN and DON that she asked him to quit and even tried hitting him to get him off her. The resident explained to Resident #1 that he was hurting her and his response was I can't do what I want anymore because it's always hurting you. When he finally finished, and wiped her off she told him it burnt because it felt like he was scraping or squeezing something inside her. Resident #27 agreed to move out of Resident #1's room to a room near her former room. Review of the Certified Nurse Practitioner (CNP) #300 progress note dated 08/28/17 revealed Resident #27 was seen due to complaints of vulvovaginal irritation for 24 hours following sexual activity that became vigorous between the Resident #27 and Resident #1. She had pain with sitting or voiding. The assessment stated the exterior genitalia had [DIAGNOSES REDACTED] and some excoriation at the gluteal crease. She had excoriation at the opening that leads to the vaginal canal and it was quite tender. The plan was to treat the vulvovaginal pain with leaving the perineum open to air for seven days, apply [MEDICATION NAME] cream to affective area twice daily for five days and avoid other products/devices to the perineum. Review of a statement from the DON dated 09/14/17 at 4:30 P.M. revealed on 08/27/17, Resident #27 told her that the incident was not consensual. She stated she was asleep alone in her room, was frightened that night and was frightened now. Interview with Resident #27 on 09/19/17 from 8:46 A.M. to 9:30 A.M. revealed on 08/27/17 she was sexually assaulted by Resident #1. She stated she was asleep and Resident #1 came into their room and stuck something up her vagina. She stated she woke up immediately with something inside her and it hurt. She stated the incident was not consensual. Interview with the DON, Administrator and LPN#119 on 09/20/17 at 10:03 A.M. revealed that Resident #1 was placed on one to one supervision the night of 08/27/17 and was discontinued on 08/28/17. Review of the facility self-reported incident (SRI) # 1 dated 09/14/17 involving Resident #27 and Resident #1 revealed Resident #27 reported to CNP #88 on 09/14/17 during assessment that she had relations with another resident but she had an event that she felt was abusive. The facility concluded that abuse did not take place on the night of 08/27/17 and stated that both residents were of sound mind and both residents consented to the sexual relationship between each other. Interview with Administrator on 09/20/17 at 12:40 P.M. verified the facility did not follow their policy to report an allegation of sexual abuse to the state agency and did not complete a thorough investigation at the time of the allegation of sexual abuse. Further interview with the Administrator confirmed the policy indicated that any type of allegation of abuse must be reported within two hours of the allegation was made. Review of the facility's undated policy and procedure on abuse, neglect, exploitation and misappropriation of resident property revealed the facility's policy was to investigate all alleged violations involving abuse. The facility would not tolerate abuse of its residents. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. The initial report would include to report immediately to the Administrator or designee. If abuse or serious bodily injury was alleged, it should be reported to ODH immediately, but not later than two hours after the allegation was made. The investigation protocol should generally take the following actions which include to interview the resident, the accused, and all witnesses. Obtain a statement from the resident, the accused, and each witness. This deficiency substantiates Complaint Number OH 533.

Based on medical record review and staff interviews, the facility failed to monitor and provide correct treatment to a pressure ulcer. This resulted in harm when a resident's pressure ulcer worsened and an additional unstageable pressure ulcer developed. This affected one (#165) of three residents reviewed for pressure ulcers. The facility identified 10 residents in the facility with pressure ulcers. The facility census was 118. Findings include: Medical record review revealed Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #165 went to the hospital for a scheduled Transurethral Resection of the Prostate (TURP) on 06/28/16 and returned to the facility on [DATE]. The medical record further revealed the resident was discharged to the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment of Resident #165 revealed the resident had moderate cognitive impairment. The quarterly assessment revealed the resident required total dependence for bed mobility, transfers, toilet use, and was an extensive staff assistance with dressing. The assessment also stated Resident #165 had an indwelling catheter in place. Review of the wound evaluation flow sheet for Resident #165 revealed the resident first developed a pressure ulcer to the penis on 05/16/16. Review of the initial measurements of wound to the penis revealed the wound measured 2.4 x 0.5 x 0.1 centimeters (cm). Review of Certified Nurse Practitioner (CNP) #101 wound visit note dated 06/05/15 revealed the pressure ulcer was a stage two. Review of Resident #165's physician orders [REDACTED]. The placement of the dressing was scheduled to be checked at 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M., 12:00 A.M., and 4:00 A.M. daily. Review of the wound evaluation flow sheet revealed the pressure ulcer was improving on 06/16/16 when the wound measured measured 0.3 x 0.6 x 0.1. Review of the wound visit notes dated 06/16/16 of CNP #101 revealed the resident would have treatment to the left side of the penis, which induced, honey paste, alginate, non-adhesive foam cut to fit, check placement every four hours and as needed. Review of Resident #165's June 2016 Treatment Administration Record (TAR), which included documentation of monitoring and treatments to pressure ulcers, revealed the placement of the dressing to the penis pressure ulcer was not checked 21 of 48 times from 06/16/16 through 06/23/16. Review of the wound evaluation flow sheet dated 06/23/16 revealed the pressure ulcer now measured larger with a measurement of 0.7 x 1.1 x 0.1 cm. The resident also was noted with unstageable pressure ulcer to the lateral penis which measured 0.1 x 0.3 x 0.1 cm. Review of the CNP #101 wound visit note, dated 06/24/16, revealed the wound showed no improvement, and was now a stage three pressure ulcer. The wound measured 0.7 x 0.1 x 0.1. The note further revealed the dressing in place was incorrect and nursing staff was educated on the treatment plan and was shown how to place the dressing properly. The wound visit note further revealed a new, unstageable, deteriorating pressure ulcer was found to the lateral penis on 06/23/16. The measurements to the new wound was 1.0 x 0.3 x 0.1 cm. During an interview on 07/14/16 at 1:01 P.M., CNP #101 stated the foam dressing which had been ordered was not in place at the time of her wound visit on 06/23/16. CNP #101 confirmed if the correct treatment was not in place, it could lead to the worsening of a pressure ulcer. CNP #101 also confirmed if the dressing placement was not checked every four hours as ordered, it could also lead to the worsening of the pressure ulcer. During an interview on 06/14/16 at 3:49 P.M., Wound Nurse #146 confirmed the TAR revealed the dressing placement was not checked 21 times from 06/16/16 through 06/23/16.

Based on medical record review, interviews with staff, residents, a family member and a local police officer, review of a facility Self-Reported Incident (SRI) and review of facility policy, the facility failed to ensure incidents of suspected physical abuse toward residents were thoroughly investigated and failed to report an allegation of abuse to the state agency as required. The facility subsequently failed to ensure residents were protected from potential further abuse when the alleged perpetrator was left unattended for an undetermined amount of time. This resulted in Immediate Jeopardy for two (#1 and #88) of three residents reviewed for abuse, who sustained actual harm when they were physically assaulted and abused by State tested Nurse Aide (STNA) #16. The facility census was 123. On 03/17/16 at 1:50 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/16 when STNA #16 assaulted Resident #1 by hitting her in the face with a closed fist. Resident #1 sustained injuries of swelling and bruising to both eyes and a skin tear and bruises to the right hand. Resident #1 was evaluated at the hospital and diagnosed with [REDACTED]. The skin tear on the resident's hand required steri-strips for closure. STNA #16 was left unattended, for an undetermined amount of time, by facility staff while they waited for the DON to arrive at the facility. Additionally, during the investigation of STNA #16, Resident #88 stated STNA #16 completed his shower on 03/12/16 and she was testing the water temperature on him and was freezing him to death. During an interview on 03/17/16, Resident #88 stated he felt abused by STNA #16. The Immediate Jeopardy was removed on 03/18/16 when all facility staff were educated on the abuse policy including, removal of an alleged perpetrator from the facility following an abuse allegation, and the facility implemented the following corrective actions: · On 03/12/16, the DON had STNA #16 leave the building and employment was terminated. · On 03/12/16, facility staff working on the first floor were informally educated on the abuse policy. No sign in sheets were kept. · On 03/15/16, individual counseling related to the abuse incident was provided to Residents #1 and #88 as needed. · On 03/16/16, the DON provided staff that was currently in the building with a written description of the facility ' s abuse policy. · On 03/17/16, the DON began an all staff in-service on abuse prevention, types of abuse, how to report abuse and signs and symptoms of abuse as well as a video on resident abuse. The facility will continue to provide abuse education at every staff meeting, quarterly, and upon orientation, regarding recognizing burnout, frustrated or stressed employees, where the policy and procedure manuals are located as well as the facility policy on resident abuse. If an employee was unable to attend the in-service, they were provided verbal education over the phone and will be handed all information to review upon return to work. · On 03/17/16, Group Counseling Services were offered to all residents in the facility by an outside counseling service titled Unusual Incident Stress Debriefing Meeting. Individual counseling was offered in resident rooms, if unable to attend group counseling. · On 03/17/16 and 03/18/16, all 123 residents in the building had been interviewed by management staff including the DON, Registered Nurse (RN) #78 and Human Resource Staff (HRS) #72 for any abuse allegations and to ensure safety by asking if residents felt safe in the building. · By 03/18/16, all facility staff was in-serviced by the DON on the abuse policy including, after an allegation of abuse is made, the alleged perpetrator is to be immediately removed from the building. The in-service was completed in person or by phone. · On 03/18/16, education was completed by an outside risk management consultant for management staff on the investigation process to include completing a thorough abuse investigation. · The DON, Administrator, and other management staff will perform resident interviews once a month for three months then every 90 days for one year. The Quality Assessment and Assurance (QAA) committee will follow the resident interviews for one year until March 2017. Although the Immediate Jeopardy was removed on 03/18/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring and verifying the corrective action taken was effective. Findings include: 1. Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had a contracture to the right arm, had little function of the right side of the body, and was also taking [MEDICATION NAME] (a blood thinning medication.) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of eight which indicated some cognitive impairment. Review of the functional assessment revealed the resident was independent for eating, required set up of one person assist for dressing and personal hygiene and was a two person assist for bed mobility and transfers. Review of the facility SRI submitted on 03/12/16 and finalized on 03/14/16 revealed, on 03/12/16 at 10:45 A.M., the DON was notified that Resident #1 had an injury that appeared to have occurred after STNA #16 was in her room and provided care. After further investigation, it was determined STNA #16 did cause physical harm to Resident #1. Resident #1 was sent to the emergency room (ER) for evaluation and returned to the facility the same day. STNA #16 was removed from the facility and was currently in the custody of the police department. Based on the facility's investigation, the allegation was substantiated for physical abuse to Resident #1. Review of the written statement obtained by the DON from Resident #1 revealed the resident reported STNA #16 was rough with her, pinched her hand on the right side, punched both eyes and hit her head on the side rail of the bed on the left side. Resident #1 stated the STNA was mouthy, not nice and stated to the resident think of what I am going to do to you in the shower. Review of the written statement obtained by the DON from STNA #16 dated 03/12/16 revealed STNA #16 was working 6:00 A.M. to 2:00 P.M. on 03/12/16 and was designated as the spa tech that day. STNA #16 entered Resident #1's room and took the blankets off the resident. STNA #16 then checked and changed Resident #1. When STNA #16 was rolling Resident #1 side to side to change her, STNA #16 stated Resident #1 dumped a cup of water over. STNA #16 stated as she was rolling Resident #1 side to side the resident hit her head on the side rails, her right hand hit the bedside table and her ring cut her hand. Review of Resident #1's nursing note dated 03/12/16 documented at 3:08 P.M. revealed at 10:38 A.M., the nurse was in the supply room gathering supplies for treatments. Upon exiting, Licensed Practical Nurse (LPN) #37 stated you may want to go look at Resident #1, the shower aid just told me she has bruising on both eyes and a skin tear on her hand. The nursing note documented LPN #63 went to the resident's room and saw the resident lying in bed with bruising noted to the outer corner of both eyes and both outer corners were noted to have some swelling. The top and side below the thumb on the right hand was noted to have bruising and two skin tears were also noted. The note revealed the nurse asked what happened and the resident stated she beat me up. The nurse asked who beat you up? and the resident replied, The shower girl. At that time, STNA #16 entered the room and was told to go to the nurses ' station and stay there. The resident was made safe and LPN #40 was notified to come to LPN #63 as soon as possible. No Neurological checks were initiated. The resident was given Tylenol for complaints of head pain and ice packs were applied to both eyes. The resident's shirt was torn down the right lower side with drops of blood noted on it. LPN #63 went to the nurses' station and approached STNA #16 to write a statement of what happened. The resident was sent to the ER for further evaluation and treatment. Review of Resident #1's nursing progress note dated 03/14/16 completed by the DON revealed social services was consistently meeting with Resident #1 to ensure the resident's emotional needs were being met. It was brought to the attention of the DON Resident #1 was having a difficult time sleeping. The resident was asked if it would help if she was provided with someone to sit with her at night to watch over her, and the resident told the DON she would like to have someone sit with her at night. On 03/15/16, the progress noted revealed in addition to social services, the DON requested the resident be seen by a licensed counselor to ensure the resident's emotional needs were being met and a referral was made. An interview on 03/16/16 at 12:00 P.M. with STNA #85 revealed STNA #85 was at lunch from 10:00 A.M. to 10:30 A.M. on 03/12/16. STNA #85 stated she returned from lunch and assisted the other aides on the floor with taking lunch orders. STNA #85 stated she passed STNA #16 in the hallway and STNA #16 stated to her Resident #1 ripped my shirt. STNA #85 then entered Resident #1's room and found the resident with both eyes swollen and bruised. STNA #85 also stated Resident #1 had two skin tears one V shaped and one that was a straight line on her right hand and the hand was bleeding. Resident #1 reported to STNA #85 that STNA #16 had dumped a glass of water in her face. STNA #85 observed STNA #16 being told to leave Resident #1's room and go to the nurse's station. STNA #85 confirmed no staff members accompanied STNA #16 to the nurse ' s station. STNA #85 stated STNA #16 was acting strange that day. STNA #16 was late to work that morning and was spacey and was talking on the cellphone during staff interaction. An interview on 03/16/16 at 12:30 P.M. with STNA #24 revealed she was walking down the hallway on the first floor and observed STNA #16 walking the opposite direction wearing only a tank top and scrub pants. STNA #24 stated she did not recognize the person and stopped her and asked her if she was an aide. STNA #16 responded that she was. STNA #24 stated STNA #16's face was red and she looked funny. STNA #24 stated she then heard about the incident involving Resident #1 and she was so mad at STNA #16 that she left the floor and went outside to keep from hitting her. STNA #24 stated while outside, STNA #16 came outside alone. STNA #24 stated she then went back into the building. An interview on 03/16/16 at 2:18 P.M. with Police Officer (PO) #600 revealed he arrived at the facility on 03/12/16 and took a report from Resident #1 and her family. PO #600 stated he interviewed STNA #16 on 03/14/16 while she was in the custody of another county jail as STNA #16 was arrested for assault, robbery and receiving stolen property in an unrelated incident. PO #600 stated at that time the case against STNA #16 involving Resident #1 was currently with the local county prosecutor's office and would most likely result in STNA #16 being charged with felony assault on Resident #1. An interview on 03/16/16 at 2:45 P.M. with LPN #63 revealed LPN #37 informed her STNA #16 had reported Resident #1 had bruises around her eyes and she should go look. LPN #63 stated she immediately went to Resident #1's room and found the resident with bruising on the outside corners of the eyes and swelling to both eyes. LPN #63 further stated Resident #1 had bruises and two skin tears to her right hand. LPN #63 asked Resident #1 what happened and the resident replied she beat me up. LPN #63 stated the resident answered it was that girl. LPN #63 stated at that moment, STNA #16 entered Resident #1 ' s room and the resident pointed and said her. STNA #16 replied I didn t beat her up. LPN #63 asked STNA #16 how she got the skin tear on her right hand and STNA #16 stated she was turning her. LPN #63 then told STNA #16 to leave the room and go to the nurse's station. LPN #63 verified STNA #16 left the room and was not accompanied by any staff member. LPN #63 assessed Resident #1 and then exited the room to call the clinical coordinator on another floor. LPN #63 stated she had STNA #16 sit at the nurses station and write a statement. LPN #63 stated after the DON arrived she was not sure where STNA #16 was. LPN #63 stated STNA #16 was acting weird that day and she was 45 minutes late to work that morning. An interview on 03/16/16 at 3:22 P.M. with STNA #128 revealed STNA #16 came and got her and asked for help with Resident #1. STNA #128 stated she entered Resident #1's room and noticed the bruises around the resident ' s eyes and her right hand was bleeding. Resident #1 told STNA #128 she hit me, she punched me. STNA #128 stated STNA #16 stated it happened when she turned Resident #1. Resident #1 was agitated with STNA #16 being in the room and at that time LPN #63 entered the room and had STNA #16 go to the nurse's station. After leaving Resident #1's room STNA #128 stated she saw STNA #16 walking down the ramp towards the outside door. STNA #128 asked STNA #16 what she was doing and she stated clocking out. STNA #128 did not see STNA #16 after that. STNA #128 stated Resident #1 was visibly upset and the next day was scared to take a shower until she was told STNA #16 was no longer in the building. An interview on 03/16/16 at 3:59 P.M. with STNA #18 revealed STNA #16 approached her in the hallway and stated I need help with Resident #1. STNA #18 stated let's get STNA #128 to help and then STNA #16 stated Resident #1 had skin tears on her hand and black marks on the corners of her eyes. STNA #18 stated STNA #16 had a hole in her tank top. STNA #18 went towards Resident #1's room and LPN #63 was there so she continued down the hall to another resident's room. STNA #18 stated she was then asked to go find STNA #16 but was unsure of what time that happened. STNA #18 stated she went to go outside to find STNA #16 and found her coming back in the building unattended. STNA #18 stated she then entered Resident #1's room to assist STNA #85 and change Resident #1's shirt which was ripped and had blood on it. STNA #18 stated Resident #1 was wet and a bloody pillowcase was found in a linen bag on the resident's floor. An interview on 03/16/16 at 4:20 P.M. with Resident #1 revealed STNA #16 had hit her in the face like a man. Resident #1 stated her fist was closed when she hit her. Resident #1 stated she had some trouble sleeping at night but a staff member had been sitting with her at night and it made her feel better. Resident #1 was unsure why STNA #16 hit her. An interview on 03/16/16 at 4:25 P.M. with Family Member (FM) #200 revealed she was notified by her brother of Resident #1's assault. FM #200 stated she arrived at the facility and went directly to Resident #1's room. FM #200 stated she wanted the facility to call the police and take her to the hospital. FM #200 stated at that time the facility notified the police and made arrangements for the resident to be evaluated at the local ER. An interview on 03/17/16 at 8:22 A.M. with the DON revealed she was notified of a resident who may have been injured. The DON stated she was near the facility and came directly to the facility. The DON stated she interviewed LPN #63 and LPN #63 had told her Resident #1 had been assaulted by STNA #16. The DON was notified of the injuries and then asked where STNA #16 was. The DON located STNA #16 outside and had her go to her office to conduct an interview. The DON stated STNA #16 was wearing a tank top with blood and saliva on it along with a hole on the left side. The DON stated she asked STNA #16 to write a statement. She stated STNA #16 was not writing legibly and was talking fast so the DON asked STNA #16 what happened and wrote the statement down for the STNA. The DON stated STNA #16 was in Resident #1's room alone and the resident was a two person assist with bed mobility and transfers. The DON stated STNA #16 should not have been in the room alone. The DON stated STNA #16's story changed several times and was inconsistent. The DON stated STNA #16 told her she had injured the resident by banging her head on the side rails when she turned her during incontinence care. The DON stated she then made sure STNA #16 left the property. The DON stated she interviewed Resident #1 several times. She stated the resident was consistent in her story and she felt the abuse did occur how the resident said it did. The DON stated the resident had been assessed with [REDACTED]. The DON verified the resident had been fearful after the incident so a staff member was sitting with her at night. An interview on 03/17/16 at 9:03 A.M. with LPN #40 revealed she was notified via text LPN #63 needed assistance as soon as possible. LPN #40 stated she went down to the first floor and found STNA #24 yelling at STNA #16 she should kill her and she should call the police. LPN #40 instructed STNA #24 to take a break and STNA #24 left the floor. LPN #40 then spoke with LPN #63 and went to Resident #1's room to assess the resident. After interviewing the resident, LPN #40 exited the room to call the DON. LPN #40 stated STNA #16 was sitting at the nurse's station writing a statement. LPN #40 then saw STNA #16 outside smoking. LPN #40 confirmed STNA #16 was not being watched by a particular staff member and was going in and out of the building. LPN #40 stated STNA #16 appeared disheveled as her hair was messy and she was not wearing any makeup which was not her normal appearance. An interview on 03/17/16 at 9:41 A.M. with LPN #37 revealed Resident #1 was not her assigned resident. LPN #37 stated on 03/12/16 STNA #16 was late to work that morning. LPN #37 further stated STNA #16 had approached her and asked her if she could remove her scrub top and wear a tank top in the shower room. LPN #37 stated when she observed STNA #16 in the nurse's station writing her statement she was acting odd and was scribbling and writing big. LPN #37 also stated STNA #16 was talking out loud to herself. LPN #37 then stated STNA #16 got up and said she was going out to smoke. LPN #37 stated STNA #16 then left the nurses station unaccompanied. An interview on 03/17/16 at 10:20 A.M. with the DON verified a thorough investigation was not completed and Resident #1's primary nurse, LPN #63 on 03/12/16, was not interviewed and a statement was not taken. 2. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #88's Activities of Daily Living (ADL) care plan dated 10/20/15 revealed the resident required extensive assistance with hygiene and showers. Review of the MDS 3.0 assessment completed on 01/05/16 revealed the resident's BIMS was a 14 indicating the resident was cognitively intact. The resident was assessed as requiring assistance of one person for dressing and toileting. Review of the written statement completed by Registered Nurse (RN) #78 from Resident #88 dated 03/12/16 revealed the resident was interviewed by RN #78 regarding the investigation of STNA #16. Resident #88 stated STNA #16 completed his shower on 03/12/16. Resident #88 further stated STNA #16 was testing the water temperature on him and was freezing him to death. Resident #88 also stated STNA #16 was flighty and hyper. An interview on 03/17/16 at 11:45 A.M. with Resident #88 revealed on 03/12/16 STNA #16 assisted him with a shower. Resident #88 stated STNA #16 pushed him quickly in his wheelchair to the shower room. STNA #16 then tested the water temperature on his skin. Resident #88 stated he asked for the nurse to come into the shower room and adjust the water temperature. Resident #88 stated he felt abused by STNA #16 testing the water temperature on him. An interview on 03/17/16 at 12:07 P.M. with the DON revealed she was aware of the incident involving Resident #88 and STNA #16. The DON verified she only interviewed the resident and did not report the incident to the Ohio Department of Health. Further interview revealed the DON confirmed the facility policy was to thoroughly investigate any allegations of abuse and report the investigations to the Ohio Department of Health. The DON also confirmed there was no facility staff responsible for staying with STNA #16 while they were awaiting the DON arrival. Review of the facility policy, titled Abuse Prevention Program dated 01/02/14, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator Review of the facility policy, titled Protecting Residents during Abuse Investigations dated 01/02/14, indicated The facility will protect residents from harm during investigations of abuse allegations. During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the Administrator. Review of the facility policy, titled Abuse Investigation dated 01/02/14 revealed All reports of resident abuse, mistreatment, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will include interviews of staff members who have had contact with the resident during the period of the alleged incident and also interview other residents to whom the accused employee provides care and/or services to. Review of the facility policy, title Reporting abuse to the state agencies dated 01/02/14 revealed all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. This deficiency substantiates Complaint Number OH 094.

Based on medical record review, interviews with staff, residents, a family member and a local police officer, review of a facility Self-Reported Incident (SRI) and review of facility policy, the facility failed to ensure staff implemented the facility's abuse policies and procedures when incidents of suspected physical abuse toward residents were not thoroughly investigated, an allegation of abuse was not reported to the state agency and the facility failed to ensure residents were protected from potential further abuse. This resulted in Immediate Jeopardy for two (#1 and #88) of three residents reviewed for abuse, who sustained actual harm when they were physically assaulted and abused by State tested Nurse Aide (STNA) #16 during the provision of care. The census was 123. On 03/17/16 at 1:50 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/16 when STNA #16 assaulted Resident #1 by hitting her in the face with a closed fist. Resident #1 sustained injuries of swelling and bruising to both eyes and a skin tear and bruises to the right hand. Resident #1 was evaluated at the hospital and diagnosed with [REDACTED]. The skin tear on the resident's hand required steri-strips for closure. STNA #16 was left unattended, for an undetermined amount of time, by facility staff while they waited for the DON to arrive at the facility. Additionally, during the investigation of STNA #16, Resident #88 stated STNA #16 completed his shower on 03/12/16 and she was testing the water temperature on him and was freezing him to death. During an interview on 03/17/16, Resident #88 stated he felt abused by STNA #16. The Immediate Jeopardy was removed on 03/18/16 when all facility staff were educated on the abuse policy including, removal of an alleged perpetrator from the facility following an abuse allegation, and the facility implemented the following corrective actions: · On 03/12/16, the DON had STNA #16 leave the building and employment was terminated. · On 03/12/16, facility staff working on the first floor were informally educated on the abuse policy. No sign in sheets were kept. · On 03/15/16, individual counseling related to the abuse incident was provided to Residents #1 and #88 as needed. · On 03/16/16, the DON provided staff that was currently in the building with a written description of the facility's abuse policy. · On 03/17/16, the DON began an all staff in-service on abuse prevention, types of abuse, how to report abuse and signs and symptoms of abuse as well as a video on resident abuse. The facility will continue to provide abuse education at every staff meeting, quarterly, and upon orientation, regarding recognizing burnout, frustrated or stressed employees, where the policy and procedure manuals are located as well as the facility policy on resident abuse. If an employee was unable to attend the in-service, they were provided verbal education over the phone and will be handed all information to review upon return to work. · On 03/17/16, Group Counseling Services were offered to all residents in the facility by an outside counseling service titled Unusual Incident Stress Debriefing Meeting. Individual counseling was offered in resident rooms, if unable to attend group counseling. · On 03/17/16 and 03/18/16, all 123 residents in the building had been interviewed by management staff including the DON, Registered Nurse (RN) #78 and Human Resource Staff (HRS) #72 for any abuse allegations and to ensure safety by asking if residents felt safe in the building. · By 03/18/16, all facility staff was in-serviced by the DON on the abuse policy including, after an allegation of abuse is made, the alleged perpetrator is to be immediately removed from the building. The in-service was completed in person or by phone. · On 03/18/16, education was completed by an outside risk management consultant for management staff on the investigation process to include completing a thorough abuse investigation. · The DON, Administrator, and other management staff will perform resident interviews once a month for three months then every 90 days for one year. The Quality Assessment and Assurance (QAA) committee will follow the resident interviews for one year until March 2017. Although the Immediate Jeopardy was removed on 03/18/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring and verifying the corrective action taken was effective. Findings include: 1) Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had a contracture to the right arm, had little function of the right side of the body, and was also taking [MEDICATION NAME] (a blood thinning medication.) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of eight which indicated some cognitive impairment. Review of the functional assessment revealed the resident was independent for eating, required set up of one person assist for dressing and personal hygiene and was a two person assist for bed mobility and transfers. Review of the facility SRI submitted on 03/12/16 and finalized on 03/14/16 revealed, on 03/12/16 at 10:45 A.M., the DON was notified that Resident #1 had an injury that appeared to have occurred after STNA #16 was in her room and provided care. After further investigation, it was determined STNA #16 did cause physical harm to Resident #1. Resident #1 was sent to the emergency room (ER) for evaluation and returned to the facility the same day. STNA #16 was removed from the facility and was currently in the custody of the police department. Based on the facility's investigation, the allegation was substantiated for physical abuse to Resident #1. Review of the written statement obtained by the DON from Resident #1 revealed the resident reported STNA #16 was rough with her, pinched her hand on the right side, punched both eyes and hit her head on the side rail of the bed on the left side. Resident #1 stated the STNA was mouthy, not nice and stated to the resident think of what I am going to do to you in the shower. Review of the written statement obtained by the DON from STNA #16 dated 03/12/16 revealed STNA #16 was working 6:00 A.M. to 2:00 P.M. on 03/12/16 and was designated as the spa tech that day. STNA #16 entered Resident #1's room and took the blankets off the resident. STNA #16 then checked and changed Resident #1. When STNA #16 was rolling Resident #1 side to side to change her, STNA #16 stated Resident #1 dumped a cup of water over. STNA #16 stated as she was rolling Resident #1 side to side the resident hit her head on the side rails, her right hand hit the bedside table and her ring cut her hand. Review of Resident #1's nursing note dated 03/12/16 documented at 3:08 P.M. revealed at 10:38 A.M., the nurse was in the supply room gathering supplies for treatments. Upon exiting, Licensed Practical Nurse (LPN) #37 stated you may want to go look at Resident #1, the shower aid just told me she has bruising on both eyes and a skin tear on her hand. The nursing note documented LPN #63 went to the resident ' s room and saw the resident lying in bed with bruising noted to the outer corner of both eyes and both outer corners were noted to have some swelling. The top and side below the thumb on the right hand was noted to have bruising and two skin tears were also noted. The note revealed the nurse asked what happened and the resident stated she beat me up. The nurse asked who beat you up? and the resident replied, The shower girl . At that time, STNA #16 entered the room and was told to go to the nurses' station and stay there. The resident was made safe and LPN #40 was notified to come to LPN #63 as soon as possible. No Neurological checks were initiated. The resident was given Tylenol for complaints of head pain and ice packs were applied to both eyes. The resident's shirt was torn down the right lower side with drops of blood noted on it. LPN #63 went to the nurses' station and approached STNA #16 to write a statement of what happened. The resident was sent to the ER for further evaluation and treatment. Review of Resident #1's nursing progress note dated 03/14/16 completed by the DON revealed social services was consistently meeting with Resident #1 to ensure the resident's emotional needs were being met. It was brought to the attention of the DON Resident #1 was having a difficult time sleeping. The resident was asked if it would help if she was provided with someone to sit with her at night to watch over her, and the resident told the DON she would like to have someone sit with her at night. On 03/15/16, the progress noted revealed in addition to social services, the DON requested the resident be seen by a licensed counselor to ensure the resident's emotional needs were being met and a referral was made. An interview on 03/16/16 at 12:00 P.M. with STNA #85 revealed STNA #85 was at lunch from 10:00 A.M. to 10:30 A.M. on 03/12/16. STNA #85 stated she returned from lunch and assisted the other aides on the floor with taking lunch orders. STNA #85 stated she passed STNA #16 in the hallway and STNA #16 stated to her Resident #1 ripped my shirt. STNA #85 then entered Resident #1's room and found the resident with both eyes swollen and bruised. STNA #85 also stated Resident #1 had two skin tears one V shaped and one that was a straight line on her right hand and the hand was bleeding. Resident #1 reported to STNA #85 that STNA #16 had dumped a glass of water in her face. STNA #85 observed STNA #16 being told to leave Resident #1's room and go to the nurse's station. STNA #85 confirmed no staff members accompanied STNA #16 to the nurse's station. STNA #85 stated STNA #16 was acting strange that day. STNA #16 was late to work that morning and was spacey and was talking on the cellphone during staff interaction. An interview on 03/16/16 at 12:30 P.M. with STNA #24 revealed she was walking down the hallway on the first floor and observed STNA #16 walking the opposite direction wearing only a tank top and scrub pants. STNA #24 stated she did not recognize the person and stopped her and asked her if she was an aide. STNA #16 responded that she was. STNA #24 stated STNA #16's face was red and she looked funny. STNA #24 stated she then heard about the incident involving Resident #1 and she was so mad at STNA #16 that she left the floor and went outside to keep from hitting her. STNA #24 stated while outside, STNA #16 came outside alone. STNA #24 stated she then went back into the building. An interview on 03/16/16 at 2:18 P.M. with Police Officer (PO) #600 revealed he arrived at the facility on 03/12/16 and took a report from Resident #1 and her family. PO #600 stated he interviewed STNA #16 on 03/14/16 while she was in the custody of another county jail as STNA #16 was arrested for assault, robbery and receiving stolen property in an unrelated incident. PO #600 stated at that time the case against STNA #16 involving Resident #1 was currently with the local county prosecutor's office and would most likely result in STNA #16 being charged with felony assault on Resident #1. An interview on 03/16/16 at 2:45 P.M. with LPN #63 revealed LPN #37 informed her STNA #16 had reported Resident #1 had bruises around her eyes and she should go look. LPN #63 stated she immediately went to Resident #1's room and found the resident with bruising on the outside corners of the eyes and swelling to both eyes. LPN #63 further stated Resident #1 had bruises and two skin tears to her right hand. LPN #63 asked Resident #1 what happened and the resident replied she beat me up. LPN #63 stated the resident answered it was that girl. LPN #63 stated at that moment, STNA #16 entered Resident #1's room and the resident pointed and said her. STNA #16 replied I didn't beat her up. LPN #63 asked STNA #16 how she got the skin tear on her right hand and STNA #16 stated she was turning her. LPN #63 then told STNA #16 to leave the room and go to the nurse's station. LPN #63 verified STNA #16 left the room and was not accompanied by any staff member. LPN #63 assessed Resident #1 and then exited the room to call the clinical coordinator on another floor. LPN #63 stated she had STNA #16 sit at the nurses station and write a statement. LPN #63 stated after the DON arrived she was not sure where STNA #16 was. LPN #63 stated STNA #16 was acting weird that day and she was 45 minutes late to work that morning. An interview on 03/16/16 at 3:22 P.M. with STNA #128 revealed STNA #16 came and got her and asked for help with Resident #1. STNA #128 stated she entered Resident #1's room and noticed the bruises around the resident's eyes and her right hand was bleeding. Resident #1 told STNA #128 she hit me, she punched me. STNA #128 stated STNA #16 stated it happened when she turned Resident #1. Resident #1 was agitated with STNA #16 being in the room and at that time LPN #63 entered the room and had STNA #16 go to the nurse's station. After leaving Resident #1's room STNA #128 stated she saw STNA #16 walking down the ramp towards the outside door. STNA #128 asked STNA #16 what she was doing and she stated clocking out. STNA #128 did not see STNA #16 after that. STNA #128 stated Resident #1 was visibly upset and the next day was scared to take a shower until she was told STNA #16 was no longer in the building. An interview on 03/16/16 at 3:59 P.M. with STNA #18 revealed STNA #16 approached her in the hallway and stated I need help with Resident #1. STNA #18 stated let's get STNA #128 to help and then STNA #16 stated Resident #1 had skin tears on her hand and black marks on the corners of her eyes. STNA #18 stated STNA #16 had a hole in her tank top. STNA #18 went towards Resident #1's room and LPN #63 was there so she continued down the hall to another resident ' s room. STNA #18 stated she was then asked to go find STNA #16 but was unsure of what time that happened. STNA #18 stated she went to go outside to find STNA #16 and found her coming back in the building unattended. STNA #18 stated she then entered Resident #1's room to assist STNA #85 and change Resident #1's shirt which was ripped and had blood on it. STNA #18 stated Resident #1 was wet and a bloody pillowcase was found in a linen bag on the resident's floor. An interview on 03/16/16 at 4:20 P.M. with Resident #1 revealed STNA #16 had hit her in the face like a man. Resident #1 stated her fist was closed when she hit her. Resident #1 stated she had some trouble sleeping at night but a staff member had been sitting with her at night and it made her feel better. Resident #1 was unsure why STNA #16 hit her. An interview on 03/16/16 at 4:25 P.M. with Family Member (FM) #200 revealed she was notified by her brother of Resident #1's assault. FM #200 stated she arrived at the facility and went directly to Resident #1's room. FM #200 stated she wanted the facility to call the police and take her to the hospital. FM #200 stated at that time the facility notified the police and made arrangements for the resident to be evaluated at the local ER. An interview on 03/17/16 at 8:22 A.M. with the DON revealed she was notified of a resident who may have been injured. The DON stated she was near the facility and came directly to the facility. The DON stated she interviewed LPN #63 and LPN #63 had told her Resident #1 had been assaulted by STNA #16. The DON was notified of the injuries and then asked where STNA #16 was. The DON located STNA #16 outside and had her go to her office to conduct an interview. The DON stated STNA #16 was wearing a tank top with blood and saliva on it along with a hole on the left side. The DON stated she asked STNA #16 to write a statement. She stated STNA #16 was not writing legibly and was talking fast so the DON asked STNA #16 what happened and wrote the statement down for the STNA. The DON stated STNA #16 was in Resident #1's room alone and the resident was a two person assist with bed mobility and transfers. The DON stated STNA #16 should not have been in the room alone. The DON stated STNA #16's story changed several times and was inconsistent. The DON stated STNA #16 told her she had injured the resident by banging her head on the side rails when she turned her during incontinence care. The DON stated she then made sure STNA #16 left the property. The DON stated she interviewed Resident #1 several times. She stated the resident was consistent in her story and she felt the abuse did occur how the resident said it did. The DON stated the resident had been assessed with [REDACTED]. The DON verified the resident had been fearful after the incident so a staff member was sitting with her at night. An interview on 03/17/16 at 9:03 A.M. with LPN #40 revealed she was notified via text LPN #63 needed assistance as soon as possible. LPN #40 stated she went down to the first floor and found STNA #24 yelling at STNA #16 she should kill her and she should call the police. LPN #40 instructed STNA #24 to take a break and STNA #24 left the floor. LPN #40 then spoke with LPN #63 and went to Resident #1's room to assess the resident. After interviewing the resident, LPN #40 exited the room to call the DON. LPN #40 stated STNA #16 was sitting at the nurse's station writing a statement. LPN #40 then saw STNA #16 outside smoking. LPN #40 confirmed STNA #16 was not being watched by a particular staff member and was going in and out of the building. LPN #40 stated STNA #16 appeared disheveled as her hair was messy and she was not wearing any makeup which was not her normal appearance. An interview on 03/17/16 at 9:41 A.M. with LPN #37 revealed Resident #1 was not her assigned resident. LPN #37 stated on 03/12/16 STNA #16 was late to work that morning. LPN #37 further stated STNA #16 had approached her and asked her if she could remove her scrub top and wear a tank top in the shower room. LPN #37 stated when she observed STNA #16 in the nurse's station writing her statement she was acting odd and was scribbling and writing big. LPN #37 also stated STNA #16 was talking out loud to herself. LPN #37 then stated STNA #16 got up and said she was going out to smoke. LPN #37 stated STNA #16 then left the nurses station unaccompanied. An interview on 03/17/16 at 10:20 A.M. with the DON verified a thorough investigation was not completed and Resident #1's primary nurse, LPN #63 on 03/12/16, was not interviewed and a statement was not taken. 2. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #88's Activities of Daily Living (ADL) care plan dated 10/20/15 revealed the resident required extensive assistance with hygiene and showers. Review of the MDS 3.0 assessment completed on 01/05/16 revealed the resident's BIMS was a 14 indicating the resident was cognitively intact. The resident was assessed as requiring assistance of one person for dressing and toileting. Review of the written statement completed by Registered Nurse (RN) #78 from Resident #88 dated 03/12/16 revealed the resident was interviewed by RN #78 regarding the investigation of STNA #16. Resident #88 stated STNA #16 completed his shower on 03/12/16. Resident #88 further stated STNA #16 was testing the water temperature on him and was freezing him to death. Resident #88 also stated STNA #16 was flighty and hyper. An interview on 03/17/16 at 11:45 A.M. with Resident #88 revealed on 03/12/16 STNA #16 assisted him with a shower. Resident #88 stated STNA #16 pushed him quickly in his wheelchair to the shower room. STNA #16 then tested the water temperature on his skin. Resident #88 stated he asked for the nurse to come into the shower room and adjust the water temperature. Resident #88 stated he felt abused by STNA #16 testing the water temperature on him. An interview on 03/17/16 at 12:07 P.M. with the DON revealed she was aware of the incident involving Resident #88 and STNA #16. The DON verified she only interviewed the resident and did not report the incident to the Ohio Department of Health. Further interview revealed the DON confirmed the facility policy was to thoroughly investigate any allegations of abuse and report the investigations to the Ohio Department of Health. The DON also confirmed there was no facility staff responsible for staying with STNA #16 while they were awaiting the DON arrival. Review of the facility policy, titled Abuse Prevention Program dated 01/02/14, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator Review of the facility policy, titled Protecting Residents during Abuse Investigations dated 01/02/14, indicated The facility will protect residents from harm during investigations of abuse allegations. During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the Administrator. Review of the facility policy, titled Abuse Investigation dated 01/02/14 revealed All reports of resident abuse, mistreatment, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will include interviews of staff members who have had contact with the resident during the period of the alleged incident and also interview other residents to whom the accused employee provides care and/or services to. Review of the facility policy, title Reporting abuse to the state agencies dated 01/02/14 revealed all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. This deficiency substantiates Complaint Number OH 094.

Based on medical record review, interviews with staff, residents, a family member and a local police officer, review of a facility Self-Reported Incident (SRI) and review of facility policy, the facility failed to ensure residents were protected from physical abuse resulting in actual harm by facility staff during the provision of direct care by State tested Nurse Aide (STNA) #16. This resulted in Immediate Jeopardy for two (#1 and #88) of three residents reviewed for abuse, who were physically abused by STNA #16. The facility census was 123. On 03/17/16 at 1:50 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/16 when STNA #16 assaulted Resident #1 by hitting her in the face with a closed fist. Resident #1 sustained injuries of swelling and bruising to both eyes and a skin tear and bruises to the right hand. Resident #1 was evaluated at the hospital and diagnosed with [REDACTED]. The skin tear on the resident's hand required steri-strips for closure. STNA #16 was left unattended, for an undetermined amount of time, by facility staff while they waited for the DON to arrive at the facility. Additionally, during the investigation of STNA #16, Resident #88 stated STNA #16 completed his shower on 03/12/16 and she was testing the water temperature on him and was freezing him to death. During an interview on 03/17/16, Resident #88 stated he felt abused by STNA #16. The Immediate Jeopardy was removed on 03/18/16 when all facility staff were educated on the abuse policy including, removal of an alleged perpetrator from the facility following an abuse allegation, and the facility implemented the following corrective actions: · On 03/12/16, the DON had STNA #16 leave the building and employment was terminated. · On 03/12/16, the facility staff working on the first floor were informally educated on the abuse policy. No sign in sheets were kept. · On 03/15/16, individual counseling related to the abuse incident was provided to Residents #1 and #88 as needed. · On 03/16/16, the DON provided staff that was currently in the building with a written description of the facility's abuse policy. · On 03/17/16, the DON began an all staff in-service on abuse prevention, types of abuse, how to report abuse and signs and symptoms of abuse as well as a video on resident abuse. The facility will continue to provide abuse education at every staff meeting, quarterly, and upon orientation, regarding recognizing burnout, frustrated or stressed employees, where the policy and procedure manuals are located as well as the facility policy on resident abuse. If an employee was unable to attend the in-service, they were provided verbal education over the phone and will be handed all information to review upon return to work. · On 03/17/16, Group Counseling Services were offered to all residents in the facility by an outside counseling service titled Unusual Incident Stress Debriefing Meeting. Individual counseling was offered in resident rooms, if unable to attend group counseling. · On 03/17/16 and 03/18/16, all 123 residents in the building had been interviewed by management staff including the DON, Registered Nurse (RN) #78 and Human Resource Staff (HRS) #72 for any abuse allegations and to ensure safety by asking if residents felt safe in the building. · By 03/18/16, all facility staff was in-serviced by the DON on the abuse policy including, after an allegation of abuse is made, the alleged perpetrator is to be immediately removed from the building. The in-service was completed in person or by phone. · On 03/18/16, education was completed by an outside risk management consultant for management staff on the investigation process to include completing a thorough abuse investigation. · The DON, Administrator, and other management staff will perform resident interviews once a month for three months then every 90 days for one year. The Quality Assessment and Assurance (QAA) committee will follow the resident interviews for one year until March 2017. Although the Immediate Jeopardy was removed on 03/18/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring and verifying the corrective action taken was effective. Findings include: 1) Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had a contracture to the right arm, had little function of the right side of the body, and was also taking [MEDICATION NAME] (a blood thinning medication.) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of eight which indicated some cognitive impairment. Review of the functional assessment revealed the resident was independent for eating, required set up of one person assist for dressing and personal hygiene and was a two person assist for bed mobility and transfers. Review of the facility SRI submitted on 03/12/16 and finalized on 03/14/16 revealed, on 03/12/16 at 10:45 A.M., the DON was notified that Resident #1 had an injury that appeared to have occurred after STNA #16 was in her room and provided care. After further investigation, it was determined STNA #16 did cause physical harm to Resident #1. Resident #1 was sent to the emergency room (ER) for evaluation and returned to the facility the same day. STNA #16 was removed from the facility and was currently in the custody of the police department. Based on the facility's investigation, the allegation was substantiated for physical abuse to Resident #1. Review of the written statement obtained by the DON from Resident #1 revealed the resident reported STNA #16 was rough with her, pinched her hand on the right side, punched both eyes and hit her head on the side rail of the bed on the left side. Resident #1 stated the STNA was mouthy, not nice and stated to the resident think of what I am going to do to you in the shower. Review of the written statement obtained by the DON from STNA #16 dated 03/12/16 revealed STNA #16 was working 6:00 A.M. to 2:00 P.M. on 03/12/16 and was designated as the spa tech that day. STNA #16 entered Resident #1's room and took the blankets off the resident. STNA #16 then checked and changed Resident #1. When STNA #16 was rolling Resident #1 side to side to change her, STNA #16 stated Resident #1 dumped a cup of water over. STNA #16 stated as she was rolling Resident #1 side to side the resident hit her head on the side rails, her right hand hit the bedside table and her ring cut her hand. Review of Resident #1's nursing note dated 03/12/16 documented at 3:08 P.M. revealed at 10:38 A.M., the nurse was in the supply room gathering supplies for treatments. Upon exiting, Licensed Practical Nurse (LPN) #37 stated you may want to go look at Resident #1, the shower aid just told me she has bruising on both eyes and a skin tear on her hand. The nursing note documented LPN #63 went to the resident's room and saw the resident lying in bed with bruising noted to the outer corner of both eyes and both outer corners were noted to have some swelling. The top and side below the thumb on the right hand was noted to have bruising and two skin tears were also noted. The note revealed the nurse asked what happened and the resident stated she beat me up. The nurse asked who beat you up? and the resident replied, The shower girl. At that time, STNA #16 entered the room and was told to go to the nurses' station and stay there. The resident was made safe and LPN #40 was notified to come to LPN #63 as soon as possible. No Neurological checks were initiated. The resident was given Tylenol for complaints of head pain and ice packs were applied to both eyes. The resident's shirt was torn down the right lower side with drops of blood noted on it. LPN #63 went to the nurses' station and approached STNA #16 to write a statement of what happened. The resident was sent to the ER for further evaluation and treatment. Review of Resident #1's nursing progress note dated 03/14/16 completed by the DON revealed social services was consistently meeting with Resident #1 to ensure the resident's emotional needs were being met. It was brought to the attention of the DON Resident #1 was having a difficult time sleeping. The resident was asked if it would help if she was provided with someone to sit with her at night to watch over her, and the resident told the DON she would like to have someone sit with her at night. On 03/15/16, the progress noted revealed in addition to social services, the DON requested the resident be seen by a licensed counselor to ensure the resident's emotional needs were being met and a referral was made. An interview on 03/16/16 at 12:00 P.M. with STNA #85 revealed STNA #85 was at lunch from 10:00 A.M. to 10:30 A.M. on 03/12/16. STNA #85 stated she returned from lunch and assisted the other aides on the floor with taking lunch orders. STNA #85 stated she passed STNA #16 in the hallway and STNA #16 stated to her Resident #1 ripped my shirt. STNA #85 then entered Resident #1's room and found the resident with both eyes swollen and bruised. STNA #85 also stated Resident #1 had two skin tears one V shaped and one that was a straight line on her right hand and the hand was bleeding. Resident #1 reported to STNA #85 that STNA #16 had dumped a glass of water in her face. STNA #85 observed STNA #16 being told to leave Resident #1's room and go to the nurse's station. STNA #85 confirmed no staff members accompanied STNA #16 to the nurse's station. STNA #85 stated STNA #16 was acting strange that day. STNA #16 was late to work that morning and was spacey and was talking on the cellphone during staff interaction. An interview on 03/16/16 at 12:30 P.M. with STNA #24 revealed she was walking down the hallway on the first floor and observed STNA #16 walking the opposite direction wearing only a tank top and scrub pants. STNA #24 stated she did not recognize the person and stopped her and asked her if she was an aide. STNA #16 responded that she was. STNA #24 stated STNA #16's face was red and she looked funny. STNA #24 stated she then heard about the incident involving Resident #1 and she was so mad at STNA #16 that she left the floor and went outside to keep from hitting her. STNA #24 stated while outside, STNA #16 came outside alone. STNA #24 stated she then went back into the building. An interview on 03/16/16 at 2:18 P.M. with Police Officer (PO) #600 revealed he arrived at the facility on 03/12/16 and took a report from Resident #1 and her family. PO #600 stated he interviewed STNA #16 on 03/14/16 while she was in the custody of another county jail as STNA #16 was arrested for assault, robbery and receiving stolen property in an unrelated incident. PO #600 stated at that time the case against STNA #16 involving Resident #1 was currently with the local county prosecutor's office and would most likely result in STNA #16 being charged with felony assault on Resident #1. An interview on 03/16/16 at 2:45 P.M. with LPN #63 revealed LPN #37 informed her STNA #16 had reported Resident #1 had bruises around her eyes and she should go look. LPN #63 stated she immediately went to Resident #1's room and found the resident with bruising on the outside corners of the eyes and swelling to both eyes. LPN #63 further stated Resident #1 had bruises and two skin tears to her right hand. LPN #63 asked Resident #1 what happened and the resident replied she beat me up. LPN #63 stated the resident answered it was that girl. LPN #63 stated at that moment, STNA #16 entered Resident #1's room and the resident pointed and said her. STNA #16 replied I didn't beat her up. LPN #63 asked STNA #16 how she got the skin tear on her right hand and STNA #16 stated she was turning her. LPN #63 then told STNA #16 to leave the room and go to the nurse's station. LPN #63 verified STNA #16 left the room and was not accompanied by any staff member. LPN #63 assessed Resident #1 and then exited the room to call the clinical coordinator on another floor. LPN #63 stated she had STNA #16 sit at the nurses station and write a statement. LPN #63 stated after the DON arrived she was not sure where STNA #16 was. LPN #63 stated STNA #16 was acting weird that day and she was 45 minutes late to work that morning. An interview on 03/16/16 at 3:22 P.M. with STNA #128 revealed STNA #16 came and got her and asked for help with Resident #1. STNA #128 stated she entered Resident #1's room and noticed the bruises around the resident's eyes and her right hand was bleeding. Resident #1 told STNA #128 she hit me, she punched me. STNA #128 stated STNA #16 stated it happened when she turned Resident #1. Resident #1 was agitated with STNA #16 being in the room and at that time LPN #63 entered the room and had STNA #16 go to the nurse's station. After leaving Resident #1's room STNA #128 stated she saw STNA #16 walking down the ramp towards the outside door. STNA #128 asked STNA #16 what she was doing and she stated clocking out. STNA #128 did not see STNA #16 after that. STNA #128 stated Resident #1 was visibly upset and the next day was scared to take a shower until she was told STNA #16 was no longer in the building. An interview on 03/16/16 at 3:59 P.M. with STNA #18 revealed STNA #16 approached her in the hallway and stated I need help with Resident #1. STNA #18 stated let's get STNA #128 to help and then STNA #16 stated Resident #1 had skin tears on her hand and black marks on the corners of her eyes. STNA #18 stated STNA #16 had a hole in her tank top. STNA #18 went towards Resident #1's room and LPN #63 was there so she continued down the hall to another resident's room. STNA #18 stated she was then asked to go find STNA #16 but was unsure of what time that happened. STNA #18 stated she went to go outside to find STNA #16 and found her coming back in the building unattended. STNA #18 stated she then entered Resident #1's room to assist STNA #85 and change Resident #1's shirt which was ripped and had blood on it. STNA #18 stated Resident #1 was wet and a bloody pillowcase was found in a linen bag on the resident's floor. An interview on 03/16/16 at 4:20 P.M. with Resident #1 revealed STNA #16 had hit her in the face like a man. Resident #1 stated her fist was closed when she hit her. Resident #1 stated she had some trouble sleeping at night but a staff member had been sitting with her at night and it made her feel better. Resident #1 was unsure why STNA #16 hit her. An interview on 03/16/16 at 4:25 P.M. with Family Member (FM) #200 revealed she was notified by her brother of Resident #1's assault. FM #200 stated she arrived at the facility and went directly to Resident #1's room. FM #200 stated she wanted the facility to call the police and take her to the hospital. FM #200 stated at that time the facility notified the police and made arrangements for the resident to be evaluated at the local ER. An interview on 03/17/16 at 8:22 A.M. with the DON revealed she was notified of a resident who may have been injured. The DON stated she was near the facility and came directly to the facility. The DON stated she interviewed LPN #63 and LPN #63 had told her Resident #1 had been assaulted by STNA #16. The DON was notified of the injuries and then asked where STNA #16 was. The DON located STNA #16 outside and had her go to her office to conduct an interview. The DON stated STNA #16 was wearing a tank top with blood and saliva on it along with a hole on the left side. The DON stated she asked STNA #16 to write a statement. She stated STNA #16 was not writing legibly and was talking fast so the DON asked STNA #16 what happened and wrote the statement down for the STNA. The DON stated STNA #16 was in Resident #1's room alone and the resident was a two person assist with bed mobility and transfers. The DON stated STNA #16 should not have been in the room alone. The DON stated STNA #16's story changed several times and was inconsistent. The DON stated STNA #16 told her she had injured the resident by banging her head on the side rails when she turned her during incontinence care. The DON stated she then made sure STNA #16 left the property. The DON stated she interviewed Resident #1 several times. She stated the resident was consistent in her story and she felt the abuse did occur how the resident said it did. The DON stated the resident had been assessed with [REDACTED]. The DON verified the resident had been fearful after the incident so a staff member was sitting with her at night. An interview on 03/17/16 at 9:03 A.M. with LPN #40 revealed she was notified via text LPN #63 needed assistance as soon as possible. LPN #40 stated she went down to the first floor and found STNA #24 yelling at STNA #16 she should kill her and she should call the police. LPN #40 instructed STNA #24 to take a break and STNA #24 left the floor. LPN #40 then spoke with LPN #63 and went to Resident #1's room to assess the resident. After interviewing the resident, LPN #40 exited the room to call the DON. LPN #40 stated STNA #16 was sitting at the nurse's station writing a statement. LPN #40 then saw STNA #16 outside smoking. LPN #40 confirmed STNA #16 was not being watched by a particular staff member and was going in and out of the building. LPN #40 stated STNA #16 appeared disheveled as her hair was messy and she was not wearing any makeup which was not her normal appearance. An interview on 03/17/16 at 9:41 A.M. with LPN #37 revealed Resident #1 was not her assigned resident. LPN #37 stated on 03/12/16 STNA #16 was late to work that morning. LPN #37 further stated STNA #16 had approached her and asked her if she could remove her scrub top and wear a tank top in the shower room. LPN #37 stated when she observed STNA #16 in the nurse ' s station writing her statement she was acting odd and was scribbling and writing big. LPN #37 also stated STNA #16 was talking out loud to herself. LPN #37 then stated STNA #16 got up and said she was going out to smoke. LPN #37 stated STNA #16 then left the nurses station unaccompanied. An interview on 03/17/16 at 10:20 A.M. with the DON verified a thorough investigation was not completed and Resident #1's primary nurse, LPN #63 on 03/12/16, was not interviewed and a statement was not taken. 2. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #88's Activities of Daily Living (ADL) care plan dated 10/20/15 revealed the resident required extensive assistance with hygiene and showers. Review of the MDS 3.0 assessment completed on 01/05/16 revealed the resident's BIMS was a 14 indicating the resident was cognitively intact. The resident was assessed as requiring assistance of one person for dressing and toileting. Review of the written statement completed by Registered Nurse (RN) #78 from Resident #88 dated 03/12/16 revealed the resident was interviewed by RN #78 regarding the investigation of STNA #16. Resident #88 stated STNA #16 completed his shower on 03/12/16. Resident #88 further stated STNA #16 was testing the water temperature on him and was freezing him to death. Resident #88 also stated STNA #16 was flighty and hyper. An interview on 03/17/16 at 11:45 A.M. with Resident #88 revealed on 03/12/16 STNA #16 assisted him with a shower. Resident #88 stated STNA #16 pushed him quickly in his wheelchair to the shower room. STNA #16 then tested the water temperature on his skin. Resident #88 stated he asked for the nurse to come into the shower room and adjust the water temperature. Resident #88 stated he felt abused by STNA #16 testing the water temperature on him. An interview on 03/17/16 at 12:07 P.M. with the DON revealed she was aware of the incident involving Resident #88 and STNA #16. The DON verified she only interviewed the resident and did not report the incident to the Ohio Department of Health. Further interview revealed the DON confirmed the facility policy was to thoroughly investigate any allegations of abuse and report the investigations to the Ohio Department of Health. The DON also confirmed there was no facility staff responsible for staying with STNA #16 while they were awaiting the DON arrival. Review of the facility policy, titled Abuse Prevention Program dated 01/02/14, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator Review of the facility policy, titled Protecting Residents during Abuse Investigations dated 01/02/14, indicated The facility will protect residents from harm during investigations of abuse allegations. During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the Administrator. Review of the facility policy, titled Abuse Investigation dated 01/02/14 revealed All reports of resident abuse, mistreatment, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will include interviews of staff members who have had contact with the resident during the period of the alleged incident and also interview other residents to whom the accused employee provides care and/or services to. Review of the facility policy, title Reporting abuse to the state agencies dated 01/02/14 revealed all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. This deficiency substantiates Complaint Number OH 094.

Based on observations, record review, resident and staff interview, and facility policy review, the facility failed to prevent potential abuse for three residents, resulting in psychosocial harm for Resident #34 when Resident #166 displayed behaviors towards these residents. This affected three (Resident #34, Resident #47, and Resident #136) of 39 residents residing on unit 2 East. The facility census was 128. Findings include: Review of the clinical record for Resident #34, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the clinical record for Resident #47, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the social service note, dated 12/13/13, revealed Resident #47 becomes easily agitated when other residents wander in her room, yelling out at them. Review of the clinical record for Resident #136, admitted [DATE], revealed [DIAGNOSES REDACTED]. Nurses notes revealed Resident #136 was unable to make her needs known, and speech was rare. Review of the clinical record for Resident #166, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident was moderately cognitively impaired and exhibited physical behavioral symptoms directed towards others daily, verbal behavioral symptoms directed towards others one to three days a week, other behavioral symptoms not directed towards others daily, and wandering daily. Review of the hospital documentation prior to admission to the facility, dated 04/18/13, revealed Resident #166 had an incident at his prior facility which included attempting to physically fight another resident and throwing a walker at an aide. The documentation also revealed continued wandering, including out of his current facility at night. Review of the initial care plan from admission for Resident #166 revealed no behavior symptoms, and no wandering. Review of the care plan for a self-care deficit related to sexual behaviors, among others, revealed interventions including redirection and teaching the resident that sexual behaviors are inappropriate. Review of the care plan for the need for 24 hour supervision due to wandering and sexual behaviors revealed interventions including giving medications as ordered, educating on inappropriate behaviors and praising for appropriate behaviors. Review of the care plan for wandering includes interventions such as monitoring for changes and updating the physician and redirecting during wandering episodes. Review of the care plan for aggressive behaviors revealed interventions including attempt distraction techniques, use a calm demeanor, and one on one as needed. Review of the physician orders [REDACTED]. Orders revealed this medication was discontinued on 05/08/13, two days after admission, and [MEDICATION NAME] and Depo-[MEDICATION NAME] were started, both to control sexual behaviors. On 09/04/13, the [MEDICATION NAME] and Depo-[MEDICATION NAME] were decreased by half, and on 11/06/13, the Depo-[MEDICATION NAME] was again decreased by half. Orders also revealed Resident #166 was receiving [MEDICATION NAME] to control other behaviors. On 11/18/13, the physician wrote a new order for 15 minute checks on the resident while he is awake and wandering; the facility had no documentation those checks were done. Review of the mood/behavior tracking sheets for August, September, and November 2013 revealed Resident #166 had behaviors of wandering daily, and grabbing, cursing, pacing, and rummaging on various days when tracked. Review of the Behavior/Interventions Monthly Flow Record for May 2013 through October 2013 revealed numerous episodes of sexual behavior, no specific behaviors noted on the tracking sheet or the nurses notes, with interventions effective about half the time. Review of the November 2013 tracking revealed staff also began to track agitation as well as sexual behaviors. Numerous episodes of both types were documented, with interventions being less effective after the most recent decrease in medication. Review of the nursing notes revealed an increase in wandering behaviors in and out of other resident's rooms since admission. The notes revealed multiple occasions where Resident #166 was physically abusive to staff members, including on 05/29/13 when he held a state-tested nursing assistant (STNA) by the upper arm, repeatedly punching her in the chest, and on 08/02/13, when he grabbed a STNA by the arm and punched her in the throat. There are no nursing notes corresponding to documented episodes of sexual behaviors from the tracking flow record. Review of the most recent MDS progress note revealed Resident #166 continued to receive [MEDICATION NAME] for behaviors and [MEDICATION NAME] and Depo-[MEDICATION NAME] for sexual behaviors. The note also revealed the resident was to have 15 minute checks completed while he was awake and wandering. Review of the social service notes revealed on 05/16/13, Resident #166 was noted to have had many episodes of inappropriate behaviors including inappropriate sexual comments and increased wandering. He was noted to be on medications for [MEDICAL CONDITION]. On 09/07/13 the social service note revealed Resident #166 had a decrease in his [MEDICATION NAME] and Depo-[MEDICATION NAME] and that " his sexual behavior will need to (be) monitored to see if they increase with decrease in medications ". [MEDICATION NAME] was noted at that time for behaviors. The note on 12/09/13 revealed Resident #166 had a decrease in his Depo-[MEDICATION NAME] and remained on the [MEDICATION NAME] for behaviors. Continued pacing and wandering in other resident's rooms was noted. On 12/16/13 during the initial tour, an observation on the 2 East locked dementia unit revealed Resident #166 wandering into female resident rooms unattended, including sitting in Resident #76's bed while she lay in it asleep. Facility staff was not present at that time, and did not remove Resident #166 until approximately five minutes after he entered the room. On 12/17/13 at 11:05 A.M., an observation revealed Resident #166 wandering into Resident #47's room, unsupervised. Resident #47 began screaming fearfully at Resident #166 to get out of her room, threatening to hit him if he came close to her. Staff then responded and attempted to redirect Resident #166 from the room. On 12/17/13 at 1:52 P.M., Resident #166 was observed wandering into Resident #136's room unsupervised. At 1:57 P.M., an observation of that room revealed Resident #166 in the doorway, wearing no pants. Facility staff was alerted at that time, redressed Resident #166, and removed him from that room. When questioned after the incident, Resident #136 was unable to respond. On 12/17/13 at 3:25 P.M., an observation revealed Resident #166 wandering in and out of other resident rooms unsupervised, including Resident #76's room, while she slept in the bed. On 12/17/13 at 1:57 P.M., a staff interview with STNA #38 revealed Resident #166 took off his clothes a lot. She revealed Resident #136 was totally dependent on staff for care and was unable to talk or call out if she needed help, such as when Resident #166 was undressing in her room. On 12/17/13 at 2:17 P.M., a staff interview with STNA #91 revealed Resident #166 had a normal behavior of taking off his pants and sometimes his depends, either in the hallway or in resident rooms. She was unaware of any sexual behaviors he had, nor of the ordered 15 minute checks. On 12/17/13 at 2:21 P.M., a staff interview with STNA #12 revealed Resident #166 does take his pants off and will wander into every resident's room. She revealed he is not always easily redirected and has laid in bed with male and female residents. She explained that other residents get upset when he wanders into their rooms, although quite a few residents on the unit cannot speak out or call for help if he wanders into their rooms. Regarding the order to check on Resident #166, STNA #12 revealed if the staff did not see him for " awhile, " they go see where he was and check on him. On 12/17/13 at 2:55 P.M., a staff interview with licensed practical nurse (LPN) #103 revealed she did not know what sexual behaviors were being tracked for Resident #166. She was unaware of any behaviors Resident #166 displayed, other than wandering. On 12/17/13 at 3:14 P.M., a staff interview with LPN #24, Resident #166's nurse, revealed sexual behaviors including grabbing at staff and tying to kiss staff. She was unaware if he displayed these behaviors toward residents, but verified he did wander in and out of resident rooms unsupervised by staff. LPN #24 revealed a majority of the residents residing on 2 East unit could not call for help if bothered by Resident #166. She explained that his 24 hour supervision care plan meant staff should be aware of where he is and do 15 minute checks on him. She also revealed that aide staff did not know why he needed supervision; the [DIAGNOSES REDACTED]. On 12/17/13 at 4:07 P.M., a staff interview with RN #132 revealed 24 hour supervision meant eyes on the resident frequently but staff did not document this in the chart. She revealed the nursing staff does not communicate [DIAGNOSES REDACTED]. She revealed staff relied on verbal reports for supervisor and physician notification. RN #132 revealed she had not been notified Resident #166 had been undressing in other resident rooms. On 12/17/13 at 4:12 P.M., the DON revealed the facility was not aware of what sexual behaviors Resident #166 had prior to entering the facility and that he was sent to the facility due to increased wandering and his need for a secured unit. On 12/17/13 at 4:37 P.M., an interview with Resident #166's family member revealed his prior behaviors included asking staff to marry him and then asking them to have sex with him. She was unaware of any physical behaviors Resident #166 had, and explained his increased wandering required he be transferred to the facility's locked unit. She was unaware of his increased behaviors such as undressing or laying in other resident's beds, or the care plan requiring 24 hour supervision. She explained Resident #166 had not received a psychiatric consult while a resident at the facility. On 12/17/13 at 6:14 P.M., a staff interview with LPN #85 revealed she has previously found Resident #166 in other resident's beds. She has heard other residents screaming at Resident #166 to get out of their rooms. On 12/17/13 at 6:30 P.M., an interview with Resident #34, a cognitively intact resident residing on unit 2 East, revealed she woke up one morning (she was unsure of date) and Resident #166 was standing over her with his pants unzipped, and then he sat in her bed. She revealed staff was not supervising Resident #166 and did not respond to her call light or cries for help during that incident. She revealed she was "sacred to death" of Resident #166 and that he always wanders in her room. When she alerts staff, they tell her they can't do anything about him because he "does not know what he is doing". Review of the nursing notes revealed no documentation of Resident #34 reporting the above incident to staff. On 12/18/13 at 9:05 A.M., an interview with the medical director revealed he was aware of Resident #166's wandering and repetitive behaviors such as counting, but that staff had not reported behaviors of undressing, lying in bed with residents, or unzipping his pants in female resident rooms. He was also unaware of the incident that occurred on 12/17/13 with Resident #166 and Resident #136. His expectations would be for the aide staff to report incidents such as that to the nursing staff. Review of the facility "Abuse Prevention Program" policy, dated 08/12/09, revealed the facility had procedures to identify occurrences and patterns of potential abuse, should timely and thoroughly investigate all reports and allegations of abuse, and protect residents during abuse investigations. The Director of Nursing confirmed the policy was not specific in how staff was to implement those things on 12/18/13.