Every finding on record at White Oak Manor

Based on medical record review, resident and staff interview and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#26) of one resident reviewed for medication administration. The facility census was 29. Findings include:Record review for Resident #26 revealed an admission date of 03/04/16 with diagnoses including acute embolism and thrombosis of deep veins of left upper extremity, traumatic subdural hemorrhage, laceration without foreign body of scalp, Type II diabetes, generalized anxiety disorder, and unspecified fall.Review of the physician's order dated 06/03/26 revealed Resident #26 was ordered Humalog Kwik Pen subcutaneous solution pen-injector 100 unit/milliliter (ml) (insulin lispro) inject per sliding scale subcutaneously after meals and at bedtime related to Type II diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for July 2026 revealed no evidence Resident #26's blood sugar was checked to determine if Humalog needed to be administered according the the sliding scale on 07/05/26, 07/06/26, and 07/10/26 for the 2:00 P.M. dose. Further review revealed no evidence the resident's blood sugar was checked to determine if Humalog needed to be administered according to the sliding scale on 07/13/26 for the 9:00 P.M. dose. Review of the nursing progress notes from 07/05/26 through 07/13/26 revealed no documentation indicating a reason Resident #26's blood sugar was not checked, and the corresponding sliding scale Humalog dose was not administered on 07/05/26, 07/06/26, 07/10/26 and 07/13/26. Interview on 07/16/26 at 8:55 A.M. with Resident #26 revealed the facility did not always check her blood sugar levels or administer her insulin.Interview on 07/16/26 at 3:30 P.M. with the Administrator verified there was no evidence Resident #26's blood sugar levels were checked, and the corresponding sliding scale dosage of Humalog was administered on 07/05/26, 07/06/26, 07/10/26 and 07/13/26 per physician order. Review of the facility policy titled, Medication Administration, dated 04/01/26, revealed medications were to be administered as ordered by the physician. Further review revealed nurses were to sign the MAR after administration. For those medications requiring vital signs, record vital signs onto the MAR. This was an incidental finding discovered during the complaint investigation.

Based on observation, staff interview, and policy review, the facility failed to maintain a comfortable homelike environment in good repair. This had the potential to affect all 32 residents residing in the facility. The census was 32. Findings include:1. Observation on 04/21/26 at 10:45 A.M. revealed three burnt out ceiling hallway lights from room [ROOM NUMBER] until the end of the 300-hallway. The end of the hallway was darker than the rest of the hallway. Interview with Licensed Practical Nurse (LPN) #447 and Maintenance Director #417 at the time of the observation confirmed the three burnt out ceiling lights starting outside room [ROOM NUMBER] and extending to the end of hallway 300, making the end of the hallway darker than the rest of the hallway. 2. Observations on 4/22/26 between 9:06 A.M. to 9:20 A.M. during a tour with the Administrator revealed a hole, approximately three inches in diameter the wall on the left of the reception window, dark scuff marks across on the Administrator's door, scuff marks across the doors of occupied resident rooms 104, 105, 110, 111, 113, 114, and 116, missing paint and chipping paint on the door of occupied resident rooms [ROOM NUMBERS], a hole in the wall to the left side of the conference room door -scuff marks across the central bathing door on hall 100, the pillars in the main dining room by the east 200 unit having peeling paint, with the lower half of the pillars covered with scuff marks, the nurse's station by the west wing of the 200 unit is missing baseboards and the walls look like the paint has been pulled off, closet door on the west 200 unit with multiple scuff marks, the heating unit in Resident #23's had no cover, the kitchenette door entering the 300 unit with multiple scuff marks all over the lower half of the door, and dark scuff marks on occupied resident rooms [ROOM NUMBER].Interview with the Administer at the time of the tour verified the building was in general disrepair, stating all the doors and walls being scuffed are caused by resident wheelchairs. The Administrator stated approximately two months ago the building was bought out and with the change of leadership comes changes in the priorities and procedures. The Administrator also stated the Maintenance Director is fairly new and that he is trying to get him on board as far as prioritizing repairs needed for the building.Interview on 04/22/26 at 10:40 A.M. with Maintenance Director #417 verified the entire building was in the need of paint. Review of the Safe and Homelike Environment policy dated 02/01/26 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The Safe and Homelike Environment policy defines orderly as an uncluttered physical environment that is neat and well kept. Furthermore, section six of the policy indicated that the facility would provide and maintain adequate and comfortable lighting levels in all areas with even light levels utilized in common areas and hallways to avoid patches of low light. The policy also stated any unresolved concerns should be reported to the Administrator. This deficiency represents non-compliance investigated under Master Complaint Number 2809313, Complaint Number 2747524 and Complaint Number 2738046.

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure medications were stored in a safe and secure manner when the medication cart was left unlocked in the facility. This had the potential to affect 20 residents (#1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #13, #14, #15, #17, #19, #20, #22, #23, #24, and #25) residing in the facility, as the facility identified nine residents as immobile (Residents #6, #12, #16, #18, #21, #26, #27, #28, and #29). Also, the facility failed to ensure medications were not removed from original labeled packaging and pre-poured prior to administration to residents. This affected four residents (Resident #1, #7, #8 and #16) of four residents reviewed for medication administration. The facility census was 29. Findings include: 1. On 01/28/26 at 8:55 A.M., an observation revealed a medication storage cart labeled 100/300 Halls was unlocked. The medication cart was located in an open hallway in front of the nurses' station and was unattended at the time of the observation. An interview on 01/28/26 at 8:56 A.M. with the Assistant Director of Nursing (ADON) #144 confirmed the medication cart was unlocked and stated the cart was required to be locked when unattended. A review of the facility policy titled Storage of Medication, dated 04/2007, revealed the facility policy stated all drugs and biologicals to be stored in a safe, secure, and orderly manner. The policy further stated nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary condition. The policy specified that compartments including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals must be locked when not in use, and carts or trays used to transport medications must not be left unattended if open or otherwise accessible. 2. Review of the medical record revealed Resident #1 was admitted on [DATE] with significant diagnoses including epilepsy. Physician orders included Phenobarbital 32.4 milligram (mg), take one tablet by mouth one time daily for seizure control. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, had a seizure disorder and received anticonvulsant medications. Review of the care plan dated 12/03/25 identified Resident #1 had a seizure disorder with interventions to administer seizure medications as ordered. 3. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses including localization-related idiopathic epilepsy and epileptic seizures. Physician orders included Phenobarbital 64.8 mg, give one tablet by mouth twice daily for seizure control. Review of the MDS assessment dated [DATE] revealed Resident #7 was cognitively intact, and received anticonvulsant medications. Review of the care plan dated 01/12/26 identified Resident #7 had altered neurological status secondary to seizure disorder with interventions to administer medications as ordered. 4. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses including chronic cholecystitis, psychoactive substance abuse, muscle weakness, and difficulty walking. Physician orders included Tramadol 50 mg, give one tablet by mouth every six hours as needed for pain. Review of the MDS assessment dated [DATE] revealed Resident #8 was cognitively intact and used opioid pain medications. Review of the care plan for Resident #8 dated 01/06/26 addressed altered comfort related to pain, difficulty walking, and muscle weakness, with interventions to administer medications as ordered. 5. Review of the medical record revealed Resident #16 was admitted on [DATE] with a diagnosis of opioid dependence in remission. Physician orders included Buprenorphine HCl-Naloxone (Suboxone) 8-2 mg, one tablet sublingually daily for history of substance abuse. Review of the MDS assessment dated [DATE] revealed Resident #16 was cognitively intact and received opioid medications. Review of the care plan for Resident #16 dated 11/05/25 identified Suboxone therapy related to substance abuse history, with interventions to administer medications as ordered. On 01/28/26 at 8:30 A.M. an observation of the medication pass revealed a clear plastic medication cup labeled with Resident #1's name contained a single pill and was sitting on top of the medication cart. Licensed Practical Nurse (LPN) #115 identified the pill as Resident #1's phenobarbital. A second clear medication cup labeled with Resident #7's name contained a single pill and was sitting on top of the medication cart. LPN #155 identified the pill as Resident #7's phenobarbitol. A third clear medication cup labeled with Resident #8's name contained a single pill and was sitting on top of the medication cart. LPN #115 identified the pill as Resident #8's tramadol. A fourth clear medication cup labeled with Resident #16's name contained a single pill and was sitting on top of the medication cart. LPN #115 identified the pill as Resident #16's Suboxone. LPN #115 verified she had pre-poured Resident #1, #7, #8 and #16's medications at one time into the medication cups so she did not have to keep going back and forth into the narcotic drawer for each resident during the medication pass. An interview on 01/28/26 at 1:30 P.M. with the Director of Nursing confirmed medications were not to be pre-poured prior to administration to each resident. An interview on 01/28/26 at 1:34 P.M. with LPN #115 revealed she routinely prepared all narcotics before beginning her medication pass to avoid repeatedly accessing the locked narcotics drawer. LPN #115 stated she believed this practice was acceptable because the medication cups were labeled with the resident names. Review of the facility policy titled Medication Administration, dated 08/22/22, revealed medications are to be administered in accordance with professional standards of practice. The policy requires medications to be removed from their source immediately prior to administration, administered as ordered, and observed for resident consumption. This deficiency represents non-compliance investigated under Complaint Number 2667734.

Based on observation, record review, review of a facility self-reported incident (SRI) investigation, review of police reports, review of the Emergency Medical Services (EMS) run report, review of hospital documentation, review of facility policy, and interviews, the facility failed to provide adequate supervision to prevent Resident #16, who was cognitively impaired, aphasic and at risk for elopement (with use of a WanderGuard device) from eloping. This resulted in Immediate Jeopardy and the potential for Actual Harm, serious physical injury or death on [DATE] when 911 dispatch for the local police department received a 911 call from a passerby in the community with concerns for an unattended individual. The individual, identified to be Resident #16 was found by the police, coming out of the woods and falling into a ditch in a residential area that was 0.6 miles from the facility. The resident was noted to be confused and wearing a monitor device on his ankle which prompted the police to check with the facility to see if they had a missing resident, as the resident could give no details and had no identification on him. Resident #16 was subsequently transferred from the scene to a local hospital for treatment of hypotension (low blood pressure) and was stabilized after resuscitation with intravenous fluids. Resident #16 returned to the facility on [DATE] and his WanderGuard remained in place. On [DATE] during the onsite investigation it was identified the facility WanderGaurd system was not functioning properly because an unknown person was entering a master override code into the system that was disarming the WanderGaurd system which placed Resident #16 and other residents at risk of accidents/hazards pertaining to elopement. The facility identified five residents (#4, #13, #16, #22, and #26) as at risk for elopement. The facility census was 32. On [DATE] at 3:34 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #349 were notified Immediate Jeopardy began on [DATE] when Resident #16, exited the facility without staff knowledge and was found 0.6 miles away from the facility in a ditch by the police department. The facility was not aware Resident #16 was missing from the building until the police arrived at the facility for identification of Resident #16. Resident #16 was subsequently transported to the emergency room by Emergency Medical Services (EMS) who arrived at the scene, received testing and treatment with intravenous (IV) fluid and then returned to the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action. On [DATE] at approximately 5:50 P.M. Regional Director of Clinical Services (RDCS) #349 completed an elopement assessment on Resident #16 and reviewed the resident's elopement risk care plan. On [DATE] Resident #16 returned to the facility from the hospital. Pain assessment, skin assessment, neurological checks through [DATE] were initiated and charted in the resident record. On [DATE] the ADON and SSD reviewed elopement assessments on 32/32 residents to ensure all current residents had elopement assessments in the last quarter. One new Resident (#13) identified at risk for elopement and wander guard placed and resident added to elopement binder. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Nurse Practitioner (NP) #351 and the DON to discuss the elopement incident, interventions initiated and plan of care. On [DATE] the Administrator and Maintenance Director completed an elopement drill on first shift. On [DATE] the Ohio Department of Health surveyor and Maintenance Director identified the wander guard system was not functioning as designed. At 4:15 P.M. the DON was notified and placed staff for door supervision. Secure Care company was notified at 5:00 P.M. by the Administrator. On [DATE] at approximately 10:00 A.M. Secure Care company arrived to inspect the wander guard system and determined a universal code, which was a separate code from the new code was being entered by unidentified staff that was overriding the system which caused the wander guard system to not alarm. On [DATE] the Administrator and RDCS #349 determined the root cause of the elopement was a universal over-ride code was being used by staff instead of the new door code that was changed on [DATE]. The universal override code, when entered into the keypad to open the secured doors, would disable the wander guard system. On [DATE] all facility door codes were changed including a change of the master override code by Administrator. The master override code would be privy to only the Administrator and Maintenance Director. On [DATE] facility staff completed a headcount to ensure all 32/32 residents were accounted for. On [DATE] 42/43 staff (2/2 Activities Staff, 14/15 Certified Nursing Assistants (CNAs), 8/8 Dietary Staff, 6/6 Housekeeping Staff, 3/3 Licensed Practical Nurses (LPNs), 2 Registered Nurses (RNs), and 7 administrative staff including the DON, ADON, Administrator, Human Resources, Social Services and Medical Records) were educated on the new facility door code, the elopement policy, and the abuse/neglect policy. One CNA was not able to be educated due to leave of absence and would receive education by the DON/designee upon return to work. Two agency staff were also provided with education, and all agency staff would receive education by the DON/designee prior to working in the facility. All new hires would be educated by the Maintenance Director during orientation process. On [DATE] a repeat door audit was completed by the Administrator to ensure all doors and alarms were functioning. On [DATE] at approximately 6:30 P.M. the ADON completed a wander guard audit on five of five residents with wander guards. On [DATE] the ADON and DON reviewed 32/32 residents elopement risk scores for accuracy. On [DATE] at approximately 7:00 P.M. the facility interdisciplinary team completed an elopement drill. On [DATE] at approximately 7:30 P.M. the SSD completed review of the elopement book to ensure all residents at risk were in binder. On [DATE] at 6:45 P.M. an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held via phone with the Medical Director, DON, ADON, RDCS #349, the Administrator, Human Resources, Maintenance Director, Social Services Director and Medical Records to review steps taken for the facility removal plan. On [DATE] auditing was initiated to include the DON/Designee to complete audits on all residents with wander guards daily for two weeks then weekly for two weeks to ensure proper placement and functioning. Maintenance Director/Designee to complete door alarm audit with emphasis on secure care alarms to ensure appropriate functioning daily for one week then five times per week for three weeks. One-to-one staff monitoring of the doors would be implemented if the alarms would be identified as not working as should. Beginning on [DATE] audits would be conducted daily for one week then five times a week for four weeks to ensure no behaviors related to wandering or elopement have occurred. Findings would be addressed if indicated. Beginning on [DATE] elopement drills would be conducted one each shift by the Administrator, Maintenance Director or designee and then weekly for four weeks. Results of facility audits would be forwarded to the QAPI committee for review and recommendations. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on going compliance. Findings include:Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, aphasia, cardiac arrhythmia, muscle weakness, lack of coordination, hypertension, dementia with behavior disturbance, difficulty walking, need for assistance with personal care, bilateral cataract, and schizoaffective disorder.Review of the comprehensive care plan, date initiated [DATE], revealed Resident #16 was at risk for falls due to multiple sclerosis and at risk for elopement/wandering related to dementia and impaired cognition. Interventions for falls included to keep a clear pathway and keep a call light in reach. Interventions for risk for elopement included to include family conference to discuss resident's attempts to leave, involve Resident #16 in activities of choice, orient Resident #16 to new surroundings and provide psychoactive medication as ordered, WanderGuard, allow one-on-one to vent feelings, assess risk factors according to facility procedures, attempt to involve Resident #16 in decision making, follow facility elopement procedures, monitor and report changes in behavior such as restlessness and pacing, monitor for medication side effects, provide diversional activities and redirect as needed. The resident was to reside on a secured unit for safety. The care plan was last reviewed on [DATE] and there were no dates of revision listed on the care plan for elopement risk since initiated on [DATE].Review of the facility document titled Weekly Risk Meeting, dated [DATE], revealed the facility had concerns regarding Resident #16's decreased cognition. The facility moved Resident #16's room and asked the physician for a WanderGuard (a technology designed to prevent residents at risk of wandering from leaving secured areas using an audible alarm when a resident approached an area equip with the WanderGuard system).Review of physician's orders dated [DATE] revealed an order for Resident #16 to have a WanderGuard to left ankle, check placement, skin and function every shift.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 had adequate hearing, unclear speech/mumbling or slurred words, was sometimes able to express himself and understand others, impaired vision requiring large print, used corrective lenses and was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 01 (out of 15). The assessment revealed Resident #16 had no behaviors and did not wander.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16's cognition was moderately impaired. A Brief Interview of Mental Status (BIMS) score was not available. The assessment revealed wandering behavior was not exhibited. Resident #16 did not need a mobility device such as a cane, walker, or wheelchair. Resident #16 was independent to walk 150 feet in a corridor or similar space.Review of the facility documents titled Elopement Risk Screen, dated [DATE] and [DATE], revealed Resident #16 was disoriented, independent for mobility, had not attempted to leave the facility and was not at risk for elopement.Review of Resident #16's Treatment Administration Records (TARs) dated [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE] and [DATE] to [DATE] revealed a physician order dated [DATE] for WanderGuard to left ankle, check placement and function each shift twice a day. Resident #16's Wanderguard was checked during the morning and evening shifts on 27 of 30 days in [DATE] of 31 days in [DATE] of 31 days in [DATE] and 26 of 29 days in [DATE].Review of a nursing note dated [DATE] at 4:50 P.M. authored by RN #335, revealed the facility was informed by local police department (name provided) that Resident #16 was found on Wick Street and transported to local hospital (name provided) emergency room for evaluation. Resident #16 had unknown pain or injuries known at that time. Awaiting lab results and electrocardiogram (EKG) results. Physician #350 was aware, and all responsible parties were aware.Review of the facility document titled Elopement Risk Screen, dated [DATE], revealed Resident #16 was disoriented, independent for mobility, wanders throughout facility or prior residence but does not leave interior setting, had a prior history of elopement and was at risk for elopement.Review of a local police department report incident number 25-19485 dated [DATE] revealed local dispatch received a wireless 911 call at 4:33 P.M. that a man fell in a ditch, came out of the woods and required an officer to come out. The address was 2615 Wick Street, [NAME], Ohio 44484. The caller stated they did not know the man. Police officer #353 was dispatched to the scene at 4:43 P.M. and arrived at 4:50 P.M. Emergency Medical Services (EMS) were dispatched at 4:53 P.M. and arrived on scene at 5:03 P.M. At 5:10 P.M. Police Officer #353 indicated to dispatch that the man may have wandered over here from [NAME] Oak off of Ridge/heading over there to see if I can ID (identify) him. At 5:17 P.M. Police Officer #353 identified Resident #16 by name and date of birth . EMS had taken Resident #16 to the local hospital for an evaluation.Review of Google Maps indicated the distance between the facility and the location where Resident #16 was found on [DATE] at 4:33 P.M. was 0.6 miles from the facility.Review of the weather conditions on [DATE] via wunderground.com (a historical archive of weather conditions) between 4:00 P.M. to 5:00 P.M. the environmental temperature ranged between 85 to 87 degrees Fahrenheit (F) and was mostly cloudy with no precipitation.Review of the EMS Run Report (Number 25-75669) dated [DATE] revealed a call was received at 4:54 P.M. for an immediate response fall victim. EMS arrived at the scene at 5:00 P.M. and left the scene at 5:10 P.M. Scene information included Resident #16 went missing from nursing home, unknown to nursing home staff. Last seen by staff before 2:30 P.M. Resident #16 was found by passerby in a vehicle who called 911. [NAME] Police was on the scene also. Chief complaint was altered mental status. EMS noted Resident #16 had an ankle monitor in place on the left ankle. Local police were to contact the facility of a possible missing resident as patient had no identification. Resident #16 was transported to local hospital emergency room.Review of the hospital emergency room (ER) documentation dated [DATE] at 5:28 P.M. revealed Resident #16 presented to the emergency department for evaluation of altered mental status. Resident escaped from [NAME] Oak Manor and was found in a ditch with altered mental status. History of present illness revealed Resident #16 presented for evaluation after he skipped from the nursing home and was found laying down in a ditch by emergency medical system. With Resident #16's mental status and aphasia (non-speaking) the resident was unable to communicate what happened. emergency room course of stay revealed Resident #16 was resuscitated with intravenous fluids. Resident #16's troponin (a specific blood protein to determine if your heart muscle has been damaged) was trended up, likely demand ischemia (a condition where the heart muscle does not receive enough oxygen to meet its increased demand) . Since Resident #16 was initially hypotensive and after resuscitation (with intravenous fluids) had stabilized. Resident #16 was discharged back to the nursing home for further care and evaluation. Review of a nursing note dated [DATE] at 12:40 A.M. written by LPN #341 revealed Resident #16 returned to the facility by EMS and two attendants. Resident #16 was alert to self. Cognition was at baseline. Resident #16 was noted to be incontinent with bowel and bladder with staff total assist. The note included Resident #16's condition was stable.Review of the facility documented titled Elopement Risk Screen, dated [DATE] revealed Resident #16 was disoriented, independent for mobility, wanders throughout facility or prior residence but does not leave interior setting, had a prior history of elopement and had a wander guard was in place.Review of the facility staffing schedule for nursing services dated [DATE] revealed the following direct care nursing staff were working in the facility at the time of the elopement: CNA #324, CNA #327, RN #335, CNA #340 and CNA #348.Review of a facility Self-Reported Incident (SRI) dated [DATE] at 9:06 P.M. revealed Resident #16 was last seen in the building (on [DATE]) at 4:00 P.M. by a Certified Nursing Assistant (not identified by name). The SRI included Resident #16 was outside of the facility within close proximity of facility property at approximately 4:33 P.M Resident without injury and safe. No witnesses were identified by name in the SRI. The facility concluded that neglect did not occur and unsubstantiated the SRI. The investigators were listed at the Administrator and the Assistant Director of Nursing. The SRI stated the facility implemented Quality Assurance Performance Improvement (QAPI) measures including head count of all residents, statements from all staff working at the time of the incident, all WanderGuards were checked for placement and function, elopement assessments reviewed and updated, completion of an incident report, elopement risk care plan review, audit of all door alarms, elopement binder review, completion of elopement drills, staff education on elopement policy, completion of skin assessment, initial audit of residents with Wander guards to ensure functioning, elopement assessments for at risk residents reviewed and updated as needed, review of progress notes for last 72 hours to check for any exit seeking behaviors, all facility door codes changed on [DATE], all residents educated on [DATE] that they were not allowed to give out door codes, and all staff education on the change of door codes on [DATE]. There was no root cause analysis identified in the SRI to explain how Resident #16 exited the facility.Review of the SRI facility investigation, dated [DATE], revealed a witness statement from RN #335 which revealed the police arrived around 4:50 P.M. The police gave a description of Resident #16. The police stated Resident #16 was found on Wick Street in a ditch and taken to the hospital (hospital name provided). The statement included Resident #16 was last seen at 2:30 P.M. sitting in the dining room with another resident. Resident #16 was wearing a WanderGuard.Review of a witness statement from CNA #340, dated [DATE], revealed CNA #340 did not interact with Resident #16 because CNA #340 worked another unit. The statement then included CNA #340 stated Resident #16 was seen on his unit walking around 4:00 P.M.Review of a witness statement from CNA #327, dated [DATE], revealed the last time CNA #327 saw Resident #16 was around 4:15 P.M. sitting in the dining room.Review of a witness statement from Activity Assistant (AA) #334, dated [DATE] revealed the last time AA #334 saw Resident #16 was when AA #334 came back in from smoke break and witnessed Resident #16 standing by the elevator.Review of the witness statement from Social Services (SS) #318, dated [DATE], revealed SS #318 last saw Resident #16 at 3:30 P.M. in the 300-wing dining room when SS #318 accompanied the ADON to let a visitor out.Review of the witness statement from CNA #324, dated [DATE], revealed CNA #324 saw Resident #16 was around 4:00 P.M. on the 100-station.On [DATE] at 5:50 P.M. Resident #16 was observed in the facility. Attempts to interview the resident at the time of the observation revealed Resident #16 was not oriented to person, place, time or situation. Resident #16 was not able to answer yes/no questions or state what door he walked out of during the incident on [DATE]. Resident #16 was observed to walk with a slow shuffle and had a WanderGuard on his ankle.Observation on [DATE] at 10:10 A.M. with the Maintenance Director #346 revealed a code was needed to open the rear foyer door in order for the door to open. Maintenance Director #346 punched a code in the module by the rear foyer door the door opened. A new WanderGuard was placed by the rear door and there was no alarm notification. Maintenance Director #346 walked out the rear foyer door with the new Wanderguard that did not properly function and stated these boxes are old. The WanderGuard alarm was attempted three times with no results of an alarm. Maintenance Director #346 verified the findings at the time of the observations.Observation on [DATE] at 4:30 P.M. with the DON and ADON #344 revealed Resident #16 had a WanderGuard on his left ankle. The DON placed a code in the box by the rear foyer door, Resident #16 walked close to the rear foyer door and out to the rear foyer door and no alarm sounded (the alarm should have sounded at that time). The DON attempted a new WanderGuard not attached to a resident and the alarm did not sound when a code was punched into the box and the WanderGuard was near the door and outside the door. The DON stated it must not be working.Interview on [DATE] at 5:05 P.M. with RN #335 revealed she did not know how Resident #16 got out of the facility (on [DATE]) and she did not know Resident #16 was missing until the police came to the facility to ask if the facility was missing a resident. The police gave the description of the person they found, and it was the description of Resident #16. The RN revealed Resident #16 was found a block away from the facility. RN #335 stated the last time she saw Resident #16 was 2:30 P.M. when Resident #16 was sitting in the facility dining room.Interview on [DATE] at 5:12 P.M. with Business Office Manager ( BOM) #336 revealed she stayed late on [DATE] for dinner service. BOM #336 revealed the facility did not know Resident #16 was missing until the police came to the facility for a missing person identification. Interview on [DATE] at 5:30 P.M. with CNA #340 revealed Resident #16 wandered from his unit on the 300 hall to the 100 hall , which was unusual for him on [DATE]. Resident #16 went missing around dinner time on [DATE]. CNA #340 did not know Resident #16 was missing until the police arrived at the facility. The CNA stated the last time he saw Resident #16 was one hour before dinner time, approximately 3:45 P.M., as dinner arrived at 4:45 P.M.Interview on [DATE] at 8:33 A.M. with the Administrator revealed the foyer doors have a WanderGuard alarm and the side doors have an egress alarm. The Administrator stated no alarms went off on [DATE] (related to Resident #16's elopement). CNA #340 was the last staff member to see Resident #16 around 4:00 P.M. The police found Resident #16 on Wick street.Interview on [DATE] at 8:45 A.M. with Regional Director of Clinical Services (RDCS) #349 revealed the facility was in the process of fixing the rear foyer door alarm at this time.Interview on [DATE] at 9:08 A.M. with the DON revealed on [DATE] Resident #16 was picked up in a ditch by the EMS and taken straight to the hospital. The police came to the facility to ask if they were missing a resident. The facility was not able to see the condition of Resident #16 when he was found. The DON stated Resident #16's cognition had declined. The facility performed a risk assessment on Resident #16 because he was walking up hallways and going to exit doors and wandering alone.Interview on [DATE] at 9:31 A.M. with Certified Nurse Practitioner (CNP) #351 revealed Resident #16 was too confused to be wandering by himself outside, as he had poor safety awareness. CNP #351 verified Resident #16 had a WanderGuard and required a secured environment.Interview on [DATE] at 11:06 A.M. with the Administrator revealed the alarm company looked at the rear foyer door WanderGuard system and determined if the master code was used to exit the building the sensors would not sound if a Wanderguard passed by the sensors. Additional interview revealed the resident was found a street over from the facility in a ditch and when the resident's ankle monitor was noticed the police officer assumed Resident #16 may be from this facility.Observation on [DATE] at 5:45 P.M. revealed the route from the facility to 2615 Wick Street per odometer reading was 0.6 miles away from the facility. Observation of 2615 Wick Street consisted of a neighborhood road that had active car traffic at the time of the observation. The wooded area had multiple dead trees, and a three-foot ditch separated the woods from the street.Interview was conducted on [DATE] at 2:21 P.M. with RDCS #349 who verified the facility did not know the root cause of how Resident #16 left the faciity on [DATE]. RDCS #349 confirmed it was discovered on [DATE] after the start of the Ohio Department of Health survey that someone was entering a master override code that disabled the WanderGaurd system.Interview on [DATE] at 8:30 A.M. with RDCS #349 verified Resident #16's care plan was not reflective of updates/revisions by date in accordance with subsequent resident assessments leading up to the actual elopement on [DATE] and verified Resident #16 had a WanderGuard ordered since [DATE] due to risk of elopement.Observation on [DATE] at 10:42 A.M. at the police station with Sergeant #354 revealed a body camera footage from [DATE] involving Resident #16 and the local police officers who were called to the scene. The footage revealed a bystander approached police officer #353 and stated his son saw a suspicious man walking on the street in the neighborhood. The bystander stated when he found Resident #16 he was in a ditch on all fours. Resident #16 was observed to be sitting in the bystander's car drinking water the bystander stated he gave Resident #16. Resident #16 was observed to have a t-shirt on, jogging pants on and socks and shoes. Police officer #352 asked Resident #16 for identification and Resident #16 handed Police Officer #353 a hairbrush. Observation of the wooded area and ditch was seen in the camera footage. The bystander stated Resident #16 told him someone pushed me in the ditch, it hurts. When the EMS arrived , Resident #16 was not able to stand on his own and needed an assistance of one person to walk from the car to the gurney. Resident #16 was observed to be pale, confused and muttering while on the gurney.Observation on [DATE] at 11:00 A.M. at the police station with Sergeant #354 revealed a second body camera footage on [DATE] at 5:11 P.M when Police Officer #353 arrived at the facility. CNA #340 verified the identity of Resident #16 and verified Resident #16 wore an ankle bracelet. It was observed Police Officer #353 told RN #335 Resident #16 was found in a ditch on Wick Street. At 5:18 P.M. ADON #344 approached the police officer and was told Resident #16 was found in a ditch on the corner of Wick Street and [NAME] Avenue. Observation at time stamp 5:20 P.M. revealed the police exited the facility, residents were eating dinner in the dining room and staff was huddled on the 100 hall.Review of facility policy titled Elopements and Wandering Residents, revision date [DATE], revealed elopement occurred when a resident leaves the premises without authorization or necessary supervision to do so. The facility was to be equipped with door locks and alarms to help avoid elopements, and alarms were not a replacement for necessary supervision. Staff was to be vigilant with response to alarms. The procedure for locating a missing person consisted of alerting staff with CODE UNIT. If the resident was not located on the grounds the administrator would notify the police and corporate office and appropriate reporting requirements to the State Survey agency would be conducted. Post elopement procedure consisted of a physical assessment, documentation and report findings to physician. Social services would reassess if counseling was needed. Staff was to be educated for elopement.This deficiency represents non-compliance investigated under Complaint Number 2599954

Based on record review and interview, the facility failed to ensure the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. This had the potential to affect all 34 residents who resided in the facility. Findings include: Review of the Facility Assessment form dated 06/21/24 revealed the assessment did not designate the amount of hours that were required for the IP to be in the facility to ensure implementation of the infection control programs and activities. Review of the IP Training Plan Proof of Completion form dated 05/30/23 revealed Registered Nurse (RN) Regional #851 was the current IP for the facility. Interview on 05/06/25 at 12:10 P.M. with the Administrator revealed RN Regional #851 was the current IP who was in the building once monthly. Interview on 05/06/25 at 12:25 P.M. with RN Regional #851 confirmed she currently completed the IP role once monthly in the facility. The previous staff member who was the IP no longer worked in the building as of 11/15/24. Review of the Infection Prevention and Control Program revised 01/07/25 revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observation, record review and interview, the facility failed to ensure Resident #1's food preferences were followed during meals. This affected one (Resident #1) of four residents reviewed for food and drink. Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and difficulty in walking. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's nutrition care plans revealed an intervention dated 02/26/16 to provide diet as ordered. Review of Resident #1's physician orders revealed an order dated 11/19/24 for a regular diet, regular texture with a regular-thin consistency. Resident #1's physician orders did not have an order for Boost or chocolate milk. Interview with Resident #1 on 05/05/25 at 8:45 A.M. revealed she was supposed to have Boost on her meal tray and it was not there. Resident #1 stated she never received the Boost. Review of Resident #1's breakfast meal ticket dated 05/05/25 revealed the resident was ordered a regular texture, regular, regular-thin breakfast. Under standing orders on the meal ticket, eight fluid ounces of Boost Very Vanilla was listed. Resident #1 had hand written on the ticket BOOST, WHERE Was Mine? Review of Resident #1's lunch meal ticket dated 05/06/25 revealed the resident was ordered a regular texture, regular, regular-thin lunch. Under notes on the meal ticket, chocolate milk was listed. Interview on 05/06/25 at 12:19 P.M. with Dietary Manager (DM) #845 confirmed Resident #1's preferences were not honored and the resident was not provided the Boost for breakfast on 05/05/25 or the chocolate milk on 05/06/25 for lunch. DM #845 revealed the facility had run out of chocolate milk on 05/06/25 and the resident should have received another Boost until the food truck came in later in the day. Review of the Nutrition Services policy revised March 2017 revealed the facility provided meals for each resident, with preferences accommodated, timely meal services and assistance with eating as needed. Review of the Therapeutic Diets policy revised June 2018 revealed the facility provided therapeutic diets per need and resident preferences. The facility worked with the resident/family, dietitian and physician to balance the medical needs of the resident with their preferences, to have fewer dietary restrictions when possible.

Based on observation, record review and interview, the facility failed to ensure medication administration bags were secured and resident names and medications were not readily visible in the common trash. This affected three (Residents #15, #27 and #136) of four residents reviewed for privacy. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, muscle weakness and difficulty in walking. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle weakness and heart failure. Review of Resident #27's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #136's medical record revealed the resident was readmitted on [DATE] with diagnoses including cellulitis of the left lower limb with acquired absence of the right leg below the knee and chronic obstructive pulmonary disease. Resident #136's MDS 3.0 assessment dated [DATE] was not completed. Observation on 05/05/25 at 12:47 P.M. with the Director of Nursing (DON) revealed Residents #15, #27 and #136's clear plastic morning medication packages with the resident's name, room number and the names of the medications administered were placed in an open trash receptacle attached to the medication administration cart which was visible when walking by the cart. Interview on 05/05/25 at 12:57 P.M. with the DON revealed staff were to remove the top label part of the medication packaging with the resident names prior to disposing of the bottom half of the plastic packaging with the medications listed. The DON stated if the name was intact, then the staff were to use a black marker and cross out the name of the resident to ensure the privacy of the resident. The DON confirmed Residents #15, #27 and #136's discarded plastic medication bags were intact with the medications listed and the resident's name and room number which was a violation of the resident's privacy. The DON also confirmed the facility did not have a policy on ensuring resident privacy when disposing of medication administration packaging with identifiable resident information intact. Review of the HIPAA Security Measures policy revised 01/01/25 revealed it was the facility policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that were in the electronic format. This deficiency represents non-compliance investigated under Complaint Number OH00165020.

Based on record review, policy review, and interviews the facility failed to ensure care planning conferences were completed quarterly. This affected two (Residents #24 and #26) of two residents reviewed for development of care plans. Facility census was 34. Findings include: 1. Review of Resident #24's medical record revealed an admitted [DATE] with diagnoses of severe dementia with other behavioral disturbances, schizophrenia, intermittent explosive disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had moderate cognitive impairment and required supervision for oral hygiene, showers, and personal hygiene. Review of the care planning conferences for Resident #24 from July 2023 to April 2024 revealed conferences were held 11/06/23, 01/17/24, 04/03/24, and 04/24/25. Further review of the care planning conferences revealed the Social Service Designee (SSD) #820 and Assistant Director of Nursing #802 were the members of the interdisciplinary team (IDT) in attendance. Interview on 05/06/25 at 12:12 P.M. with SSD #820 for Resident #24 revealed a care planning conference was held 04/24/25 but prior to that the previous care conference was 07/03/24. SSD #820 confirmed that other members of the IDT including the MDS nurse, floor nurse, dietary, and activities staff were not notified/invited to the care planning conferences. 2. Review of Resident #26's medical record revealed an admitted [DATE] with diagnoses of Alzheimer's disease, leakage of aortic graft, chronic obstructive pulmonary disease, and anemia. Review of the MDS assessment dated [DATE] revealed Resident #26 had severe cognitive impairment and required maximal assistance with toileting, showers, dressing, and transfers and required a wheelchair for locomotion. Review of the care planning conferences revealed Resident #26 had one care planning conference which occurred on 02/25/25. Interview on 05/07/25 at 11:09 A.M. with SSD #820 confirmed no other care conferences were held. Review of the Care Planning-Resident Participation Policy dated 06/01/24 revealed the facility was to discuss the plan of care with the resident and/or representative at regular scheduled care plan conferences, at routine intervals, and after significant changes.

Based on record review and interview, the facility failed to ensure Resident #1's laboratory bloodwork was completed per the physician orders. This affected one (Resident #1) of two residents reviewed for laboratory services. Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and cardiomyopathy. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's physician orders revealed an order dated 04/04/25 (discontinued 05/06/25) to obtain a potassium level weekly. Review of Resident #1's laboratory bloodwork revealed the potassium level was obtained on 04/04/25, 04/11/25 and 05/02/25. The potassium bloodwork was not obtained on 04/18/25 and 04/25/25 as ordered. Interview on 05/07/25 at 8:30 A.M. with the Director of Nursing (DON) confirmed Resident #1's potassium bloodwork was not completed as ordered. Review of the Laboratory Services and Reporting policy revised 01/02/25 revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law.

Based on medical record review and staff interview, the facility failed to obtain an electrocardiogram (EKG) services per physician orders for Resident #36. This affected one resident (#36) of three residents reviewed for change in condition. The facility census was 32. Findings include: Review of the closed medical record of Resident #36 revealed an admitted [DATE]. Medical diagnoses included acute respiratory failure, nonrheumatic aortic valve insufficiency, metabolic encephalopathy, hypothyroidism, disorder bilirubin metabolism, edema, congestive heart failure, panic disorder, hepatic failure, atherosclerotic heart disease, jaundice, acute myocardial infarction, presence of coronary angioplasty, Turner's syndrome (a chromosomal disorder in which a female is born with only one X chromosome), and abnormal electrocardiogram (EKG). Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #36 dated 02/07/25 revealed the resident's cognition was moderately impaired, and she was dependent upon staff to roll left to right in bed, toileting, hygiene, and bathing. She required moderate assistance for eating and oral hygiene. She had no indwelling catheter and was not on a toileting program. She was always incontinent bowel and bladder. She received oxygen therapy. Review of the physician's telephone orders dated 02/06/25 at 4:56 P.M. revealed a diagnostic order to obtain a STAT (immediate) chest x-ray, STAT EKG related to congestive heart failure, obtain a STAT complete blood count (CBC) with differential, complete metabolic panel (CMP), thyroid stimulating hormone (TSH), T4, and a lipid profile. Review of nursing note for dated 02/06/25 at 5:25 P.M. revealed Resident #36's pulse oximeter read 77 percent on five liters of oxygen per minute of oxygen. Her lung sounds were diminished with crackles. The physician was notified and provided new orders to obtain a STAT EKG, STAT chest x-ray, STAT lab work and Lasix 10 milligrams (mg) (diuretic) intramuscular (IM) for a one-time dose. The charge nurse called mobile x-ray and the lab. Review of the Treatment Administration Record (TAR) for February 2025 revealed on the order dated 02/06/25 to obtain a STAT EKG related to congestive heart failure was marked with an x, and the order dated 02/06/25 for the STAT chest x-ray revealed the order was signed off as completed. Review of nursing note dated 02/07/25 at12:25 P.M. revealed the chest x-ray results were received and showed bilateral patchy infiltrates. The physician was called, and new orders were given. There was no documented evidence that the STAT EKG was completed and no documented evidence that the staff followed up with the physician or the mobile x-ray company regarding the order for the STAT EKG. Interview on 02/20/25 at 2:20 P.M. with the Director of Nursing (DON) verified that the STAT EKG was not completed for Resident #36. She also verified the record contained no documented evidence that staff followed up on the STAT EKG order and/or notified the physician that the STAT EKG was not completed. This deficiency represents non-compliance investigated under Master Complaint Number OH00162779 and Complaint Number OH00162715.

Based on record review, interview and facility policy review, the facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refuses for certain staff to be in her room. Interventions included allow resident to discuss feelings, approach and speak to resident in a calm voice. On 05/07/02 at 10:26 A.M. an interview with Long Term Care Ombudsman (LTCOs) #98 and #99 revealed they were at the facility on 04/23/24. They interviewed Resident #2 during their visit, and Resident #2 told them State tested Nurse Aide (STNA) #63 had called her a [expletive]. LTCOs #98 and #99 stated they told the facility Administrator immediately after the interview with Resident #2. LTCOs #98 and #99 stated they called the facility for follow-up on 04/26/24 and were informed by the Administrator a care conference was held with Resident #2, and the allegation of staff-to-resident abuse did not need to be thoroughly investigated. On 05/07/24 at 1:00 P.M.an nterview with the Administrator and the Director of Nursing (DON) revealed they did not thoroughly investigate the allegation of staff-to-resident verbal abuse for Resident #2. Both stated they had a care conference with Resident #2, and her son and Resident #2 did not feel abused or mistreated. Both stated STNA #63 was removed from being assigned to Resident #2 but was not removed from schedule. Both verified there were no staff witness statements for the day of the occurrence nor were there resident interviews regarding the incident. A review of the policy titled, Abuse, Neglect and Exploitation dated 10/01/22, revealed on page four, section five, point A: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. This deficiency represents non-compliance investigated under Complaint Number OH00153594

Based on record review, interview and facility policy review, the facility failed to implement their abuse policy regarding thoroughly investigating and failing to submit a self-reported incident (SRI) to the state agency of an allegation of staff-to-resident verbal abuse for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refused for certain staff to be in her room. Interventions included allow resident to discuss feelings, approach and speak to resident in a calm voice. On 05/07/02 at 10:26 A.M. an interview with Long Term Care Ombudsman (LTCOs) # 98 and #99 revealed they were at the facility on 04/23/24. They interviewed Resident #2 during their visit, and Resident #2 told them State tested Nurse Aide (STNA) #63 had called her a [expletive]. LTCOs #98 and #99 stated they told the facility Administrator immediately after the interview with Resident #2. LTCOs #98 and #99 stated they called the facility for follow-up on 04/26/24 and were informed by the Administrator a care conference was held with Resident #2, and the allegation of staff-to-resident abuse did not need to be thoroughly investigated. On 05/07/24 at 1:00 P.M.an interview with the Administrator and the Director of Nursing (DON) revealed they did not implement their abuse policy and investigated the allegation of staff-to-resident verbal abuse for Resident #2. Both stated they had a care conference with Resident #2, and her son and Resident #2 did not feel abused or mistreated. Both stated State tested Nursing Assistant (STNA) #63, the alleged perpetrator, was removed from being assigned to Resident #2 but was not removed from schedule. Both verified there were no staff witness statements for the day of the occurrence nor were there resident interviews regarding the incident. In addition, the facility did not submit an (SRI) to the state agency. A review of the policy titled, Abuse, Neglect and Exploitation dated 10/01/22, revealed on page four, section five, point A: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The policy also revealed on page four, section seven, point A, subpoint 1: Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agency within specified timeframes: shall occur no later than two hours if events that cause the allegation do involve abuse and result in serious bodily injury. Reporting should not occur later than 24 hours if events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number OH00153594

Based on record review, interview and facility policy review, the facility failed to report an allegation of staff-to-resident verbal abuse to the state agency for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact and had verbal behaviors one to three times in the seven day look back period. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refuses for certain staff to be in her room. Interventions included allow resident to discuss feelings, approach and speak to resident in a calm voice. On 05/07/02 at 10:26 A.M. an interview with Long Term Care Ombudsman (LTCOs) #98 and #99 revealed they were at the facility on 04/23/24. They interviewed Resident #2 during their visit, and Resident #2 told them State tested Nurse Aide (STNA) #63 had called her a [expletive]. LTCOs #98 and #99 stated they told the facility Administrator immediately after the interview with Resident #2. LTCOs #98 and #99 stated they called the facility for follow-up on 04/26/24 and were informed by the Administrator a care conference was held with Resident #2, and the allegation of staff-to-resident abuse did not need to be thoroughly investigated. An interview was conducted on 05/07/24 at 1:00 P.M. with the Administrator and the Director of Nursing (DON) who both verified they had not reported the allegation of staff-to-resident abuse involving Resident #2 to the state agency. The Administrator and DON verified the allegation was brought to administration's attention by the Ombudsman on 04/23/24. A review of the policy titled, Abuse, Neglect and Exploitation, dated 10/01/22, revealed on page four, section seven, point A, subpoint 1: Reporting of alleged violations to the Administrator, stated agency, adult protective services and to all other required agency within specified timeframes: shall occur no later than two hours if events that cause the allegation do involve abuse and result in serious bodily injury. Reporting should not occur later than 24 hours if events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number OH00153594

Based on record review, observation and interview, the facility failed to thoroughly investigate an alleged physical altercation between Resident #5 and Resident #15 in order to take appropriate corrective action. This effected two residents (Resident #5 and Resident #15) of five residents reviewed for abuse. The facility census was 33. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnoses including movement disorder, dementia, chronic obstructive pulmonary disease, schizoaffective disorder and anxiety. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment. Resident #5 was independent to roll in bed, sit to lie flat on the bed, lie to sit on side of the bed and sit to stand. Resident #5 required moderate assistance to walk ten feet. Review of the Plan of Care dated 11/17/22 revealed Resident #5 was a risk for problematic behavior and not easily redirected. Resident #5 had paranoid schizophrenia, vascular dementia with behavior disturbance, restlessness and agitation, and psychosis. Interventions included administering medication thirty minutes before attempt at activities of daily living ( ADL) , allow for flexibility in ADL routine to accommodate resident's mood. Discuss with Resident #5 implications of not complying with therapeutic regime. Document care being resisted. Elicit family input for best approaches to resident. Encourage resident to express feelings and concerns. Encourage resident to take calm, deep breaths when exhibiting increased anxiety or anger as tolerated. If resident was refusing care, make sure she was safe and reapproach at a later time. Inform resident of ADL that was required ahead of time to give two options of time to be done. Praise and reward resident for demonstrating consistent desired behavior. Provide time for non-care related conversation . Try to redirect undesirable behavior. Review of a nurse progress note dated 02/09/24 written by Licensed Practical Nurse (LPN) #149 at 10:06 P.M. revealed staff observed Resident #5 in a physical altercation (no specific details were provided) with another resident in the bedroom. The staff separated the residents and took Resident #5 out into the common area/dining room, then placed Resident #5 into an empty room temporarily. No redness, swelling or injuries were noted to resident and the resident did not complain of any pain. The note stated the Director of Nursing (DON) was notified. 2. Record review for Resident #15 revealed an admitted [DATE] with diagnoses including cerebral infarction, hypertension, difficulty walking, schizoaffective disorder, anemia, major depressive disorder, dysphagia, gastro esophageal reflux, restlessness and agitation, tobacco use, angina, insomnia. Review of Resident #15's MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #15 was independent for bed mobility, transfers and dressing. Resident #15 was independent to walk ten feet. Review of the Plan of Care dated 01/16/24 revealed Resident #15 had mood problems such as agitation, depression, schizophrenia. Interventions included administering medication as ordered, encouraging resident to express feelings. Invite or assist resident in activities of choice. Observe acute episodes of feelings of sadness, loss of pleasure of doing things. Notify physician as needed. Psych counseling services as needed. Staff to provide one on one as needed. Review of a nurse progress note dated 02/09/24 at 10:08 P.M. written by LPN # 149 revealed staff observed resident in a physical altercation (no specific details were provided) with another resident in the bedroom. Staff separated the residents, and left resident (#15) in her current room and placed the other resident (#5) in a separate room. No redness, swelling or injuries were noted to the resident and Resident #15 did not complain of any pain. The note indicated the DON was notified. Review of a nurse note dated 02/12/24 at 12:32 P.M. written by the DON revealed the DON spoke with Resident #15's daughter to update her on residents refusal to take medications, and physical and verbal behaviors. The daughter was made aware Resident #5 was moved to a private room per resident request because of complaints she did not like her current roommate. The daughter gave recommendations to see if any medication could be discontinued or any given intra muscular. The DON informed the daughter she would notify the resident's primary care physician and the psych nurse practitioner for a medication review. Observation conducted on 03/07/24 of the resident room in which the documented incident occurred revealed it was a large room with three bed capacity. The room revealed only two residents resided in this room which were Resident #13 and Resident #5. Observation within the rest of the facility revealed Resident #15's room was on an entirely different unit which was separated from Resident #15's unit by a large, common area room closed off by doors. Interview on 03/07/24 at 1:28 P.M. with the DON revealed a thorough and timely investigation was not conducted to determine if abuse had occurred because LPN #149 never notified her of the physical altercation on 02/09/24 despite the documentation she was notified. The DON was not able to investigate the incident immediately to identify staff responsible for interventions, identify and interview all involved persons, including alleged victims and/or perpetrator and other witnesses who might have knowledge of the altercation. No incident report was started. The DON stated she educated LPN # 149 and documented the education that the DON was to be notified immediately. The DON also stated because she was not notified immediately after the incident occurred, the incorrect resident (Resident #5) was placed in a separate bedroom. The DON said it would have been more appropriate for Resident #15 to be moved into a room by herself since she was having some verbal and physical behaviors directed towards others which were addressed with her care providers. Interview on 03/07/24 at 3:00 P.M. with the DON verified LPN #149 documented the physical altercation in the progress note but no incident report was filed on 02/09/24 and therefore the plan of care was not updated for Resident #5 or Resident #15. Review of the facility policy titled Abuse, Neglect, and Exploitation dated 10/01/22 revealed abuse was defined as the willful infliction of injury and physical abuse including slapping. Investigation of alleged abuse would include an immediate investigation when suspicion of abuse occurred. The facility was to provide complete and thorough documentation of the investigation. This deficiency represents non-compliance investigated under Complaint Number OH00151164.

Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #3's left lower leg (LLE) surgical wound dressing was completed per the physician order and failed to ensure the medical record accurately reflected Resident #3's LLE surgical wound care. This finding affected one resident (#3) of three residents reviewed for wounds. Findings include: Review of Resident #3's medical record revealed she was admitted on [DATE], discharged out to the hospital on 06/22/23, and returned to the facility on [DATE] with diagnoses including displaced bicondylar fracture of the left tibia, unspecified fall, and unspecified fracture of the left patella. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #3's physician orders revealed an order dated 06/29/23 to change the dressing to the left lower leg (LLE) every other day and as needed. Keep the knee straight for four weeks with a brace. Review of Resident #3's treatment administration record (TAR) dated 06/29/23 revealed Licensed Practical Nurse (LPN) #814 documented she had completed the LLE surgical wound care. Review of Resident #3's TAR dated 07/01/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Review of Resident #3's progress note dated 07/02/23 at 12:46 A.M. revealed the resident refused the leg treatment because she was sleeping. Review of Resident #3's TAR dated 07/03/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Observation on 07/06/23 at 3:52 P.M. with LPN #809 and the Director of Nursing (DON) of Resident #3's LLE surgical wound care revealed the DON held up the LLE while LPN #809 unwrapped the ace wrap and cast type dressing from the leg, removed her gloves, washed her hands, replaced her gloves, and placed abdominal pads and Kerlix gauze around the sutures to Resident #3's LLE. Interview on 07/06/23 at 4:05 P.M. with LPN #809 revealed the facility did not have the cast type dressing which she had removed from Resident #3's LLE during the surgical wound care dressing change, and the dressing on Resident #3's LLE was the original surgical dressing. Interview on 07/06/23 at 4:14 P.M. with the DON confirmed LPN #814 documented on Resident #3's TAR that she had completed the LLE surgical wound care on 06/29/23, LPN #815 documented on Resident #3's TAR that she had completed the LLE surgical wound care on 07/01/23 and 07/03/23. The DON confirmed the wound care was not completed as ordered and she would launch an investigation into the concern. Interview on 07/06/23 at 4:16 P.M. with Resident #3 confirmed staff had not changed her LLE surgical wound dressing since her return to the facility on [DATE]. Telephone interview on 07/07/23 at 2:49 P.M. with the DON revealed she called Resident #3's surgeon, and he did not use the type of dressing which was removed from Resident #3's leg on 07/06/23 by LPN #809. She stated she also called LPN #815 who told her that she completed Resident #3's wound care on 07/03/23. The DON confirmed she did not provide evidence of the completion of the wound care including staff statements or phone numbers because the facility had a surprise admission. Review of the undated Wound Care policy indicated dry dressing protection was to follow the order or per nursing judgement and use house stock dry dressing, Kerlix gauze, abdominal dressing, or four by four dressings. This deficiency represents non-compliance investigated under Master Complaint Number OH00143723.

Based on record review, interview, and policy review the facility did not ensure accurate medication administration records for Residents #8, #21 and #22. This affected three residents (Residents #8, #21 and #22) of five residents reviewed for unnecessary medications. The facility census was 27. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnoses included cerebral ischemia, diabetes mellitus (DM) type 2, schizoaffective disorder bipolar type, chronic kidney disease stage 3, epilepsy and epileptic syndromes with complex partial seizures, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, major depressive disorder, anxiety disorder, and delusional disorder. Review of Resident #8's medication administration record (MAR) for October 2022 revealed the following medications were not documented as administered: Atorvastatin (medication to treat high cholesterol) 10 milligrams (mg) daily at bedtime for hyperlipidemia (high cholesterol) on 10/08/22 at hs 2 (from 6:00 P.M. to 10:00 P.M.) Lamotrigine (anticonvulsant) 200 mg daily at bedtime for seizures on 10/08/22 at hs 2 Lantus (insulin) 100 units (U) per milliliter (ml), inject 18 U subcutaneously (SQ) at bedtime for DM type 2 on 10/02/22, 10/05/22, 10/08/22, 10/16/22 and 10/30/22 at hs 2 Olanzapine (antipsychotic) 5 mg daily at bedtime for schizoaffective disorder bipolar type on 10/08/22 at hs 2 Protonix (medication to treat acid reflux and/or heartburn) 40 mg daily in the morning for GERD on 10/01/22, 10/03/22, 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at 4:00 A.M. Carvedilol (medication to treat high blood pressure) 12.5 mg twice daily for hypertension on 10/08/22 at hs (from 8:00 P.M. to 10:00 P.M) Keppra (anticonvulsant) 500 mg twice daily for seizures on 10/08/22 at hs Depakote (anticonvulsant) 250 mg three time daily for seizures on 10/01/22, 10/03/22, 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at noc (from 4:00 A.M. to 6:00 A.M.), and on 10/08/22 at hs Humalog (insulin Lispro) inject per sliding scale SQ before meals and at bedtime for DM type 2 on 10/01/22, 10/03/22, 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at 4:00 A.M., on 10/08/22 at pm, and on 10/02/22, 10/05/22, 10/08/22, 10/16/22 and 10/30/22 at hs Review of Resident #8's MAR for November 2022 revealed the following medications were not documented as administered: Lantus (insulin) 100 U/ml, inject 18 U SQ at bedtime for DM type 2 on 11/22/22 at hs 2 Protonix 40 mg daily in the morning for GERD on 11/14/22 at 4:00 A.M. Depakote 250 mg three time daily for seizures on 11/14/22 at noc Humalog (insulin Lispro) inject per sliding scale SQ before meals and at bedtime for DM type 2 on 11/13/22 and 11/14/22 at 4:00 A.M., and on 11/22/22 at hs 2. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included hyperlipidemia, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease with acute exacerbation, anxiety disorder, anemia due to intrinsic factor deficiency, and restless and agitation. Review of Resident #21's MAR for October 2022 revealed the following medications were not documented as administered: Atorvastatin 20 mg daily at bedtime for hyperlipidemia on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs 2 Benztropine (anti-tremor) 1 mg at bedtime for schizoaffective disorder, bipolar type on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs 2 Depakote 125 mg, give four tablets daily at bedtime for schizoaffective disorder bipolar type on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs 2 Depakote 125 mg, give five tablets daily in the morning for schizoaffective disorder bipolar type on 10/01/22, 10/03/22, 10/07/22, 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at 4:00 A.M. Melatonin (hormone that aids in sleep) 3 mg at bedtime for insomnia on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs 2 Docusate sodium (stool softener) 100 mg twice daily for constipation on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs Lasix (diuretic) 20 mg twice daily for edema on 10/01/22, 10/03/22, 10/07/22, 10/08/22, 10/17/22, 10/22/22, 10/30/22 and 10/31/22 at 6:00 A.M. Lactulose solution (laxative and ammonia reducer) 10 grams per 15 ml, give 30 ml three times daily for long term current drug therapy on 10/01/22, 10/03/22, 10/07/22, 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at noc, and on 10/02/22, 10/05/22, 10/08/22 and 10/31/22 at hs Review of Resident #21's MAR for November 2022 revealed the following medications were not documented as administered: Atorvastatin 20 mg daily at bedtime for mild protein-calorie malnutrition on 11/20/22 hs 2 Divalproex (anticonvulsant) 125 mg, give 4 tablets at bedtime for schizoaffective disorder bipolar type on 11/20/22 at hs 2 Melatonin 3 mg at bedtime for insomnia on 11/20/22 at hs 2 Docusate sodium 100 mg twice daily for constipation on 11/20/22 at hs Divalproex 125 mg, give 5 tablets twice daily for schizoaffective disorder bipolar type on 11/13/22 and 11/14/22 at 6:00 A.M., and on 11/16/22 at 2:00 P.M. Lasix 20 mg twice daily for edema on 11/03/22 at 1:00 P.M., on 11/08/22, 11/13/22 and 11/14/22 at 6:00 A.M., and on 11/16/22 at 2:00 P.M. Lactulose solution 10 grams per 15 ml, give 30 ml three times daily for constipation on 11/14/22 at noc, and on 11/20/22 at hs 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included acute kidney failure, obstructive and reflux uropathy, adult failure to thrive, anxiety disorder, schizoaffective disorder, psychoactive substance dependence, bipolar disorder, heart failure, chronic pain, hypertension, anemia, encephalopathy, and congestive heart failure. Review of Resident #22's MAR for October 2022 revealed the following medications were not documented as administered: Pantoprazole (Protonix) 40 mg daily for indigestion on 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at 4:00 A.M. Benztropine 1 mg twice daily for psychoactive substance dependence on 10/16/22 at hs 2 Buprenorphine-naloxone film (narcotic) 8-2 mg, 1 film sublingually twice daily for psychoactive substance dependence on 10/08/22, 10/13/22, 10/17/22, 10/22/22, 10/30/22 and 10/31/22 at 6:00 A.M., and on 10/05/22 and 10/16/22 at 6:00 P.M. Carvedilol 12.5 mg twice daily for hypertension on 10/16/22 at hs 2 Doxycycline (antibiotic) 100 mg every 12 hours for intravenous infiltrate for 10 days on 10/05/22, 10/08/22 and 10/13/22 at 6:00 A.M., and on 10/05/22 at 6:00 P.M. Levetiracetam (anticonvulsant) 500 mg twice daily for seizures on 10/16/22 at hs 2 Magnesium oxide (supplement) 400 mg twice daily for supplement on 10/16/22 at hs 2 Rifaximin 550 (antibiotic) mg twice daily for encephalopathy at hs 2 Hydroxyzine (antihistamine) 25 mg three times daily for anxiety on 10/08/22, 10/17/22, 10/22/22 and 10/31/22 at noc, and on 10/16/22 at hs Review of Resident #22's MAR for November 2022 revealed the following medications were not documented as administered: Pantoprazole 40 mg daily for indigestion on 11/14/22 at 4:00 A.M. Buprenorphine-naloxone film 8-2 mg, 1 film sublingually twice daily for psychoactive substance dependence on 11/13/22 and 11/14/22 at 6:00 A.M. Hydroxyzine 25 mg three times daily for anxiety on 11/14/22 at noc Interview on 12/06/22 at 1:42 P.M. with the Director of Nursing (DON) verified the above findings for Residents #8, #21 and #22. The DON confirmed Residents #8, #21 and #22's medications listed above were not documented after administration as required. Review of the undated facility medication administration times revealed noc was 4:00 A.M. to 6:00 A.M., hs was 8:00 P.M. to 10:00 P.M., and hs 2 was 6:00 P.M. to 10:00 P.M. Review of the undated facility policy, Administering Medications revealed the individual administering a medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation and interview the facility failed to ensure pureed foods were the correct consistency and served at an appetizing temperature. This affected two residents (Resident #10 and Resident #19) of 27 residents who received food from the facility. The facility census was 27. Findings include: Interview and observation on 12/04/22 at 8:57 A.M. with Resident #10 revealed the resident had received a pureed breakfast tray. Resident #10 did not eat the items provided and indicated they didn't taste good. Observation of a test tray on 12/05/22 at 12:52 P.M., tested after all residents had been served and were eating, revealed the pureed Chicken [NAME] was 117 degrees Fahrenheit (F). It had good flavor, was the correct consistency, but was not hot enough. The pureed rice was 125 degrees F, had good flavor, but was not a smooth enough consistency for puree. The pureed squash was 147 degrees F. It was hot enough, but bland and lumpy. Interview on 12/05/22 at 12:58 P.M. with Corporate Dietitian #639 and Dietary Manager #636 verified the pureed rice and squash were not the correct consistency for a puree diet, and the temperature of the pureed chicken was not hot enough.

Based on observation, interview, record review, and policy review the facility did not ensure Resident #11 had a physician order and/ or care plan for the use of ankle foot orthosis (AFO) to the bilateral lower extremities per therapy recommendation. This affected one resident (Resident #11) of one resident (Resident #11) reviewed for a splinting device. This had the potential to affect two residents (Residents #10 and #11) with recommendations for a splinting device. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including osteoarthritis, difficulty walking, muscle wasting with atrophy, split foot (birth defect that consists of missing toes), and major depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. He was independent with bed mobility, transfers, and locomotion. He required limited assist of one staff with dressing. He was unable to ambulate. Review of the November 2022 physician orders revealed there was no physician order for Resident #11 to have AFO's to his bilateral extremities. Review of undated comprehensive care plan for Resident #11 revealed there was nothing in the care plan regarding the use of AFO's. Review of the Occupational Therapy Discharge Summary dated 11/21/22 and completed by Occupational Therapist (OT) #642 revealed Resident #11 was discharged from therapy because he was at his highest practical level. The summary revealed Resident #11 completed his lower extremity dressing with minimal assist including the use of bilateral AFO's. Review of the Kardex Report dated 11/28/22 revealed under the dressing section Resident #11 was independent with dressing. The Kardex revealed there was nothing in regard to the use of AFO's to the bilateral lower extremities. Observation on 12/04/22 at 9:24 A.M. revealed Resident #11 was sitting in his wheelchair and placed his right lower leg up onto his bed as he was trying to apply his AFO. Observation revealed he had difficulty applying the AFO especially with fitting the Velcro strap through the hole. Resident #11's roommate, Resident #7, observed Resident #11 having difficulty and Resident #7 revealed he usually had to help him in the morning apply his brace as he had a hard time putting it on. Resident #7 then proceeded to assist Resident #11 apply his AFO to his right lower leg. Interview on 12/04/22 at 9:26 A.M. with Resident #11 revealed most the time he was able to put his AFO on himself but at times his hands just did not work as well in the morning specially to apply the Velcro strap. He revealed his roommate, Resident #7, then assisted in putting it on. Interview on 12/05/22 at 10:02 A.M. with Rehabilitation Director #641 revealed Resident #11 had bilateral AFO's for many years and that he recently received occupational therapy until 11/21/22. She revealed Resident #11 had a recommendation to complete his lower extremity dressing with minimal assist including his AFO's. She revealed he needed minimal assistance as at times he had difficulty applying the AFO's due to arthritis in his hands. Interview on 12/05/22 at 10:39 A.M. and 11:13 A.M. with Regional Director of Clinical Operations #640 verified Resident #11 did not have a physician order and/ or care plan regarding the use of AFO's. She also verified they had no documented evidence when his AFO's were applied and/ or checked. She revealed Resident #11 should have had both a physician order and care plan indicating when he should wear his AFO's and if he needed assistance with the AFO's being applied as well as documentation that the AFO's were applied. Review of the undated facility policy labeled; Use of Splints revealed a resident with limited range of motion was to receive appropriate treatment and services to prevent further decrease in range of motion. The policy revealed for residents who based on assessment required the use of a splint, that the splint be applied in accordance with the written plan of care, monitor for consistent use of the splint, report changes in condition or problems associated with the splint and update the care pan with new or modified intervention as needed.

Based on interview, observation, record review, and facility procedure review the facility failed to maintain a clean and sanitary environment including no dead bugs in the light fixtures and failed to ensure bathtubs were maintained in a clean sanitary manner. This had the potential to affect all residents except for four (Resident's #3, #12, #18 and #20) identified by the facility as never leaving their rooms and do not utilize the bathroom. The facility census was 31. Findings include: Environmental tour on the 200 hall and 300 hall was conducted on 08/15/22 from 8:21 A.M. to 9:02 A.M. (there were no residents residing on the 100 hall) revealed the following: · The bathtub in the bathroom for Resident's #11 and #21 had a brown film ring around the base of the inside of the bathtub and contained dirt and debris material inside the bathtub. · The bathtub in the bathroom for Resident #4 had a brown film ring around the base of the inside of the bathtub and contained dirt and debris material inside the bathtub. Resident #4 did not share a bathroom with any residents. · The bathtub in the bathroom for Resident's #8 and #14 had a brown film ring around the base of the inside of the bathtub. The light fixture in the bathroom for Resident's #8 and #14 contained several dead bugs inside the light fixture. · The bathtub in the bathroom for Resident's #5 and #9 had a brown film ring around the base of the inside of the bathtub and contained dirt and debris material inside the bathtub. · The bathtub in the bathroom for Resident #28 had a brown film ring around the base of the inside of the bathtub and contained dirt, debris material, and a dead spider. · The central bathroom on the 300-hall unit contained dead bugs in the light fixture. · The light fixture in the bathroom for Resident's #10 and #15 contained several dead bugs. · The light fixture in the bathroom for Resident's #13, #19, #23, and #31 contained several dead bugs. · Five light fixtures on the 200-hall unit in the hallway contained several dead bugs. Interview on 08/15/22 from 8:21 A.M. to 9:02 A.M. with the Administrator verified the above findings. He revealed Maintenance Director #900 had been off and he had not gotten to the light fixtures. He revealed housekeeping should have cleaned the bathtubs in the identified bathrooms as he verified, they were dirty. Interview on 08/15/22 at 11:13 A.M. with Housekeeping #600 revealed he had worked in housekeeping for approximately three months. He revealed at first, he was the only housekeeper as the facility was short staffed. He revealed when there was only one housekeeper on duty, he was unable to clean the bathtubs in the resident's rooms as they should be cleaned as he was not able to get to them. He recently revealed most days they had two housekeepers as staffing had improved so hopefully, he could start cleaning the bathtubs effectively. He verified several of the bathtubs did have brown film rings and dirt and debris inside of them. Interview on 08/15/22 at 11:38 A.M. with Resident #5 revealed she felt housekeeping could do a lot better job at cleaning including cleaning her bathroom/ bathtub. She revealed there was some days they only had one housekeeper on duty so housekeeping would just empty the trash and not clean the bathroom. Review of the undated facility procedure for housekeeper one and housekeeper two revealed a time schedule for cleaning. The schedule included when to clean the rooms and which rooms assigned but did not go into detail regarding ensuring the bathtubs were cleaned and/ or what to clean if only one housekeeper. This deficiency substantiates Complaint Number OH 830.

Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #27 had access to her toilet in her bathroom and failed to have documented evidence Resident #27 and/ or her guardian approved duct taping the toilet and restricting access. This affected one resident (Resident #27) of six residents (Resident's #3, #11, #24, #26, #27, and #30) reviewed for access to their bathroom. This had the potential to affect 31 residents. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had impaired cognition. She had verbal and other behaviors daily. She was independent with transfers and ambulation. She required extensive assist of one staff with toileting and was frequently incontinent of bowel and bladder. Review of the care plan dated 07/10/22 revealed Resident #27 had incontinent episodes of bladder related to at times voided on self and required cueing. Interventions included assist resident to the bathroom as needed, check for incontinence as needed, and observe for peri-area redness or skin breakdown. Review of the nursing note dated 07/20/22 at 1:13 P.M. and completed by Medical Records #605 revealed a care conference was held with Resident #27's guardian and Resident #27 and they discussed personal hygiene, medications, behaviors, and physician appointments. Nothing was documented regarding duct taping the toilet in her bathroom and/ or consent for duct taping her toilet to prevent use. Review of the care plan dated 07/27/22 revealed Resident #27 had a bedside commode. Interventions included encourage resident to use the call light for staff assist when needed. (There was nothing in her care plan regarding duct taping her toilet in her bathroom to prevent use, or regarding Resident #27 having any behaviors regarding flushing items down her toilet clogging the plumbing). Review of the nursing note dated 07/29/22 at 1:14 P.M. and completed by Medical Records #605 revealed she spoke to Resident #27's guardian about her bathroom habits and how it was affecting other residents. (Nothing was documented regarding duct taping the toilet in her bathroom to prevent use and/ or consent for duct taping her toilet to prevent use.) Observation during initial tour on 08/15/22 from 7:53 A.M. to 8:08 A.M. revealed Resident #27 was not in her room. She had a bedside commode next to her bed in her room. The toilet in her bathroom was taped down with duct tape to secure it so that Resident #27 could not use it. Environmental tour 08/15/22 from 8:21 A.M. to 9:02 A.M. with the Administrator verified Resident #27's toilet in her bathroom was duct taped to secure the lid preventing Resident #27 from using the toilet in her bathroom. He revealed Resident #27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He revealed the facility had implemented duct taping Resident #27's toilet preventing her from using her toilet and providing Resident #27 with a bedside commode to use. Interview on 08/15/22 at 11:09 A.M. with Resident #27 revealed she was frustrated with not being able to use the toilet in her bathroom. She revealed she thought she was not able to because the facility had said she had flushed too many tissues down the toilet. She revealed the facility taped up her toilet so that she could not use the toilet in her room. She stated the facility gave her a potty to use by her bed. She revealed she was frustrated as she had to ring the buzzer anytime she used the potty and wait for staff instead of just flushing the toilet. She revealed she did not understand and stated, why I cannot use the toilet in the bathroom as I do not feel I flushed things down it. Interview with the Director of Nursing on 08/15/22 at 12:23 P.M. revealed Resident #27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She verified she had no documented evidence regarding Resident #27 flushing items inappropriately down the toilet. She verified she did not have anything in the care plan regarding Resident #27's behavior of flushing items down the toilet. She verified there was nothing in the care plan regarding the restriction of duct taping the toilet in her bathroom in her care plan. She also verified she did not have any documented evidence of consent to duct taping Resident #27's toilet in her bathroom from Resident #27's guardian. Review of facility policy labeled Resident Rights, dated 09/19/19, revealed residents had the right to participate in decisions that affected the resident's life and the right to a safe and clean-living environment. This deficiency substantiates Complaint Number OH 830.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure care and services were provided, physician orders were followed, and care planned interventions were implemented to ensure one resident (Resident #6) did not elope from the facility. This affected one resident (Resident #6) out of three residents reviewed for elopement. On 12/02/21 at 2:51 P.M. the Administrator, Vice President of Operations #805, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/30/21 at 7:15 P.M. when Resident #6 was unable to be located in the facility or on the facility grounds. Licensed Practical Nurse (LPN) #305 entered Resident #6's room at 7:15 P.M. to administer her night-time medications and discovered Resident #6 was not in her room. At 7:20 P.M. LPN #305 initiated a resident head count, Resident #6 was not located. The DON and Assistant Director of Nursing/Minimum Data Set Nurse (ADON/MDS) #303 were in the facility and notified Resident #6 could not be found. A thorough search of the facility and premises was conducted, Resident #6 was not found, and at 7:45 P.M. The Administrator was notified Resident #6 was missing. All available staff began to search the facility, the facility grounds, and areas and roads around the facility. The local police were notified at 9:33 P.M. that Resident #6 was missing and joined the search to locate her. The facility administration personnel searched until 12/01/21 at 2:30 A.M. and the police continued to search for Resident #6 all night without success. The temperatures from 11/30/21 at 6:30 P.M. through 12/01/21 at 10:10 A.M. ranged from 28 degrees to 40 degrees Fahrenheit (F). On 12/01/21 at 10:10 A.M. Dietary Aide (DA) #507 saw Resident #6 outside a local business while she was driving to visit her grandmother. DA #507 convinced Resident #6 to enter her car and drove her immediately to the facility. Resident #6's vital signs were taken by LP) #308. Her temperature was 96.2 F, blood pressure 107/72, pulse was 110, respirations 20, and oxygen saturation was 98 percent. On 12/01/21 at 10:30 A.M. Resident #6 was transported to the local hospital Emergency Department by Vice President of Operations #805 and accompanied by Transport Driver/Medical Records Associate (TD/MRA) #608 to be evaluated and treated. The police, MD #800, and Resident #6's guardian were notified Resident #6 was found and transported to the Emergency Department. The Immediate Jeopardy was removed on 12/01/21 when the facility implemented the following corrective action: · On 11/30/2021 at 7:15 P.M., facility staff and LPN #305 observed Resident #6 was potentially absent from the facility during medication pass. · On 11/30/2021 at 7:20 P.M., a complete head count was completed by LPN #305, 39 of 40 residents were present, staff were notified of a missing resident, and search of the facility and facility grounds was conducted of missing resident. · On 11/30/2021 at 7:45 P.M. the Administrator and DON were notified by LPN #305 of Resident #6 missing. · On 11/30/2021 at 7:45 P.M. through 12/01/2021 at 10:10 A.M., various management and direct care staff continued driving the local area in search of the resident. · On 11/30/2021 at 8:00 P.M. all nine of nine facility doors were checked by Social Services Designee (SSD) #606 and State tested Nursing Assistant (STNA) #608 and noted to be functioning properly. · On 11/30/2021 at 9:00 P.M., Medical Director (MD) #800 was notified by Assistant Director of Nursing (ADON) #303 of Resident #6 missing. · On 11/30/2021 at 9:01 P.M., SSD #606 notified the local police Resident #6 missing. · On 11/30/2021 at 9:15 P.M., the Administrator notified Guardian #807 of Resident #6 missing. · On 11/30/2021 from 9:15 P.M. through 12/01/2021 at 4:10 P.M., facility staff conducted facility rounds to visualize facility doors every 15 minutes. · On 11/30/2021 at 9:45 P.M., Vice President of Operations #805 educated the Administrator, DON, and SSD #606 on the Elopement Prevention Policy, Missing Resident Policy and observing for residents when exiting the facility to ensure door code was protected. · On 11/30/2021 from 10:00 P.M. through 12/01/2021 at 11:59 P.M., the DON and SSD #606 educated 11 of 11 STNA staff, 5 of 5 Hospitality staff, 12 of 12 licensed nursing staff, 8 of 8 dietary staff, 1 of 1 maintenance staff, 4 of 4 housekeeping/laundry staff, 2 of 2 activities staff and 7 of 7 therapy staff members on the Elopement Prevention Policy, Missing Resident Policy, and observing for residents when exiting the facility to ensure code is protected. Staff were not permitted to work until education has been provided. · On 12/01/2021 at 8:30 A.M., the Regional Director of Clinical Operations #808 educated Business Office Manager #607 on the Elopement Prevention Policy, the Missing Resident Policy, and observing for residents when exiting the facility to ensure the door code is protected. · On 12/01/2021 at 10:10 A.M., Dietary Aide (DA) #507 located Resident #6 outside a local business office and she was transported to the facility. · On 12/01/2021 at 10:20 A.M., Resident #6 was assessed by LPN #308, and her blood pressure was 107/72, pulse 110, respirations 20, temperature 96.2 F, oxygen saturation 98% on room air. Resident #6's mood and behavior was pleasant with no signs and symptoms of physical or emotional distress. Resident #6 denied pain or discomfort. · On 12/01/2021 at 10:30 A.M., Guardian #807, MD #800, and local police were notified Resident #6 was located and appeared at her baseline but would be transported to the local hospital for evaluation. · On 12/01/21 at 10:30 A.M., Resident #6 was transported to the local hospital Emergency Department by Vice President of Operations #805 and accompanied by Transport Driver/Medical Records Associate (TD/MRA) #608 to be evaluated and treated. · On 12/01/2021 at 8:30 P.M., Resident #6 was assessed by LPN #307 upon return from hospital with no concerns. Neurological checks were initiated, and a wander guard was applied to resident. · On 12/01/2021 at 8:30 P.M., Resident #6 was placed on 1 on 1 supervision until admitted into another facility (psych facility) for evaluation. · On 12/01/2021 form 7:30 A.M through 4:30 P.M., ADON/MDS #303 and the DON reviewed and revised 40 of 40 resident elopement assessments. · On 12/01/2021 at 4:00 P.M. ADON/MDS #303 reviewed and updated two of three facility elopement binders. · On 12/01/2021 at 4:10 P.M., all 9 of 9 facility door codes were changed by the Administrator. · On 12/01/2021 at 4:20 P.M., ADON/MDS #303 created an updated list for 10 of 10 residents at risk for elopement. · On 12/01/2021 at 6:30 P.M., the remaining elopement book was updated to complete updates of 3 of 3 binders. · On 12/02/2021 at 3:00 P.M., Resident #6 was accepted into a local behavior health facility for inpatient psychiatric stay for admission at 7:00 P.M. · By 12/01/21 the Administrator/Designee conducted an Elopement Drill on 7:00 A.M. through 7:00 P.M. and 7:00 P.M. through 7:00 A.M. to ensure staff knowledge and comprehension of Elopement and Missing Resident Policy & Procedure. · DON/Designee will complete a headcount on every resident on the secured unit every shift for one week, then daily for one month, then as determined by the Quality Assurance and Assessment (QAA) Committee. · The Administrator/Designee will conduct random elopement drills on each shift weekly for 4 weeks to ensure staff knowledge and comprehension of Elopement and Missing Resident Policy & Procedure, then as determined by the QAA Committee. · The Administrator/designee will audit by direct observation, staff entering and exiting the facility to ensure codes are entered with no resident observation on random shifts 5 times a week for 4 weeks. If a resident appears to be near or observing, the code will be changed immediately then as determined by QAA committee Although the Immediate Jeopardy was removed on 12/01/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident 10's medical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)] disorder, [CONDITION(S)] type, [CONDITION(S)], dementia, and major depressive disorder. Review of Resident #6's care plan, dated 08/04/21, revealed the resident had potential for behavior problems related to a diagnosis of [CONDITION(S)] and interventions included staff were to perform checks on Resident #6 every 15 minutes. Further review did not reveal a care plan for wandering or elopement was initiated until 12/01/21, after Resident #6 eloped from the facility on 11/30/21. Review of Resident #6's Elopement Risk Assessment, dated 09/02/21, revealed the resident was physically capable of leaving the facility. The assessment revealed it included a box to check if resident wandered, roamed, or paced, and it did not identify the resident paced around the facility. The assessment indicated Resident #6 did not display exit seeking behaviors. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment, dated 09/03/21, revealed the resident had moderate cognitive impairment and fluctuating periods of inattention, disorganized thinking and delusions. Resident #6 did not exhibit wandering behavior. Review of Resident #6's physician orders on 09/14/21 identified orders for frequent checks every day and night shift for behavior monitoring. Review of Resident #6's psychiatric physician progress notes on 10/11/21 revealed Resident #6 had poor judgement regarding day-to-day activities, hallucinations and paranoia, and lacked insight regarding matters of self. Review of Resident #6's progress notes on 11/23/21 at 12:26 P.M. revealed Resident #6 was exhibiting bizarre behavior, walking up to staff and looking into space, acting very vague and tired, acting as if she was going to collapse. Vital signs were assessed and indicated blood pressure 142/98, pulse 100, respirations 20, temperature 96.9 F, oxygen saturation 97% on room air. Resident #6 was able to ambulate back to her room with assistance, and her psychiatrist and the DON were notified of the resident's behavior. Review of Resident #6's progress note on 11/28/21 written by Nurse Practitioner (NP) #806 revealed Resident #6 was having increased bizarre behaviors and acting out. Labs were reviewed, and there were no new orders at this time. Review of the facility Elopement Risk Binder from 06/25/21 through 11/30/21 did not reveal Resident #6 was listed as an elopement risk. Review of Resident #6's facility elopement timeline revealed on 11/30/21 at 7:15 P.M. Resident #6 was potentially absent from the facility during the medication administration. On 11/30/21 at 7:20 P.M. a complete resident head count was completed, staff were notified Resident #6 was missing, and a thorough search of the facility and the facility grounds was conducted. The facility administration, resident guardian, and physician were notified Resident #6 was missing. Facility personnel and police searched for the resident through the night until she was located on 12/01/21 at 10:10 A.M. by DA #507 outside a local business, and transported first to the facility, then the local hospital emergency department for evaluation and treatment as needed. Review of LPN #305's Witness Statement dated 11/30/21 revealed LPN #305 saw Resident #6 at 6:20 P.M. in the common area and entered the resident's room at 7:00 P.M. to administer her medications, but Resident #6 was not in her room. It was customary for Resident #6 to pace the facility halls and LPN #305 returned to the resident's room at 7:15 P.M. and Resident #6 was still not in her room. A resident head count was completed, and Resident #6 was unable to be located. The Administrator was immediately notified Resident #6 was missing. Review of the local police department report titled, Ohio Uniform Incident Report,, dated 11/30/21 at 9:33 P.M. included the complainant (Social Services Designee (SSD) #606) was contacted and revealed Resident #6 was missing from the facility some time between 6:30 P.M. and 7:30 P.M. and suffered from chronic mental disease including depression and [CONDITION(S)]. Resident #6 was last seen wearing yellow socks, green sweatshirt, a red jacket, and a flower dress. Review of Resident #6's progress notes from 11/30/21 at 6:30 P.M. through 12/01/21 at 10:20 A.M. did not reveal documentation the resident had eloped from the facility and could not be located or that the police were notified of the elopement. Review of the Emergency Department (ED) documentation on 12/01/21 at 10:39 A.M. revealed when Resident #6 arrived at the hospital vital signs were not taken. Further review of the documentation revealed on 12/01/21 at 12:16 P.M. Resident #6 was five feet tall, weighed 113 pounds, vital signs were temperature 97.2 Fahrenheit, pulse 105, blood pressure 117/62, respirations 18, and oxygen saturation was 96 percent. The report revealed Resident #6 was brought to the ED after she escaped from her nursing home, was out all night, and returned to the nursing home this morning. Resident #6 was sent to the ED by nursing facility staff who felt her [CONDITION(S)] was worsening and could possibly be the reason she left the facility. Resident #6 demonstrated knowledge of leaving the facility in the winter with temperatures so cold it could be life-threatening. Resident #6 stated she wanted to go for a walk to get some fresh air, wanted to be alone with God, and came back on her own. Resident #6 did not meet criteria for in-patient treatment and was discharged back to the facility. Observation on 11/29/21 at 8:00 A.M. of the facility entrance revealed locked glass doors leading to the outside area at each end of a hallway and a code or buzzer was needed to enter and leave the facility. Observations on 11/29/21 at 10:30 A.M., 1:00 P.M., 2:00 P.M., and 4:00 P.M., and on 11/30/21 at 8:30 A.M., 10:00 A.M., and 1:00 P.M. revealed Resident #6's clothing was disheveled, her hair was pulled back and contained with a rubber-band, loose strands of hair not captured in the rubber-band were noted, and she was walking at a fast pace in the common areas of the facility. Observation on 11/30/21 at 4:15 P.M. revealed Resident #6 sitting in the common area by the entrance to the facility. Interview on 12/01/21 at 2:14 P.M. with Resident #801 revealed on 11/30/21 after the 6:30 P.M. smoke break Resident #6 was unable to be found. Resident #801 stated the doors were locked by an electronic device or a key, but somehow Resident #6 got out of the facility and was wearing only socks on her feet when she disappeared. The facility administration, nurses, and the police were looking for her all night, but she was not found. Interview on 12/01/21 at 2:57 P.M. with STNA #209 revealed on 11/30/21 at 6:30 P.M. Resident #6 went outside to the patio for a supervised smoke break. STNA #209 stated she was supervising the smoke break and Resident #6 took a couple puffs of her cigarette, then went back inside the facility. STNA #209 stated Resident #6 tried to come back out to the smoking area after a few minutes, but STNA #209 told her not to come out because the smoke break was almost over. STNA #209 stated during smoke breaks Resident #6 would sometimes walk down the ramp from the patio towards the parking lot and she would have to follow her and bring her back to the smoking area. STNA #209 verified she did not see Resident #6 in the facility after the smoke break was over, and the staff did not realize she was missing until LPN #305 tried to find her to administer her medications around 7:00 P.M. STNA #209 stated everybody was looking for Resident #6 and the staff were worried for her safety. They did not know how Resident #6 got out of the facility. Resident #6 was not found during the remainder of STNA #209's shift and she left the facility at 10:30 P.M. STNA #209 stated the facility staff were looking for Resident #6 through the night until she was found outside a local business the morning of 12/01/21 and transported to the hospital. Interview on 12/01/21 at 3:10 P.M. with the Administrator revealed STNA #209 supervised the 6:30 P.M. smoke break, the management team left at 6:40 P.M., and at approximately 7:45 P.M. she received a phone call from LPN #305 stating Resident #6 was missing and unable to be found. The Administrator stated the management team immediately drove back to the facility, started looking for Resident #6, and continued to drive around the area looking for her until 12/01/21 at 2:30 A.M. The Administrator stated the police were notified Resident #6 was missing around 9:00 P.M. and were looking for her also. The Administrator revealed Resident #6 was seen walking outside of a local business on 12/01/21 around 11:00 A.M. by Dietary Aide (DA) #507, brought back to the facility, and transported immediately to the local emergency department. The Administrator stated Resident #6 told her she was walking around outside all night. The Administrator stated Resident #6 scored low on an exit seeking assessment. Interview on 12/01/21 at 3:19 P.M. with the Director of Nursing (DON) revealed Resident #6's legal guardian was notified she was missing on 11/30/21. Interview on 12/01/21 at 3:36 P.M. with LPN #305 revealed on 11/30/21 she worked from 3:00 P.M. until 11:30 P.M. LPN #305 stated Resident #6 continually paced around the facility and did not wear shoes, would never stop walking, and was always moving. LPN #305 stated Resident #6 went out for a supervised smoke break at 6:30 P.M. and around 6:50 P.M. she looked for her to administer medications and did not see her in her room. LPN #305 stated she administered medications to other residents then came back to Resident #6's room, she was not in her room again, and at 7:15 P.M. Resident #6 was still not in her room, and no staff members had seen her. LPN #305 stated she initiated a resident head count, searched the facility thoroughly, notified the Administrator, and told the DON, and Assistant Director of Nursing (ADON) #305 Resident #6 was missing. LPN #305 stated the outside area of the facility was thoroughly searched but Resident #6 was not found. Interview on 12/01/21 at 4:37 P.M. with DA #507 revealed she was driving to her grandmother's house on 12/01/21 around 10:30 A.M., saw Resident #6 walking outside by a local business, knew she was missing from the facility, and stopped her car to talk to her. Resident #6 told her she was hungry and going to get something to eat. DA #507 told her she would drive her, and Resident #6 agreed to get into her car. DA #507 called to notify the facility Resident #6 was found and was told to drive her to the facility. DA #507 stated she did not remember if Resident #6 looked cold, and Resident #6 did not say what she was doing all night, she just wanted a cigarette. DA #507 stated she drove Resident #6 to the facility and she was taken from her car by facility staff. Interview on 12/02/21 at 7:52 A.M. with the Administrator and DON revealed Resident #6 returned from the hospital emergency department on 12/01/21 at 8:30 P.M. The Administrator stated Resident #6 was being continually monitored by the staff on a one-to-one basis following her return. The Administrator stated Resident #6 told her she memorized the code by watching as people went in and out of the door, and that was how she was able to leave the facility. The Administrator stated the facility had security cameras facing both entrances but, they did not record. The Administrator stated Resident #6 frequently sat in the chairs located by the door. During the day the cameras were monitored by Business Office Manager #607, and during off hours when the doorbell would ring a staff member responded and stood at the door until it was closed. The Administrator stated Resident #6 was immediately assessed by LPN #308 when she returned to the facility. Interview on 12/02/21 at 8:07 A.M. with the DON confirmed Resident #6 paced around the facility at a fast speed and it was not marked on the Elopement Risk Assessment because they did not think she was a wanderer. The DON stated she did not have a history of elopement. Interview on 12/02/21 at 8:55 A.M. with MD #800 revealed he couldn't figure out how Resident #6 was able to leave the facility, and he was not told the door alarms went off. MD #800 stated there had not been any problems with her up until now. MD #800 stated it would not be safe for anyone to be walking around all night in the cold weather, much less a 100-pound girl. MD #800 stated he called the emergency department and spoke to the nursing supervisor. The nursing supervisor told him Resident #6 had to be brought in from the parking lot a couple times while she was waiting because she walked out and wanted a cigarette. In addition, she was running through the emergency department and staff needed to bring her back to her room. MD #800 stated he had not been notified Resident #6 returned to the facility on [DATE], he thought she was still in the emergency department. Interview on 12/02/21 at 9:00 A.M. with Resident #6 revealed she was tired, wanted to sleep. She was unable to be interviewed. Interview on 12/02/21 at 11:38 A.M. with ADON #303 revealed she called MD #800 on 12/01/21 around 9:00 P.M. to notify him Resident #6 returned to the facility, he did not answer, and she did not leave a voice mail. ADON #303 stated she did not document the attempted phone call in Resident #6's progress notes. Interview on 12/02/21 at 1:17 P.M. with LPN #308 revealed Resident #6 was brought to her when she arrived at the facility after being outside walking around all night. LPN #308 stated Resident #6 was alert and oriented, had a jacket on, was bundled up with blankets and her skin was not cold. Review of Resident #6's late entry progress notes on 12/01/21 at 6:38 P.M. documented by LPN #308 included on 12/01/21 at 10:20 A.M. Resident #6's skin was warm, dry, and intact, temperature of 96.2 F, blood pressure 107/72, pulse 110, respirations 20 and oxygen saturation of 98 percent on room air. The progress notes indicated Resident #6 did not have signs and symptoms of emotional distress. Interview on 12/02/21 at 9:26 A.M. with Transport Driver/Medical Records Associate (TD/MRA) #608 revealed she supervised Resident #6 while she was in the hospital until 7:00 P.M. when STNA #209 relieved her. TD/MAR #608 stated Resident #6 was not left alone while she was in the emergency department, but she was quick and impulsive and a couple times wanted a cigarette and went outside. TR/MAR #608 stated she was not aware of any emergency department staff chasing Resident #6. TR/MAR #608 stated the hospital staff did not take her temperature or any vital signs until close to 1:00 P.M., about an hour and a half after she arrived at the emergency department. Interview on 12/02/21 at 10:05 A.M. with STNA #250 revealed Resident #6 was not on 15-minute checks before she eloped from the facility, but some days she was disoriented and needed to be watched closely. STNA #250 stated for the past couple days she was keeping a close eye on her because Resident #6 told her she didn't know what was wrong with her head. Interview on 12/02/21 at 10:14 A.M. with STNA #202 and LPN #302 revealed Resident #6 was not on 15-minute checks before she eloped from the facility on 11/30/21, but she was now. STNA #202 stated there were clip boards at each of the nurse's stations for documentation of residents requiring every 15-minute checks and Resident #6 did not have a documentation record on the clipboard. LPN #302 stated Resident #6 did not have a record on the clipboard for documenting every 15-minute checks and had never been exit seeking. Observation on 12/02/21 at 10:30 A.M. of clipboards at the nurses' station for documenting residents requiring every 15-minute checks did not reveal evidence 15-minute checks were completed for Resident #6. Interview on 12/02/21 at 10:49 A.M. with STNA #212 revealed she was working on 11/30/21 and was assigned to care for Resident #6 during the time she eloped from the facility. STNA #212 stated Resident #6 was her usual self on 11/30/21 and paced around the facility continually, Resident #6 always paced around the facility at a fast speed and had done so since her admission. STNA #212 stated Resident #6 was roaming the hallways during the dance party activity on 11/30/21 at 6:00 P.M., and the dance party was [NAME] down around 6:30 P.M. when the residents had a supervised smoke break. STNA #212 stated she never knew she was supposed to do 15-minute checks on Resident #6, but she usually knew where she was. STNA #212 stated she was with another resident during the 6:30 P.M. smoke break and did not see Resident #6 after the dance party. STNA #212 stated she talked to Resident #6 after she returned to the facility on [DATE] at 8:30 P.M. and was told by Resident #6 she needed air, wanted to feel close to God, and followed Medical Doctor #804 out of the front entrance. STNA #212 stated during supervised smoke breaks before she eloped, Resident #6 would often walk down the ramp towards the parking lot and need to be brought back to the smoking patio. Interview on 12/06/21 at 1:58 P.M. with the DON revealed there were clipboards at the nurses' stations for resident's requiring every 15-minute checks and the nurses initiated the documentation when the checks were required for a resident. The DON stated either the nurse's or the STNAs could fill the sheets out depending on who did the checks for each 15-minute period. Interview on 12/06/21 at 3:12 P.M. with the DON and ADON/MDS #303 confirmed Resident #6 had a care plan for every 15-minute checks since 08/04/21 and physician orders for every 15-minute checks since 09/14/21 and the checks were not documented. Observation on 12/02/21 at 1:52 P.M. of the facility entrance and exit doors revealed the secured alarm system was in place and functioning, and it took 13 seconds for the doors to close after being opened. Review of facility policy titled, Elopement Prevention, undated, revealed it was the policy of the facility to ensure that the resident's environment was safe, and used the least restrictive measures possible. Residents would be assessed for elopement risk upon admission, routinely, and upon a significant change in condition. If a resident was identified to be at risk for elopement, and individualized care plan would be implemented to prevent elopement. Nursing staff would document when circumstances related to exit seeking or wandering was observed and notify the Director of Nursing.

Based on review of the medical record, facility investigation, hospital record, facility abuse prevention, investigation, and reporting policies and procedures, interview with facility staff and residents, the facility failed to ensure observations of sexual abuse involving one male resident (Resident #9) and three cognitively impaired female residents (Residents #2, #6, and #10) were thoroughly investigated and actions were immediately taken to prevent further sexual abuse. This resulted in the likelihood of serious harm that is Immediate Jeopardy on 08/09/19 when Resident #9 was witnessed by State tested Nursing Assistant (STNA) #602 in bed with Resident #6 engaging in sexual actions. Resident #9 then continued on 08/10/19 to publicly rub Resident #2's shoulders and kiss her on the lips. Later on that day Resident #9 was observed by STNA #609 on top of Resident #10 in her bed and both residents were undressed, making sexual motions. STNA #602 and STNA #609 did not intervene at the time of these observations to protect the residents and prevent further sexual abuse from occurring with other residents. There was also no evidence the incidents were immediately investigated as they were not reported to the Administrator or the Director of Nursing (DON) by STNAs #602, #609, #618 and LPNs #614, and #617 who were aware of the incidents. An investigation was not begun until 08/11/19 after an incident between Resident #9 and Resident #10 that occurred beginning on 08/10/19 was reported by LPN #637 to the DON, who then began an investigation which uncovered the previous incidents between Resident #9 and Residents #6 and #2. This affected three residents (Residents #6, #2, and #10). The facility identified five residents at risk for sexual abuse (Residents #6, #2, #10, #12, and #14). Six residents were reviewed for sexual abuse. The facility census was 52 residents. On 08/15/19 at 6:08 P.M. Regional Director of Operations (RDO) #612, the Administrator, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/09/19 at approximately 10:30 P.M. when Resident #9 was observed in sexual acts in the bed of Resident #6, who was assessed to have impaired judgement and severe mental illness and continued on with sexual activity with Residents #2 and #10 who were assessed with [REDACTED]. These actions were not investigated immediately by the facility. An investigation did not begin until 08/11/19 after a sexual related incident involving Residents #9 and #10 that occurred on the night shift of 08/10/19 to 08/11/19 was reported to the DON by LPN #637 at 10:00 [NAME]M. on 08/11/19. The DON then discovered the previous incidents of 08/09/10 and 08/10/10 that occurred between Resident #9 and Residents #6 and #2. The Immediate Jeopardy was removed on 08/22/19 when the facility implemented the following corrective action: · On 08/11/19 the DON and ADON #606 began reviewing and updating care plans for Residents #2, #6, #10, #12 and #14 regarding sexual behavior risk education and guardian/self-consent. These care plan updates were completed on 08/16/19. · On 08/13/19 at 1:36 P.M., Resident #9 discharged himself against medical advice (AMA) and left the facility with his brother who lived in the community. · On 08/15/19 between 8:00 P.M. and 8:45 P.M., the Regional Director of Operations (RDO) educated the Administrator, DON, ADON #606, SSD #610, and BOM/HRM #629 on the facility Abuse Prevention Policy, Abuse Reporting Policy, Reasonable Suspicion of a Crime, Investigation of an Incident, and Screening Admissions for Aggression. · On 08/15/19 from 8:45 P.M. to 11:00 P.M., the Administrator, Business Office Manager/Human Resource Manager (BOM/HRM) #629 and DON educated 51 of 54 facility staff on abuse prevention; immediate reporting of suspected abuse; immediate intervention to ensure resident safety; and warning signs of potential sexual behaviors and/or abuse. The remaining three employees will be inserviced prior to returning to work. · On 08/15/19 from 9:00 P.M. to 10:30 P.M., SSD # 610 audited all residents' medical records for residents at risk of engaging in inappropriate sexual activity and identified two additional residents (Residents #12 and #14) who were at risk. · On 08/15/19, the Administrator submitted the initial facility Self-Reported Incidents (SRI) for sexually related incidents that occurred between Resident #9 and Resident #6 on 08/09/19, Resident #9 and Resident #2 on 08/10/19, and Resident #9 and Resident #10 on the night shift of 08/10/19 to 08/11/19. · On 08/19/19 the Administrator began random interviews with three staff members weekly regarding abuse prevention, reporting abuse, and identifying warning signs of sexual abuse. The interviews will continue weekly for four weeks. · On 08/19/19 from 11:12 [NAME]M. to 12:07 P.M., interview with the Director of Nursing, Maintenance Director #622, Licensed Practical Nurse (LPN) #637, LPN #638, STNAs #603, #605, Activities Aide #636, Dietary Manager #628, Dietary Aide #640, and Housekeeping/ Laundry Staff (HLS) #624 and #639 verified they had knowledge regarding abuse prevention, immediate reporting of suspected abuse, immediate intervention to ensure resident safety, and warning signs of the potential to engage in sexual activity. · On 08/20/19, the DON submitted the final SRI investigation report to the State Agency for the sexually related incidents that occurred between Resident #9 and Resident #6 on 08/09/19, Resident #9 and Resident #2 on 08/10/19, and Resident #9 and Resident #10 on the night shift of 08/10/19 to 08/11/19. · On 08/21/19 at 3:30 P.M., an Ad Hoc Quality Assurance Committee meeting was held with the Administrator, all department heads, and Medical Director #611 to discuss the incidents of sexual behaviors involving Residents #9, #6., #2, and #10, and the facility action plan to address these incidents. · On 08/22/19 the facility implemented a new procedure for the DON to review incident reports daily to ensure previous reportable incidents were communicated to the Administrator and DON. During the next four weeks, the RDO and RCN will ensure any reportable event has a facility SRI submitted and a thorough investigation completed. The DON will also review abuse reporting during her monthly nurse meetings for the next three months. Although the Immediate Jeopardy was removed on 08/22/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: Review of Resident #9's medical record revealed he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. On 08/13/19, Resident #9 discharged himself from the facility AMA and left the facility with his brother who lived in the community. Review of hospital information sent to the facility, and available in Resident #9's facility record, revealed a Review of Statement of Expert Evaluation for Resident #9 (dated 08/02/19) completed by the resident's Primary Care Physician (PCP) #613 prior to admission to the facility. This expert evaluation documented that Resident #9 had a tendency to violence, both verbal and physical and lacks self control when does not get what he wants; has anger issues; has no respect for authority or following rules; memory and judgement are very impaired. On 08/06/19, PCP #613 wrote in the hospital Department of Family Practice Adult Daily Progress Note that Resident #9 continued with obnoxious belligerent behaviors. He was rude and obscene with staff. Review of an undated facility history and physical for Resident #9, completed by PCP #613 after admission, revealed the resident exhibited very aggressive and inappropriate behaviors. Review of a facility investigation that the DON began on 08/11/19, and interview with the DON on 08/15/19 at 7:21 [NAME]M., revealed male Resident #9 was involved in three incidents of sexual behavior with three different female residents. (Residents #6, #2, and #10) between 08/09/19 and the night shift of 08/10/19. Review of Resident #6's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a Statement of Expert Evaluation (dated 12/03/18) completed by Physician #615 that documented Resident #6's insight and judgement were poor due to her mental illness. She had poor impulse control and was not able to take care of herself. She lacked the capacity to make any decisions regarding her care due to her mental illness. Physician #615 recommended guardianship, however, Resident #6 did not have a named guardian at the time of the sexual abuse. Review of a care plan dated 12/14/18 revealed Resident #6 had ineffective coping and agitation related to anxiety and psychiatric illness. Resident #6 was indecisive; lacked insight, hostile, distrustful, and impulsive. Resident #6 had intellectual deficit, lacked morals and ethics and had poor judgement. Review of a care plan dated 02/12/19 for Resident #6 revealed she had inappropriate sexual behavior as she physically exposed herself and made inappropriate remarks. Interventions included constant supervision in recreation programs; protect other residents if they were unable to protect themselves; and set limits for acceptable behavior. On 07/03/19, Psychiatric Nurse Practitioner (PNP) #616 evaluated Resident #6 and documented in the related progress note that Resident #6 had [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS], depression, and anxiety. PNP #616 documented Resident #6 was sexually inappropriate and propositioning males and females at the facility. The resident was hearing voices; pulling out her own hair; physically aggressive; and had increased anxiety with disorganized thought processes. The resident lacked judgment regarding every day activities. Review of a witness statement from STNA #602 (dated 08/12/19) revealed on 08/09/19 around 10:30 P.M. she was looking for Resident #6 and found her in her bedroom with Resident #9. She said all she could see was Resident #9 did not have a shirt on, but she did not know if he had any other clothing on. Resident #9 came out of the room about five minutes later. She said she told the nurse (LPN #614). Resident #6 then came out of her room and went to Resident #9's room and LPN #614 asked another nurse to ask Resident #6 to come out of Resident #9's room because Resident #9 had a roommate. She said Resident #6 did come out of Resident #9's room. A witness statement dated 08/13/19, that was transcribed by ADON #606 for Resident #6, revealed Resident #6 said she and Resident #9 completed oral sexual actions to one another as Resident #9 was unable to get an erection. Interview on 08/14/19 at 11:18 [NAME]M. with STNA #602 revealed she saw Resident #9 in Resident #6's bed. She said Resident #9 did not have a shirt on, and she was unsure if he had any other clothing on or if Resident #6 had clothing on. She said she walked back out of the room and reported what she saw to LPN #614. She revealed Resident #9 came out of Resident #6's room, and shortly after Resident #6 went to go into Resident #9 room LPN #614 asked her to come out of his room. During interview with Resident #6 on 08/14/19 at 12:04 P.M. she said Resident #9 had kissed her and they had sex. Interview on 08/15/19 at 5:59 [NAME]M. with LPN #614 revealed she was not aware of Resident #9 being in Resident #6's bed on 08/09/19. She revealed STNA #602 did not report to her they were in Resident #6's bed. She revealed she was aware of Resident #6 going into Resident #9's room and they redirected her out of Resident #9's room as he had a roommate. She said when she redirected her out of the room, they were watching television in the room and they were not engaged in sexual activity. She said she saw Resident #6 and Resident #9 kissing and holding hands on several occasions. She said Resident #6 had stated to her that she had sex with Resident #9 and some of the other male residents at the facility, but she did not observe any of these sexual interactions. She said she did not report any of these observations and interview statements to administration. Record review for Resident #2 revealed she was admitted on [DATE] and her daughter was her legal guardian. Her [DIAGNOSES REDACTED]. Review of a care plan dated 10/26/15 revealed Resident #2 had altered cognition related to oxygen use and [MEDICAL CONDITION] disorder. Interventions included orient to person, place, and time and explain events prior to starting. Review of a psychiatric progress note dated 07/03/19 completed by PNP #616 revealed Resident #2 had paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION]. She was appointed a guardian in (MONTH) 2012. The note indicated Resident #2 lacked judgment regarding every day activities. Review of a witness statement written by STNA #618 on 08/12/19 revealed on 08/10/19, Resident #2 and Resident #9 were outside smoking. She said Resident #9 was rubbing on Residents #2's upper shoulder and then they pecked each other on the lips. STNA #618 revealed she told them to quit and she moved Resident #9 away from Resident #2 so they could not touch each other in an inappropriate manner. She said she knew Resident #2 had a guardian. She said Resident #2 said she was Resident #9's mother. Review of a nursing note written by ADON #606 on 08/12/19 at 11:16 [NAME]M. revealed Resident #2 thought he was visiting with her son, as she believed Resident #9 was her son. She stated, He's my son's twin. My other son. It's been a long time since I have seen him. He's missed his mother. Interview with Resident #2 on 08/14/19 at 10:31 [NAME]M. revealed she rambled in the interview from topic to topic and was difficult to understand. She said Resident #9 was her son. On 08/16/19, at 12:26 P.M., interview with STNA #618 revealed on 08/10/19 at approximately 10:45 [NAME]M. during the resident's smoke break outside, Resident #9 started rubbing Resident #2's upper shoulder and they were holding hands. She revealed Resident #9 then kissed Resident #2 on the lips. She revealed Resident #2 was confused as she continued to state that Resident #9 was her son. She said she separated the two and Resident #9 went inside. STNA #618 said she did not tell the nurse about the incident. Record review for Resident #10 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of form titled, Letter of Successor Guardianship dated 07/01/16 revealed Resident #10 was deemed incompetent and was assigned a legal guardian by the court. Review of a care plan dated 07/18/19 revealed Resident #10 had a chronic progressive decline in intellectual functioning characterized by a deficit in memory, judgement, decision making, and thought process related to mental illness. Interventions included explain each procedure prior to beginning and modify environment to prevent situations that trigger inappropriate behavior. Review of PNP #616's progress note dated 07/03/19 revealed Resident #10 had paranoid [MEDICAL CONDITIONS] disorder, and conduct disorder. She had a legal guardian. She heard voices and was physically aggressive towards others. Resident #10 lacked insight concerning matters of herself and lacked judgement with every day activities. Review of STNA #609's witness statement dated 08/11/19 revealed she went into Resident #10's room (on 08/10/19) to check on her and found Resident #9 on top of her. They were both undressed. She reported the incident to LPN #617. Review of a witness statement (undated) written by the DON after she spoke with LPN #617 revealed LPN #617 did not intervene or report Resident #9 and #10 having sex. She revealed LPN #617 thought it was the resident's right to have sex, and he provided privacy. The DON said she educated LPN #617 on the policy for residents engaging in sexual activity and making sure if they have a guardian they were notified, and management notified immediately. During interview on 08/14/19 at 1:59 P.M., Resident #10 was confused and her discussion during the interview jumped from topic to topic. She said she had sex with Resident #9 as she was gesturing to her private area. She said she had sex once in her bed and once in his bed. She was unable to provide dates and times of when the sexual activity occurred. She continued to say that another female resident wanted him. She then stated I think I have gonorrhea. Do you know what that is? That is from him when he had sex with me. Am I going to die? I am scared. She revealed she told LPN #601 she was scared, and the nurse was contacting the doctor and he was going to order medication. Interview on 08/14/19 at 5:15 P.M. with STNA #609 revealed on 08/10/19 before she was leaving for the night at approximately 10:30 P.M. she witnessed Resident #9 on top of Resident #10 while in her bed. She revealed they were both undressed and appeared to be having sex. She revealed she reported the incident to LPN #617, and she was not sure what LPN #617 did as she had to leave since it was the end of her shift. She said she did not intervene with the residents. On 08/15/19 at 7:21 [NAME]M., interview with the DON revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. from LPN #637 who was concerned about information she received in report from LPN #617, that Resident #10 and Resident #9 had sexual activity during the night shift. LPN #637 was concerned as Resident #10 had a guardian. The DON then began an investigation and obtained witness statements from the staff and residents, including the roommates of these residents. The DON indicated review of these witness statements revealed two additional sexual related incidents occurred involving Resident #9 and Resident #6 on 08/09/19, and Resident #9 and Resident #2 on 08/10/19. There was no evidence these incidents were reported when they occurred to the DON or Administrator. Interview on 08/16/19 at 11:55 [NAME]M. with LPN #617 revealed STNA #609 had informed him Resident #9 was on top of Resident #10 in her bed and they were having sex. LPN #617 revealed he did not intervene as he felt it was their right to have sex. He said they hung around each other all night and went back and forth in her bed and his bed most of the night between smoke breaks. He said they were in Resident #9's bed even though Resident #9 had a roommate that was in the room at the same time. He said he was aware Resident #10 had a legal guardian. He said he did not report this incident to the Administrator or the DON. Interview on 08/15/19 at 7:71 [NAME]M. with the Director of Nursing revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. regarding Resident #9 and Resident #10 having sexual relations, as the dayshift nurse (LPN #637) was concerned when she received report that the residents had sex that night and Resident #10 had a legal guardian. She revealed she was giving a disciplinary action to LPN #617 as he did not follow their policy and procedures since Resident #10 had a legal guardian and he did not separate Resident #9 from Resident #10 during sexual activity. The DON said she was unable to initiate an investigation timely as she was not notified until the next morning. She said she did not know about Resident #2 and Resident #6 having sexual relations with Resident #9 until after they began investigating the sexual activity between Residents #9 and #10. She revealed the police were not contacted regarding the sexual activity Resident #9 had with Residents #2, #6, or #10. Review of the facility Resident Privacy Policy (dated (MONTH) 2014) revealed the social service department would meet with residents who appear to desire intimate activities to provide education, ensure the resident's ongoing participation is consensual, and verify the resident understands they have the right to refuse the intimate advances of others. This policy also indicated residents who express or demonstrate they may be engaging in intimate activities will be interviewed by the social services department or director of nursing to ensure they are participating willingly and understand related health risks. The procedure included with this policy indicated that if residents were observed participating in intimate activities, staff were to notify the DON/Administrator so they could assure all appropriate actions were implemented. Review of facility policy, Abuse Prevention Policy and Procedure dated 01/01/16 revealed if abuse was witnessed by a staff member the staff member would first and foremost take whatever action was needed to protect the resident. The facility would investigate all allegations of abuse. The facility would provide protection of the residents during and after the investigation. In the case of resident-to-resident suspected abuse, the parties were separated from one another until the investigation has been completed. The facility would report all allegations of abuse to the (State Agency) as soon as possible, but no more than 24- hours after the alleged incident was discovered. This deficiency substantiates Complaint Number OH 357.

Based on review of the medical record, hospital record, facility investigation, facility abuse prevention, investigation, and reporting policies and procedures and interview with facility staff and residents, the facility failed to ensure incidents of sexual abuse involving one male resident (Resident #9) and three female residents (Residents #2, #6, and #10), assessed as cognitively impaired with impaired judgement, were reported to the Administrator and the State Agency (SA) immediately or no later than two hours after being observed. This resulted in the likelihood of serious harm that is Immediate Jeopardy on 08/09/19 when staff witnessed Resident #9 in bed with Resident #6 engaging in sexual actions, on 08/10/19, staff witnessed Resident #9 publicly rub Resident #2's shoulders and kiss her on the lips and later that same day staff witnessed Resident #9 on top of Resident #10 in her bed, both residents were undressed, making sexual motions while in bed. Staff failed to immediately report the observed sexual abuse to administration and a report of the event was not immediately made to the SA and a final reporting to the SA was not received within five working days. This affected three residents (Residents #6, #2, and #10). The facility identified five residents at risk for sexual abuse (Residents #6, #2, #10, #12, and #14). Six residents were reviewed for sexual abuse. The facility census was 52 residents. On 08/15/19 at 6:08 P.M. Regional Director of Operations (RDO) #612, the Administrator, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/09/19 at approximately 10:30 P.M. when Resident #9 was observed in sexual acts in the bed of Resident #6 continued on with sexual activity with Residents #2 and #10 who were assessed with [REDACTED]. The Immediate Jeopardy was removed on 08/22/19 when the facility implemented the following corrective action: · On 08/13/19 at 1:36 P.M., Resident #9 discharged himself against medical advice (AMA) and left the facility with his brother who lived in the community. · On 08/15/19 between 8:00 P.M. and 8:45 P.M., the Regional Director of Operations (RDO) educated the Administrator, DON, ADON #606, SSD #610, and BOM/HRM #629 on the facility Abuse Prevention Policy, Abuse Reporting Policy, Reasonable Suspicion of a Crime, Investigation of an Incident, and Screening Admissions for Aggression. · On 08/15/19 from 8:45 P.M. to 11:00 P.M. the Administrator, Business Office Manager/Human Resource Manager (BOM/HRM) #629 and DON educated 51 of 54 facility staff on abuse prevention; immediate reporting of suspected abuse; immediate intervention to ensure resident safety; and warning signs of potential sexual behaviors and/or abuse. The remaining three employees will be inserviced prior to returning to work. · On 08/15/19, the Administrator submitted the initial facility Self-Reported Incidents (SRI) to the SA for sexually related incidents that occurred between Resident #9 and Resident #6 on 08/09/19, Resident #9 and Resident #2 on 08/10/19, and Resident #9 and Resident #10 on the night shift of 08/10/19 to 08/11/19. · On 08/19/19 the Administrator began random interviews with three staff members weekly regarding abuse prevention, reporting abuse, and identifying warning signs of sexual abuse. The interviews will continue weekly for four weeks. · On 08/19/19 from 11:12 [NAME]M. to 12:07 P.M., interview with the Director of Nursing, Maintenance Director #622, Licensed Practical Nurse (LPN) #637, LPN #638, STNAs #603, #605, Activities Aide #636, Dietary Manager #628, Dietary Aide #640, and Housekeeping/ Laundry Staff (HLS) #624 and #639 verified they had knowledge regarding abuse prevention, immediate reporting of suspected abuse, immediate intervention to ensure resident safety, and warning signs of the potential to engage in sexual activity. · On 08/20/19, the DON submitted the final SRI investigation report to the SA for the sexually related incidents that occurred between Resident #9 and Resident #6 on 08/09/19, Resident #9 and Resident #2 on 08/10/19, and Resident #9 and Resident #10 on the night shift of 08/10/19 to 08/11/19. · On 08/21/19 at 3:30 P.M., an Ad Hoc Quality Assurance Committee meeting was held with the Administrator, all department heads, and Medical Director #611 to discuss the incidents of sexual behaviors involving Residents #9, #6., #2, and #10, and the facility action plan to address these incidents. · On 08/22/19 the facility implemented a new procedure for the DON to review incident reports daily to ensure previous reportable incidents were communicated to the Administrator and DON. During the next four weeks, the RDO and RCN will ensure any reportable event has a facility SRI submitted and a thorough investigation completed. The DON will also review abuse reporting during her monthly nurse meetings for the next three months. Although the Immediate Jeopardy was removed on 08/22/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: Review of Resident #9's medical record revealed he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. On 08/13/19, Resident #9 discharged himself from the facility AMA and left the facility with his brother who lived in the community. Review of hospital information sent to the facility, and available in Resident #9's facility record, revealed a Review of Statement of Expert Evaluation for Resident #9 (dated 08/02/19) completed by the resident's Primary Care Physician (PCP) #613 prior to admission to the facility. This expert evaluation documented that Resident #9 had a tendency to violence, both verbal and physical and lacks self control when does not get what he wants; has anger issues; has no respect for authority or following rules; memory and judgement are very impaired. On 08/06/19, PCP #613 wrote in the hospital Department of Family Practice Adult Daily Progress Note that Resident #9 continued with obnoxious belligerent behaviors. He was rude and obscene with staff. Review of an undated facility history and physical for Resident #9, completed by PCP #613 after admission, revealed the resident exhibited very aggressive and inappropriate behaviors. Review of a facility investigation that the DON began on 08/11/19, and interview with the DON on 08/15/19 at 7:21 [NAME]M., revealed male Resident #9 was involved in three incidents of sexual behavior with three different female residents. (Residents #6, #2, and #10) between 08/09/19 and the night shift of 08/10/19. Review of Resident #6's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a Statement of Expert Evaluation (dated 12/03/18) completed by Physician #615 that documented Resident #6's insight and judgement were poor due to her mental illness. She had poor impulse control and was not able to take care of herself. She lacked the capacity to make any decisions regarding her care due to her mental illness. Physician #615 recommended guardianship, however, Resident #6 did not have a named guardian at the time of the sexual abuse. Review of a care plan dated 12/14/18 revealed Resident #6 had ineffective coping and agitation related to anxiety and psychiatric illness. Resident #6 was indecisive; lacked insight, hostile, distrustful, and impulsive. Resident #6 had intellectual deficit, lacked morals and ethics and had poor judgement. Review of a care plan dated 02/12/19 for Resident #6 revealed she had inappropriate sexual behavior as she physically exposed herself and made inappropriate remarks. Interventions included constant supervision in recreation programs; protect other residents if they were unable to protect themselves; and set limits for acceptable behavior. On 07/03/19, Psychiatric Nurse Practitioner (PNP) #616 evaluated Resident #6 and documented in the related progress note that Resident #6 had [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS], depression, and anxiety. PNP #616 documented Resident #6 was sexually inappropriate and propositioning males and females at the facility. The resident was hearing voices; pulling out her own hair; physically aggressive; and had increased anxiety with disorganized thought processes. The resident lacked judgment regarding every day activities. Review of a witness statement from STNA #602 (dated 08/12/19) revealed on 08/09/19 around 10:30 P.M. she was looking for Resident #6 and found her in her bedroom with Resident #9. She said all she could see was Resident #9 did not have a shirt on, but she did not know if he had any other clothing on. Resident #9 came out of the room about five minutes later. She said she told the nurse (LPN #614). Resident #6 then came out of her room and went to Resident #9's room and LPN #614 asked another nurse to ask Resident #6 to come out of Resident #9's room because Resident #9 had a roommate. She said Resident #6 did come out of Resident #9's room. A witness statement dated 08/13/19, that was transcribed by ADON #606 for Resident #6, revealed Resident #6 said she and Resident #9 completed oral sexual actions to one another as Resident #9 was unable to get an erection. On 08/13/19, Resident #11 (who was Resident #9's roommate) was assisted by Social Service Director (SSD) #610 to transcribe his witness statement. Resident #11 said in his statement that Resident #9 had sex with two different women on two different days. He said one of the women was Resident #6. He said they were loud and moaning and they kept him awake. He said SSD #610 offered to provide a counselor for him however, Resident #11 declined. Resident #11 was glad Resident #9 had left the facility. Interview on 08/14/19 at 11:18 [NAME]M. with STNA #602 revealed she saw Resident #9 in Resident #6's bed. She said Resident #9 did not have a shirt on, and she was unsure if he had any other clothing on or if Resident #6 had clothing on. She said she walked back out of the room and reported what she saw to LPN #614. She revealed Resident #9 came out of Resident #6's room, and shortly after Resident #6 went to go into Resident #9 room, LPN #614 asked her to come out of his room. During interview with Resident #6 on 08/14/19 at 12:04 P.M. she said Resident #9 had kissed her and they had sex. On 08/14/19 at 2:31 P.M., interview with Resident #13 who was the roommate of Resident #6, revealed Resident #9 came into their room almost every night when he lived at the facility. Resident #13 revealed Resident #6 and Resident #9 had sex several times when she was in the room. She said they pulled the curtain, but she heard them both moaning. She said they should have had a private room as she should not have had to listen to them having sex. She said sometimes they had sex three to four times a night and would stay up most the night, and this bothered her. Interview on 08/14/19 at 2:54 P.M. with Resident #11who was Resident #9's roommate revealed on 08/09/19 around 8:00 P.M., Resident #6 came into his room. He said Resident #6 and Resident #9 had sex in the bed next to his bed while he was in the room. He said he did not see them have sex as the curtain was pulled, but he could hear them making loud moaning sounds. He said this bothered him. He said staff did not come into the room during the time they were there together. Interview on 08/15/19 at 5:59 [NAME]M. with LPN #614 revealed she was not aware of Resident #9 being in Resident #6's bed on 08/09/19. She revealed STNA #602 did not report to her they were in Resident #6's bed. She revealed she was aware of Resident #6 going into Resident #9's room and they redirected her out of Resident #9's room as he had a roommate. She said when she redirected her out of the room, they were watching television in the room and they were not engaged in sexual activity. She said she saw Resident #6 and Resident #9 kissing and holding hands on several occasions. She said Resident #6 had stated to her that she had sex with Resident #9 and some of the other male residents at the facility, but she did not observe any of these sexual interactions. She said she did not report any of these observations to administration. Record review for Resident #2 revealed she was admitted on [DATE] and her daughter was her legal guardian. Her [DIAGNOSES REDACTED]. Review of a care plan dated 10/26/15 revealed Resident #2 had altered cognition related to oxygen use and [MEDICAL CONDITION] disorder. Interventions included orient to person, place, and time and explain events prior to starting. Review of care plan for Resident #2 dated 12/16/15 revealed she may go on supervised leave of absence as she had a legal guardian due to poor decision making and mental health status. Resident #2 was impulsive and at times neglectful of safety concerns. Review of a psychiatric progress note dated 07/03/19 completed by PNP #616 revealed Resident #2 had paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION]. She was appointed a guardian in (MONTH) 2012. The note indicated Resident #2 lacked judgment regarding every day activities. Review of a witness statement written by STNA #618 on 08/12/19 revealed on 08/10/19, Resident #2 and Resident #9 were outside smoking. She said Resident #9 was rubbing Residents #2's upper shoulder and then they pecked each other on the lips. STNA #618 revealed she told them to quit and she moved Resident #9 away from Resident #2 so they could not touch each other in an inappropriate manner. She said she knew Resident #2 had a guardian. She said Resident #2 said she was Resident #9's mother. Review of a nursing note written by ADON #606 on 08/12/19 at 11:16 [NAME]M. revealed Resident #2 thought he was visiting with her son, as she believed Resident #9 was her son. She stated, He's my son's twin. My other son. It's been a long time since I have seen him. He's missed his mother. Interview with Resident #2 on 08/14/19 at 10:31 [NAME]M. revealed she rambled in the interview from topic to topic and was difficult to understand. She said Resident #9 was her son. On 08/16/19, at 12:26 P.M., interview with STNA #618 revealed on 08/10/19 at approximately 10:45 [NAME]M. during the resident's smoke break outside, Resident #9 started rubbing Resident #2's upper shoulder and they were holding hands. She revealed Resident #9 then kissed Resident #2 on the lips. She revealed Resident #2 was confused as she continued to state that Resident #9 was her son. She said she separated the two and Resident #9 went inside. STNA #618 said she did not tell the nurse about the incident. Record review for Resident #10 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of form titled, Letter of Successor Guardianship dated 07/01/16 revealed Resident #10 was deemed incompetent and was assigned a legal guardian by the court. Review of a care plan dated 07/18/19 revealed Resident #10 had a chronic progressive decline in intellectual functioning characterized by a deficit in memory, judgement, decision making, and thought process related to mental illness. Interventions included explain each procedure prior to beginning and modify environment to prevent situations that trigger inappropriate behavior. Review of PNP #616's progress note dated 07/03/19 revealed Resident #10 had paranoid [MEDICAL CONDITIONS] disorder, and conduct disorder. She had a legal guardian. She heard voices and was physically aggressive towards others. Resident #10 lacked insight concerning matters of herself and lacked judgement with every day activities. Review of STNA #609's witness statement dated 08/11/19 revealed she went into Resident #10's room (on 08/10/19) to check on her and found Resident #9 on top of her. They were both undressed. STNA #609 said she reported the incident to LPN #617. Review of a witness statement (undated) written by the DON after she spoke with LPN #617 revealed LPN #617 did not intervene or report Resident #9 and #10 having sex. She revealed LPN #617 thought it was the resident's right to have sex, and he provided privacy. The DON said she educated LPN #617 on the policy for residents engaging in sexual activity and making sure if they have a guardian they were notified, and management notified immediately. During interview on 08/14/19 at 1:59 P.M., Resident #10 was confused and her discussion during the interview jumped from topic to topic. She said she had sex with Resident #9 as she was gesturing to her private area. She said she had sex once in her bed and once in his bed. She was unable to provide dates and times of when the sexual activity occurred. She continued to say that another female resident wanted him. She then stated I think I have gonorrhea. Do you know what that is? That is from him when he had sex with me. Am I going to die? I am scared. She revealed she told LPN #601 she was scared, and the nurse was contacting the doctor and he was going to order medication. Interview on 08/14/19 at 5:15 P.M. with STNA #609 revealed on 08/10/19 before she was leaving for the night at approximately 10:30 P.M. she witnessed Resident #9 on top of Resident #10 while in her bed. She revealed they were both undressed and appeared to be having sex. She revealed she reported the incident to LPN #617, and she was not sure what LPN #617 did as she had to leave since it was the end of her shift. She said she did not intervene with the residents. On 08/15/19 at 7:21 [NAME]M., interview with the DON revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. from LPN #637 who was concerned about information she received in report from LPN #617, that Resident #10 and Resident #9 had sexual activity during the night shift. LPN #637 was concerned as Resident #10 had a guardian. The DON then began an investigation and obtained witness statements from the staff and residents, including the roommates of these residents. The DON indicated review of these witness statements revealed two additional sexual related incidents occurred involving Resident #9 and Resident #6 on 08/09/19, and Resident #9 and Resident #2 on 08/10/19. There was no evidence these incidents were reported when they occurred to the DON or Administrator. Interview on 08/16/19 at 11:55 [NAME]M. with LPN #617 revealed STNA #609 had informed him Resident #9 was on top of Resident #10 in her bed and they were having sex. LPN #617 revealed he did not intervene as he felt it was their right to have sex. He said they hung around each other all night and went back and forth in her bed and his bed most of the night between smoke breaks. He said they were in Resident #9's bed even though Resident #9 had a roommate that was in the room at the same time. He said he was aware Resident #10 had a legal guardian. He said he did not report this incident to the Administrator or the DON. Interview on 08/15/19 at 7:71 [NAME]M. with the Director of Nursing revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. regarding Resident #9 and Resident #10 having sexual relations, as the dayshift nurse (LPN #637) was concerned when she received report that the residents had sex that night and Resident #10 had a legal guardian. She revealed she was giving a disciplinary action to LPN #617 as he did not follow their policy and procedures since Resident #10 had a legal guardian and he did not separate Resident #9 from Resident #10 during sexual activity. The DON said she was unable to initiate an investigation timely as she was not notified until the next morning. She said she did not know about Resident #2 and Resident #6 having sexual relations with Resident #9 until after they began investigating the sexual activity between Residents #9 and #10. She revealed the police were not contacted regarding the sexual activity Resident #9 had with Residents #2, #6, or #10. Interview with the Administrator on 08/15/19 at 7:35 [NAME]M. revealed he notified Resident #10's guardian on 08/11/19 after he was notified of Resident #9 and #10's sexual activity the previous night. He revealed he received consent from the guardian for Resident #10 approving sexual relations, but also verified he received that consent after the sexual relations had taken place. Interview with the Administrator and RDO #612 on 08/15/19 at 10:37 [NAME]M. revealed they did not notify the police of Resident #9's sexual activity with Residents #6, #2, and 10 at the facility. Review of the facility Resident Privacy Policy (dated (MONTH) 2014) revealed the social service department would meet with residents who appear to desire intimate activities to provide education, ensure the resident's ongoing participation is consensual, and verify the resident understands they have the right to refuse the intimate advances of others. This policy also indicated residents who express or demonstrate they may be engaging in intimate activities will be interviewed by the social services department or director of nursing to ensure they are participating willingly and understand related health risks. The procedure included with this policy indicated that if residents were observed participating in intimate activities, staff were to notify the DON/Administrator so they could assure all appropriate actions were implemented. Review of facility policy, Abuse Prevention Policy and Procedure dated 01/01/16 revealed if abuse was witnessed by a staff member the staff member would first and foremost take whatever action was needed to protect the resident. The facility would investigate all allegations of abuse. The facility would provide protection of the residents during and after the investigation. In the case of resident-to-resident suspected abuse, the parties were separated from one another until the investigation has been completed. The facility would report all allegations of abuse to the (State Agency) as soon as possible, but no more than 24- hours after the alleged incident was discovered. Review of facility Self-Reported Incidents (SRI) submitted by the facility to the SA revealed the following: · The sexually related incident between Resident #6 and Resident #9 that occurred on 08/09/19 was documented as discovered on 08/11/19; the SRI was created on 08/15/19; and the completion date was 08/20/19. · The sexually related incident that occurred between Resident #2 and Resident #9 on 08/10/19 was discovered on 08/11/19; the SRI was created on 08/15/19; and completion date was 08/20/19. · The sexually related incident that occurred between Resident #10 and Resident #9 on the night shift of 08/10/19 to 08/11/19 was reported in the SRI as occurring on 08/11/19 at 12:00 [NAME]M. However, this incident was observed by STNA #609 on 08/10/19 at 10:30 P.M. The SRI indicated the date of discovery was 08/11/19; the SRI was created on 08/15/19; and completion date was 08/20/19. There was no evidence that the final reports of these facility SRI investigations were submitted to the State Agency within five working days of the respective incidents. This deficiency substantiates Complaint Number OH 357.

Based on review of the medical record, facility investigation, hospital record, facility abuse prevention, investigation, and reporting policies and procedures, interview with Medical Director (MD) #611, and facility staff and residents, the facility failed to ensure three residents (Residents #2, #6, and #10) who were cognitively impaired, had impaired judgement and [DIAGNOSES REDACTED].#9). This resulted in the likelihood of serious harm that is Immediate Jeopardy on 08/09/19 when Resident #9 was witnessed by State tested Nursing Assistant (STNA) #602 in bed with Resident #6 engaging in sexual actions. Resident #9 then continued on 08/10/19 to publicly rub Resident #2's shoulders and kiss her on the lips. Later in the day on 08/10/19, Resident #9 was observed by STNA #609 on top of Resident #10 in her bed and both residents were undressed, making sexual motions while in bed. Resident #10 later said they had sex and she was scared she was going to become ill with a [MEDICAL CONDITION] and die. STNA #602 and STNA #609 did not intervene at the time of these observations and the incidents were not immediately reported to administration. This affected three residents (Residents #6, #2, and #10). The facility identified five residents at risk for sexual abuse (Residents #6, #2, #10, #12, and #14). Six residents were reviewed for sexual abuse. The facility census was 52 residents. On 08/15/19 at 6:08 P.M. Regional Director of Operations (RDO) #612, the Administrator, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/09/19 at approximately 10:30 P.M. when Resident #9 who was reported to have impaired judgement and a tendency for violence, was observed in sexual acts in the bed of Resident #6, who was assessed to have impaired judgement and severe mental illness and continued on with sexual activity with Residents #2 and #10 who were assessed with [REDACTED]. The Immediate Jeopardy was removed on 08/22/19 when the facility implemented the following corrective action: · On 08/11/19 the DON and ADON #606 began reviewing and updating care plans for Residents #2, #6, #10, #12 and #14 regarding sexual behavior risk education and guardian/self-consent. These care plan updates were completed on 08/16/19. · On 08/13/19 at 1:36 P.M., Resident #9 discharged himself against medical advice (AMA) and left the facility with his brother who lived in the community. · On 08/15/19 between 8:00 P.M. and 8:40 P.M., Social Service Designee (SSD) #610 completed psychosocial assessments for Residents #2, #6, and #10 with no new concerns identified. · On 08/15/19 between 8:00 P.M. and 8:45 P.M., the Regional Director of Operations (RDO) educated the Administrator, DON, ADON #606, SSD #610, and BOM/HRM #629 on the facility Abuse Prevention Policy, Abuse Reporting Policy, Reasonable Suspicion of a Crime, Investigation of an Incident, and Screening Admissions for Aggression. · On 08/15/19 from 8:45 P.M. to 11:00 P.M. the Administrator, Business Office Manager/Human Resource Manager (BOM/HRM) #629, and DON educated 51 of 54 facility staff on abuse prevention; immediate reporting of suspected abuse; immediate intervention to ensure resident safety; and warning signs of potential sexual behaviors and/or abuse. The remaining three employees will be inserviced prior to returning to work. · On 08/15/19 at 8:45 P.M. the DON began completing head to toe assessments of eight residents (Resident #1, #7, #18, #19, #20, #21, #22, and #23,) who were cognitively impaired, with no adverse findings identified relative to sexual abuse. · On 08/15/19 at 8:45 P.M. ADON #606 began interviews of 39 residents (Resident #3, #4, #5, #8, #11, #12, #13, #14, #15, #16, #17, #50, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #77, #78, #79, #80, and #81) who were assessed as cognitively intact, regarding any unwanted sexual encounters. · On 08/15/19 between 9:00 P.M. and 9:30 P.M., the DON and ADON #606 interviewed and assessed Residents #2, #6, and #10 regarding any concerns or fears they may have regarding inappropriate sexual advances from Resident #9 or other residents. No adverse effects were identified with these residents. · On 08/15/19 between 9:00 P.M. and 9:30 P.M., ADON #606 notified the physicians of Residents #2, #6, and #10 of the sexual related incidents that occurred with Resident #9. No new orders were obtained at that time. · On 08/15/19 between 9:00 P.M. and 9:30 P.M. ADON # 606 notified the guardian or family members of Residents #2, #6, and #10 of the sexually related incidents with Resident #9. · On 08/15/19 from 9:00 P.M. to 10:30 P.M., SSD # 610 audited all residents' medical records for residents at risk of engaging in inappropriate sexual activity and identified two additional residents (Residents #12 and #14) who were at risk. · On 08/15/19, the Administrator submitted the initial facility Self-Reported Incidents (SRI) for sexually related incidents that occurred between Resident #9 and Resident #6 on 08/09/19, Resident #9 and Resident #2 on 08/10/19, and Resident #9 and Resident #10 on 08/11/19. · On 08/15/19, SSD #610 conducted therapeutic visits with Residents #2, #6, and #10 to ensure no new concerns or psychosocial effects had developed. The visits will continue weekly for one month. · On 08/16/19, the facility began a new procedure of reporting all nursing staff report offs to the DON or ADON #606 for schedule adjustments to ensure sufficient staffing and supervision of residents. · On 08/19/19 the Administrator began random interviews with three staff members weekly regarding abuse prevention, reporting abuse, and identifying warning signs of sexual abuse. The interviews will continue weekly for four weeks. · On 08/19/19 from 11:12 [NAME]M. to 12:07 P.M., interview with the Director of Nursing, Maintenance Director #622, Licensed Practical Nurse (LPN) #637, LPN #638, STNAs #603, #605, Activities Aide #636, Dietary Manager #628, Dietary Aide #640, and Housekeeping/ Laundry Staff (HLS) #624 and #639 verified they had knowledge regarding abuse prevention, immediate reporting of suspected abuse, immediate intervention to ensure resident safety, and warning signs of the potential to engage in sexual activity. · On 08/21/19 at 3:30 P.M., an Ad Hoc Quality Assurance Committee meeting was held with the Administrator, all department heads, and Medical Director #611 to discuss the incidents of sexual behaviors involving Residents #9, #6., #2, and #10, and the facility action plan to address these incidents. · On 08/22/19 the facility implemented a new procedure for new admissions who will be placed on 15 minute checks for 48 hours during the establishment of their baseline care plan to ensure behaviors were accurately addressed with appropriate interventions. This baseline care plan will be reviewed by the DON within 48 hours to ensure accuracy and determination of discontinuing the 15 minute checks. · On 08/22/19 the facility implemented a new procedure for the Regional Clinical Nurse (RCN) to conduct a final review of all admission referrals prior to accepting new residents into the facility to ensure their needs could be met, and any history of aggression was reviewed with the medical director prior to accepting the resident. · On 08/22/19 the facility implemented a new procedure for the DON to review incident reports daily to ensure previous reportable incidents were communicated to the Administrator and DON. During the next four weeks, the RDO and RCN will ensure any reportable event has a facility SRI submitted and a thorough investigation completed. The DON will also review abuse reporting during her monthly nurse meetings for the next three months. Although the Immediate Jeopardy was removed on 08/22/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: Review of Resident #9's medical record revealed he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. On 08/13/19, Resident #9 discharged himself from the facility AMA and left the facility with his brother who lived in the community. Review of hospital information sent to the facility, and available in Resident #9's facility record, revealed a Review of Statement of Expert Evaluation for Resident #9 (dated 08/02/19) completed by the resident's Primary Care Physician (PCP) #613 prior to admission to the facility. This expert evaluation documented that Resident #9 had a tendency to violence, both verbal and physical and lacks self control when does not get what he wants; has anger issues; has no respect for authority or following rules; memory and judgement are very impaired. On 08/06/19, PCP #613 wrote in the hospital Department of Family Practice Adult Daily Progress Note that Resident #9 continued with obnoxious belligerent behaviors. He was rude and obscene with staff. Review of an undated facility history and physical for Resident #9, completed by PCP #613 after admission, revealed the resident exhibited very aggressive and inappropriate behaviors. Review of a facility investigation that the DON began on 08/11/19, and interview with the DON on 08/15/19 at 7:21 [NAME]M., revealed male Resident #9 was involved in three incidents of sexual behavior with three different female residents. (Residents #6, #2, and #10) between 08/09/19 and the night shift of 08/10/19. Review of Resident #6's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a Statement of Expert Evaluation (dated 12/03/18) completed by Physician #615 that documented Resident #6's insight and judgement were poor due to her mental illness. She had poor impulse control and was not able to take care of herself. She lacked the capacity to make any decisions regarding her care due to her mental illness. Physician #615 recommended guardianship, however, Resident #6 did not have a named guardian at the time of the sexual abuse. Review of a care plan dated 12/14/18 revealed Resident #6 had ineffective coping and agitation related to anxiety and psychiatric illness. Resident #6 was indecisive; lacked insight, hostile, distrustful, and impulsive. Resident #6 had intellectual deficit, lacked morals and ethics and had poor judgement. Review of a care plan dated 02/12/19 for Resident #6 revealed she had inappropriate sexual behavior as she physically exposed herself and made inappropriate remarks. Interventions included constant supervision in recreation programs; protect other residents if they were unable to protect themselves; and set limits for acceptable behavior. Review of SSD #610's progress note dated 06/20/19 revealed Resident #6 was incapable of making decisions. On 07/03/19, Psychiatric Nurse Practitioner (PNP) #616 evaluated Resident #6 and documented in the related progress note that Resident #6 had [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS], depression, and anxiety. PNP #616 documented Resident #6 was sexually inappropriate and propositioning males and females at the facility. The resident was hearing voices; pulling out her own hair; physically aggressive; and had increased anxiety with disorganized thought processes. The resident lacked judgment regarding every day activities. Review of a progress note written by SSD #610 dated 07/25/19 revealed Resident #6 would remain long-term at the facility as she was unable to care for herself in the community. The resident had [MEDICAL CONDITION], hallucinated, had [MEDICAL CONDITION], and required 24-hour supervision for safety. Review of a witness statement from STNA #602 (dated 08/12/19) revealed on 08/09/19 around 10:30 P.M. she was looking for Resident #6 and found her in her bedroom with Resident #9. She said all she could see was Resident #9 did not have a shirt on, but she did not know if he had any other clothing on. Resident #9 came out of the room about five minutes later. She said she told the nurse (LPN #614). Resident #6 then came out of her room and went to Resident #9's room and LPN #614 asked the another nurse to ask Resident #6 to come out of Resident #9's room because Resident #9 had a roommate. She said Resident #6 did come out of Resident #9's room. A witness statement dated 08/13/19, that was transcribed by ADON #606 for Resident #6, revealed Resident #6 said she and Resident #9 completed oral sexual actions to one another as Resident #9 was unable to get an erection. On 08/13/19, Resident #11 (who was Resident #9's roommate) was assisted by SSD #610 to transcribe his witness statement. Resident #11 said in his statement that Resident #9 had sex with two different women on two different days. He said one of the women was Resident #6. He said they were loud and moaning and they kept him awake. He said SSD #610 offered to provide a counselor for him however, Resident #11 declined. Resident #11 was glad Resident #9 had left the facility. Interview on 08/14/19 at 11:18 [NAME]M. with STNA #602 revealed she saw Resident #9 in Resident #6's bed. She said Resident #9 did not have a shirt on, and she was unsure if he had any other clothing on or if Resident #6 had clothing on. She said she walked back out of the room and reported what she saw to LPN #614. She revealed Resident #9 came out of Resident #6's room, and shortly after Resident #6 went to go into Resident #9 room but LPN #614 asked her to come out of his room. During interview with Resident #6 on 08/14/19 at 12:04 P.M. she said Resident #9 had kissed her and they had sex. Review of PCP #611's physician order [REDACTED].#6 revealed he ordered the following lab work: complete blood count (CBC), human immunodeficiency virus ,[MEDICAL CONDITION]., venereal disease laboratory test (VDRL), [MEDICAL CONDITION], Urinalysis with culture and sensitivity. On 08/14/19 at 2:31 P.M., interview with Resident #13 who was the roommate of Resident #6, revealed Resident #9 came into their room almost every night when he lived at the facility. Resident #13 revealed Resident #6 and Resident #9 had sex several times when she was in the room. She said they pulled the curtain, but she heard them both moaning. She said they should have had a private room as she should not have had to listen to them having sex. She said sometimes they had sex three to four times a night and would stay up most the night, and this bothered her. Interview on 08/14/19 at 2:54 P.M. with Resident #11 who was Resident #9's roommate revealed on 08/09/19 around 8:00 P.M., Resident #6 came into his room. He said Resident #6 and Resident #9 had sex in the bed next to his bed while he was in the room. He said he did not see them have sex as the curtain was pulled, but he could hear them making loud moaning sounds. He said this bothered him. He said staff did not come into the room during the time they were there together. Interview on 08/14/19 at 5:28 P.M. with SSD #610 revealed Resident #6 had an expert evaluation completed recommending her to have a guardian but they had not proceeded with that recommendation. She said Resident #6 attempted to leave with Resident #9 when he left the facility AMA, so they are now looking into a guardian for Resident #6 as she lacked good judgment. She revealed Resident #9 also was recommended to have a guardian according to the expert evaluation, and the facility thought Resident #9's brother was going to proceed with obtaining guardianship, however he did not obtain guardianship. Interview on 08/15/19 at 5:59 [NAME]M. with LPN #614 revealed she was not aware of Resident #9 being in Resident #6's bed on 08/09/19. She revealed STNA #602 did not report to her they were in Resident #6's bed. She revealed she was aware of Resident #6 going into Resident #9's room and they redirected her out of Resident #9's room as he had a roommate. She said when she redirected her out of the room, they were watching television in the room and they were not engaged in sexual activity. She said she saw Resident #6 and Resident #9 kissing and holding hands on several occasions. She said Resident #6 had stated to her that she had sex with Resident #9 and some of the other male residents at the facility, but she did not observe any of these sexual interactions. She said she did not report any of these observations and interview statements to administration. Record review for Resident #2 revealed she was admitted on [DATE] and her daughter was her legal guardian. Her [DIAGNOSES REDACTED]. Review of a care plan dated 10/26/15 revealed Resident #2 had altered cognition related to oxygen use and [MEDICAL CONDITION] disorder. Interventions included orient to person, place, and time and explain events prior to starting. Review of care plan for Resident #2 dated 12/16/15 revealed she may go on supervised leave of absence as she had a legal guardian due to poor decision making and mental health status. Resident #2 was impulsive and at times neglectful of safety concerns. There was no evidence in Resident #2's medical record that the facility or the resident's physician had evaluated this resident for her capacity to consent to sexually related activity with other residents. Review of a psychiatric progress note dated 07/03/19 completed by PNP #616 revealed Resident #2 had paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION]. She was appointed a guardian in (MONTH) 2012. The note indicated Resident #2 lacked judgment regarding every day activities. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had impaired cognition and required extensive assist of one person with bed mobility, transfers, and ambulation. Resident #2 had verbal behaviors and rejected care. Review of a witness statement written by STNA #618 on 08/12/19 revealed on 08/10/19, Resident #2 and Resident #9 were outside smoking. She said Resident #9 was rubbing on Residents #2's upper shoulder and then they pecked each other on the lips. STNA #618 revealed she told them to quit and she moved Resident #9 away from Resident #2 so they could not touch each other in an inappropriate manner. She said she knew Resident #2 had a guardian. She said Resident #2 said she was Resident #9's mother. Review of a nursing note written by ADON #606 on 08/12/19 at 11:16 [NAME]M. revealed Resident #2 thought he was visiting with her son, as she believed Resident #9 was her son. She stated, He's my son's twin. My other son. It's been a long time since I have seen him. He's missed his mother. Review of nursing note written by ADON #606 on 08/12/19 at 11:31 [NAME]M. revealed Resident #2's legal guardian was contacted at the time of the nursing note on 08/12/19 and gave consent for Resident #2 to have sexual relations. Review of nursing note written by ADON #606 on 08/12/19 at 4:19 P.M. revealed PNP #616 was contacted and increased Resident #2's [MEDICATION NAME] (Antipsychotic Medication) to two milligrams every day. Review of nursing note written by LPN #600 on 08/13/19 at 11:23 [NAME]M. revealed Resident #2 continued with delusional behavior and thought she lost six babies because of the medications she was taking. Interview with Resident #2 on 08/14/19 at 10:31 [NAME]M. revealed she rambled in the interview from topic to topic and was difficult to understand. She said Resident #9 was her son. On 08/16/19, at 12:26 P.M., interview with STNA #618 revealed on 08/10/19 at approximately 10:45 [NAME]M. during the resident's smoke break outside, Resident #9 started rubbing Resident #2's upper shoulder and they were holding hands. She revealed Resident #9 then kissed Resident #2 on the lips. She revealed Resident #2 was confused as she continued to state that Resident #9 was her son. She said she separated the two and Resident #9 went inside. STNA #618 said she did not tell the nurse about the incident. Record review for Resident #10 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of form titled, Letter of Successor Guardianship dated 07/01/16 revealed Resident #10 was deemed incompetent and was assigned a legal guardian by the court. Review of a care plan dated 07/18/19 revealed Resident #10 had a chronic progressive decline in intellectual functioning characterized by a deficit in memory, judgement, decision making, and thought process related to mental illness. Interventions included explain each procedure prior to beginning and modify environment to prevent situations that trigger inappropriate behavior. Review of PNP #616's progress note dated 07/03/19 revealed Resident #10 had paranoid [MEDICAL CONDITIONS] disorder, and conduct disorder. She had a legal guardian. She heard voices and was physically aggressive towards others. Resident #10 lacked insight concerning matters of herself and lacked judgement with every day activities. There was no evidence in the Resident #10's medical record that the facility or the resident's physician had evaluated the resident for her capacity to consent to sexually related activity with other residents. Review of STNA #609's witness statement dated 08/11/19 revealed she went into Resident #10's room (on 08/10/19) to check on her and found Resident #9 on top of her. They were both undressed. She reported the incident to LPN #617. Review of a witness statement (undated) written by the DON after she spoke with LPN #617 revealed LPN #617 did not intervene or report Resident #9 and #10 having sex. She revealed LPN #617 thought it was the resident's right to have sex, and he provided privacy. The DON said she educated LPN #617 on the policy for residents engaging in sexual activity and making sure if they have a guardian they were notified, and management notified immediately. During interview on 08/14/19 at 1:59 P.M., Resident #10 was confused and her discussion during the interview jumped from topic to topic. She said she had sex with Resident #9 as she was gesturing to her private area. She said she had sex once in her bed and once in his bed. She was unable to provide dates and times of when the sexual activity occurred. She continued to say that another female resident wanted him. She then stated I think I have gonorrhea. Do you know what that is? That is from him when he had sex with me. Am I going to die? I am scared. She revealed she told LPN #601 she was scared, and the nurse was contacting the doctor and he was going to order medication. Review of PCP #611 physician order [REDACTED].#10 revealed he ordered the following lab work: complete blood count (CBC), human immunodeficiency virus ,[MEDICAL CONDITION]., venereal disease laboratory test (VDRL), [MEDICAL CONDITION], Urinalysis with culture and sensitivity,[MEDICATION NAME](antibiotic) 500 milligrams twice a day for ten days, and consult with a gynecologist. Interview on 08/14/19 at 5:15 P.M. with STNA #609 revealed on 08/10/19 before she was leaving for the night at approximately 10:30 P.M. she witnessed Resident #9 on top of Resident #10 while in her bed. She revealed they were both undressed and appeared to be having sex. She revealed she reported the incident to LPN #617, and she was not sure what LPN #617 did as she had to leave since it was the end of her shift. She said she did not intervene with the residents. On 08/15/19 at 7:21 [NAME]M., interview with the DON revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. from LPN #637 who was concerned about information she received in report from LPN #617, that Resident #10 and Resident #9 had sexual activity during the night shift. LPN #637 was concerned as Resident #10 had a guardian. The DON then began an investigation and obtained witness statements from the staff and residents, including the roommates of these residents. The DON indicated review of these witness statements revealed two additional sexual related incidents occurred involving Resident #9 and Resident #6 on 08/09/19, and Resident #9 and Resident #2 on 08/10/19. There was no evidence these incidents were reported when they occurred to the DON or Administrator. Interview on 08/16/19 at 11:55 [NAME]M. with LPN #617 revealed STNA #609 had informed him Resident #9 was on top of Resident #10 in her bed and they were having sex. LPN #617 revealed he did not intervene as he felt it was their right to have sex. He said they hung around each other all night and went back and forth in her bed and his bed most of the night between smoke breaks. He said they were in Resident #9's bed even though Resident #9 had a roommate that was in the room at the same time. He said he was aware Resident #10 had a legal guardian. He said he did not report this incident to the Administrator or the DON. Interview on 08/14/19 at 1:10 P.M. with Medical Director #611 revealed he warned the facility about Resident #9's behaviors and history. He said he told the facility they should watch Resident #9 closely. He revealed he was Resident #6's PCP and he was unsure if she was able to make decisions regarding sexual relations especially due to her [MEDICAL CONDITION]. He said he also was Resident #10's PCP and he did not feel Resident #10 was able to consent to sexual relations especially since she had a legal guardian because of her cognitive status. He said he had told the Administrator he was going to contact the probate court regarding Resident #10's guardian deciding she could have sexual relations as he did not feel this was right, and the probate court should decide this situation. He revealed the Administrator stated not to contact the probate court and he did not make that contact. He said he was ordering lab testing [MEDICAL CONDITION].VDRL, and [MEDICAL CONDITION] for Residents #6 and #10. Interview on 08/15/19 at 7:71 [NAME]M. with the Director of Nursing revealed she received a call on 08/11/19 at approximately 10:00 [NAME]M. regarding Resident #9 and Resident #10 having sexual relations, as the dayshift nurse (LPN #637) was concerned when she received report that the residents had sex that night and Resident #10 had a legal guardian. She revealed she was giving a disciplinary action to LPN #617 as he did not follow their policy and procedures since Resident #10 had a legal guardian and he did not separate Resident #9 from Resident #10 during sexual activity. The DON said she was unable to initiate an investigation timely as she was not notified until the next morning. She said she did not know about Resident #2 and Resident #6 having sexual relations with Resident #9 until after they began investigating the sexual activity between Residents #9 and #10. She revealed Residents #2, #6, and #10 were not educated prior to the incidents on health risks of sexual activity. She revealed the police were not contacted regarding the sexual activity Resident #9 had with Residents #2, #6, or #10. Interview with the Administrator on 08/15/19 at 7:35 [NAME]M. revealed he notified Resident #10's guardian on 08/11/19 after he was notified of Resident #9 and #10's sexual activity the previous night. He revealed he received consent from the guardian for Resident #10 approving sexual relations, but also verified he received that consent after the sexual relations had taken place. Interview on 08/15/19 at 5:28 P.M. with SSD #610 revealed she had not assessed residents for sexual activity including providing education, ensuring the resident's ongoing participation was consensual, and verifying the resident understood they had the right to refuse the intimate advances of others. After these incidents occurred with Residents #9, #6, #2, and #10 she said she planned on using a facility assessment form that assessed the resident's sexual interest Interview with ADON #606 on 08/16/19 at 9:11 [NAME]M. revealed Medical Director #611 was in the building when Resident #9 was admitted and stated he knew him previously and to watch him closely. She revealed the facility implements a form labeled, Resident Care Plan Summary as their base line care plan. She revealed she was unable to find where a baseline care plan was implemented for Resident #9 on admission. She revealed they did not have a baseline care plan identifying Resident #9's behaviors. Interview with the Administrator and RDO #612 on 08/15/19 at 10:37 [NAME]M. revealed they did not notify the police of Resident #9's sexual activity with Residents #6, #2, and 10 at the facility. Review of the facility Resident Privacy Policy (dated (MONTH) 2014) revealed the social service department would meet with residents who appear to desire intimate activities to provide education, ensure the resident's ongoing participation is consensual, and verify the resident understands they have the right to refuse the intimate advances of others. This policy also indicated residents who express or demonstrate they may be engaging in intimate activities will be interviewed by the social services department or director of nursing to ensure they are participating willingly and understand related health risks. The procedure included with this policy indicated that if residents were observed participating in intimate activities, staff were to notify the DON/Administrator so they could assure all appropriate actions were implemented. Review of facility policy, Abuse Prevention Policy and Procedure dated 01/01/16 revealed if abuse was witnessed by a staff member the staff member would first and foremost take whatever action was needed to protect the resident. The facility would investigate all allegations of abuse. The facility would provide protection of the residents during and after the investigation. In the case of resident-to-resident suspected abuse, the parties were separated from one another until the investigation has been completed. The facility would report all allegations of abuse to the (State Agency) as soon as possible, but no more than 24- hours after the alleged incident was discovered. Review of facility policy, Baseline Care Plan Policy and Procedure dated 12/01/18 revealed the facility would develop and implement baseline care plans within 48 hours for each resident that meet professional standards of quality care. There was no evidence in the facility policies and procedures that the facility would include in their investigation whether the resident had the capacity to consent to sexual activity, and that the resident was evaluated for their capacity to consent to sexual activity. This deficiency substantiates Complaint Number OH 357.

Based on observation, interviews with staff and residents, review of the medical record, and review of facility documents titled Leave of Absence, Smoking Policy and Procedure, and Elopement: Missing Resident Policy and Procedure, the facility failed to implement interventions to prevent the elopement of one resident (Resident #1) who had a court appointed guardian related to poor decision making and a physician order [REDACTED]. when Resident #1 left the facility unsupervised, without staff knowledge through a security exit door that did not alarm properly. The likelihood of Actual Harm that is Immediate Jeopardy occurred as Resident #1, who was only able to use his left arm and left leg to self-propel his wheelchair, was found wheeling himself down a street approximately sixth tenths to one mile from the facility after crossing a four lane intersection in the dark. This affected one of five residents reviewed for elopement risk. The facility identified five residents at risk for elopement. The facility census was 51 residents. On 07/23/19 at 12:17 P.M., the Administrator, Director of Nursing, Regional Administrator and Corporate Nurse were notified Immediate Jeopardy began on 07/08/19 at 2:48 A.M. when Resident #1 left the facility unsupervised and without staff knowledge through a faulty security exit door that continuously sounded an alarm, and exited down a ramp to access the parking lot that led to the adjacent street. The Immediate Jeopardy was removed on 07/25/19 at 3:00 P.M. when the facility implemented the following corrective actions: · On 07/08/19 at 3:00 A.M. Licensed Practical Nurse (LPN) #100 was alerted by Resident #6 that Resident #1 had left the property through the smoking area, and she sent State tested Nursing Assistant (STNA) #102 to look for Resident #1. Resident #1's guardian, the Director of Nursing (DON), and the Administrator were notified. · On 07/08/19 from 3:00 A.M. to 7:15 A.M. the smoking area exit door was monitored by LPN #100, STNA #102, STNA #103, and RN #104 due to a malfunction in the door security system. · On 07/08/19 at 3:42 A.M., STNA #101 located Resident #1 and returned him to the facility at 4:12 A.M. Upon return Resident #1 was assessed by LPN #100 and found with no injuries and placed on 15 minute checks by LPN #100 and STNA #102 until 07/08/19 at 7:00 A.M. · On 07/08/19 from 7:15 A.M. to 11:00 A.M., Maintenance Director #500 repaired the smoking area security exit door so it would close and stop continually alarming. However, the door required further repair as it would not completely close at the bottom of the door. The door code was reset during the repair. All other doors were checked for security features and function by Maintenance Employee #501. · On 07/08/19 from 7:00 A.M. to 3:00 P.M., four additional residents at risk for elopement (Residents #2, #3, #4, and #5) were reassessed by the Administrator and Assistant Director of Nursing (ADON). Appropriate care plans with interventions were in place relative to their wandering risk, elopement risk, and level of supervision while smoking. · On 07/08/19 between 7:00 A.M. and 3:00 P.M., the ADON reeducated ten of ten independent smoking residents on the smoking policy related to signing out and signing in according to the policy. · On 07/08/19 from 7:00 A.M. to 7:00 P.M., 42 of 42 facility staff members (7 management, 23 nursing, 1 activity, 6 dietary, 5 laundry/housekeeping) were educated either by phone or in person by the Administrator and Director of Nursing on the Neglect, Leave of Absence, and Elopement Policy. · On 07/08/19 from 7:00 A.M. to 7:00 P.M., 23 of 42 facility employees were educated to not give out the door security codes to any residents or face immediate termination from employment. The remaining employees will be educated upon their return to work. · On 07/08/19 at 9:46 A.M., the ADON reassessed Resident #1's elopement risk assessment, smoking assessment, and care plan and updated those to reflect he was an elopement risk and required supervised smoking. · On 07/08/19 at 1:25 P.M. the facility began checking all nine exit doors and the two doors leading to the lower level of the facility for function. This will be completed five times a week for four weeks, then as determined by the Quality Assurance committee. This was verified with facility documentation. · On 07/08/19, the STNA break area for the 10:30 P.M. to 6:30 A.M. shift was moved to the common dining room area adjacent to the smoking deck to facilitate supervision of the smoking area exit door and ensure residents were signing in and out of the facility before and after smoking according to the smoking policy. · On 07/08/19 at 11:30 P.M., an elopement drill was conducted by the Director of Nursing with five staff members from nursing. · On 07/09/19 at 11:30 A.M. Resident #1 was added to the one-to-one visits with the Activity Department twice a day for closer observation. This continued through 07/11/19 at 7:20 P.M. · On 07/10/19 at 8:30 A.M. and 4:30 P.M. elopement drills were conducted by the Director of Nursing with seven and eight staff members respectively from nursing, dietary, and activity departments. · On 07/23/19 from 10:38 A.M. to 11:01 A.M., interview with Residents #7, #8, #9, #10, and #11 revealed they did not know the exit door code to leave the facility. · On 07/24/19 at 10:30 A.M. the Administrator provided written verification that the new exit door to the smoking area, ordered on [DATE], was being replaced on 07/25/19. · On 07/24/19 from 10:38 A.M. to 11:01 A.M. the surveyor observed the smoking area exit door and only the staff were entering the door security codes to let residents in and out the door. · On 07/24/19 from 10:55 A.M. to 1:15 P.M., 15 employees, LPN #800, STNA #801, STNA #802, Maintenance Employee #501, STNA #803, Environmental Aide #804, STNA #805, Business Office Manager #806, Activity Aide #807, Housekeeper #808 and Housekeeper #809, LPN #810, STNA #811, Dietary Manager #812, and Cook #813, were interviewed and were aware of the five residents who were at risk for elopement, the elopement policy and procedure, the exit door security codes, and the facility policy not to give the security door codes to anyone. · On 07/25/19 at 3:00 P.M., the facility completed installation of a new exit door to the smoking area. This door was observed by the surveyor on 07/26/19 at 1:20 P.M., and it was closing and locking properly. A keypad exit code was still required for exit and entry of the facility through the door. The door had a 15 second delay in the event emergency exit was required for the residents and staff. Interview with the DON and BOM #806 verified the residents no longer knew the code to the key pad, and staff were instructed to let the residents in and out of the facility doors as needed according to facility policy. Although the Immediate Jeopardy was removed on 07/25/19, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to monitor staff and resident compliance with the exit door security, smoking policy, and elopement policy. Findings include: Review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care initiated on 11/26/14, revealed the resident had impaired cognitive function/impaired thought process related to a [MEDICAL CONDITION], and cognitive loss with communication deficit. Interventions included to cue, reorient, and supervise as needed. According to the Minimum Data Set 3.0 assessment completed on 04/17/19, Resident #1 also needed supervision for locomotion on and off the unit, and needed staff assistance for dressing, toilet use, and personal hygiene. Review of physician orders [REDACTED]. The resident was able to move about the facility by using his left arm and left leg to self-propel a manual wheelchair. Review of the Plan of Care initiated on 11/26/14 revealed Resident #1 had impaired thought process, impaired decision making, and the inability to speak ([MEDICAL CONDITION]) related to a stroke. His communication ability was to nod yes or no if the staff person was getting close to guessing what the resident was trying to communicate, or at times writing things down. On 01/14/15 the plan was updated with supervision with smoking. The Plan of Care initiated on 12/16/15 revealed Resident #1 had a legal guardian related to poor decision making, and required the guardian's approval before going out on any leave of absence with supervision. Review of the Elopement Risk assessment dated [DATE] indicated Resident #1 was not at risk for elopement. Review of the Elopement Risk assessment dated [DATE] completed by ADON #600 after Resident#1's elopement from the facility indicated Resident #1 had a history of [REDACTED]. On 07/08/19 the care plan was updated to include the following interventions: care conference with resident and guardian to discuss resident's attempt to leave; routine elopement risk assessment; involve resident in activities of choice; notify physician and guardian of any changes; psychoactive medication as ordered; toileting program as indicated; one to one to allow to vent feelings; follow facility elopement procedures; monitor and report changes in behavior, restlessness, and pacing; provide diversional activities of interest; and redirect as needed. Review of the elopement investigation dated 07/08/19 to 07/10/19, revealed written statements provided by LPN #100 and STNA #101 who directly cared for Resident #1 on the day of the elopement, and an interview statement from Resident #6 conducted by ADON #600. The statement written by LPN #100 dated 07/08/19 revealed Resident #6 notified her at 3:00 A.M. that Resident #1 wheeled himself off the smoking deck and into the parking lot. LPN #100 indicated she went outside to see where the resident was and couldn't see him, so she went back inside to instruct STNA #101 to go find Resident #1 while she called the local police department. STNA #101 called the facility at approximately 3:30 A.M. and told LPN #100 she found Resident #1, and he was returned to the facility at approximately 4:00 A.M. LPN #100 also noted the door (used to exit by Resident #1) was monitored by the staff. Review of the written statement provided by STNA #101 dated 07/08/19 revealed at 3:00 A.M., LPN #100 came to her in the 300 unit breakroom and asked her to ride up the street to look for Resident #1 because he had left the facility property alone. While looking for Resident #1. STNA #101 saw a police officer and asked if he saw a man in a wheelchair and he said no but he would help look. STNA #101 went back to the facility and LPN #100 told her that Resident #1 had asked LPN #100 to take him to (named) Rd. STNA#101 went back out in the direction of (named) Rd and found him on a nearby street. Resident #1 did not know where he was going and was pointing to some houses. STNA #101 said she was assigned to Resident #1's unit (100 Unit) and the last time she saw the resident was around 1:00 A.M. to 1:30 A.M. STNA #101 indicated there were only two STNAs on duty during that shift so she was on the opposite side of the building answering call lights. Review of the written statement dated 07/08/19 provided by STNA #814 (who was assigned to the 200 unit and covering the call-off of STNA #815 on the 300 unit) revealed she did not know Resident #1 left the building. Review of ADON #600's written statement dated 07/08/19 revealed Resident #6, who witnessed the elopement of Resident #1, said around 2:45 A.M. to 3:00 A.M. Resident #1 and Resident #8 were on the smoking deck with her. Resident #1 rolled by them in his wheelchair towards the bottom of the deck with his finger over his mouth gesturing for them not to say anything. About five to ten minutes went by and Resident #6 notified the nurse. Resident #6 said Resident #1 knew the code for the exit door to the smoking area, and could put the code in himself to get out the door. Review of ADON #600's written statement dated 07/08/19 at 9:10 A.M. revealed Resident #1 said he was trying to go to his family on (named) Rd to get money. Resident #1 indicated he did not know why he went out at 3:00 A.M. nor did he know where his family lived. ADON #600 educated Resident #1 on the Leave of Absence policy and said his smoking status was changed to supervised, which was also approved by his guardian. Review of the Missing Person Report provided by Police Officer #900 dated 07/08/19 at 3:25 A.M. revealed Resident #1 left the building in a wheelchair about 2:45 A.M. and was located at 3:48 A.M. and a police report was completed. On 07/22/19 at 10:38 A.M., Resident #1 was observed in his room. He appeared underweight for his frame, had a pale skin color, and was dressed appropriately wearing socks and a backless slipper on his left foot. Upon greeting him he waved a greeting with his left hand but could not speak any words. When asked if he wanted to write he shook his head no. When asked if he was supervised by the staff when he smoked before the elopement he shook his head no. When asked if he knew the code to get out the secured smoking exit door before he eloped he nodded his head yes. When asked if he left the facility property on 07/08/19 at approximately 3:00 A.M. he nodded yes. When asked why he wanted to leave the facility he made a punching motion in the air with his left hand in a fist and his face looking angry. When asked if someone was trying to hurt him, he nodded no. When asked if he wanted to leave the facility because he did not like being around the other residents his eyes got wide and he nodded yes. When asked if the facility staff knew he wanted to leave the facility he nodded yes. When asked if he had a guardian he nodded yes and motioned a thumbs down. On 07/22/19 at 10:48 A.M., interview with LPN #200 revealed she had worked at the facility for approximately two years and knew Resident #1 very well. LPN #200 said before his elopement on 07/08/19, he was an independent smoker who was frequently breaking the smoking policy by bringing partial cigarettes into the facility and smoking them inside his room. She said he was known to go to the smoking exit door, entering the security code himself, and going out to smoke between smoking breaks. If the security code was changed Resident #1 would push on the smoking door until it opened, and then go out to smoke. On 07/22/19 at 11:05 A.M., observations were conducted on the smoking deck while interviewing Activity Aide (AA) #400. AA #400 said that prior to Resident #1's elopement on 07/08/19, all the residents had the security code to the exit door to open it and go out on the smoking deck, whether they were supervised smokers or independent smokers. She said the code was changed after Resident #1 eloped, and the staff were educated not to give the code to anyone. Resident #1 was observed wheeling himself toward the smoking deck exit door in his manual wheelchair. He was self-propelling the wheelchair using his left arm and kicking with his left foot. When he arrived at the exit door, AA #400 went to the door and entered in a code opening the door for him to roll out onto the smoking deck. He was smiling and waved a greeting with his left hand. This alarmed exit door was observed to be in poor condition. Upon applying light pressure to the panic bar, the entire bottom half of the door opened to form a wide gap approximately four to six inches wide exposing the outside environment. As more pressure was applied the door remained closed only at the top magnetic security latch. The door did not alarm, nor completely open during that observation. The door was heavily covered with scratches and dents as if it had been rammed by something multiple times. On 07/22/19 at 11:10 A.M., interview with Social Service Designee (SSD) #700 revealed she has been working with Resident #1 and his relatives on establishing community placement somewhere else than this facility. SSD #700 said she had been at the facility for approximately one month and was not educated on the elopement policy until after Residents #1's elopement on 07/08/19. Interview with the DON on 07/22/19 at 12:35 P.M. revealed there were four other residents (Residents #2, #3, #4, and #5) who were at risk for elopement in the facility. The DON said that since 2:26 P.M. on 07/07/19, the exit door to the outdoor smoking area had been malfunctioning and was continuously alarming as it was not able to close securely as it should. The DON said Maintenance Director #500 was notified the afternoon of 07/07/19 (exact time unknown) by a nurse at the facility, but he would not come out to look at the door until the next day on 07/08/19 at 7:00 A.M., after Resident #1 had left the facility through that same exit door. On 07/22/19 between 12:47 P.M. and 12:59 P.M., observations were made of the facility exit doors with MD #500. On the east end of the 300 unit at 12:59 P.M. the panic bar of the secured door was pushed and the door opened immediately, with no 15 second delay . The alarm did sound. MD #500 said he checked all nine secured doors once a week and had not identified any problems with the 300 east hall exit door prior to this observation with the surveyor. During interview with MD #500 he verified that he did not respond to the repair request for the smoking area exit door until 07/08/19 at 7:00 A.M. Interview was conducted on 07/22/19 at 2:12 P.M. with Resident #6 who the facility identified as witnessing Resident #1 leave the facility. Resident #6 said Resident #1 let himself out onto the smoking deck and was wearing a hat, t-shirt, sweatpants, two socks, and a slipper on his left foot. Upon rolling by her in his wheelchair he put his finger over his mouth as if to gesture for her to keep quiet and he proceeded to go down the ramp to the parking lot and disappear out of her sight into the darkness. She said that occurred at approximately 2:48 A.M., and at 2:58 A.M. she sent a text from her cellular phone to the personal cellular phone of LPN #100 to tell her something was unusual with Resident #1 because he went off the deck in his wheelchair and did not return. Resident #6 said the smoking door was broke the entire day so there was no way to keep anyone who wanted to go out that door from getting out, and it stayed that way until the maintenance man came in to fix it the next morning. Resident #6 said she saw STNA #101 leave the facility to go look for him. Resident #6 said they were low on staff that night because one of the three scheduled STNAs reported off and that only left two nurses and two STNAs to cover all three units. An interview was conducted on 07/22/19 at 3:03 P.M with Resident #8 who verified the smoking area exit door was broken all day on 07/07/19 and into the midnight shift on 07/08/19. She said she was on the smoking deck on 07/08/19 at 2:45 A.M. with Resident #6 and saw Resident #1 leave the facility from the smoking deck. She said that before he left that day, everyone knew the code to get out that door. She said her brother who lived five minutes from the facility also knew the codes to let himself in and out of the building. On 07/22/19 from 3:15 P.M. to 3:36 P.M. interview with LPN #100 verified she was the LPN on duty and caring for Resident #1 the night he eloped. LPN #100 said he came to her around 8:00 P.M. or 9:00 P.M. with names on a piece of paper. She asked him if those were his kids and he nodded yes. She said by asking him questions she figured out he wanted her to take him to see his kids, and he often told her he wanted to leave the facility. LPN #100 said Resident #1 took his pain medication around 2:30 A.M. and she saw him wheeling toward the smoking area after that, but did not think anything of it because he often went to the vending machines in that area. At 3:00 A.M. Resident #6 alerted her that Resident #1 had left the property so she called the police and sent STNA #101 to look for him. LPN #100 said Resident #1 had traveled alone in the dark in his wheelchair to (named) street, which was close to a mile away from the facility. On 07/22/19 at 4:38 P.M. interview with the Administrator revealed he was not notified by the facility of the smoking are exit door not properly functioning on 07/07/19. The Administrator said he was notified on 07/08/19 at 3:30 A.M. that Resident #1 had eloped and was found approximately 0.6 miles away from the facility in his wheelchair trying to get to (named) Road to get money from his family. The Administrator verified Resident #1 had a guardian. According to the Administrator the smoking area exit door was to be replaced on 08/02/19 due to it not closing as it should. An interview was conducted on 07/24/19 at 9:46 A.M. with the Administrator who said the new smoking door was now scheduled to be installed on 07/25/19. He said all nine secured exit doors on the resident units and the two secured doors in the foyer were all checked and secured and would continue to be checked daily five days a week by the maintenance department (MD #500 and Maintenance Employee #501). The Administrator added no one except employees have the code to get out of the building since it was changed on 07/08/19, including the independent smokers and family members, and the only way to exit the building was by having a staff member enter the code. An interview was conducted on 07/24/19 at 11:21 A.M. with the DON who said she had the activity department begin providing Resident #1 with two one-to-one activities a day to more closely monitor his whereabouts in the facility. The DON said that she did not believe there would be any further elopements after educating the staff on enforcing the smoking policy, the Leave of Absence policy, and not giving out the secured door codes to any residents or family. The DON verified they did not have a policy on building security, and she had not done any interviews with residents, staff, or visitors to ensure staff were not giving out the door security codes to the resident smokers, other residents, or visitors. On 07/24/19 from 10:55 A.M. to 1:15 P.M. the surveyor interviewed 15 facility employees on duty (LPN #800, STNA #801, STNA #802, Maintenance Employee #501, STNA #803, Environmental Aide #804, STNA #805, Business Office Manager #806, AA #807, Housekeeper #808, Housekeeper ,#809, LPN #810, STNA #811, Dietary Manager #812, and Cook #813) regarding which residents were at risk for elopement, how to implement the elopement policy, and the door security codes. All the interviewed employees were able to verbalize a good understanding of which residents were at risk, how to implement the elopement policy, and not to give out the security door codes to anyone. This deficiency is an example of continued non-compliance from the 07/03/19 Annual survey. This deficiency substantiates Complaint Number OH 519.

Based on record review, interview, and review of a Self-Reported Incident (SRI) revealed, the facility failed to prevent physical abuse by staff of one resident (Resident #31). This resulted in actual harm when Resident #31 sustained injuries and subsequent decline in range of motion and his ability to perform activities of daily living. This affected one of three residents reviewed relative to prevention of abuse. Findings include: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #31 was seen monthly by the facility psychiatric services for additional [DIAGNOSES REDACTED]. A psychiatrist progress note dated 04/05/17 revealed Resident #31 was alert to person, place and time, his attention span and concentration was appropriate and his mood was depressed. The resident had organized and goal directed processes, and logical thought content. Review of a care plan dated 03/01/16 related to mood and behaviors indicated the resident had behavioral outbursts. Review of nurses notes from 12/12/16 through 04/20/17 revealed no evidence Resident #31 exhibited physically aggressive behaviors toward staff or other residents. Review of physician's exam and progress notes dated 03/01/17 and 04/05/17 revealed Resident #31's muscle strength was good and his gait was normal and steady. Review of an SRI dated 04/20/17 and witness statements revealed on that same date, at 8:05 P.M., Licensed Practical Nurse (LPN) #7 physically abused Resident #31 Resident #42's witness statement indicated on 04/20/17 at 8:00 P.M., she heard yelling and observed Resident #31 yelling at LPN #7. Resident #31 was walking toward LPN #7 and she told the resident to stop and go into his room. Resident #42 said the next thing she saw was LPN #7 grab onto Resident #7 with his arm behind his back. LPN #7 put the resident in his room, told him to stay there and shut the door. Resident #31 came back out of his room and began shouting at LPN #7 and she tried to get hold of him again and then pushed him against the wall and got the resident back in his room. Then someone else came down the hall. Resident #10's witness statement revealed on 04/20/17 at 8:05 P.M., he was awakened by a loud bang coming from the room next door, Resident #31's room. Resident #10 heard muffled yelling from Resident #31 and put his call light on. The he heard LPN #7 yell, I'll kill you! STNA #6 came and opened Resident #10's door and got Resident #31 away from LPN #7. State tested Nurse Aide (STNA) #6's witness statement revealed on 04/20/17 at 7:45 P.M., she went to the other unit to get some snacks then started washing the tables in the dining room. STNA #6 heard a loud noise, as if someone fell , then heard Resident #31 screaming. She ran to see what happened and went to Resident #10's room because his call light was on. Resident #10 said to check on Resident #31 because he thought he heard him fall. STNA #6 went to Resident #31's room which was next door just as the resident was coming out of the room. Resident #31 told STNA #6 that LPN #7 threw him on the floor and choked him. The resident had scratches on his chest, under his neck. STNA #6 took Resident #31 by the hand and told him to walk with her. Resident #31 kept swearing and yelling and LPN#7 started yelling back. STNA #6 told LPN #7 to please walk away, but LPN #7 yelled at STNA #6 to get the resident away from her. STNA #6 told LPN #7 to get out of the way and continued walking with the resident who said he thought his ribs were broken. STNA #6 called out for help and two nurses came. She stayed with Resident #31 and when the ambulance came she went with him to the hospital. LPN #5's witness statement revealed on 04/20/17 at 8:05 P.M., she was called by STNA #6 to check Resident #31 regarding alleged physical abuse. Resident #31 complained of rib pain and LPN #5 observed bruises on the resident's right clavicle. The medical director was present in the facility and ordered the resident sent to the emergency room . LPN #5 immediately notified the Administrator, DON and the local police. Upon completion of the investigation the facility concluded physical abuse of Resident #31 by LPN #7 had occurred. The facility notified LPN #7's employer of the incident that evening and also reported the incident to the Ohio Board of Nursing. Review of nurses' notes dated 4/20/17 at 8:20 pm, revealed Resident #31 stated that the nurse and him got into a verbal altercation and she slammed him on the ground in his room. The resident complained of left flank and rib pain. Scratches were observed on his right neck and right clavicle area. Resident #31 complained of generalized soreness upon ambulation and was medicated with Tylenol 325 milligrams (mg) two tablets for pain. The resident's physician was notified and ordered the resident sent to the emergency room for evaluation and treatment. The DON local police, and the resident's power of attorney were all notified. A nurses' note dated 04/20/17 at 8:45 P.M., revealed the resident was transported to the hospital via ambulance. A nurses' note dated 04/21/17 at 1:00 A.M., revealed Resident #31 returned to facility from the hospital. Hospital discharge papers confirmed contusions of the left neck area and ribs and chest. Tests including a CAT scan of the brain and spine and X-ray of the spine, elbow and left ribs showed no fractures. New orders were in place for ice pack to bruised areas up to three times a day, cleanse abrasions with warm soapy water, rinse and pat dry twice daily until healed. New medications ordered included [MEDICATION NAME] (anti -[MEDICAL CONDITION]) 500 milligrams (mg) twice a day for ten days and Tylenol with [MEDICATION NAME] every six hours as needed for pain for three days. The resident denied pain. A nurses' note dated 04/21/17 at 11:21 A.M., revealed the resident denied pain and the attending physician ordered Tylenol (without [MEDICATION NAME]) 325 milligrams (mg) two tablets, every four hours as needed for pain, instead of Tylenol with [MEDICATION NAME]. Review of Medication Administration Records revealed Resident #31 took the as needed Tylenol on only three occasions, on 04/23/17, 04/24/17 and again on 05/01/17. On 05/04/17 at 10:02 A.M., interview with Resident #10 revealed he was friends with Resident #31 and resided in the adjacent room. Resident #10 was aware that Resident #31 had been physically abused on 04/20/17 by an agency nurse, LPN #7. Resident #10 said Resident #31 sometimes got verbal and swore but all the regular staff knew him and none of them had any problem dealing with him. Resident #10 heard yelling and then he saw LPN #7 with Resident #31 pinned against wall in the hall, and then put him to the ground twice. Resident #10 put his call light on, and STNA #6 came running down the hall, and helped Resident #31. Resident #10 said he'd seen scratches and marks on Resident #31's neck and shoulder later on. On 05/04/17 at 10:41 A.M., interview with Resident # 42 revealed she was in her room, across the hall from Resident #31's room on 04/20/17 watching TV when she heard LPN #7 and the resident yelling back and forth. Resident #31 walked over to med cart, and LPN #7 put his arm behind his back, took him to his room, and shut the door. The resident came back out asked her why she did that. LPN #7 tried to do it again. She pushed him into the wall, had him by scruff of his neck, and the resident was trying to get loose. LPN #7 dragged the resident to his room, threw him in there, shut the door and went back to work. STNA #6 came to calm Resident #31 and staff took LPN #7 away. Interview with LPN #5 on 05/04/17 at 10:41 A.M. revealed, she recalled the incident on 04/20/17 when LPN #7 physically abused Resident #31. She was passing medications when STNA #6 asked her to come quickly to look at Resident #31. LPN #5 saw scratches on his upper chest area and she could tell by the way he was moving that he was hurt. LPN #5 took him to the 300 wing where the resident told her LPN #7 choked and slammed him. The Medical Director was present and assessed the resident. LPN #5 immediately went to find LPN # 7 and told her to clock out. She then called the DON, Administrator and the police. LPN #7 was at the nurses' station; she finished her charting at the nurses station with LPN #7 in attendance and was walked out of the building by LPN #7; she did not go into any resident areas. On 05/04/17 at 11:45 A.M., phone interview with STNA #6 revealed on 04/20/17 at 7:55 P.M., she was working the 100 unit when she heard a loud noise. She went to Resident #10's room because his call light was on and he said the noise came from Resident #31's room. LPN #7 followed STNA #6 into Resident #31's room. The resident came out into the hall and said LPN #7 threw him down twice on the floor. LPN #7 told her the resident bit her and showed a small red mark, no teeth marks apparent, on her forearm. Resident #31 had a mark and a little blood near his collar. STNA #6 told LPN #7 to get away and immediately took Resident #31 by the hand and went to find help. She called to two nurses she saw down the hall and they came to assist Resident #31 and told LPN #7 she had to leave the building. On 05/04/17 at 1:50 P.M., interview with Resident #31 revealed LPN #7 had physically abused him. Resident #31 said he didn't know why, but she grabbed his arm and pushed it behind his back, tried to do it again, then knocked him to the ground. His ribs and his left arm were hurt and he went to the hospital. Now he can't lift his left arm anymore. At the time of the interview the resident was sitting at the bedside eating. He held a bowl of food in his left arm close to his chest and lowered his face to the bowl while eating. He didn't move his left arm during the interview. On 05/04/17 at 2:10 P.M., interview with Registered/Licensed Occupational Therapist (OTR-L) #12 and review of the Occupational Therapy (OT) evaluation and progress notes revealed Resident #31 was evaluated on 04/27/17 for decreased loss of range of motion and strength. The OT evaluation form, dated 04/27/17 revealed [DIAGNOSES REDACTED]. The impression stated the resident suffered left shoulder and rib cage injury and presented with a decline in range of motion (ROM) and some gait problems. The treatment plan was for therapy to improve ROM and strength and return to previous level of function. OTR-L #12 reported prior to the injury Resident #31 had 120 degrees ROM of his left arm and was able to lift his arm over his head, dress and put his shirt on without assistance. Review of the OT assessment dated [DATE] revealed the resident's left upper extremity and shoulder ROM and strength were now impaired. ROM for the left shoulder had flexion at 60 degrees, abduction at 50 degrees, internal rotation at 60 degrees, and external rotation at 30 percent. OTR-L #12 explained this was one -half what the resident had previously. The resident could no longer raise his left arm up to dress himself or put his shirt on. Resident #31's left upper extremity strength was two+ out of five which meant strength in his left shoulder, elbow, forearm and wrist were all impaired. OTR-L#12 verified the decreased ROM and strength were directly related to injury sustained as a result of the incidence of abuse that occurred on 04/20/17. OTR-L #12 could not say if Resident #31 would be able to return to his previous level of function.

Based on observation, interview, self-reported incident (SRI) review, and record review, the facility failed to ensure emergency guardianship for Resident #39. Actual harm occurred to Resident #39 when failure to ensure emergency guardianship resulted in delayed treatment to manage an acute leg fracture. In addition, the facility failed to respond to a resident's complaint of illness following a medication error affecting Resident #10. This affected two of three residents reviewed for incidents and/or accidents (Resident #39 and #10). Findings include: 1. Record review revealed Resident #39 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #39 was legally blind. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment and his legal guardian was his sister. Review of physician progress notes [REDACTED].#39 was being weaned from [MEDICATION NAME], a narcotic pain patch used to treat severe pain. The [MEDICATION NAME] was decreased from 75 micrograms per hour to the current dose of 12 micrograms per hour. [MEDICATION NAME], a narcotic pain medication to treat mild to moderate pain, was ordered 03/23/17. Review of the Medication Administration Record [REDACTED]. However, review of a nurse progress note dated 03/30/17 at 7:35 P.M., revealed Resident #39 complained of increased knee pain and the resident's knee was red and swollen. The physician was notified and ordered an X-ray and Doppler study (test to check for blood clots) to be completed 03/31/17. Review of a nurse progress note, X-ray result and Self Reported Incident (SRI) dated 03/31/17 at 10:00 A.M., revealed an acute femoral (thigh bone) shaft fracture at the knee area. Resident #39 was transported to the emergency room for treatment. Review of the emergency room written discharge instructions of the same date (03/31/17), revealed an orthopedic visit was to be completed within one week. A CT scan (a computed tomography scan using X-rays to make detailed pictures of parts of the body and the structures inside the body), prior to the orthopedic consult, was recommended. Review of the emergency room written education of the same date (03/31/17), revealed a femoral shaft fracture usually required surgery. In rare cases for which surgery was not an option, a cast or splint may be used to immobilize the bone while it healed. Symptoms included severe pain. Review of the SRI final disposition dated 04/03/17 revealed the family had been left several messages and did not respond. Nursing and social services were initiating steps to obtain emergency guardianship due to lack of response from a family member. Resident #39 was stable with effective pain management. An interview and review of a typed notation from the orthopedic office (dated 04/04/17) was completed with the Director of Nursing (DON) on 04/18/17 at 10:36 A.M. The DON and orthopedic office note revealed Resident #39 was transported for the orthopedic follow-up appointment on 04/04/17. Resident #39 was accompanied by a facility nurse aide. However, the physician refused to see the resident. The same note revealed the physician refused to see the resident because the resident was unable to answer the questions for the required paperwork, there was no guardian or power of attorney (POA) contact information on the facility provided paperwork, and Resident #39 was unable to make his own medical decisions. The note revealed the physician did look at the X-ray and suggested a CT scan be completed prior to a return visit. The orthopedic office note indicated the office notified the facility at the time of the visit and the responding nurse voiced understanding. The office also suggested the facility admit the resident to the hospital where he could be seen in the hospital as a patient consult. During the same interview, the DON revealed guardian consent for the CT scan with contrast was required by the resident's managed care source. Despite several attempts, the facility could not reach the guardian. Therefore, the Certified Nurse Practitioner (CNP) from the managed care source wrote an order for [REDACTED]. The DON stated, but was unable to provide evidence, that she had contacted the hospital several times to schedule the CT scan but the hospital had never returned the call. The DON revealed she contacted Resident #39's primary physician to request assistance with guardianship. The primary physician refused and referred her to the resident's psychiatrist. The DON revealed she had been attempting to contact the psychiatrist since last week but he had not returned the telephone call until yesterday, 04/17/17. Per the DON, the psychiatrist advised the DON to refer to his progress notes. The DON and review of the psychiatrist progress notes, revealed Resident #39 was competent. The DON revealed she asked the psychiatrist to update the progress notes and he refused. The DON revealed the psychiatrist informed her she did not have to use the traditional process to establish emergency guardianship. The DON could not provide evidence of the content of conversation with the primary physician or psychiatrist. The DON verified she was not aware of a process to establish emergency guardianship. During the same interview, the DON revealed she believed the Social Service Designee (SSD) #2, was handling the guardianship. However, SSD #2 resigned without notice on 04/12/17. The DON verified she had no evidence SSD #2 had proceeded with emergency guardianship. During an interview with the Administrator and DON on 04/18/17 at 12:00 P.M., each verified they did not contact the Medical Director to notify him of the problem and request assistance to ensure the CT scan was scheduled, emergency guardianship was obtained and an orthopedic consult was completed to determine appropriate treatment of [REDACTED]. During the same interview, the DON revealed she believed the Medical Director may be aware of the problem and might have been notified by SSD #2 prior to her resignation. Resident #39 was observed on 04/18/17 at 12:08 P.M. in the common lounge in a geriatric lounge chair. The resident's legs were elevated and a full left leg immobilizer was in place. Resident #39 was alert and appropriately responsive to simple questions. When asked how he was feeling, Resident #39 responded It hurts patted the immobilizer on his left leg, and said My leg. When asked what happened to his leg, Resident #39 responded, I don't know. It hurts. When asked how long it had been hurting, Resident #39 responded All day. and then asked Can you fix it? A telephone interview was completed with the Medical Director on 04/18/17 at 12:18 P.M. The Medical Director revealed he was not familiar with Resident #39 because he was not the resident's physician. The Medical Director verified he had not been contacted for assistance to establish emergency guardianship, consult with the resident's primary physician or ensure the local hospital scheduled the CT scan. The Medical Director revealed it was his role as Medical Director to assist with these types of problems and he would be available to assist the facility to initiate an emergency guardianship process. 2. Record review revealed Resident #10 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #10 was recently hospitalized [DATE] for recurrent [MEDICAL CONDITION], a [MEDICAL CONDITION] (stroke) and a laparoscopic appendectomy. Resident #10 returned to the facility 03/30/17. Review of a Minimum Data Set assessment dated [DATE] revealed Resident #10 was alert and oriented with no cognitive impairment. Review of a self reported incident (SRI) dated 04/07/17 revealed Resident #10 approached the Director of Nursing on 04/06/17 upon her arrival to the facility. Resident #10 revealed he was not feeling well and was feeling outside of his body. Resident #10 revealed he was concerned because he had been given the wrong medication on the previous evening. Resident #10 revealed he reported feeling ill to Licensed Practical Nurse (LPN) #3, the nurse who administered the medication. Resident #10 revealed he reported feeling ill several times during the night and LPN #3 did not address his concerns. At one point LPN #3 responded with You'll be alright and exited the facility. Review of the SRI investigation revealed a written statement from LPN #3 dated 04/06/17. The written statement revealed LPN #3 believed she had followed the Medication Administration Record [REDACTED]. The written statement verified Resident #10 did not recognize the medication and questioned the purpose of the medication. The statement revealed LPN #3 had a discussion with Resident #10 and he never refused the medication. Review of the SRI and interview with the DON on 04/19/17 at 10:40 A.M., revealed the medication was not prescribed for Resident #10 and was given despite the resident's inquiry. In addition, LPN #3 did not respond to the resident's complaint of feeling ill. The investigation verified LPN #3 failed to assess the resident, document the resident's concerns and/or notify the physician. The allegation was substantiated as neglect and LPN #3 was terminated. The DON reported the incident to the state Board of Nursing. This deficiency substantiates Complaint Number OH 655.

Based on observation, record review and staff interview, the facility failed to provide pain control during the changing of multiple pressure ulcer dressings. This resulted in actual harm for Resident #96 who continued to call out/yell out in pain throughout the dressing change procedure. This affected one of three residents reviewed for pain. The facility failed to apply antiembolism compression hose (TED hose) as ordered by the physician. This affected two (Resident #74 and Resident #99) of two residents reviewed for TED hose. The facility also failed to implement appropriate interventions to prevent or reduce skin alterations and/or contagious rashes. This affected three (Resident #28, #99 and #13) of five residents reviewed for skin conditions. The facility census was 58. Findings include: 1. Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] indicated Resident #96 was confused except to person. The resident scored a 14 on her skin risk assessment with scores of (13-14) indicating she was at moderate risk for pressure ulcer development, however she was admitted with seven areas of skin impairment. Review of the pain assessment from admission indicated she exhibited negative verbalizations/vocalizations of pain such as groaning, crying/whimpering or screaming. The assessment stated Resident #96 was currently in pain. There was no documentation of any attempt to have her rate her pain or of any interventions to be used to control the pain. An acute plan of care or immediate needs plan of care to address pain was not initiated. The wound physician, registered nurse (RN) #12, state tested nursing assistant (STNA) #13 and restorative aide (RA) #14 were observed on 07/30/14 from 11:05 A.M. until 12:05 P.M. completing the dressing changes for Resident #96's multiple pressure ulcers. Observation revealed the following: The right shoulder dressing was dated 07/28/14. The wound physician removed the dressing and the pressure ulcer was observed with yellow slough nearly covering the wound bed. The physician measured the area and stated it was 7 centimeters (cm) by 1.7 cm. The physician sprayed the wound with [MEDICATION NAME] (numbing) spray and completed a sharp debridement of the pressure ulcer and then applied pressure to stop the bleeding. When the bleeding stopped, the physician stepped aside for the dressing application to be done by RN # 12. RN #12 applied the dressing as ordered by the physician. Resident #96 did not complain of pain with this procedure and lay quietly as they used the numbing spray first. Resident #96 denied pain when asked by STNA #13 and the physician. Resident #96 had an ankle-foot orthotic (AFO) on her right foot/lower leg and a pressure ankle foot orthotic (PRAFO) to her left foot/lower leg. The right AFO was removed and the right heel dressing was dated 07/28/14. The right lower leg was observed with a moderate amount of bloody drainage. Resident #96 was observed to call out in pain, saying "ow, ow, ow" when her leg was moved and as they poured normal saline on the dressing which was dried to her right heel and outer foot ulcers. The right outer foot was measured by the physician and was 2.4 cm by 0.8 cm by 0.1 cm. The physician stepped aside and RN #12 applied the ordered dressing without first cleansing the ulcer. The right heel dressing was removed and Resident #70 was observed to call out in pain repeatedly. The heel was blackened and the physician indicated it was a deep tissue injury and measured it at 2.6 cm by 4.4 cm. The physician ordered a foam dressing and RN #12 applied the dressing. The right posterior lower leg dressing was removed and the resident was calling out "ow" repeatedly. The areas were measured by the physician at 11 cm by 10.5 cm. As RN #12 used normal saline to clean the pressure ulcer, Resident #96 continued to call out in pain. The new dressing was applied. As Resident #96 was calling out in pain the staff in the room were saying to her "it's okay, we're almost done" and that they knew it hurt. At 11:45 A.M., RN #12 told Resident #96 if she still had pain after the dressing changes were done he would get her something for pain. At no time did they stop the dressing changes to give her pain medications. When the PRAFO was removed from Resident #96's left leg a dressing was observed on the lower, outer leg. The physician asked RN #12 if there was a treatment to that area and he said there was not one listed on the treatment record. The date on the dressing was clearly marked "5/25". STNA #13 and the physician said that could not be right. The physician attempted to remove the dressing but it was dried onto Resident #96's leg. The physician poured normal saline onto her leg and Resident #96 yelled out in pain. As the physician was working the dressing loose, the resident continued to call out "ow" in pain. After the dressing was removed, the physician picked off a black, scab like piece of material about nickel size and again Resident #96 was yelling out in pain. Under the scab was a whitish scarred area but the skin was intact. The physician ordered padding and protection and it was applied. Resident #96 called out in pain every time her legs were moved. Resident #96 was then turned to her side. The dressing on her left buttocks was removed. The area was measured by the physician to be 1.1 cm by 2.3 cm and was a pink healing area and was not open. The physician ordered a treatment and RN #12 cleaned the ulcer with normal saline and the foam dressing was applied. After the dressing treatments were completed and Resident #96's clothing was adjusted and she was laying still, RN #12 offered Resident #96 pain medication. At 2:04 P.M. on 07/30/14, RN #12 was interviewed. RN #12 verified Resident #96 continued to complain of pain and yell out in pain during all of her dressing changes after the shoulder dressing was completed. Some of the dressings were dried and stuck in her pressure ulcers and with handling, lifting and moving of her legs and feet, Resident #96 repeatedly called out/yelled out in pain. On 07/31/14 at 11:13 A.M., RN #12 reviewed and verified the admission pain assessment was not thoroughly completed and no immediate needs care plan was initiated to address her pain. Review of the medication administration record for July 2014 revealed extra strength Tylenol, 500 milligram tablets, two tabs was ordered to give as needed for pain every six hours. Resident #96 was not given any pain medication prior to the dressing change observation on 07/30/14. 2. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a physician order [REDACTED].#74's lower extremities/feet due to [MEDICAL CONDITION] (swelling) to be applied in the morning and removed at night. Resident #74 was interviewed on 07/28/14 at 11:29 A.M. The resident was up in his room in his wheelchair wearing a t-shirt and shorts. There were no [MEDICATION NAME] or TED ([MEDICAL CONDITION] device) hose of any kind on his legs. He was observed with some swelling noted in both of his ankle/lower legs. Resident #74 verified he had swelling in his feet and legs and was on a fluid restriction for this reason. Resident #74 was observed later on 07/28/14 at 6:10 P.M. in his wheelchair in the conference room in shorts and he did not have TED hose or [MEDICATION NAME] on his legs. On 07/29/14 at 8:50 A.M. Resident #74 was observed on his side in bed sleeping. He had shorts on and no TED hose or [MEDICATION NAME] were on either of his legs. On 07/30/14 at 5:40 P.M. Resident #74 wheeled himself into the conference room wearing a t-shirt and shorts and no TED hose or [MEDICATION NAME] were observed on his legs. On 07/31/14 at 1:45 P.M. Resident #74 verified he was on a fluid restriction and had swelling in his feet and lower legs. When asked why he was not wearing the [MEDICATION NAME] or TED hose on his legs he stated they had been ordered and if we could get them for him he would wear them. The corporate nurse (RN) #2 reviewed the physician orders [REDACTED]. No other follow-up was found. Interview with the director of nursing (DON) at approximately 3:30 P.M. on 07/31/14 revealed [MEDICATION NAME] were usually kept on hand and if they needed ordered, they got shipments of medical equipment twice a week and it would not take long to obtain them. The DON indicated she did the ordering of supplies and was not aware that Resident #74 needed [MEDICATION NAME] and they did not have any at the facility. #3. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed a nursing progress note dated 03/01/14 at 6:00A.M. indicating Resident #28's skin was observed with red, distinct, splotchy areas throughout lower extremities and trunk. A nursing progress note dated 03/12/14 revealed the skin rash areas were observed to be red splotchy areas to to upper and lower extremities, trunk, back and peri area. There was no documented evidence of notification of the rash to the physician or the responsible party. Review of a nursing progress note dated 03/14/14 revealed staff was unable to reach the dermatologist's office to get sooner appointment about the rash because the office was closed and that staff would call on the next business day. A nursing progress note dated 03/17/14 at 1:15A.M. revealed splotchy red areas remain to upper and lower extremities, back, trunk, and peri area. There was no documented evidence that the dermatologist was contacted regarding the rash until 03/25/14 when an appointment was scheduled for 04/14/14. A review of a nursing progress noted dated 04/14/14 revealed Resident #28 went out to the dermatologist office and returned with new orders for [MEDICATION NAME] ointment twice daily to the rash on the body, [MEDICATION NAME] 25 mg one tablet by mouth at bedtime as needed for itching, and [MEDICATION NAME] cream 2.5% as needed to the rash in the groin area. A nursing progress note dated 05/08/14 2:00A.M. revealed the resident continued to have a red, splotchy, rash with distinct circular areas on skin throughout entire back, and described as extremely red in groin area. Resident #28 went out to see the dermatologist on 05/08/14 and returned to the facility with a [DIAGNOSES REDACTED]. An interview with STNA #21 and STNA #22 on 07/30/14 at 8:57A.M. verified that none of the residents receiving treatment for [REDACTED]. A review of the medical record revealed no documented evidence that Resident #28 was placed in contact isolation for the [DIAGNOSES REDACTED]. An interview with the DON on 07/31/14 at 3:08P.M verified that the resident was not placed in contact isolation for the [DIAGNOSES REDACTED]. #4. A closed record review revealed that Resident #99 was admitted to the facility 10/22/08 with [DIAGNOSES REDACTED]. A review of the nursing progress note dated 10/16/13 revealed an order to consult the dermatologist for the rash on the resident's trunk and back. Review of a nurses note dated 10/22/13 revealed the resident returned from the dermatologist with a [DIAGNOSES REDACTED]. An interview with STNA #21 and STNA #22 on 07/30/14 at 8:57A.M. verified that none of the residents receiving treatment for [REDACTED]. A review of the medical record revealed no documented evidence that Resident #99 was placed in contact isolation for the [DIAGNOSES REDACTED]. An interview with registered nurse (RN) #2 on 07/30/14 at 4:30P.M. verified that the resident was not placed in contact isolation for the [DIAGNOSES REDACTED]. #5. A closed record review revealed that Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed telephone orders dated 08/31/13 and 10/18/13 for TED hose (compression stockings) to be applied in the A.M. and removed at hours of sleep. There was no order to discontinue the TED hose after the initial order dated 08/31/13 prior to the second order written on 10/18/13. An interview with state tested nursing assistant (STNA) #27 on 07/31/14 at 2:08P.M. revealed that the STNA's apply the resident's TED hose if ordered by the physician. The STNA's are made aware of an order for [REDACTED]. A review of the current resident care card for Resident #99 revealed no instructions to apply TED hose. A review of the plan of care revealed no care plan to apply TED hose. A review of the treatment administration record (TAR) for 09/2013 and 10/2013 revealed the TED hose were not signed as completed on 09/1/13, 09/02/13, 09/03/13, 09/30/13,10/03/13, 10/04/13, 10/05/13, 10/06/13, 10/08/13, 10/09/13, 10/10/13, 10/11/13, 10/11/13, 10/12/13, 10/13/13, 10/14/13, 10/15/13, 10/16/13, 10/17/13, 10/18/13 and 10/28/13. An interview with the DON on 07/31/14 at 3:12P.M. verified the duplicate orders for TED hose on 08/31/13 and 10/18/13, no plan of care to apply the TED hose, no instructions to apply the TED hose on the resident care card, and the lack of documented evidence for the application of the TED hose on multiple dates on the TAR for 09/2013 and 10/2013. 6. Review of Resident #13's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's most recent Minimum (MDS) data set [DATE] revealed a brief interview of mental status score of 14 indicating Resident #13 is cognitively intact. Review of a fax sheet to the physician dated 05/04/14 revealed Resident #13 was scratching and complaining of itching on legs, abdomen and arms. The note revealed there was no rash noted at this time. Review of the nurses note dated 05/07/14 revealed Resident #13 was resting in bed with complaints of itching due to rash on abdomen legs and thighs and indicated a treatment was done as ordered. Review of the physician order [REDACTED].#13 was ordered five percent [MEDICATION NAME] cream ([MEDICATION NAME] 5% Cream is a topical scabicidal agent for the treatment of [REDACTED]. Review of the physician order [REDACTED]. There was no evidence of the [MEDICATION NAME] lotion being applied in May 2014 as ordered. Review of the treatment administration record revealed no evidence of a treatment for [REDACTED]. Review of the Medication administration record revealed on 05/06/14 Resident #13 began receiving [MEDICATION NAME] (an [MEDICATION NAME]). The [MEDICATION NAME] cream was noted to be given on 05/16/14. Review of the skin documentation form for Resident #13 dated 05/19/14 revealed Resident #13 was noted to have a rash all over. There were no further skin checks documented on 05/15/14, 05/19/14, 05/22/14, 05/26/14, or 05/29/14. Current physician order [REDACTED]. Review of the physician order [REDACTED]. Review of the MAR and TAR for June of 2014 revealed the [MEDICATION NAME] was applied on 06/12/14 and on 06/25/14. There was no evidence in Resident #13's medical record that contact isolation precautions were implemented in May or in June of 2014. Review of the skin check documentation revealed on 07/29/14 no evidence of Resident #13 having a rash. Observation on 07/28/14 at 10:53 A.M. revealed Resident #13 in bed with rash noted on right forearm and elbow area. Interview with Resident #13 at this time revealed Resident #13 has had a rash for at least three weeks and the rash is itchy. Observation on 07/28/14 at 12:27 P.M. revealed Resident #13 in the main dining area noted scratching both arms at the dining table. Interview on 07/30/14 at 8:30 A.M. with State tested Nurse's Aide (STNA) #21 confirmed Resident #13 was not placed in isolation and did have scabies. STNA #21 and STNA #22 indicated the rash had been present on Resident #13's back and legs for an extended period of time. STNA #22 indicated that it did improve but has been there since prior to Resident #13 being treated for [REDACTED].#21 and STNA #22 indicated the nurses were notified multiple times about Resident #13's rash. Observation on 07/30/14 at 8:48 A.M. with Registered Nurse (RN) #12 revealed Resident #13 with red raised rash area on back, bilateral back of legs and right arm. RN #12 confirmed this observation. Interview on 07/31/14 at 9:15 A.M. with Registered Nurse #16 confirmed there was no evidence of the [MEDICATION NAME] treatment being completed on 05/20/14. Registered Nurse #16 indicated Resident #13 was treated for [REDACTED].#16 confirmed there was no treatment specific to the rash on 05/07/14 and no evidence of physician notification related to Resident #13's rash. RN #16 indicated the treatment for [REDACTED]. RN #16 verified the treatments with the [MEDICATION NAME] cream ordered on [DATE] was completed on that date and then was not completed again until 06/25/14. RN #16 verified the second treatment is normally done a week after the first treatment. Review of the Contact precautions policy and procedure dated June of 2013 revealed contact precautions may be considered for scabies. This deficiency substantiates Complaint #OH 752 and #OH 453.

Based on observation, interview and record review, the facility failed to identify Resident #9's pressure ulcer, prior to it becoming a Stage III ulcer and failed to assess and monitor Resident #70's pressure ulcer, prior to it becoming unstageable. This affected one of three residents sampled for pressure ulcers. The facility had a total of five residents with pressure ulcers. The facility census was 52. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the pressure ulcer risk assessments completed on 06/24/11, 07/14/11, 10/01/11 and 12/02/11 indicated the resident was at high risk for developing pressure ulcers. Review of the minimum data set 3.0 (MDS) assessments dated 06/24/11 and 12/29/11 determined the resident was alert and oriented, had multiple mood and behavior issues and required extensive staff assistance for all activities of daily living. Review of the plan of care, last updated on 02/08/12, revealed it addressed the resident's risk for pressure ulcers. The plan listed multiple interventions, including weekly skin checks, providing incontinence care, observing skin during care and applying preventative ointments. The plan also indicated Resident #9 was resistive to care. Resident #9 was observed on 02/13/12 at 5:06 P.M. The resident was on her back in bed. She indicated she had a pressure ulcer on her buttocks for a week. Review of a wound evaluation flow sheet dated 02/08/12 confirmed a Stage III pressure ulcer to the natal cleft (lower sacrum) was found on that date. A Stage III pressure ulcer is full thickness tissue loss with subcutaneous fat, that may be visible but bone, tendon or muscle is not exposed. The wound evaluation flow sheet revealed the pressure ulcer was 3.2 centimeters (cm) long by 2.8 cm wide by 0.2 cm deep with drainage. A treatment order for a calcium alginate packing and [MEDICATION NAME] dressing to cover was obtained on 02/08/12. Review of a wound management consultation report, dated 02/09/12, further confirmed that the resident had a Stage III pressure ulcer on her natal cleft. There were no corresponding nurses note written at the time the pressure ulcer was found and there was no evidence that the ulcer was identified prior to it becoming a Stage III pressure ulcer. The wound nurse, Licensed Practical Nurse (LPN) #1, was interviewed on 02/15/12 at 8:10 A.M. and 02/16/12 at 8:18 A.M. She explained that Resident #9 was noncompliant with care and fought with the staff. She revealed a state tested nursing assistant (STNA) found the pressure ulcer on 02/08/12 at approximately 2:30 P.M. The STNA notified LPN #1 immediately for assessment. She confirmed the pressure ulcer was a Stage III ulcer at the time it was found. She explained that the reason the pressure ulcer was not identified prior to it becoming a Stage III ulcer was because the resident clenched her buttock and would not allow the staff to do completed pericare when she was involuntary of stool. She revealed the resident would also not allow the staff to do a complete shower at times, which included refusing to allow the staff to clean her from the waist down. LPN #1 and review of treatment administration records (TARs) for February, 2012 confirmed orders for incontinence care and sensicare cream to the buttocks, peri-area, coccyx and gluteal folds after each incontinence episode. The order was in place since 01/05/12. The nurses signed that the care was provided and cream applied as ordered every shift between 02/01/12 and 02/08/12, when the Stage III ulcer was identified. There was no indication on the TAR that the resident refused the incontinence care and sensicare cream or that changes to the skin were occurring. LPN #1 verified there was no evidence that the resident refused incontinence care or sensicare cream on the TAR. She verified that there were no nurses notes written between 01/07/12 and 02/08/12, which would indicated refusals of care. Review of the bath sheets, completed on 02/02/12 and 02/06/12, identified no evidence that the resident refused to allow the showers to be complete. The facility provided no evidence that the resident was resistant to care between 02/01/12 and 02/08/12, that prevented the staff from identifying Resident #9's pressure ulcer, prior to it becoming a Stage III. Resident #9 allowed the surveyor to observe the pressure ulcer on her natal cleft on 02/16/12 at 10:00 A.M. The pressure ulcer remained on the resident's lower sacral region, where the right and left buttocks meet. The pressure ulcer was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) at the time of the observation. 2. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Evaluation and Interim Care Plan dated 12/05/11 identified a reddened area to Resident #70's lower back and buttocks. There were no measurements of the reddened area included with the assessment. The admission Pressure Ulcer Risk Assessment identified Resident #70 at risk for the development of pressure ulcers. Review of the MDS assessment dated [DATE] identified the resident's thinking as disorganized or incoherent. The assessment indicated Resident #70 was frequently incontinent of bowel and bladder and required extensive assistance for bed mobility. The same assessment indicated the resident had no pressure ulcers at that time. Review of the potential for pressure ulcer plan of care initiated on 01/04/12 indicated Resident #70 had an excoriation of the natal cleft. The natal cleft is the vertical groove between the buttocks just below the sacrum to the perineum. Review of the physician orders [REDACTED].#70's buttocks and peri-area until the excoriation was resolved. A subsequent physician's telephone order dated 01/13/12 revealed a treatment to cleanse Resident #70's natal cleft with normal saline, apply calcium alginate and padded dressing every 72 hours. Calcium alginate wound dressing are indicated for moderate to heavy exudating (draining) partial thickness and/or full thickness pressure wounds. There was no corresponding documentation, assessment or tracking of the natal cleft wound. Review of a Wound Evaluation Flow Sheet dated 02/02/12 revealed an unstageable wound to Resident #70's natal cleft. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). The pressure ulcer measured 4.4 centimeters (cm) by 2.5 cm with a depth of 0.2 cm. The wound was described with a moderate amount of yellow exudate, described as loose, yellow slough. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy (at times). The presence of slough made the wound unstageable, since the entire wound bed was not visible. Review of the wound consultant's Wound Management Progress Problem Focused Consultation report dated 02/02/12 indicated the wound showed signs and symptoms of local infection, with a moderate amount of purulent exudate. The report revealed the wound had 75 to 100 percent necrotic tissue described as loose, adherent yellow slough. The wound physician wrote for a new wound treatment using Mesalt. Mesalt supports the cleansing of moderately to heavily discharging wounds, including infected wounds. Review of a physician's telephone order dated 02/03/12 revealed an order for [REDACTED]. Resident #70 was hospitalized from [DATE] until 02/14/12. She returned with wound treatment dressing changes to be completed every 72 hours. Review of the medical record revealed the treatment was completed on 02/14/12, however no new measurements and/or description of the wound was documented at that time. The dressing was not due to be changed until 02/17/12, which was after the annual survey. The surveyor requested to observe wound care treatment if the wound required an as needed wound dressing change. No such observation of the wound was offered. During an interview on 02/15/12 at 09:17 A.M., the wound nurse, LPN #1, verified a physician's orders [REDACTED]. LPN #1 revealed they had been watching the area of the natal cleft since the resident's admission because it had been excoriated. LPN #1 verified, however, there were no measurements and or descriptions of the excoriated area. LPN #1 explained she asked for the order for calcium alginate on 01/13/12 because the natal cleft area of excoriation had "a lot" of drainage. An open wound with exudate/drainage is consistent with a stage two pressure ulcer. LPN #1 acknowledged, however, there was no documentation of wound tracking or assessments of the wound, including descriptions and/or measurements until 02/02/12 when the wound developed yellow slough and advanced to unstageable. LPN #2 acknowledged that without such on-going wound tracking, the wound could not be monitored for deterioration and/or improvement. LPN #1 verified no documented assessment or measurement of the wound was completed upon the resident's return from the hospital on [DATE]. On 02/15/12 at 09:46 A.M., Resident #70 was observed lying on her bed without a low air loss mattress in place. During an interview on 02/15/12 at 09:47 A.M., LPN #1 verified Resident #70 had no air mattress on her bed. LPN #1 explained that Resident #70 returned to the facility from the hospital the previous day (02/14/12) and acknowledged the resident should have had an air mattress on her bed. She verified the order written on 02/03/12 that indicated a low air loss mattress was to be on the resident's bed at all times.