Every finding on record at Wyant Woods Healthcare Center

Based on medical record review, observations, interview, manufacturers guidelines and policy review, the facility failed to sanitize blood glucose monitors appropriately. This affected one (Resident #243) of five residents who required blood glucose monitoring. The facility also failed to ensure infection control standards were followed when administering medications. This affected three (Residents #131, #199 and #218) of five residents observed for medication administration. This had the potential to affect all residents residing in the facility. The facility census was 170.Findings include:Review of medical record for Resident #131 noted an admission date of 04/17/24. Diagnoses included Alzheimer's disease, heart failure and diabetes mellitus.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #131 had impaired cognition. Review of medical record for Resident #199 noted an admission date of 08/09/22. Diagnoses included Alzheimer's disease and chronic obstructive pulmonary disease.Review of the annual MDS assessment dated [DATE] revealed Resident #199 had intact cognition. Review of medical record for Resident #218 noted an admission date of 07/28/25. Diagnoses included schizoaffective disorder, depressive type and chronic obstructive pulmonary disease.Review of the quarterly MDS assessment dated [DATE] revealed Resident #218 had intact cognition. Review of medical record for Resident #243 noted an admission date of 11/11/24. Diagnoses included diabetes and peripheral vascular disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #243 had intact cognition. Observation on 02/26/26 at 8:44 A.M., LPN #652 was administering a medication to Resident #131. LPN #652 placed 11 medications into her hand without sanitizing or wearing a glove. LPN #652 was also observed carrying a blood glucose meter in her hand after checking the glucose level for Resident #243. LPN #652 placed the meter in the top drawer of the medication cart without sanitizing it. Interview immediately following the observation, LPN #652 verified the findings stating, I don't sanitize my hands between residents, I worked at other places, and no one has said anything to me. LPN #652 was also asked about the policy and procedure for disinfecting blood glucose meters. LPN #652 stated I don't clean the meters between residents, how would I clean them anyway, with alcohol? LPN #652 stated she had worked at the facility for three weeks and never cleaned the meters. Observation on 02/26/26 at 8:44 A.M., LPN #584 was administering medication to Resident #218. LPN #584 placed one medication into her hand without sanitizing or wearing a glove. Observation on 02/26/26 at 8:44 A.M., LPN #584 was administering a medication to Resident #199. LPN #584 placed three medications into her hand without sanitizing or wearing a glove. Interview immediately after the observation LPN #584 verified the findings and stated she should have put on a glove before touching medications.Interview on 02/26/26 at 3:50 P.M., Regional Director of Clinical Operations (RDCO) #686 verified staff should not be popping medications into their hands and blood glucose meters should be sanitized between each resident. Review of the manufactures guidelines for maintaining the meter stated cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe.Review of the undated facility policy titled Medication Administration noted staff are not touch the medication, either when opening a liquid or dose pack.Review of the undated facility policy titled Cleaning and Disinfection of Glucose Meter noted glucose meters should be disinfected with a high-level antimicrobial wipe.This deficiency was an incidental finding identified during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on interview, record reviews, review of the facility self-reported incident (SRI), Board of Pharmacy documentation review, observation and facility policy review, the facility failed to protect Residents #101, #108, #111, #114, #115, #127, #219, #265, #400, and #401 from misappropriation of medications. This affected 10 (Residents #101, #108, #111, #114, #115, #127, #219, #265, #400, and #401) of 10 residents reviewed for misappropriation of medications. The facility census was 170. Findings include: 1. Review of the medical record revealed Resident #101's was admitted on [DATE] with diagnoses including paranoid schizophrenia, unspecified dementia and delusional disorders.Review of Resident #101's physician's order revealed an order dated 07/08/23 for Ibuprofen (nonsteroidal anti-inflammatory) 600 milligrams (mg) by mouth three times a day for arthritis or pain (prescription number 10481545). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #101's Brief Interview of Mental Status (BIMS) score was 12, indicating Resident #101 had moderate cognitive impairment. Resident #101 required supervision for bathing, bed to chair to transfers and walking ten feet. Resident #101 was on antipsychotic medication, antianxiety medication, antidepressant medication, antiplatelet medication, and anticonvulsant medication. 2. Review of the medical record revealed Resident #108's was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, paranoid schizophrenia, and chronic obstructive pulmonary disease (COPD).Review of Resident #108's physician orders revealed an order dated 06/19/24 with a stop date of 11/24/24 for quetiapine (antipsychotic) 100 mg by mouth at bedtime for paranoid schizophrenia (prescription number 9867530).Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #108 exhibited severe cognitive impairment. Resident #108 was dependent on staff for bathing, transfers from bed to chair and did not attempt to walk ten feet. Resident #108 received antipsychotic medication. 3. Review of the medical record revealed Resident #111's was admitted on [DATE] with diagnoses including COPD, bipolar disorder and schizoaffective disorder bipolar type.Review of Resident #111's physician orders revealed an order dated 12/15/24 for ondansetron (antinausea) 4 mg give one tablet every six hours as needed for nausea and vomiting and before Trulicity injection (prescription number 20049187).Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #111 exhibited intact cognition and required set up assistance for bathing, transfers from bed to chair and to walking ten feet. Resident #111 received antipsychotic medication, antianxiety medication, antidepressant medication, diuretic medication, antiplatelet medication, and hypoglycemic medication. 4. Review of the medical record revealed Resident #114 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder, schizoaffective disorder and diabetes.Review of Resident #114's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Moderate assistance was needed for bathing. Supervision was needed to transfer from bed to chair and to walk ten feet. Resident #114 received antipsychotic medication, antianxiety medication, antidepressant medication, diuretic medication, antiplatelet medication, hypoglycemic medication, and anticonvulsant. Review of Resident #114's pharmacy documentation revealed an order dated 08/07/25 for Ibuprofen 800 mg give one tablet by mouth every eight hours as needed for pain at a level of one to three (prescription number 9332723), an order dated 11/15/21 for hydroxyzine 25 mg (antihistamine) give one tablet every four hours as needed for anxiety for fourteen days (prescription number 10338019), and an order dated 04/12/25 for ondansetron 4 mg (antinausea) give one tablet by mouth every six hours as needed for nausea and vomiting (prescription number 20018721) . 5. Review of the medical record revealed Resident #115 was admitted on [DATE] with diagnoses including Alzheimer's disease, primary generalized osteoarthritis and paranoid schizophrenia.Review of Resident #115's physician orders revealed an order dated 10/05/24 for olanzapine 10 mg (antipsychotic) give one tablet by mouth one time a day for schizophrenia (prescription number 10501858).Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #115 exhibited moderate cognitive impairment and required supervision for bathing, transfers from bed to chair and to walking ten feet. Resident #115 received antipsychotic medication. 6. Review of the medical record revealed Resident #127 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including borderline personality disorder, paranoid schizophrenia and generalized anxiety disorder. Review of Resident #127's physician orders revealed an order dated 05/10/24 for cyproheptadine 4 mg (midodrine) give one tablet by mouth every morning and at bedtime for an appetite stimulant (prescription number 9867527).Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #127 exhibited moderate cognitive impairment and required supervision for bathing, set up assistance to transfers from bed to chair and to walking ten feet. Resident #127 received antipsychotic medication, antidepressant medication, antiplatelet, and anticonvulsant medication. 7. Review of the medical record revealed Resident #219 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including diabetes, essential hypertension and major depressive disorder.Review of Resident #219's physician orders revealed an order dated 11/01/24 for ampicillin (antibiotic) give one capsule by mouth every six hours for a skin infection for ten days (prescription number 9787296).Review of the discharge return anticipated MDS 3.0 assessment dated [DATE] revealed Resident #219 exhibited intact cognition and required moderate assistance for bathing, did not attempt to transfer from bed to chair or walk ten feet. Resident #219 received antidepressant, anticoagulant, and opioid medication. 8. Review of the medical record revealed Resident #265 was admitted on [DATE] with diagnoses including paranoid schizophrenia, Alzheimer's disease and anxiety disorder.Review of Resident #265's physician orders revealed an order dated 05/22/25 for gabapentin (antiseizure and nerve pain) give one capsule by mouth every morning and at bedtime for pain (prescription number 20084636).Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #265 exhibited moderate cognitive impairment and was dependent on staff for bathing, transfers from bed to chair, and did not attempt to walk ten feet. Resident #265 received antipsychotic and antianxiety medications. 9. Review of the medical record revealed Resident #400 was initially admitted on [DATE], readmitted on [DATE] and discharged on 08/15/25 with diagnoses including paraplegia, end stage renal disease and anxiety disorder. Review of Resident #400's physician orders revealed an order dated 12/23/24 for metronidazole 500 mg (antibiotic) by mouth three times per day for a wound infection until 01/23/25 (prescription number 10069527).Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #400 exhibited intact cognition and required set up assistance to transfer from bed to chair. Resident #400 received antianxiety, antidepression, diuretic, opioid and anticonvulsant medication. 10. Review of the medical record revealed Resident #401 was admitted on [DATE] and discharged on 01/02/26 with diagnoses including bilateral primary osteoarthritis of the knee, schizoaffective disorder bipolar type and COPD.Review of Resident #401's physician orders revealed an order dated 04/17/25 for baclofen 10 mg (muscle relaxant) give one tablet every six hours as needed for spasms for 10 days (prescription number 20025599), an order dated 06/07/24 baclofen 10 mg by mouth every eight hours as needed with a discontinue date of 04/17/25, and an order dated 06/07/24 for baclofen 10 mg by mouth twice a day for muscle spasms.Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #401 exhibited intact cognition and required set up assistance for bathing, supervision for transfers from bed to chair, and set up assistance to walk ten feet. Resident #401 received antipsychotic, antianxiety, antidepressant, diuretic, opioid, and anticonvulsant medication. Review of SRI tracking number 266132 dated 10/07/25 revealed on 10/06/25 the Board of Pharmacy visited the facility and reported there was medication found at an outside location at a previous employee's house. The Board of Pharmacy released the names of the residents related to the medication that were found. The medication listed by the Board of Pharmacy were found to been removed from the facility after the medications were discontinued. All medications were from discharged or transferred residents and were discontinued after 24-hour discharge timeframe. Zero residents had adverse effected. The facility notified all required parties including the physician, psych physician, the medical director, and pharmacies, residents, residents' guardians/responsible parties and police department were notified. Staff education was started and completed on 10/07/25. Education included Medication Controlled Drugs and Security Policy, Pathway to narcotic management: Shift to Shift Count, Storage of Medications, Controlled Substance Storage, Medication Administration, Liberalized Medication Pass Times, Stock Medications, Clinical Documentation Standards, Missed Medication/Medication Error, Nurse Shift Change and Walking Rounds, Blood Glucose Quality Checks, Refrigerator Maintenance and Temperature, Abuse, Neglect, and Misappropriation. Review of the Board of Pharmacy letter dated 12/01/25 revealed a Case Cover Sheet Investigation #502-6239 revealed a probable drug diversion from long term facilities by Licensed Practical Nurse (LPN) #901. LPN #901 was reported to work in the facility and was believed to have diverted the prescription medication from the facility. An inspection was completed of the facility. On 07/21/25 the Regional Agent in Charge (RAC) with the Ohio Board of Pharmacy received information regarding a probable drug diversion by LPN #901. The information came from Summit County Sheriff's Office (SCSO). SCSO reported that LPN 901 worked at two long term care facilities and believed there could be systemic drug security failures at one or both facilities. On 09/04/25 the SCSO reported LPN #901's cause of death was an overdose of prescription drugs. Photos on the scene of LPN #901's residence revealed the following medications were found: Resident #114 Ibuprofen 800 mg 21 tablets Resident #219 Ampicillin 500 mg 25 tablets/capsules Resident #101 Ibuprofen 600 mg 30 tablets/capsules Resident #400 Metronidazole 500 mg eight tablets/capsules Resident #108 Quetiapine 100 mg 30 tablets/capsules Resident #265 Gabapentin 300 mg empty blister pack Resident #401 Baclofen 10 mg 14 tablets/capsules Resident #115 Olanzapine 10 mg 29 tablets/capsules Resident #111 had Ondansetron 4 mg five tablets/capsules *Resident #127 Cyproheptadine 4 mg 60 tablets/capsules On 10/06/25 the Ohio Board of Pharmacy conducted an inspection of the facility. The inspection was explained to the Administrator and Former Director of Nursing (DON) #596. Former DON #596 identified multiple residents on the list of prescription medication found at LPN's #901 residence. The Ohio Board of Pharmacy inspection noted the following: Signatures of documentation were inconsistent varying from initials, full names, and first initial with last name. Shift to shift counts were found to be pre-signed by the off going nurse. Documentation of cards/sheet did not match the actual count. Shift to shift counts were missing documentation, including dates, signatures and counts. On 11/03/26 The Board of Pharmacy reviewed Former DON #569's resident to resident interviews conducted on 10/07/25. A medication cart audit and medication administration record (MAR) audit was conducted on applicable residents. On 10/07/25 Former DON #569 completed assessments and interviews for concerns related to missing medication, and on 10/07/25, Former DON #569 educated all nursing staff and nursing managers and will educate all new nursing staff and nursing managers during orientation on the following: Medication Controlled Drugs and Security Policy, Pathway to Narcotic Management: Shift to Shift Count, Storage of Medications, Controlled Substances Storage, Stock Medications, Missed Medications and Medication Error, Nurse Shift Change and Walking Rounds, Refrigerator Maintenance and Temperature, Abuse, Neglect, and Misappropriation. Interview on 02/23/26 at 11:22 A.M. with the Administrator and Regional Director of Clinical Operations #686 revealed LPN #901 was hired on 07/11/22 and worked in the facility part time. LPN #901's last day working in the facility was 07/11/25. Regional Director of Clinical Operations #686 stated that if a non-narcotic medication was discontinued, the medication was to be removed by the nurse from the medication cart and placed in a Pharmacy Return Bag for disposal by the pharmacy. Regional Director of Clinical Operations #686 verified the investigation result of the Ohio Board of Pharmacy inspection. Interview on 02/24/26 at 9:44 A.M. with LPN #652 revealed if a medication was discontinued the medication was to be taken out of the medication cart and placed in a Pharmacy Return Bag. LPN #652 stated there was no way others would know if a nurse put the discontinued medication in the bag or not. Observation on 02/24/26 at 9:49 A.M. of the [NAME] unit revealed three filled white bags labeled Pharmacy Return Bags were in a locked medication room.Interview on 02/24/26 at 4:10 P.M. with Regional Clinical Director of Operations #686 stated there was no feasible method the facility had to track whether a non-narcotic medication had been placed in the Pharmacy Return Bag when the medication was discontinued. Review of the undated facility policy titled Ohio Abuse, Neglect, and Misappropriation revealed misappropriation was defined at the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings without the resident consent. The deficient practice was corrected on 10/08/25 when the facility implemented the following corrective action: On 10/07/25 Former DON #596 educated 26 of 26 LPNs and 11 of 11 Registered Nurses (RNs) regarding Medication Controlled Drugs and Security Policy, Pathway to Narcotic Management: Shift to Shift Count, Storage of Medications, Controlled Substance Storage, Medication Administration, Liberalized Medication Pass Times, Stock Medications, Clinical Documentation Standards, Missed Medication/ Medication Error, Nurse shift change and Walking Rounds, Blood Glucose Quality Checks, Refrigerator Maintenance and Temperature, Abuse/neglect/Misappropriation. On 10/07/25 Former DON #596 interviewed all applicable residents listed. On 10/07/25 Former DON #596 and designee reviewed and assessed all applicable residents listed. No residents experienced any adverse effects. On 10/07/25 Former DON #596 and designee initiated began daily medication cart audits which were completed on 10/30/25. No concerns noted. On 10/07/25 Former DON #596 and designee initiated and completed staff interviews related to the Board of Pharmacy Survey. No concerns were noted. On 10/07/25 Former DON #596 and designee initiated and completed assessments and or interviews for missing medications or concerns related to missing medications. All residents were interviewed and assessed. No concerns were noted. On 10/08/25 the Administrator contacted the local police department after the facility was contacted by the Ohio Board Of Pharmacy regarding residents medication that were found in a home of a former employee of the facility. The police report stated there were 263 pills belonging to 10 different residents in the facility and none of the medications were narcotics. On 10/08/25 the facility completed an Ad Hoc QAPI meeting. The Medical Director was in attendance by phone. On 10/08/25 Former DON #596 and designee completed skin sweeps and interviews on all 90 non-interviewable residents. No concerns were noted. Review of facility resident interviews revealed 73 of 73 residents were able to be interviewed, BIMS score was documented. No concerns were noted. Review of the facility pharmacy audits beginning on 10/08/25 revealed daily audits were completed until 10/30/25 regarding two full signatures on narcotic logs, documentation cards matched actual count, administration time of medication matched, medication including narcotics were destroyed or returned, documentation strike outs are completed per policy. Audits were done on Hickory, Buckeye, Willow, Maple, Oak, Walnut, Elm, Birch, This deficiency represents non-compliance under Complaint Number 2692620 and Complaint Number 2735853 .

Based on record review, interview and policy review, the facility failed to administer Resident #402's medications within appropriate timeframes. This affected one (Resident #402) of five residents observed for medication administration. The facility census was 170.Findings include:Review of the closed medical record for Resident #402 noted an admission date of 06/27/25. Resident #402 was discharged on 11/11/25. Diagnoses included hemiplegia and hemiparesis, major depressive disorder and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #402 had intact cognition. Review of the medication administration record (MAR) noted Resident #402 was receiving acetaminophen (analgesic) 1000 milligrams (mg) dated 06/27/25 twice a day for pain, hydroxyzine (antianxiety) 50 mg 09/20/25 twice a day for anxiety, Rabeprazole (acid reducer) 20 mg dated 10/11/25 twice a day for heartburn.Review of medication administration audit report which the facility utilizes to track medications that were administered late noted Resident #402' s medications as follows:10/01/25- acetaminophen 1000 mg scheduled at 7:00 A.M., was administered at 4:20 P.M. acetaminophen 1000 mg scheduled at 7:30 P.M., was administered at 12:46 A.M. on 10/02/25.10/29/25-hydroxyzine 50 mg and Rabeprazole 20 mg scheduled for 7:00 A.M. were administered at 1:24 P.M.10/31/25- acetaminophen 1000 mg, hydroxyzine 50 mg and Rabeprazole 20 mg scheduled for 7:00 A.M. were administered at 12:51 P.M.11/01/15- Rabeprazole 20 mg scheduled for 7:00 A.M. was administered at 12:08 P.M.11/04/25- acetaminophen 1000 mg, hydroxyzine 50 mg and Rabeprazole 20 mg scheduled for 7:00 A.M. was administered at 12:50 P.M.11/06/25- acetaminophen 1000 mg scheduled for 7:30 P.M. was administered at 12:25 A.M. on 11/07/25.11/07/25- acetaminophen 1000 mg scheduled for 7:30 P.M. was administered at 12:19 A.M. on 11/08/25.11/10/25- acetaminophen 1000 mg, hydroxyzine 50 mg and Rabeprazole 20 mg scheduled for 7:00 A.M. were administered at 12:09 P.M., hydroxyzine 50 mg and Rabeprazole 20 mg scheduled for 9:00 P.M. were administered at 5:42 A.M. on 11/11/25.Interview on 02/26/26 at 3:50 P.M., Regional Director of Clinical Operations #686 reviewed the audit and verified the medications were administered out of the timeframe scheduled.Resident #402 was not available for interview.Review of the undated facility policy titled Medication Administration noted medications would be administered within the times frame of one hour before and one hour after the time ordered.Review of the facility Liberalized Medication Pass Times, noted medications listed as early morning were from 4:00 A.M. to 7:00 A.M., medications listed as A.M. were from 6:00 A.M. to 11:00 A.M., medications listed as afternoon were from 12:00 P.M. to 3:00 P.M., medications listed as P.M. were from 4:00 P.M. to 7:00 P.M., and medications listed as HS were from 8:00 P.M. to 11:00 P.M.This deficiency represents non-compliance investigated under Complaint Number 2667132.

Based on record review, observation, interview, manufactures guidelines and policy review, the facility failed to ensure Resident #218 rinsed his mouth after using a steroid inhaler. This affected one (Resident #218) of five residents observed for medication administration. The facility census was 170.Findings include:Review of the medical record for Resident #218 noted an admission date of 07/28/25. Diagnoses included schizoaffective disorder, depressive type and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #218 had intact cognition. Observation on 02/26/26 at 8:44 A.M. of medication administration noted Licensed Practical Nurse (LPN) #584 administering medications to Resident #218. LPN #584 handed Resident #218 a BREO steroid inhaler, Resident #218 took one breath and gave the inhaler back to LPN #584. LPN #584 did not encourage or prompt Resident #218 to rinse his mouth after inhaling the steroid.During an interview with LPN #584 immediately after the observation, LPN #584 stated Resident #218 refused to rinse his mouth in the past, so I did not say anything. LPN #584 agreed that she should have prompted Resident #218 to rinse his mouth.During an interview on 02/26/26 at 3:50 P.M., Regional Director of Clinical Operations #686 verified staff should be encouraging residents to rinse their mouths after using a steroid inhaler.Review of the BREO inhaler guidelines from accessdata.fda.gov, noted after inhalation, the resident should rinse his/her mouth with water without swallowing to help reduce the risk of overgrowth of yeast in the mouth (oropharyngeal candidiasis).Review of the undated facility policy titled Medication Administration noted residents were to rinse their mouths after using a steroid inhaler.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, observation and interview, the facility failed to ensure adequate supervision and implement appropriate safety interventions for Resident #138, who continued to operate a power wheelchair at excessive speeds inside the facility despite multiple Occupational Therapy (OT) assessments identifying the resident as unsafe and recommending restriction of power wheelchair use to outdoor areas only. This affected one (Resident #138) of four residents reviewed for accidents. The facility census was 170.Findings include:Review of the medical record revealed Resident #138's was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension and muscle weakness.Review of Resident #138's OT progress note dated 10/28/25 revealed the resident hit the door and ran over someone's foot while driving his scooter. The resident needed safety education and training. The resident was very impulsive and showed aggressive behavior very quickly.Review of the Social Services note dated 10/30/25 noted staff including Social Services staff, Therapy Director and the Nurse Unit Manager met with Resident #138 to discuss recent safety concerns with his wheelchair scooter in the facility. The Therapy Director offered a new, more appropriate wheelchair, but Resident #138 declined. Staff informed Resident #138 any more incidents involving the scooter would result in the scooter being taken away. Staff stated this information was provided in writing.Review of Resident #138's OT progress note dated 11/03/25 revealed the resident was provided safety education for the power scooter regarding use in the facility provided again on this date. Despite all the education and demonstration, Resident #138 continued to demonstrate poor maneuverability skills and refused to adhere to appropriate facility speed settings to improve safety of the resident as well as other residents and staff in the building. It was the therapy recommendation that the resident did not utilize the power scooter safely in the facility. The manual wheelchair was provided with safety/mobility education. The resident returned the ability to utilize the manual wheelchair in the facility with good safety and good mobility. It is recommended that the power scooter is utilized only outside of the facility in the community.Review of the OT progress note dated 11/05/25 revealed Resident#138 was observed outside the facility. Staff provided safety sequence education concerning wheelchair use in the and out of doorways and various entryways. Resident #138 was reluctant to participate in the education and demonstrated poor safety despite verbal cues.Review of Resident #138's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #138 had intact cognition.Telephone interview on 02/23/26 at 2:23 P.M. with Certified Nurse Assistant (CNA) #615 revealed Resident #138 was upset at some point in 10/2025 and ran full speed into her leg with a mobility scooter fracturing her leg. CNA #615 indicated she had observed Resident #138 run into other people on the mobility scooter, but she could not name those people. She also indicated there was a lack of staffing including on 02/08/26 on the 6:00 A.M. to 6:00 P.M. shift.Review of Resident #138's OT progress note dated 02/25/26 revealed Resident#138 had poor safety awareness with the wheelchair scooter trying to fit through doorways that were too narrow.Observation on 02/25/26 at 8:07 A.M., Resident #138 was observed speeding down the hallway, wheelchair scooter was set on high (rabbit) mode.Interview on 02/25/26 at 8:07 A.M., Licensed Practical Nurse (LPN) #584 stated Resident #138 always sped down the hall, but it wasn't intentional. Interview on 02/25/26 at 11:38 A.M., CNA #592 stated Resident #138 flies down the hall all the time, staff educate the resident, but he refuses to cooperate.Observations and interview on 02/25/26 at 2:56 P.M., Resident #138's wheelchair scooter was observed to be heavily damaged in the front missing half of the front panel and one headlight, Resident #138 was asked about the condition of the scooter and stated he ran into something but could not remember what. Resident #138 further stated his hand got stuck in the space where the trigger was to engage/disengage the scooter. Resident #138 was asked about the speed settings on the scooter, Resident #138 stated he always had the scooter set between the turtle (slow) and the rabbit (fast) mode. Observations at time of interview noted the scooter was set at the fastest speed. Resident #138 denied hitting a staff member stating, she ran into me.Interview on 02/25/26 at 3:00 P.M., the OT #543 stated Resident #138 was assessed and educated several times; however, Resident #138 was stubborn and would not give up the scooter.Observation on 02/26/26 at 1:00 P.M. and at 4:00 P.M. was observed speeding down the hallway, and the wheelchair scooter was set on high (rabbit) mode.This deficiency represents non-compliance investigated under Complaint Number 2736364 and Complaint Number 2736364.

Based on record review, interviews and facility policy review, the facility failed to ensure Resident #117's antibiotic medication was administered according to the physician orders. This affected one resident (#117) out of four residents reviewed for medications. The facility census was 162. Findings include:Review of the medical record for Resident #117 revealed an admission date of 11/25/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, encephalopathy, impulse disorder and mood affective disorder. Resident #117 had a guardian since 2015. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #117 had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Resident #117 was dependent on staff for showers, lower body dressing, footwear and personal hygiene and required substantial assistance for toileting, upper body dressing, and oral hygiene and set up assistance for eating. Review of the chest x-ray report dated 08/18/25 at 10:14 P.M. revealed resident #117 had left lower lobe atelectasis/infiltrate. Review of the physician's order dated 08/20/25 revealed Resident #117 was ordered Levofloxacin (antibiotic) 250 milligram (mg) give three tablets, to total 750 mg, by mouth (PO) one time a day for infection for five days at 7:00 A.M. The order was discontinued on 08/20/25 after administering the dose. Review of the physician's order dated 08/21/25 revealed Resident #117 was ordered Levofloxacin 250 mg give three tablets, to total 750 mg, by mouth (PO) one time a day for pneumonia until 08/26/25 to start on 08/21/25 at 7:00 A.M. Review of the Medication Administrator Records (MAR) for August 2025 revealed Levofloxacin 250 mg, three tablets, totaling 750 mg was administered on 08/20/25 and 08/21/25 per the physician's order. On 08/22/25 and 08/23/25 the MAR had a number nine and the nurses initials. Review of the progress notes for 08/22/25 revealed the Levofloxacin 250 mg, three tablets, totaling 750 mg was on order. There was no documented evidence that the physician was notified. Review of the progress notes for 08/23/25 revealed the Levofloxacin 250 mg, three tablets, totaling 750 mg were not available. There was no documented evidence that the physician was notified. Interview on 10/07/25 at 3:45 P.M. with Corporate Nurse #800 confirmed Resident #117 did not receive his antibiotic medication as ordered on 08/22/25 and 08/23/25. Corporate Nurse #800 reported the medication was not available. Interview on 10/09/25 at 9:19 A.M. with Registered Nurse (RN)# 693 confirmed Levofloxacin for pneumonia was not administered on 08/22/25 and 08/23/25 due to the medication not available from pharmacy. RN #693 reported she checked in the Pixus machine, which usually had the medication, but it was out. RN #693 reported she contacted the pharmacy, and they were supposed to have it drop shipped, but it never came. RN #693 confirmed that there was no documented evidence that the physician was notified that the medication was not available to administer to Resident #117. Review of the facility policy titled Medication Administration, dated 2013, revealed to administer medications only as prescribed by the provider. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interviews, laboratory test reviews, hospital medical records review, pharmacy reviews and facility policy review, the facility failed to ensure the monthly pharmacy reviews recommended Resident #117's seizure medications were monitored with laboratory tests timely to prevent high/critical/toxic levels. This affected one resident (#117) out of three residents reviewed for medication monitoring. The facility census was 162. Findings include:Review of the medical record for Resident #117 revealed an admission date of 11/25/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, encephalopathy, impulse disorder and mood affective disorder. Resident #117 had a guardian since 2015. Review of the laboratory for Phenobarbital done at the facility for Resident #117 revealed a date of 01/24/25. The Phenobarbital level was 21 (normal range 10 to 40 micrograms per milliliter UG/ML). Review of the laboratory results dated [DATE] revealed the Levetiracetam (Keppra) (seizure medication) was high at 76, with normal range 6.00 to (-) 46.00 micrograms per milligram (ug/ml), Phenobarbital (seizure medication) was 23 ug/ml within normal limits (WNL) of 10-40 ug/ml, and Carbamazepine (Tegretol) (seizure medication) was 7.6 ug/ml WNL of 4-12 ug/ml. A repeat lab was done on 01/31/25 and revealed Levetiracetam (Keppra) was 30 ug/ml which was WNL, and Phenobarbital was 21 ug/ml which was WNL. There were no further laboratory tests done for seizure medication monitoring through the start of the investigation on 09/24/25. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #117 had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Resident #117 was dependent on staff for showers, lower dressing, footwear and personal hygiene and required substantial assistance for toileting, upper dressing, and oral hygiene and set up assistance for eating. Review of the May and August 2025 Medication Administration Records (MARs) revealed an order Carbamazepine Extended Release (ER) (Tegretol) (anticonvulsant) 200 mg po BID for seizures (start date 12/28/23 and discontinue date of 07/28/25) on 07/28/25 the Tegretol 200 mg was re-ordered one tablet BID for seizures/epilepsy, an order for Levetiracetam (Keppra) (anticonvulsant) 1000 milligrams (mg) one tablet by mouth (po) two times daily (BID) for seizures (start date 12/28/23), Gabapentin 600 mg (anticonvulsant) one tablet po at bedtime (start date 08/06/24) and 600 mg two tablets po in the morning (start date 08/07/24), Dilantin (anticonvulsant) 100 mg one capsule po three times daily (TID) for seizures (start 01/27/25), Phenobarbital (anticonvulsant) 64.8 mg give 1 tablet po BID for convulsions (start date 04/07/25), and Divalproex Sodium capsule delayed release Sprinkle (Depakote) (anticonvulsant) 125 mg one capsule po TID (start 07/06/25). Review of the pharmacy recommendations from 06/01/25 to 08/25/25 revealed the pharmacist failed to identify the need for lab tests for levels for the anticonvulsants that Resident #117 was receiving. Review of the progress note dated 08/25/25 at 6:32 P.M. revealed a change in condition for Resident #117. Resident #117 had a decrease in food and fluid intake and a functional decline with worsening function and mobility. The resident's diet was downgraded to a puree diet with thickened liquids due to the concern of aspiration, and the resident was no longer able to assist with his personal care as he used to before and was now requiring total care. Review of the progress note dated 08/25/25 at 6:48 P.M. revealed Resident #117's guardian, unit manager, and physician were notified of the change in condition. Review of progress note dated 08/26/25 at 11:11 A.M. revealed Resident #117 was tested for Respiratory Syncytial Virus/Coronavirus Disease of 2019 (RSV/COVID) due to related symptoms, and the results were negative. Plan of care continued, and all parties notified per change in condition (CIC) form. Review of the progress note dated 08/26/25 at 1:30 P.M. revealed therapy notified the nurse that the resident was having a hard time eating. The nurse notified the physician, and he ordered to send the resident to the hospital for an evaluation. The Director of Nursing (DON) and guardian were notified. Review of the progress note dated 08/26/25 at 1:36 P.M. revealed Resident #117 was sent to hospital via 911 for altered mental status and poor intake of food and liquids. Resident #117 appeared to be lethargic and not swallowing well. Emergency Medical Services (EMS) arrived at 1:45 P.M. All notifications were made to include the physician, DON, unit manager, and guardian of the transfer to the hospital for evaluation. Review of the progress note dated 08/26/25 at 4:35 P.M. revealed Resident #117 was admitted to the hospital with diagnoses of altered mental status (AMS) and adult failure to thrive. All required parties were notified. Review of the progress noted dated 08/26/25 at 4:36 P.M. revealed Resident #117's guardian was notified of the hospital transfer. Review of the progress note dated 08/26/25 at 5:53 P.M. revealed Resident #117's guardian was updated on the resident's status at the hospital. Review of the hospital medical records dated 08/26/25 revealed Resident #117 was admitted to the hospital with diagnosis of AMS. Review of the hospital medical laboratory records dated 08/26/25 at 5:48 P.M. revealed Resident #117's Phenobarbital results were 55.9 ug/ml which was a HIGH ALERT, (meaning the Phenobarbital level in the person's blood is outside the normal therapeutic range and has reached a potentially toxic level, further because phenobarbital is a high-alert medication with a narrow therapeutic window, a critical result requires immediate attention from a healthcare provider to prevent serious harm. A High-Alert Phenobarbital lab value is a red flag indicating a potentially life-threatening drug level that requires an immediate and serious response from medical professionals.) The normal range for Phenobarbital is 15.0 to 40.0 ug/ml. A high level of Phenobarbital in the blood can cause serious complications including significant drowsiness and confusion, dangerously slowed or stopped breathing, slurred speech, poor coordination and coma or death. Review of the hospital medical laboratory records dated 08/27/25 at 11:15 P.M. revealed Resident #117's Phenobarbital results were 49.9 ug/ml which was considered HIGH. Review of the hospital medical records revealed Neurology held Resident #117's Phenobarbital for a short period of time due to the elevated levels. Review of the progress note dated 08/28/25 at 1:21 P.M. revealed Resident #117's guardian called Former Assistant Director of Nursing (ADON) #900, who is no longer at the facility, and stated she no longer wanted the facility Psychiatric Physician #805 to follow the resident due to concerns of polypharmacy. Resident 117's guardian further stated she only wanted Physician #815 to follow the resident. Psychiatric Physician #805 was notified and agreed to no longer follow Resident #117 as requested by the guardian. Physician #815 was notified and agreed to follow Resident #117 to include psychiatric medication. Review of the progress note dated 08/31/25 at 1:29 P.M. revealed Resident #117 returned to the facility. Physician #815 and guardian notified of return to facility. Review of the pharmacy recommendation review, form titled Note To Attending Physician with Medical Regimen Review (MMR), dated 09/17/25 by Pharmacist #810, revealed Resident #117 is ordered Tegretol, Phenobarbital, and Keppra, all seizure medications. Request to order labs to include Complete Blood Count with differential (CBC w/Diff), Phenobarbital, Carbamazepine (Tegretol), and Levetiracetam (Keppra) every (Q) six (6) months. The form was not addressed by the physician. The physician prescriber response of agree, disagree, or other was left blank, and there was no signature of completion as of 09/29/25. Interview on 09/25/25 at 1:55 P.M. with Corporate Nurse #800 confirmed there was no labs ordered for the seizure medications. Corporate Nurse #800 confirmed the last lab done for seizure medication monitoring in the facility was 01/27/25. Corporate Nurse #800 confirmed the pharmacy recommendation form dated 09/17/25 was not completed. Corporate Nurse #800 reported the facility had 30 days to address the pharmacy recommendations. Interview on 09/25/25 at 1:58 P.M. with Pharmacist #810 confirmed residents on seizure medications should have labs done at least three times a year if stable. Pharmacist #810 is the pharmacist that did the monthly recommendations. Interview on 09/25/25 at 2:22 P.M. with Physician #815 confirmed for residents on medications for seizures, to include Resident #117 should have labs checked at least a couple times a year. Interview on 09/29/25 at 9:54 A.M. with the DON confirmed there was no lab ordered to monitor Resident #117's three seizure medication since January 2025 prior to the resident being admitted to the hospital on [DATE] with a HIGH ALERT Phenobarbital level. The DON confirmed the pharmacy recommendation form dated 09/17/25 requested the physician to order labs for seizure medications every six months was not addressed. Review of facility policy, Medication Regimen Review, undated, revealed the monthly medication review will be performed by a licensed pharmacist according to federal and state regulations meeting current standards of practice and to review and report any identified medication irregularities in accordance with this policy. The pharmacist will report any irregularities to the attending medical practitioner and DON and these reports must be acted upon in a timely manner that meets the needs of the residents. DON will be responsible for addressing all medication irregularity reports with the medical practitioner in a manner that meets the needs of the resident. Urgent or significant medication irregularity is communicated the day it is observed and non-urgent irregularities within 72 hours or their last scheduled consultation visit for the month or sooner. This deficiency represents non-compliance investigated under Complaint Number 2603626.

Based on record reviews, interviews and facility policy review, the facility failed to ensure care plan meetings were offered timely to residents and guardians. This affected two residents (#117 and #134) out of three resident residents reviewed for care plan meetings. The facility census was 162. Findings include:1. Review of the medical record for Resident #117 revealed an admission date of 11/25/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, encephalopathy, impulse disorder and mood affective disorder. Resident #117 had a guardian since 2015. Review of the progress note dated 05/13/25, authored by Social Service Designee (SSD) #619 revealed a care conference was had last on 05/13/25. There was no documentation after 05/13/25 indicating a care conference for August 2025 or September 2025. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #117 had intact cognition. Resident #117 was dependent on staff for showers, lower body dressing, footwear and personal hygiene and required substantial assistance for toileting, upper body dressing, and oral hygiene and set up assistance for eating. Resident #117 was frequently incontinent of bladder and bowel. Interview on 09/29/25 at 11:05 A.M. via phone with Resident #117's guardian revealed she was not offered any care conferences in about four months. She reported the last care conference she had was about four months ago. Interview on 09/30/25 at 7:24 A.M. with Licensed Social Worker (LSW) #610 and SSD #619 confirmed Resident #117 did not have a care plan meeting timely. LSW #610 and SSD #619 reported last care plan meeting held for Resident #117 was 05/13/25, and he should have had one in August 2025 to be timely as required. LSW #610 and SSD #619 reported they were unable to state why the care plan meeting wasn't completed timely. Interview on 09/30/25 at 7:44 A.M., via phone with Licensed Practical Nurse (LPN) #605, confirmed care plan meetings were to be done quarterly. LPN #605 confirmed Resident #117 did not have a care plan meeting done timely and didn't know why. 2. Review of the medical record for Resident #134 revealed an admission date of 11/03/21. Diagnoses included fibromyalgia, type II diabetes mellitus with peripheral angiopathy, delusional disorders, bipolar disorder, panic disorder, phobic disorder and impulse disorder. Review of the progress note dated 05/29/25, authored by LSW #610 revealed a care conference was held last on 05/29/25. There was no documentation after 05/29/25 indicating a care conference for August 2025 or September 2025. Review of the quarterly MDS 3.0 assessment dated [DATE], revealed Resident #134 had intact cognition. Resident #134 required set up assistance for oral hygiene, personal hygiene and dressing and supervision for toileting and showers. Interview on 09/25/25 at 7:52 A.M. with Resident #134 denied having a care conference. She reported she couldn't remember when the last care conference was. Interview on 09/30/25 at 7:24 A.M. with LSW #610 and SSD #619 confirmed Resident #134's care plan meeting was not timely. LSW #610 and SSD #619 reported Resident #134's last care plan meeting was 05/29/25, and she was scheduled for her next care plan meeting 10/21/25. LSW #610 and SSD #619 unable to give a reason as to why the care plan meeting was late. Interview on 09/30/25 at 7:44 A.M., via phone with LPN #605 confirmed care plan meetings were to be done quarterly. LPN #605 confirmed Resident #134 did not have a care plan meeting done timely and didn't know why. Review of the undated facility policy titled Plan of Care Overview revealed attendees will sign and date care plan meeting agendas/documents. This deficiency is an incidental finding identified during the complaint investigation.

Based on interview, record review and review of facility policies, the facility failed to ensure residents were appropriately supervised while smoking, resulting in an elopement. This affected one resident (#144) and had the potential to affect all 11 residents who smoked on the Hickory Unit (#24, #55, #75, #101, #102, #122, #129, #134, #144, #148 and #157). Facility census was 163. Findings include: Review of Resident #144's medical record revealed an admission date of 06/05/18 and diagnoses including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, paranoid schizophrenia, bipolar disorder, delusional disorder, mild cognitive impairment, impulsive disorder, intermittent explosive disorder, cocaine abuse and dementia in other diseases, severe, with other behavioral disturbances, psychotic disturbance and mood disturbance. Review of a plan of care dated 02/18/21 and revised 07/18/22 revealed Resident #144's guardian had no plans for discharge secondary to Resident #144 walked away from about 20 group homes and was not safe to live alone. Interventions included invite and encourage to attend activities of interest; monitor for signs and symptoms of anxiety, distress, withdrawal or depression relating to not returning to previous home environment and provide visits for support and observe for any concerns. Review of a plan of care dated 02/18/21 and revised 12/14/23 revealed Resident #144 wished to smoke and her guardian agreed to implement a money plan where Resident #144 would receive four dollars a week for spending money and the rest would be set aside to purchase cigarettes so that she could smoke; Resident #144 would attempt to go outside to smoke outside of designated smoking times. Interventions included complete smoking evaluation; educate resident/resident representative to designated smoking areas and long term side effects of extended nicotine use; educate resident/resident representative to facility smoking policy and obtain resident signature and provide supervision during designated smoke times. Review of Resident #144's current physician's orders revealed an order dated 04/13/25 for secured unit placement due to paranoid schizophrenia and need for decreased stimuli and a controlled environment. Review of a wander observation tool dated 04/13/25 revealed Resident #144 was at risk for elopement. Review of a plan of care dated 04/13/25 and revised on 04/15/25 revealed Resident #144 was an elopement risk. Interventions included assess for hunger, thirst, ambulation, toileting needs; complete wandering evaluation, upon admission/readmission, quarterly, and as needed (PRN); educate resident/resident representative of the need for secured unit/device to maintain resident safety; evaluate for need of secured unit, notify medical provider as needed; notify medical provider and resident representative of behavior changes; notify staff of elopement risk; obtain a current photograph and list of identifiable characteristics, and place in the elopement risk identification book; provide diversionary activities as needed and redirect when appropriate; provide structured activities at times of increased elopement risk, diversional tasks, redirection of ambulation pattern and utilization of safe wandering area. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 was cognitively intact, displayed verbal behaviors four to six days, wandered one to three days and displayed other behaviors one to three days of the review period. Resident #144 was independent or required set up for activities of daily living and required supervision for walking 150 feet. Review of a nurses' note dated 05/22/25 timed 4:30 P.M. and signed by the Director of Nursing (DON) revealed Resident #144 was returned safely to her room by the DON. Resident #144 stated she wanted food from a restaurant. Resident #144 voiced no complaints or concerns. Resident #144 denied pain or discomfort, and did not display any signs or symptoms of pain, discomfort, or distress. A head to toe assessment was completed including vital signs and skin assessment which was within normal limits to resident's baseline, no injuries or skin alterations noted, skin warm to touch. All required parties were notified with new orders for psychiatric medication changes. The note indicated to see new orders for detailed medication changes. The guardian was notified and guardian noted that Resident #144 had a history of exit seeking and the police did not need to be notified at that time. Review of the facility investigation into Resident #144's elopement on 05/22/25 revealed a timeline including the following: • On 05/22/25 at 4:05 P.M. Former Activities Director (FAD) #211 called the DON and explained while leaving for the day, he saw Resident #144 in the parking lot. The DON told FAD #211 to remain with Resident #144 and instructed unit managers and floor nurses to call a Code Green and complete head counts while Director of Maintenance (DOM) #205 checked gates and doors. • On 05/22/25 at 4:06 P.M. the DON arrived to the parking lot and saw Resident #144 and began to talk to her. • On 05/22/25 at 4:07 P.M. the DON spoke with Resident #144 who stated she did not want to return to the facility because she wanted to see her family and eat at a restaurant. When asked, Resident #144 would not state how she left the secured unit. Resident #144 was returned safely to her secured unit and placed on one on one (1:1) supervision. Review of a witness statement dated 05/22/25 and authored by Certified Nursing Assistant (CNA) #210 revealed he let the residents out to smoke and watched from the window because it was raining. The witness statement indicated Resident #144 must have eloped while CNA #210 helped Resident #129 back into the building, which was when the code green was called. Review of a witness statement dated 05/22/25 and authored by Registered Nurse (RN) #23 revealed she last saw Resident #144 just right before she was about to start passing medications at 4:00 P.M. Resident #144 was standing a few feet away from the medication cart at that time. Review of a witness statement dated 05/22/25 and authored by FAD #211 revealed on 05/22/25 at approximately 4:15 P.M. while he was leaving the facility/premises for the day, he observed Resident #144 walking through the employee parking lot in the front of the building down towards the entrance and exit. FAD #211 immediately called the DON who arrived moments later and began conversing with Resident #144. Continued review of the facility investigation identified CNA #210 and CNA #212 as the staff responsible for supervising the smoke break on 05/22/25 at 4:00 P.M. CNA #210 and CNA #212 failed to supervise smoke break which led to a resident [Resident #144] kicking the courtyard gate during smoke break and eloping. Both staff were suspended and received final written warnings on 05/27/25 for violating facility policy and failing to supervise smoke break resulting in a resident elopement. Review of a plan of care dated 05/23/25 revealed Resident #144 wandered aimlessly from place to place. Interventions included assess for hunger, thirst, ambulation, toileting needs; complete wandering evaluation, upon admission/readmission, quarterly, and PRN; evaluate for need of secured unit, notify medical provider as needed; notify medical provider, resident representative of behavior changes; notify staff of wandering risk; personalize room with familiar objects and/or photographs; provide diversionary tactics/activities as needed and redirect when appropriate and provide structured activities at times of increased wandering, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas. Interview on 06/12/25 at 10:18 A.M. with Resident #144 revealed she had been at the facility 37 years and had eloped from the facility twice. Resident #144 stated she was caught within 20 minutes this last time. When asked why she left the facility, Resident #144 stated she did not like the facility. Interview on 06/12/25 at 2:00 P.M. with CNA #210 revealed on 05/22/25 they were doing smoke break on the unit between 4:00 P.M. and 5:00 P.M. and the snack cart had come so staff were waiting on a few residents to come out for smoking. CNA #210 stated it was raining so he was watching smoking from the window inside the Hickory unit. CNA #210 stated at this time Resident #144 slipped out and estimated she was gone 15 minutes as they began to count the residents and heard the Code [NAME] over the overhead paging system. During an interview on 06/12/25 at 3:38 P.M. with the DON and Corporate Nurse #209, the DON verified the content of the investigation provided and indicated the root cause of Resident #144's elopement was staff not supervising the resident smoke break appropriately on the Hickory unit. The DON stated when she interviewed CNA #210 he admitted he was looking away at the time of the actual elopement and was not actually outside during the smoke break. The DON confirmed both CNA #210 and CNA #212 did not supervise the smoke break appropriately which enabled Resident #144 to elope from the Hickory courtyard. When asked how long Resident #144 was gone for, the DON estimated Resident #144 was gone for five or six minutes. Review of the facility's undated policy Resident Smoking Guidelines revealed the facility would promote resident centered care by providing a safe smoking area for residents that requested to smoke. Supervised smoking would be performed by a staff member. Review of the facility's undated policy Elopement Prevention and Management Overview revealed elopement was defined as when a resident left the premises or a safe area without authorization and/or any necessary supervision and placed the resident at risk for harm or injury . The interdisciplinary team planned the least restrictive interventions to promote mobility and safety and to meet the individualized needs and goals of the resident. This deficiency represents noncompliance investigated under Master Complaint Number OH00166205.

Based on observation, interview, record review, and review of facility policy, the failed to provide activities to meet the interest and needs of residents. This affected eleven residents (#16, # 21, #23, #24, #28, #32, #42, #47, #56, #62, and #112) of 30 residents observed for activities and had the potential to affect the 22 additional residents (#29, #73, #90, #103, #104, #107, #113, #114, #119, #120, #132, #136, #137, #138, #139, #142, #145, #150, #151, #152, #209, and #210) residing on the Birch unit. The facility census was 158. Findings include: 1. Review of the facility activity calendar for April 2025 revealed no activities were provided after 4:00 P.M. Further review noted handouts were the only activity provided after 4:00 P.M. Review of Resident Council Meeting minutes dated January 2024 through April 2025 noted residents requested more activities in and out of the facility in January, February, June, July, September, December of 2024 and January and March of 2025. a. Review of the medical record for Resident #16 noted an admitted [DATE]. Diagnoses included generalized anxiety disorder and paranoid schizophrenia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 had intact cognition. Attending activities of interest was noted to be very important to Resident #16. Review of a revised plan of care dated 11/04/24 noted Resident #16 attended activities of interest. b. Review of the medical record for Resident #21 noted an admitted [DATE]. Diagnoses included unspecified dementia, anxiety disorder and schizoaffective disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #21 had intact cognition. Attending activities of interest was very important to Resident #21. Review of a revised plan of care dated 11/04/24 noted Resident #21 attended activities of interest. c. Review of the medical record for Resident #32 noted an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #32 had intact cognition. Attending activities of interest was very important to Resident #32. Review of a revised plan of care dated 08/07/23 noted Resident #32 attended activities of interest. d. Review of the medical record for Resident #42 noted an admitted [DATE]. Diagnoses included major depressive disorder and schizophrenia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #42 had intact cognition. Attending activities of interest was very important to Resident #42. Review of a revised plan of care dated 07/03/24 noted Resident #42 attended activities of interest. e. Review of the medical record for Resident #47 noted an admitted [DATE]. Diagnoses included generalized anxiety disorder, paranoid schizophrenia, and intermittent explosive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #47 had intact cognition. Attending activities of interest was very important to Resident #47. Review of a revised plan of care dated 02/03/25 noted Resident #47 attended activities of interest. f. Review of the medical record for Resident #56 noted an admitted [DATE]. Diagnoses included generalized anxiety disorder, schizoaffective disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #56 had intact cognition. Attending activities of interest was very important to Resident #56. Review of a revised plan of care dated 11/16/24 noted Resident #56 attended activities of interest. g. Review of the medical record for Resident #112 noted an admitted [DATE]. Diagnoses included Alzheimer's disease and delusional disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #112 had intact cognition. Attending activities of interest was very important to Resident #112. Review of a revised plan of care dated 02/24/24 noted Resident #112 attended activities of interest. Interview on 04/07/25 at 2:19 P.M., Resident #32 who was the Resident Council President (RCP) stated the facility has not a a transportation bus in years. The RCP stated no activities are offered after 4:00 P.M. or on the weekends due to lack of staffing. The RCP stated residents complain about activities all the time. Interview on 04/07/25 at 2:27 P.M., Activity Leader (AL) #873 stated she worked every other weekend and was unable to provide activities because she was the only one working. AL #873 also stated residents complain about not being able to attend activities outside the facility like going to the store or going to the movies. Interview on 04/08/25 at 8:52 A.M., AL #822 stated the facility did not have sufficient staff to provide activities as scheduled and did not have a transportation van for years. AL#822 stated residents complain all the time about not having activities and not being able to go to activities outside the facility. AL #822 stated staff used to take residents to see Christmas lights, see movies, go to museums, and parks. AL #822 stated activities were not provided on the weekends because there was usually one staff working. AL #822 stated that at times, the residents will help pass out the handouts and run the activities. A Resident Council meeting was held on 04/08/24 at 2:08 P.M. with Resident #16, #21, #32, #42, #47, #56, and Resident #112. All residents stated they voice concerns all the time to activity staff, including the Activity Director. Residents stated they would like to go to outside activities including shopping, movies, and bowling. 42730 2. Observation on 04/07/25 at 10:20 A.M. and 04/08/25 at 3:00 P.M. of the locked Birch unit, revealed multiple residents seated in the common area. One television was mounted to the wall playing a black and white movie. No residents were observed watching the television. Interview on 04/08/25 at 3:19 P.M. with Licensed Practical Nurse (LPN) #809, revealed the activity department did not visit the unit as they should. LPN #809 revealed someone from the activity department would come at 2:00 P.M. on scheduled day and to do the store activity. However, if a resident did not have funds they couldn't get anything. LPN #809 revealed, in return caused residents to be confused on why they couldn't get something causing more issues. LPN #809 revealed the activities and activity department was not great at all and the last outside trip was before COVID-19 pandemic. 3. Observations on 04/08/25 at 11:18 A.M., of the Buckeye unit noted residents seated in the dining room watching television. Review of the activity calendar noted an activity of crafts including painting was scheduled. Interview on 04/08/25 at 11:10 A.M., Residents #23, #24, and Resident #28 who were seated in the dining room stated activities were not provided on the unit. Interview on 04/08/25 at 11:40 A.M., CNA #813 and CNA #890 stated they must initial the activities and there was not enough staff to provide activities every day. Interview on 04/08/25 at 2:18 P.M., Activity Director #867 stated he had worked at the facility for three years. AD#867 stated there were not enough staff to provide activities as scheduled and the facility was not able to provide transportation for residents to attend outside activities. AD #867 stated all activity staff leave at 4:00 P.M. daily. AD #867 stated direct-care staff provide handouts to residents for activities after 4:00 P.M. Interview on 04/08/25 at 4:04 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #900 and RDCS #901 noted staff were aware that the facility had no transportation bus for years and the lack of daily activities. The Administrator stated he recently purchased items for staff to provide activities on the units. Staff had little response to concerns voiced regarding residents attending outside activities. Review of facility policy titled Activities Program, dated 10/16/24 noted the activity program consists of individual and small and large group activities which are designed to meet the needs and interests of each resident. The activities program included social activities, indoor and outdoor activities, activities away from the facility, religious activities, exercise activities, individualized activities, in-room activities, and community activities.

Based on record review, observations and interviews, the facility failed to respond to or resolve concerns voiced by residents. This affected seven residents (#16, #21, #32, #42, #47, #56, and #112) of seven residents reviewed for Resident Council. The facility census was 158. Findings include: Review of Resident Council Meeting minutes dated January 2024 through April 2025 noted residents requested more activities both in and out of the facility in January, February, June, July, September, and December of 2024 and January and March of 2025. There were no responses or actions documented or provided to indicate the facility was acting on the concerns voiced every month by residents. Interview on 04/07/25 at 2:19 P.M. with Resident #32, who was the Resident Council President (RCP), stated the facility has not a a transportation bus in years. The RCP stated no activities are offered after 4:00 P.M. or on the weekends due to lack of staffing. The RCP stated residents complain about activities all the time. Interview on 04/07/25 at 2:27 P.M. with Activities Leader (AL) #873 stated she worked every other weekend and was unable to provide activities because she was the only one working. AL #873 also stated residents complain about not being able to attend activities outside the facility, like going to the store or going to the movies. Interview on 04/08/25 at 8:52 A.M. with AL #822 stated the facility did not have sufficient staff to provide activities as scheduled and did not have a transportation van for years. AL#822 stated residents complain all the time about not having activities and not being able to go to activities outside the facility. AL#822 stated staff used to take residents to see Christmas lights, see movies, go to museums, and parks. AL #822 stated activities were not provided on the weekends because there was usually only one staff working. AL #822 stated that, at times, the residents will help pass out the handouts and run the activities. A Resident Council meeting was held on 04/08/24 at 2:08 P.M. with Resident #16, #21, #32, #42, #47, #56, and Resident #112. All residents stated they voice concerns all the time to activity staff, including the Activity Director. Residents stated they would like to go to outside activities including shopping, movies, and bowling. Interview on 04/08/25 at 2:18 P.M., Activity Director (AD) #867 stated he had worked at the facility for three years. AD#867 stated he was aware of resident concerns related to activities and stated there were not enough staff to provide activities as scheduled and the facility was not able to provide transportation for residents to attend outside activities. AD #867 stated all activity staff leave at 4:00 P.M. daily. AD #867 stated direct-care staff provide handouts to residents for activities after 4:00 P.M. Interview on 04/08/25 at 4:04 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Services #900 and #901 confirmed staff were aware that the facility had no transportation bus for years and aware of the resident concerns regarding lack of daily activities. The Administrator stated he recently purchased items for staff to provide activities on the units. Staff had little response to concerns voiced regarding residents attending outside activities.

Based on observations, interview, record review, and review of facility policy, the facility failed to ensure residents received proper assistance with personal hygiene and grooming tasks. This affected three residents (#25, #99, and #114) of five residents reviewed for activities of daily living. The census was 158. Findings include: 1. Review of the medical record for Resident #99 revealed an admitted [DATE] with diagnosis of hypertensive heart and chronic kidney disease, asthma, moderate intellectual disabilities, abnormalities of gait and mobility, arthritis, peripheral vascular disease, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #99 required moderate assistance with personal hygiene. Review of the Plan of Care dated 02/05/25 revealed Resident #99 had a deficit related to Activities of Daily Living (ADL) and required moderate assistance with personal hygiene. Observation and interview of Resident #99 on 04/09/25 at 8:11 A.M. revealed resident had a full beard and long fingernails. Resident #99 stated he would like to be shaved and have his nails cut. Observation and interview on 04/09/25 at 9:02 A.M. with Certified Nursing Assistant (CNA) #818 confirmed Resident #99 had a beard and long fingernails. Resident #99 confirmed with CNA #818 that he would like to be shaved and for his fingernails to cut. 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD), arthritis, dementia, and cataracts. Review of the Plan of Care dated 01/07/25 revealed Resident #25 had a deficit related to ADLs and required moderate assistance with personal hygiene. Observation on 04/07/25 at 2:20 P.M. of Resident #25 revealed the resident had a mustache and chin hairs. Resident #25 said she would like her mustache shaved and that staff has not done it. On 04/08/25 05:20 P.M. Licensed Practical Nurse (LPN) #740 confirmed mustache and chin hairs on Resident #25. Resident #25 confirmed with LPN #740 that she would like to be shaved by staff. 42730 3. Review of the medical record for Resident #114 revealed he admitted to the facility on [DATE] with diagnoses that included bipolar disorder, Alzheimer's disease, and osteoarthritis. Review of the physician orders dated 12/29/23 revealed an order for podiatry consultation. Review of the MDS annual assessment dated [DATE] revealed Resident #114 was alert and oriented to person, place, and time with a cognitive impairment. Review of the MDS assessment revealed Resident #114 required assistance from staff for ADLs. Review of the care plan dated 02/13/25 revealed Resident #114 had a self-care performance deficit that required staff assistance for ADL completion related to dementia. Observation on 04/07/25 at 10:43 A.M. revealed Resident #144 laying in bed with his feet exposed. Resident #114 toenails located on both left and right feet revealed long, jagged, in various lengths, and brownish yellow in color. Interview and observation on 04/07/25 at 10:44 A.M. with CNA #880 revealed Resident #114 toenails were never clipped or maintained. CNA #880 revealed herself or other CNA's maintained resident toenails during shower or bath days, but staff never maintained Resident #114's toenails. CNA #880 revealed some resident's toenails were maintained by the podiatrist, but she could not remember the last time the podiatrist was in the facility. CNA #880 observed, confirmed, and verified Resident #114 toenails at the time of the interview. Interview on 04/07/25 at 10:46 A.M. with LPN #809 revealed Resident #114 was unable to maintain his toenails on his own. LPN #809 revealed sometimes residents could not utilize the podiatrist due to the resident's payor source. LPN #809 confirmed and verified Resident #114 brownish yellow, long, and jagged toenails in various lengths at the time of the interview. Observation on 04/08/25 at 3:18 P.M. revealed Resident #114 laying in bed with nails in the same condition as observed on 04/07/25 at 10:43 A.M. Follow-up interview on 04/08/25 at 3:19 P.M. with LPN #809 revealed the schedule of the podiatrist visits was hard to know due to her not being notified until the day prior by social services. LPN #809 confirmed and verified Resident #114 toenails had not been maintained by staff or the podiatrist and she could not state when the last time they were was clipped or trimmed. Interview on 04/08/25 at 3:25 P.M. with CNA #708 revealed she had not touched Resident #114 feet, and they always looked like that. Interview on 04/08/25 at 3:42 P.M. with Licensed Social Worker (LSW) #823 revealed she was responsible for setting up ancillary services including podiatry appointments. LSW #823 revealed she kept a running list of residents needing to be seen by the podiatrist, who visited the facility twice a month. LSW #823 revealed Resident #114 had not been added to the list, had not been seen by the podiatrist, and could not confirm the last time he received care related to his feet. Follow-up interview on 04/09/25 at 9:20 A.M. with LSW #823 confirmed and verified Resident #114 had not been seen by the podiatrist and was now placed on the list to be seen on 04/22/25. Review of the facility document titled Nail and Hair Hygiene Services undated, revealed the facility had a policy in place to provide routine nail hygiene services that included trimming, cleaning, and filing. Review of the document revealed the facility did not implement the policy.

Based on record review, observation and interview, the facility failed to maintain infection control standards during medication administration and failed to appropriately clean a glucometer. This affected one resident (#32) of four residents reviewed for medication administration. The facility identified 29 residents who required blood sugar monitoring. The facility census was 158. Findings include: Review of medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #32 had intact cognition. Review of plan of care noted Resident #32 had diabetes. Interventions included to administer medications as ordered and check blood sugars before meals. Observation on 04/07/25 at 11:54 A.M. revealed Licensed Practical Nurse (LPN) #891 preparing medications to be administered to Resident #32. LPN #891 prepared four medications into a medication cup. LPN #891 then bumped into the medication cart, causing the medications to fall out of the cup and land on top of the medication cart. LPN #891 proceeded to pick up the medications up with a bare, ungloved hand and place the medications back into the medication cup. Interview with LPN #891 following the observation revealed LPN #891 confirmed the lack of glove use and touching the bare medications. LPN #891 looked confused as to what was asked regarding hand hygiene during medication administration. Continued observations at 12:04 P.M. revealed LPN #891 was observed checking blood sugar for Resident #32. LPN #891 completed the task and returned to the medications cart. LPN #891 placed the un-sanitized glucometer on top of the medication cart. Approximately 5 minutes later, LPN #891 was asked if he was going to clean the still un-sanitized glucometer. LPN #891 proceeded to use an alcohol wipe to cleanse the glucometer. LPN #891 was asked what he usually used to sanitize the glucometer, LPN #891 stated he used alcohol wipes and bleach wipes. LPN #891 stated the bleach wipes were hard to come by, so he used the alcohol wipes in place of bleach wipes. Review of the undated facility policy titled Medication Administration noted not to touch the medications, either by opening a liquid or dose pack. Review of the undated facility policy titled Cleaning and Disinfecting of Glucose Meter noted to use an Environmental Protective Agency (EPA) approved disinfectant against Hepatitis B and C and human immunodeficiency virus (HIV). The policy also indicated alcohol wipes were not appropriate for cleaning/disinfecting a used glucometer.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility's self-reported incident (SRI) and associated facility investigation, review of police reports, review of facility policy, and interviews, the facility failed to prevent an incident of staff to resident abuse for Resident #78. This resulted in Immediate Jeopardy and actual physical and psychosocial harm on 09/19/24 when State tested Nursing Assistant (STNA) #942 physically abused Resident #78 by spraying the resident in the face with oleoresin capsicum (OC) spray (also known as pepper spray). As a result, Resident #78 complained of his eyes burning and facility staff observed his eyes were red. In addition, a Post-Traumatic Stress Disorder (PTSD) Assessment was completed for Resident #78 on 09/20/24, which indicated Resident #78 considered the event traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. On 10/17/24 at 4:38 P.M., the Administrator, Director of Nursing (DON), Regional Nurse #938, and Regional Director of Operations #943 were notified Immediate Jeopardy began on 09/19/24 when STNA #942 physically abused Resident #78 by spraying the resident in the face with pepper spray. Resident #78 complained of his eyes burning and his eyes were red as observed and reported by Licensed Practical Nurse (LPN) #941. STNA #919 alerted Unit Manager #809 via text message on 09/19/24 at 9:54 A.M. that a resident had been maced and help was needed. Per the facility's timeline for the incident, an investigation did not begin until 09/19/24 at 1:56 P.M., approximately four hours after the incident was reported to Unit Manager #809. STNA #942 continued working in the facility until 2:17 P.M. A PTSD Assessment, completed 09/20/24, indicated Resident #78 considered the incident traumatic and described the incident as he had a heated conversation with staff and then he was sprayed in the face with pepper spray. The Immediate Jeopardy was removed and the deficient practice was corrected on 09/25/24 when the facility implemented the following corrective actions: On 09/19/24 at 1:51 P.M. STNA #919 notified the DON that Resident #78 was maced. Educated STNA #919 that she was to report any incidents related to abuse to the Administrator and DON immediately. Obtained STNA #919's witness statement. On 09/19/24 at 1:54 P.M. the DON interviewed STNA #942 of the alleged incident. STNA #942 relayed she was cleaning the hallway and Resident #78 must have touched the railing and touched his eyes. She also stated the floor nurse already educated her and made her dispose of the cleaning supplies. The DON obtained STNA #942's witness statement and placed STNA #942 in the receptionist area to immediately separate Resident #78 and STNA #942. On 09/19/24 at 1:59 P.M. the DON interviewed Licensed Practical Nurse (LPN) #941 who communicated cleaning supplies were used on Hickory unit and that she made STNA #942 empty the chemical mixture and educated her on not using cleaning supplies in the facility again. On 09/19/24 at 2:00 P.M. the DON notified the Administrator, Regional Director of Operations #943 and Regional Director of Clinical Operations #944 of the incident. On 09/19/24 at 2:00 P.M. the DON notified the facility's nurse practitioner (NP) of the incident and requested for NP to assess resident. The resident was assessed at 2:28 P.M. On 09/19/24 at 2:10 P.M. the DON suspended STNA #942 for possibly spraying [NAME] towards Resident #78. On 09/19/24 at 2:30 P.M. the DON obtained a new order to monitor Resident #78's eyes and face for abnormalities. New order confirmed. The resident was assessed by the DON on 09/19/24 at 3:20 P.M. related to the incident and for pain. Additional assessment was completed on 09/20/24 at 4:37 P.M. On 09/19/24 at 2:30 P.M. the DON attempted to call Resident #78's guardian to notify the guardian of the incident. A voicemail message was left. The guardian was notified at 6:46 P.M. On 9/19/24 2:59 P.M. the DON notified the local police department of the incident. On 09/19/24 at 3:00 P.M. Unit Manager #809 completed a respiratory assessment on Resident #78. On 09/19/24 at 3:03 P.M. Unit Manager #835 suspended LPN #941. On 09/19/24 3:45 P.M. all residents on the Hickory unit were assessed for respiratory, skin and eye concerns related to the chemicals that were sprayed on the unit. On 09/19/24 all interviewable residents were interviewed regarding abuse by Unit Manager #861. Skin sweeps were completed for residents with a low cognition. On 09/19/24 at 4:20 P.M. facility managers completed skin checks and interviews on all facility residents. On 09/19/24 at 4:30 P.M. the DON notified the Medical Director of the incident. On 09/19/24 at 4:52 P.M. social services staff met with Resident #78 to provide support to the resident. On 09/19/24 at 7:04 P.M. Resident #78's psych physician was notified of incident and new orders were given to increase Seroquel (antipsychotic medication). On 09/19/24 the DON/Designee interviewed staff on any potential abuse to ensure all incidents had been investigated and reported. On 09/19/24 the DON/Designee interviewed all staff on the current shift and next shift to identify if any weapons were on the facility grounds. On 09/19/24 the DON/Designee educated all staff on the facility policy identified as, abuse, neglect, and misappropriation with emphasis on timely reporting, who to report incidents of abuse to, ensuring safety of the residents, and effective investigation. On 09/19/24 the DON/Designee educated all staff on no tolerance/allowance of weapons in the facility with emphasis on what was considered a weapon. Staff were educated that all harmful substances on person, key chains, purses, backpacks must be left outside of facility. All harmful substances on keychains must be removed prior to entrance in the building. Staff educated that increase observation would be ongoing for such items and that all violations identified would result in suspension until a thorough investigation was completed and had the potential to lead to termination. On 09/19/24 the DON/Designee educated all facility department managers on increase supervision and Ambassador rounds with emphasis on monitoring and observation of any form of weapon, this includes observation of uniforms, keys, and open bags or purses. On 09/19/24 around 5:00 P.M. via a zoom call Divisional [NAME] President of Risk educated the DON and Unit Managers on reporting guidelines related to abuse, investigation, reporting, maintaining safety of residents, and what constitutes an allegation, company weapons policy and expectations. On 09/20/24 STNA #942's employment was terminated related to the incident with Resident #78. On 09/20/24 at 7:34 P.M. local police were updated with findings of the facility investigation. The police were pursuing assault charges against STNA #942. On 09/23/24 the Administrator/Designee reviewed LPN #941 and STNA #942's employee files for background checks, references, abuse and resident rights training due to the fact they were the perpetrators in this incident. On 09/23/24 all facility staff were educated by an outside company on Empathy, Psychiatric Behaviors, and De-Escalation. Staff on Leave or Paid Time Off will be educated upon return and prior to working. Two employees remain on leave and will be educated by the ED/Designee upon return. Beginning the week of 09/25/24 the facility implemented a plan for the DON/Designee to educate all new staff in behavioral health management, abuse, and weapons policy. This would be ongoing as part of new hire orientation which was ongoing. Beginning the week of 09/24/24 the DON/Designee would interview five residents weekly for four weeks for any abuse concerns. Then three residents weekly for four weeks. Then randomly thereafter until compliance was confirmed. Beginning the week of 09/25/24 the Administrator/Designee would interview five staff members weekly for four weeks for any abuse concerns. Then three staff members weekly for four weeks. Then randomly thereafter until compliance was confirmed. Beginning the week of 09/25/24 the DON/Designee would review five weekly skin assessments on residents who were unable to be interviewed to ensure no new skin findings for four weeks. Then three weekly skin assessments weekly four weeks. Then randomly thereafter. Beginning the week of 09/25/24 the Administrator/Designee would audit completion of daily ambassador rounds for increased surveillance of weapons in the facility daily for four weeks then three times weekly for four weeks, then randomly thereafter. Beginning the week of 09/25/24 the Administrator/Designee would audit completion of new hire education on Weapon Free Workplace policy weekly for four weeks then randomly thereafter. Beginning the week of 09/25/24 the Administrator or DON would monitor compliance in monthly Quality Assessment and Performance Improvement (QAPI) meeting for three months, then as needed for one year. Beginning on 10/01/24 to ensure staff comprehend understanding of education on responding to challenging behaviors the facility implemented monthly monitoring with education and pre/post test times for months. The facility implemented a plan for all allegations of abuse to be reported to the Regional Director of Clinical Operations #944 by the Director of Nursing or Administrator as soon as the allegation was made as additional oversight. The facility implemented a plan for Regional Director of Clinical Operations #944 to monitor compliance during monthly visits for three months then on an as needed basis. Findings include: Review of the medical record for Resident #78 revealed an admitted [DATE] and re-admitted [DATE]. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder. Review of the behavior care plan, revised 08/27/24, revealed Resident #78 had a behavior problem related to impulse disorder, dementia, bipolar disorder, verbally aggressive or threatening, touching staff inappropriately, making inappropriate comments, and refusal of care. Interventions included provide medications as ordered (01/06/23), approach and speak in a calm manner (01/06/23), consult behavioral health as needed (01/06/23), communicate with resident regarding behaviors and treatment (01/06/23), encourage resident to express feelings (01/06/23), encourage resident to maintain as much independence and control or decision making as possible (01/06/23), intervene as necessary to protect the rights and safety of others (01/06/23), minimize the potential for disruptive behaviors by offering snacks that divert attention (01/06/23), monitor behavioral episodes and attempt to determine underlying causes (01/06/23), notify medical director of increased behaviors (01/06/23), observe and anticipate resident's needs (01/06/23), praise any indication of progress in behaviors (01/06/23), psychosocial assessment completed (09/19/24), and PTSD screen completed (09/19/24). Review of a nursing note dated 09/19/24 at 2:00 P.M. revealed the nurse practitioner was notified by the Director of Nursing (DON) that Resident #78 had possible contact with chemical to eyes. Another note dated 09/19/24 at 2:00 P.M. revealed the DON notified the Administrator, Regional Director of Operations, and Regional Director of Clinical Services of the incident. A note dated 09/19/24 at 2:28 P.M. revealed the nurse practitioner assessed Resident #78 and noted Resident #78's face and eyes were clear with no redness or swelling noted. Resident #78 denied pain and reported to the nurse practitioner that he had been rubbing his eyes. A note dated 09/19/24 at 3:20 P.M. revealed Resident #78 was assessed to be pleasant without signs of discomfort or distress and there was no redness or irritation to Resident #78's eyes, face, or skin. Review of a facility submitted SRI dated 09/19/24 revealed a chemical made contact with Resident #78's eyes. Further review of the facility's SRI investigation revealed STNA #942 had sprayed oleoresin capsicum (OC) spray (also known as pepper spray) toward Resident #78. Review of facility witness statements revealed Resident #81 witnessed STNA #942 spray Resident #78 with [NAME]. STNA #919's statement indicated STNA #942 told STNA #919 that she sprayed Resident #78 with [NAME] and STNA #919 reported it to the nurse and unit manager immediately. Licensed Practical Nurse (LPN) #941's statement indicated Resident #78's eyes were burning and red and Resident #78 indicated he was sprayed with something. STNA #942's witness statement indicated she was cleaning the unit railings and door handles with a cleaning chemical and Resident #78 got some on his hands and then touched his face. There was no mention of pepper spray or [NAME] in STNA #942's witness statement. Review of Maintenance Director #899's witness statement indicated he was notified of a chemical odor on 09/19/24 at 9:40 A.M., he went to the designated unit, he did not smell anything unusual, and staff on the unit reported the odor was cleaning chemicals. The facility's timeline of their investigation indicated the alleged incident occurred around 10:00 A.M., facility management were not notified of the alleged abuse until 1:55 P.M., and the investigation of the incident began at 1:56 P.M. The facility's timeline further indicated STNA #942 was suspended on 09/19/24 at 2:15 P.M. and LPN #941 was suspended on 09/19/24 at 3:03 P.M. as a result of the incident. Review of the time punch detail for STNA #942 revealed she worked on 09/19/24 from 7:07 A.M. to 2:17 P.M. Review of the time punch detail for LPN #941 revealed she worked on 09/19/24 from 6:03 A.M. to 3:06 P.M. Review of the nurse aide behavior task record for 09/19/24 revealed Resident #78 refused care at 2:06 A.M. and no other behaviors were documented to have occurred. Review of the behavior monitoring report for September 2024 revealed Resident #78 had no documented behaviors on 09/19/24. Review of the police report, dated 09/19/24 at 2:59 P.M., revealed the local police department was contacted by the DON to report Resident #78 got a chemical in his eyes. Review of a second police report, dated 09/20/24 at 7:34 P.M., revealed the local police department was contacted by the DON to report staff to resident abuse and to update that the chemical in Resident #78's eyes was pepper spray. Review of the Post-Traumatic Stress Disorder (PTSD) Assessment, dated 09/20/24, indicated Resident #78 considered the event (that had occurred on 09/19/24) traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. Resident #78 described the event as he got into a heated conversation with staff about the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with pepper spray. Review of the PTSD Assessment, dated 09/21/24, indicated Resident #78 considered the event (that occurred on 09/19/24) traumatic and had been frequently on guard or watchful or easily startled. He described the event as he got into an argument with staff over the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with that spray. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 09/23/24, revealed Resident #78 was rarely or never understood with moderately impaired cognitive skills for daily decision making. The assessment indicated Resident #78 did not have any indicators of psychosis and no physical or verbal behaviors during the seven-day lookback period. Further review of Resident #78's record revealed there was no other documentation regarding the incident prior to the progress note dated 09/19/24 at 2:00 P.M. On 10/16/24 at 9:11 A.M., an interview with LPN Unit Manager #835 revealed Resident #78 could be combative with care sometimes and that his behaviors were not serious enough to cause fear or require restraint. She stated Resident #78 was usually cooperative with care. On 10/16/24 at 11:55 A.M., an interview with the Administrator and DON revealed the Administrator was out of town at the time of the incident and the DON conducted the investigation. The Administrator and DON confirmed STNA #942 sprayed Resident #78 with pepper spray. The Administrator and DON said initially it was reported that Resident #78 got cleaning chemicals in his eyes and further investigation determined that was inaccurate. On 10/16/24 at 2:00 P.M., an interview with Unit Manager #861 stated the management team was sitting in morning meeting around 9:30 A.M. on the day of the incident when one of the managers received a text about someone being maced on the unit and there was an odor. Unit Manager #861 stated maintenance staff went to the unit and the nurse closed the door in his face. Unit Manager #861 asked LPN #941 three times about the reported odor on the unit and LPN #941 told him on the third time, which Unit Manager #861 said was around 12:00 P.M., that it was cleaning chemicals that had been used and since thrown out. Unit Manager #861 said he was not involved in the entire investigation. On 10/16/24 at 2:31 P.M., an attempt was made to contact STNA #942 was unsuccessful. A recorded message indicated the number was out of service. On 10/16/24 at 2:50 P.M., an interview with the Administrator and DON confirmed the facility's timeline for the incident as noted above, including that management staff were not aware of the incident until 09/19/24 at 1:55 P.M. and suspensions were implemented after management staff were notified. On 10/17/24 at 10:49 A.M., an interview with STNA #919 revealed she was assisting another resident with breakfast when she heard a commotion in the hallway. Upon entering the hallway, she noted Resident #78 had an orange residue dripping down his face and STNA #942 told her Resident #78 tried to hit STNA #942 and she maced him. STNA #919 stated she alerted the nurse, Resident #78's eyes were cleaned, and Resident #78 was given a shower to remove the remaining orange residue from his hair and face. STNA #919 said she texted Unit Manager #809 on 09/19/24 at 9:54 A.M. to notify her that Resident #78 had been maced on the unit. Observation of the text conversation at the time of interview confirmed the date and time the text message notification was sent from STNA #919 to Unit Manager #809. On 10/17/24 at 11:27 A.M., an interview with Unit Manager #809 revealed she was in morning meeting when someone reported an odor on the unit. Unit Manager #809 confirmed STNA #919 texted her on 09/19/24 at 9:54 A.M. notifying her that someone had been massed on the unit, STNA #919 then clarified it smelled like bear [NAME], and STNA #919 said Resident #78 needed help. Unit Manager #809 said she asked STNA #919 if the nurse was over there and STNA #919 said she told LPN #941 and LPN #941 was in the office. Unit Manager #809 said she texted LPN #941 on 09/19/24 at 10:34 A.M. to ask if everything was okay and LPN #941 texted back that Resident #78 must have gotten a chemical in his eyes because his eyes were burning, and they flushed his eyes. Unit Manager #809 stated she went to the unit around 11:15 A.M. to assess Resident #78 with no significant findings, there was no odor of [NAME] on the unit, and none of the residents complained of burning sensations or difficulty breathing at that time. Unit Manager #809 further stated that STNA #919 did not approach management staff until later in the day to state what really happened and that's when management began investigating the possibility of [NAME] instead of a cleaning chemical. On 10/22/24 at 1:07 P.M., and interview with LPN #941 revealed Resident #78 got some sort of chemical in his eyes, she assessed him, flushed his eyes, and alerted the unit manager he got a chemical in his eyes and she had flushed them. LPN #941 revealed she had the STNA dispose of the chemical and she denied knowledge of the chemical being [NAME] or pepper spray. LPN #941 revealed later in the day she was suspected pending an investigation and at the time, she didn't have any reason to suspect it was anything other than a cleaning chemical because what is what the STNA reported to her. LPN revealed she was fired for supposedly covering up abuse of a resident but she denies she did this. LPN #941 revealed staff were fearful for their lives because of the dangerous people in the building, and management staff did not care and told staff they couldn't restrain residents or lay a hand on the residents to protect themselves in any way from resident behaviors. LPN #941 reiterated it was dangerous at the facility. Review of the facility's policy titled OHIO Abuse, Neglect & Misappropriation, dated 10/27/21, revealed the facility would prevent abuse, mistreatment, or neglect of residents and provide guidance to staff to manage any concerns or allegations of abuse or neglect. Employees would receive abuse prevention training during orientation, annually, and as needed. Staff would be educated upon hire, annually, and as needed to include reporting allegations of abuse or neglect without fear of reprisal, interventions to deal with aggressive behaviors, and timely reporting of reasonable suspicion of a crime in the facility. Any employee who was alleged or accused of being a party to abuse or neglect would be immediately removed from the area of resident care, interviewed by facility leadership for a written statement, and not left alone. After completing their statement, the employee(s) would be asked to vacate the facility until further investigation of the incident was completed. Appropriate measures would be taken with the employee post investigation including disciplinary action and termination if appropriate. Each occurrence of resident incidents or alleged abuse would be identified and reported to the supervisor for timely investigation. The supervisor or designee would notify the DON and ED of the allegation immediately and the ED would direct the investigation. This deficiency represents non-compliance investigated under Complaint Numbers OH00159114, OH00158216, and OH00158183.

Based on observation and interview, the facility failed to discard expired food items timely and appropriately label or date opened and prepared food items. This had the potential to affect all 166 of 167 resident who received food from the kitchen as Resident #151 received nothing by mouth (NPO). The facility census was 167. Findings include: On [DATE] from 6:45 A.M. to 7:00 A.M., the initial walkthrough of the kitchen revealed the reach-in refrigerator contained the following: - One container of beans that was not labeled or dated. - One container of mayonnaise that was not labeled with the open date. - One container of sour cream with an expiration date of [DATE]. - Three plastic wrapped bundles of sliced cheese that were not labeled or dated. - One bag of lettuce that was not labeled or dated. - One plastic tub containing open packages of hot dogs that was not labeled or dated. - Two small containers of a brown substance that were not labeled or dated. - One container of Dannon Light + Fit vanilla yogurt with an expiration date of [DATE] and writing in black marker indicated the container had been opened on [DATE]. Interview at the time of observation with Culinary Supervisor #818 verified the above observations. Culinary Supervisor #818 stated all staff in the kitchen were responsible for ensuring items were appropriately labeled and dated and to check the expiration date on food items. Culinary Supervisor #818 further stated the expiration date of the yogurt should have been checked before it was opened and served to residents. This deficiency represents non-compliance investigated under Complaint Numbers OH00158037 and OH00158183.

Based on record review, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to remove a perpetrator of abuse from the facility immediately to ensure all residents were protected from further abuse. This affected one resident (#78) and had the potential to affect 22 additional residents (#61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, and #83) who resided on the secured Hickory unit. The facility census was 167. Findings include: Review of the medical record for Resident #78 revealed an admitted [DATE] and re-admitted [DATE]. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder. Review of the facility submitted SRI dated 09/19/24 revealed a chemical made contact with Resident #78's eyes. Further review of the facility's SRI investigation revealed STNA #942 had sprayed oleoresin capsicum (OC) spray (also known as pepper spray) toward Resident #78. Review of the witness statements revealed Resident #81 witnessed STNA #942 spray Resident #78 with [NAME], STNA #919's statement indicated STNA #942 told STNA #919 that she sprayed Resident #78 with [NAME] and STNA #919 reported it to the nurse and unit manager immediately, and Licensed Practical Nurse (LPN) #941's statement indicated Resident #78's eyes were burning and red and Resident #78 indicated he was sprayed with something. The facility's timeline of their investigation indicated the alleged incident occurred around 10:00 A.M., facility management were not notified of the alleged abuse until 1:55 P.M., and the investigation of the incident began at 1:56 P.M. The facility's timeline further indicated STNA #942 was suspended on 09/19/24 at 2:15 P.M. and LPN #941 was suspended on 09/19/24 at 3:03 P.M. Review of the time punch detail for STNA #942 revealed she worked on 09/19/24 from 7:07 A.M. to 2:17 P.M. Review of the time punch detail for LPN #941 revealed she worked on 09/19/24 from 6:03 A.M. to 3:06 P.M. Review of the Post-Traumatic Stress Disorder (PTSD) Assessment, dated 09/20/24, indicated Resident #78 considered the event traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. Resident #78 described the event as he got into a heated conversation with staff about the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with pepper spray. Review of the PTSD Assessment, dated 09/21/24, indicated Resident #78 considered the event traumatic and had been frequently on guard or watchful or easily startled. He described the event as he got into an argument with staff over the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with that spray. On 10/16/24 at 2:00 P.M., an interview with Unit Manager #861 stated the management team was sitting in morning meeting around 9:30 A.M. on the day of the incident when one of the managers received a text about someone being maced on the unit and there was an odor. On 10/16/24 at 2:50 P.M., an interview with the Administrator and DON confirmed the facility's timeline for the incident, including that management staff were not aware of the incident until 09/19/24 at 1:55 P.M. and suspensions were implemented after management staff were notified. On 10/17/24 at 10:49 A.M., an interview with STNA #919 stated she was assisting another resident with breakfast when she heard a commotion in the hallway. Upon entering the hallway, she noted Resident #78 had an orange residue dripping down his face and STNA #942 told her Resident #78 tried to hit STNA #942 and she maced him. STNA #919 stated she alerted the nurse, Resident #78's eyes were cleaned, and Resident #78 was given a shower to remove the remaining orange residue from his hair and face. STNA #919 said she texted Unit Manager #809 on 09/19/24 at 9:54 A.M. to notify her that Resident #78 had been maced on the unit. Observation of the text conversation at the time of interview confirmed the date and time the text message notification was sent from STNA #919 to Unit Manager #809. On 10/17/24 at 11:27 A.M., an interview with Unit Manager #809 confirmed STNA #919 texted her on 09/19/24 at 9:54 A.M. notifying her that someone had been massed on the unit, STNA #919 then clarified it smelled like bear [NAME], and STNA #919 said Resident #78 needed help. Unit Manager #809 said she asked STNA #919 if the nurse was over there and STNA #919 said she told LPN #941 and LPN #941 was in the office. Unit Manager #809 said she texted LPN #941 on 09/19/24 at 10:34 A.M. to ask if everything was okay and LPN #941 texted back that Resident #78 must have gotten a chemical in his eyes because his eyes were burning and they flushed his eyes. Review of a list of residents STNA #942 cared for on 09/19/24 revealed Resident #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, and #83 had the potential to be affected. Review of the facility's policy titled OHIO Abuse, Neglect & Misappropriation, dated 10/27/21, revealed the facility would prevent abuse, mistreatment, or neglect of residents and provide guidance to staff to manage any concerns or allegations of abuse or neglect. Staff would be educated upon hire, annually, and as needed to include reporting allegations of abuse or neglect without fear of reprisal, interventions to deal with aggressive behaviors, and timely reporting of reasonable suspicion of a crime in the facility. Any employee who was alleged or accused of being a party to abuse or neglect would be immediately removed from the area of resident care, interviewed by facility leadership for a written statement, and not left alone. After completing their statement, the employee(s) would be asked to vacate the facility until further investigation of the incident was completed. Appropriate measures would be taken with the employee post investigation including disciplinary action and termination if appropriate. This deficiency represents non-compliance investigated under Complaint Numbers OH00159114, OH00158216, and OH00158183.

Based on observation, record review and interview, the facility failed to appropriately assess and monitor Resident #80's closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. This finding affected one (Resident #80) of three residents reviewed for quality of care. Findings include: Review of Resident #80's hospital progress note prior to facility admission, dated 08/08/24 at 10:36 A.M., revealed the resident had a closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. A closed reduction of the left ankle was completed in the hospital. The left lower extremity was placed in a bulky splint and the toes had minimal edema. Review of Resident #80's medical record revealed the resident was admitted on [DATE] with diagnoses including nondisplaced fracture of the medial malleolus of the left tibia, anemia and schizoaffective disorder bipolar type. Review of Resident #80's Modified Admission Minimum Data Set (MDS) 3.0 Comprehensive assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #80's history and physical form dated 08/10/24 revealed the resident was identified to have a closed left ankle fracture and a first proximal phalanx fracture and was placed in a fixed mobilization. The facility would continue her care as ordered and would work with therapy to improve the resident's function and plan for post-acute care as well. Review of Resident #80's physician orders, medication administration records (MARS) and treatment administration records (TARS) from 08/09/24 to 10/16/24 did not reveal evidence of assessments and monitoring of the closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. A telephone interview on 10/16/24 at 10:56 A.M. with Hospital Scheduling #940 indicated the resident's original orthopedic appointment was on 09/12/24 and the appointment was canceled. Hospital Scheduling #940 stated on 10/01/24 a staff member called in and rescheduled the appointment for 10/31/24. She indicated their office needed the financial information for the resident. Review of Resident #80's physician orders revealed an order dated 10/30/24 for an orthopedic follow-up appointment dated 10/31/24; and an order dated 08/09/24 for a wound consult. Observation on 10/16/24 at 11:27 A.M. with Regional Nurse #938 of Resident #80's bilateral feet revealed the resident had wrapped her right foot in paper products and debris. No wounds were identified on the right foot when the resident removed the dressings. Further observations revealed the resident removed a plastic bag and paper on the left foot. The left foot/leg was wrapped with a soiled ace wrap and underneath of the wrap, the resident had a soft sided cast. The resident's toes appeared within normal limits and no edema or odors were identified. Telephone interview on 10/16/24 at 11:40 A.M. with Nurse Practitioner (NP) #939 indicated she did not follow Resident #80's left lower extremity fracture, and the facility wound nurse as well as the wound NP followed this resident for the left lower extremity. Interview on 10/16/24 at 12:02 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #807 (facility wound nurse) stated the resident was a surgical resident and was not being followed by her or the Wound NP on the left lower extremity fracture. Interview on 10/16/24 at 12:10 P.M. with the Administrator confirmed Resident #80's orthopedic appointment was canceled on 09/12/24 because of insurance issues and the resident was rescheduled for an appointment on 10/31/24 with Medicaid insurance. The Administrator confirmed Resident #80's medical record did not have assessments and monitoring of the closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. Review of the undated Wound Care policy revealed residents/patients admitted with or develop skin integrity issues would receive treatment as indicated based on location, stage and drainage. This deficiency represents non-compliance investigated under Complaint Number OH00158183.

Based on record review, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to ensure staff reported allegations of abuse in a timely manner. This affected one resident (#78) of three reviewed for abuse. The facility census was 167. Findings include: Review of the medical record for Resident #78 revealed an admitted [DATE] and re-admitted [DATE]. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder. Review of the behavior care plan, revised 08/27/24, revealed Resident #78 had a behavior problem related to impulse disorder, dementia, bipolar disorder, verbally aggressive or threatening, touching staff inappropriately, making inappropriate comments, and refusal of care. Interventions included provide medications as ordered (01/06/23), approach and speak in a calm manner (01/06/23), consult behavioral health as needed (01/06/23), communicate with resident regarding behaviors and treatment (01/06/23), encourage resident to express feelings (01/06/23), encourage resident to maintain as much independence and control or decision making as possible (01/06/23), intervene as necessary to protect the rights and safety of others (01/06/23), minimize the potential for disruptive behaviors by offering snacks that divert attention (01/06/23), monitor behavioral episodes and attempt to determine underlying causes (01/06/23), notify medical director of increased behaviors (01/06/23), observe and anticipate resident's needs (01/06/23), praise any indication of progress in behaviors (01/06/23), psychosocial assessment completed (09/19/24), and PTSD screen completed (09/19/24). Review of the facility submitted SRI dated 09/19/24 revealed a chemical made contact with Resident #78's eyes. Further review of the facility's SRI investigation revealed STNA #942 had sprayed oleoresin capsicum (OC) spray (also known as pepper spray) toward Resident #78. Review of the witness statements revealed Resident #81 witnessed STNA #942 spray Resident #78 with [NAME], STNA #919's statement indicated STNA #942 told STNA #919 that she sprayed Resident #78 with [NAME] and STNA #919 reported it to the nurse and unit manager immediately, and Licensed Practical Nurse (LPN) #941's statement indicated Resident #78's eyes were burning and red and Resident #78 indicated he was sprayed with something. The facility's timeline of their investigation indicated the alleged incident occurred around 10:00 A.M., facility management were not notified of the alleged abuse until 1:55 P.M., and the investigation of the incident began at 1:56 P.M. Review of the Post-Traumatic Stress Disorder (PTSD) Assessment, dated 09/20/24, indicated Resident #78 considered the event traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. Resident #78 described the event as he got into a heated conversation with staff about the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with pepper spray. Review of the PTSD Assessment, dated 09/21/24, indicated Resident #78 considered the event traumatic and had been frequently on guard or watchful or easily startled. He described the event as he got into an argument with staff over the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with that spray. On 10/16/24 at 11:55 A.M., an interview with the Administrator and DON stated the Administrator was out of town at the time of the incident and the DON conducted the investigation. The Administrator and DON confirmed STNA #942 sprayed Resident #78 with pepper spray. The Administrator and DON said initially it was reported that Resident #78 got cleaning chemicals in his eyes and further investigation determined that was inaccurate. On 10/16/24 at 2:00 P.M., an interview with Unit Manager #861 stated the management team was sitting in morning meeting around 9:30 A.M. on the day of the incident when one of the managers received a text about someone being maced on the unit and there was an odor. On 10/16/24 at 2:50 P.M., an interview with the Administrator and DON confirmed the facility's timeline for the incident, including that management staff were not aware of the incident until 09/19/24 at 1:55 P.M. On 10/17/24 at 10:49 A.M., an interview with STNA #919 stated she was assisting another resident with breakfast when she heard a commotion in the hallway. Upon entering the hallway, she noted Resident #78 had an orange residue dripping down his face and STNA #942 told her Resident #78 tried to hit STNA #942 and she maced him. STNA #919 stated she alerted the nurse, Resident #78's eyes were cleaned, and Resident #78 was given a shower to remove the remaining orange residue from his hair and face. STNA #919 said she texted Unit Manager #809 on 09/19/24 at 9:54 A.M. to notify her that Resident #78 had been maced on the unit. Observation of the text conversation at the time of interview confirmed the date and time the text message notification was sent from STNA #919 to Unit Manager #809. On 10/17/24 at 11:27 A.M., an interview with Unit Manager #809 stated she was in morning meeting when someone reported an odor on the unit. Unit Manager #809 confirmed STNA #919 texted her on 09/19/24 at 9:54 A.M. notifying her that someone had been massed on the unit, STNA #919 then clarified it smelled like bear [NAME], and STNA #919 said Resident #78 needed help. Unit Manager #809 said she asked STNA #919 if the nurse was over there and STNA #919 said she told LPN #941 and LPN #941 was in the office. Unit Manager #809 said she texted LPN #941 on 09/19/24 at 10:34 A.M. to ask if everything was okay and LPN #941 texted back that Resident #78 must have gotten a chemical in his eyes because his eyes were burning and they flushed his eyes. Unit Manager #809 stated she went to the unit around 11:15 A.M. to assess Resident #78 with no significant findings, there was no odor of [NAME] on the unit, and none of the residents complained of burning sensations or difficulty breathing at that time. Unit Manager #809 further stated that STNA #919 did not approach management staff until later in the day to state what really happened and that's when management began investigating the possibility of [NAME] instead of a cleaning chemical. Review of the facility's policy titled OHIO Abuse, Neglect & Misappropriation, dated 10/27/21, revealed the facility would prevent abuse, mistreatment, or neglect of residents and provide guidance to staff to manage any concerns or allegations of abuse or neglect. Each occurrence of resident incidents or alleged abuse would be identified and reported to the supervisor for timely investigation. The supervisor or designee would notify the DON and ED of the allegation immediately and the ED would direct the investigation. This deficiency represents non-compliance investigated under Complaint Numbers OH00159114, OH00158216, and OH00158183.

Based on observation, interview, record review, and policy review the facility failed to maintain proper infection control techniques during wound care and insulin administration. This affected one (#40) of three residents observed for wound care, one (#165) of one resident observed for insulin administration, and had the potential to affected 52 residents (#2, #11, #12, #19, #21, #22, #26, #27, #35, #40, #46, #55, #56, #59,#62, #64, #69, #72, #73, #81, #83,#87, #91,#98, #102, #103, #106, #110, #111, #112, #115, #120, #122, #123, #126, #128, #129, #131, #134, #137, #140, #141, #142, #147, #149, #151, #153, #156, #157, #165 #166 and #169) residing on the Oak and Walnut halls where Registered Nurses #427 and 304 were providing care. The facility census was 170. Findings include: 1. Review of Resident #40's medical records revealed an admitted [DATE]. Diagnoses included diabetes and non-compliance with medical treatments. Review of Resident #40's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition. Review of Resident #40's care plan dated 09/06/24 revealed Resident #40 required Enhanced Barrier Precautions (EBP) related to a wound. Interventions included to wear appropriate Personal Protective Equipment (PPE) during high contact care. Review of Resident #40's current physician orders for September 2024 revealed Resident #40 required EBP related to wound. Observation on 09/10/24 at 10:28 A.M. revealed a sign posted outside of Resident #40's room that indicated Resident #40 was on (EBP) and an isolation bin with PPE was located outside of Resident #40's room. Interview with Registered Nurse (RN) #427 at the time of observation revealed she believed Resident #40 was no longer on EBP because he had completed his course of antibiotics for an infection in his wound. RN #304 and RN #427 proceeded to enter Resident #40's room without donning PPE. RN #427 placed wound care supplies on Resident #40's bedside table without cleaning the surface of the table or placing a barrier down. RN #427 placed a soiled towel that was on the floor underneath Resident #40's left leg and then using scissors that were removed from her pocket cut the dressing covering Resident #40's wound. RN #304 and RN #427 cleansed Resident #40's wound, and while wearing the soiled gloves RN #427 proceeded to open Resident #40's dresser drawers to look for additional wound care supplies. Without changing gloves or completing hand hygiene the RNs placed a new dressing on Resident #40's wound. RN #427 returned to Resident #40's drawer and obtained a pair or socks and placed them on Resident #40's feet. After completing the wound care RN #304 and RN #427 discarded their gloves and without completing hand hygiene exited the room. Interviews with RN #304 and RN #427 immediately after the observation revealed they did not don PPE prior to entering Resident #40's because they did not believe he required isolation; RN #304 and RN #427 confirmed they had not performed hand hygiene; RN #427 confirmed she placed a soiled towel under Resident #40's leg stating it was already dirty, and RN #427 confirmed she did not clean the surface of the table or disinfect the scissors she removed from her pocket stating she was not aware that was a required. Immediately after interviewing RNs #304 and #427, Unit Manager LPN #326 and Wound Care Nurse LPN #352 asked how Resident #40's dressing change went they were made aware of the observations. LPNs #326 and #352 confirmed Resident #40 was currently on EBP and staff were required to wear PPE prior to providing care. Review of facility policy titled Enhanced Barrier Precautions undated, revealed EBP was indicated for residents with wounds and staff were to don PPE when providing high contact care activities. 2. Review of Resident #165's medical records revealed an admitted [DATE]. Diagnoses included diabetes, developmental delays and schizophrenia. Review of Resident #165's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 had intact cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of Resident #165's current physician orders for September 2024 revealed Resident #165 was ordered Fiasp (fast acting insulin) 15 units before meals. Observation of medication administration on 09/10/24 at 7:56 A.M. for Resident #165 with Registered Nurse (RN) #427 revealed RN #427 checked Resident #165's blood sugar. RN #427 then obtained Resident #165's Fiasp insulin pen and dialed in 12 units and administered the insulin to Resident #165. RN #165 did not wear gloves while obtaining the blood sugar or while preparing or administering the insulin, nor did RN #165 complete hand hygiene after completion of the tasks. Interview with RN #427 at time of observation confirmed she did not wear gloves while obtaining the blood sample and completing the blood sugar check or while administering Resident #165's insulin. RN #427 stated she was unaware she was required to wear gloves during these tasks. RN #427 stated she should have performed hand hygiene after completion of blood sugar check and insulin administration. Review of facility's undated policy titled Medication Administration revealed staff were to perform appropriate hand hygiene before and after each residents' medication was administered. This deficiency represents non-compliance investigated under Complaint Number OH00157390 and OH00157395.

Based on observation, interview, record review, and policy review the facility failed to ensure Resident #165's diabetes was managed appropriately by ensuring insulin was administered according to physician orders. This affected one (#165) of four residents observed for medication administration. The facility census was 170. Findings include: Review of Resident #165's medical records revealed an admitted [DATE]. Diagnoses included diabetes, developmental delays and schizophrenia. Review of Resident #165's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 had intact cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of Resident #165's current physician orders for September 2024 revealed Resident #165 was ordered Fiasp (fast acting insulin) 15 units before meals. Observation of medication administration on 09/10/24 at 7:56 A.M. for Resident #165 with Registered Nurse (RN) #427 revealed RN obtained Resident #165's insulin pen and the packaging indicated to administer 12 units. RN #427 removed the Fiasp out of the package and dialed in the dosage of the insulin to be administered. Observation of the pen revealed the dosage was dialed to deliver 18 units. RN #427 took the pen back and stated Oh I was only supposed to draw up 12 units. RN #427 then dialed in 12 units of Fiasp and administered the Fiasp. Interview on 09/10/24 at 1:08 P.M. with the Director of Nursing (DON) confirmed Resident #165's physician orders were to administer 15 units of Fiasp. Review of facility policy titled Medication Administration undated revealed to administer medications only as prescribed by the provider. This deficiency represents non-compliance investigated under Complaint Number OH00157395.

Based on observations, record review, facility investigation review, police report review, facility policy review, review of weather information from www.wunderground.com and interviews, the facility failed to maintain a safe environment and provide necessary supervision to prevent Resident #158, who had diagnoses including schizoaffective disorder, auditory hallucinations, dementia with other behavioral disturbance, homicidal ideations and delusional disorder from eloping from the facility. This resulted Immediate Jeopardy and the potential for actual harm on 07/14/24 when Resident #158 exited the facility without staff knowledge after State tested Nursing Assistant (STNA) #356 propped the back (locked) door of the secured Buckeye unit open with a wet floor sign. Resident #158 was subsequently located at her father's house in a city approximately 16 miles away from the facility on 07/15/24 around 8:00 A.M. after Family Member (FM) #474 called the facility asking where Resident #158 was and informed Receptionist #451 that Resident #158 was at his home, not at the facility. FM #474 reported the resident had been at his home since 07/15/24 at 4:00 A.M. This affected one resident (#158) of three residents reviewed for elopement. The facility identified 38 residents at risk for elopement (Residents #3, #17, #19, #39, #41, #42, #43, #44, #48, #54, #55, #66, #67, #73, #75, #77, #82, #87, #91, #92, #101, #105, #109, #110, #122, #134, #141, #144, #147, #150, #151, #156, #157, #158, #160, #162, #163 and #167). The facility census was 161 residents. On 08/01/24 at 2:37 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #475 were notified Immediate Jeopardy began on 07/14/24 when Resident #158, who had a legal guardian and was care-planned as an elopement risk, left the facility unauthorized and without staff knowledge after STNA #356 had placed a wet floor sign in the secured door in the back of the Buckeye unit, rendering it unsecured and accessible to residents. On night shift on 07/14/24, STNA #337 and Licensed Practical Nurse (LPN) #432 did not conduct complete rounding and were unaware Resident #158 had exited the facility. On day shift on 07/15/24, STNA #341, STNA #357 and LPN #431 failed to conduct timely and complete rounding and were unaware Resident #158 had exited the facility until 07/15/24 at approximately 7:45 A.M. when STNA #341 went into Resident #158's room to deliver her breakfast tray and discovered Resident #158 was not there. The facility was unaware of Resident #158's whereabouts until 07/15/24 at 8:00 A.M. when FM #474 called the facility asking where Resident #158 was, and informed Receptionist #451 that Resident #158 was at his home 16 miles away and had been there since 4:00 A.M. that morning. Resident #158 was returned to the facility by the police. The Immediate Jeopardy was removed on 08/02/24 when the facility implemented the following corrective actions: On 07/15/24 at 7:55 A.M. LPN/Unit Manager (UM) #466, LPN/UM #464, LPN/UM #465 and RN/UM #467 completed whole house head count. All residents were accounted for except for Resident #158. On 07/15/24 at 9:45 A.M. Resident #158 returned to facility with police. Full head to toe assessment and Wandering Observation Tool completed by RN/UM #467. No injuries noted on assessment. Brief Interview for Mental Status (BIMS) completed by Minimum Data Set (MDS)/LPN #439. On 07/15/24 at 9:45 A.M. LPN/Assistant Director of Nursing (ADON)/Risk #469/Designee conducted staff interviews. Staff interviews determined STNA #356 had been responsible for propping open a door on the Buckeye Unit. STNA #356 was immediately suspended by Administrator and was subsequently terminated from employment on 07/25/24. On 07/15/24 at 9:50 A.M. Maintenance Technician (MT) #436 assessed all coded doors to ensure they were working properly and there were no items in them to prohibit proper locking. On 07/15/24 at 11:12 A.M. LPN/ADON/Risk #469 notified Medical Director (MD) #470 of Resident #158's return. MD #470 requested Resident #158 be seen at hospital for further evaluation. Non-emergent transportation requested. On 07/15/24 at 12:00 P.M. the DON/Designee implemented daily audits for resident counts, shift change reports, and removal of items used to prop doors once per week for four weeks, then randomly thereafter. Night shift supervisors LPN #435, LPN #413 or Designee to audit using midnight census, rounding on residents and doors daily for four weeks, then randomly thereafter. All findings would be reported to the Quality Assurance Committee. DON/Designee to audit night shift randomly for three months. On 07/15/24 at 12:30 P.M. Social Service Designee (SSD) #457 spoke with Resident #158 finding that she believed everything was ok, she feels safe and remains at baseline. SSD #457 followed up on 07/16/24 to offer support. Licensed Social Worker (LSW) #410 and in house counseling services to continue offering support to Resident #158 as needed. On 07/15/24 at 12:45 P.M. RN/UM #467 made Psychiatrist #476 aware of Resident #158's elopement. Psychiatrist #476 made medication adjustments for Resident #158. Psychiatrist #476 to continue following Resident #158 as needed. On 07/15/24 the DON/Designee educated all staff regarding elopement prevention and management, emergency door use, not propping doors open, as well as nurse shift change and walking rounds procedures. Education completed same day. All staff not scheduled during education were educated via telephone. On 07/15/24 door vendors called to building to inspect doors. On 07/15/24 Elopement drills completed on day and night shift by DON/Designee. Drills to capture 6:00 A.M. to 2:00 P.M. shift completed 08/02/24 by LPN/UM #465. On 07/15/24 DON/Designee reviewed all facility elopement books. Elopement books included a list of residents at risk for elopement, the face sheets, photos, contact information, diagnosis, of all residents at risk. There was an elopement binder at each nurse's station on the first and the second floor as well as the front receptionist's desk. On 07/15/24 DON/Designee assessed all residents for elopement risk. Beginning on 07/15/24 night shift supervisors LPN #435, LPN #413 or Designee to complete head count daily on night shift using midnight census report and this would be ongoing. This was to be signed and documented on the midnight census report generated in Point Click Care (electronic medical record). Interview on 07/30/24 at 1:53 P.M. with STNA #367 revealed she was aware of Resident #158's elopement from the facility but was not physically present that date. STNA #367 was asked if STNA #357 was available for interview, and she reported STNA #357 had left for the day already before shift change at 2:00 P.M. Interview on 07/31/24 at 5:48 A.M. with STNA #337 indicated nothing different was occurring with staff at shift change since Resident #158 eloped from the facility. Interview on 08/01/24 at 7:38 A.M. with STNA #341 also indicated the facility was not auditing staff at shift change to ensure staff did not leave before the on-coming shift arrived and there remained no STNA to STNA report since Resident #158 eloped from the facility. On 08/02/24 DON/Designee re-assessed Resident #158 for elopement risk and reviewed the resident's care plan to provide structured activities, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas (safe and highly visible areas). On 08/02/24 DON/Designee re-reviewed all residents' elopement risk assessments with no changes. On 08/02/24 DON/Designee re-educated all staff regarding elopement prevention/management, emergency door use, not propping doors open, as well as nurse shift change and walking rounds procedures. The facility implemented a plan for the DON/Designee to audit resident counts at shift change log on locked units weekly for four weeks then randomly thereafter. Unit Managers (LPN/UM #466, LPN/UM #464, LPN/UM #465 and RN/UM #467) and Night shift supervisors (LPN #435 and LPN #413) or Designee to audit walking rounds weekly for four weeks then randomly thereafter. Walking rounds and door check logs to be placed on all units and these would be audited by the DON/Designee weekly for four weeks. The facility implemented a plan for the Administrator/Designee to audit all coded doors to ensure they were latched and had no props in or near them weekly for four weeks then randomly thereafter. The facility implemented a plan for the Administrator to monitor compliance in monthly Quality Assurance Performance Improvement meetings for three months then as needed until compliance was maintained. On 08/05/24 from 1:40 P.M. to 2:00 P.M. interviews with LPN #425, RN #390, STNA #353 and STNA #319 confirmed they received education regarding elopement, not propping emergency doors open, emergency door use, nurse shift changes and walking rounds procedures. Although the Immediate Jeopardy was removed on 08/02/24 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 monitoring to ensure continued compliance. Findings include: Review of Resident #158's medical record revealed an admitted [DATE] with diagnoses including obsessive-compulsive personality disorder, schizoaffective disorder-bipolar type, polydipsia, attention-deficit hyperactivity disorder, auditory hallucinations, dementia with other behavioral disturbance, generalized anxiety disorder, delusional disorders, other psychoactive substance abuse in remission and homicidal ideations. Record review revealed Resident #158 had a legal guardian, identified as Legal Guardian (LG) #472. Review of a historical social service note dated 01/23/23 revealed Resident #158 lived at a group home prior to nursing home stay and was homicidal at that time. She was not following any of the rules at the group [NAME] and was using a family member's money to use Uber and not let anyone know where she was going. Resident #158 was not safe in the community. Resident #158 was incompetent with a guardian and the guardian reported the plan was for Resident #158 to be placed permanently. Review of a court order dated 01/26/23 revealed Resident #158's guardianship was to continue as FM #474 enabled her harmful behavior. FM #474 would give Resident #158 large sums of money and a cell phone and Resident #158 would use these items to purchase such things as Uber (rideshare service) rides to spend time at a homeless shelter in Cleveland and Amazon orders of food, drink and dietary supplements. A crack pipe was found in her room at her previous group residence after one such visit. Due to her diagnosis of psychogenic polydipsia her nutrition intake must be closely monitored. Resident #158 continued to require LG #472 as her insight and judgement was severely impaired due to her mental illness, her insight and judgement were too limited due to psychosis to make decisions and Resident #158 remained detached from reality and unable to make reasoned decisions. The order found it was in Resident #158's best interests to not be allowed to visit FM #474 and FM #474 could only have contact with Resident #158 via phone going forward. Review of historical wandering observation tools for Resident #158 dated 06/08/23 and 02/15/24 indicated Resident #158 had a history of elopement and was at risk for elopement. Review of a historical nurse practitioner note dated 09/27/23 revealed Resident #158 remained on the locked unit for safety of potential elopement. Review of a historical social service note dated 02/05/24 revealed Resident #158 continued to have behaviors on the behavior unit, was delusional and was not appropriate to be moved off of the locked unit. Doctors recommend no discharge for resident, and she needed continued placement on the locked unit. Failed attempts in the community due to her non-compliance make her unsafe and she already has a guardian in place. Review of Resident #158's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #158 had moderate cognitive impairment, experienced delusions, displayed other behavioral symptoms not directed towards others one to three days in the seven-day look-back period and wandered one to three days in the seven-day look-back period. Resident #158 required set up assistance for most activities of daily living, supervision or touching assistance for bathing/showering and required supervision for ambulation. Review of Resident #158's physician's orders revealed an order dated 01/04/24 for Haloperidol (antipsychotic medication) oral tablet 5 milligrams (mg) give three tablets by mouth at bedtime for schizophrenia; an order dated 02/15/23 for Depakote (anticonvulsant medication) oral tablet delayed release 250 mg give 250 mg by mouth three times a day for mood; an order dated 06/26/23 for Invega (antipsychotic medication) oral tablet extended release 24 hour 3 mg give 3 mg by mouth in the morning for schizoaffective disorder bipolar type; an order dated 10/23/23 for Propranolol Hydrochloride (beta blocker medication) tablet 20 mg give one tablet by mouth every morning and at bedtime for anxiety; an order dated 07/11/24 for secured unit placement due to need for decreased stimuli and controlled environment and an order dated 07/16/24 for Invega Sustenna intramuscular suspension pre-filled syringe 234 mg inject 234 mg intramuscularly every day shift every four weeks on Tuesday for schizoaffective disorder bipolar type. Review of Resident #158's wandering observation tool dated 04/23/34 and completed by RN/UM #467 revealed Resident #158 was not identified as a risk for elopement at the time of this assessment. Review of the next available wandering observation tool dated 07/15/24 and completed by RN/UM #467 revealed Resident #158 was identified at risk for elopement. Review of Resident #158's care plan (dated 01/04/23) revealed Resident #158 required a secured unit due to schizophrenia diagnosis. Listed interventions also dated 01/04/23 included provide diversionary activities as needed and redirect as appropriate. Review of Resident #158's care plan (dated 01/09/23) revealed Resident #158 was an elopement risk. Listed interventions dated 01/09/23 included: assess for hunger, thirst, ambulation and toileting needs; complete wandering evaluation upon admission, re-admission, quarterly and as-needed (PRN); educate resident/resident representative of the need for secured unit/device to maintain resident safety; evaluate for need of secured unit, notify medical provider as needed; notify medical provider, resident representative of behavior changes; notify staff of elopement risk; and obtain a current photograph and list of identifiable characteristics and place in the elopement risk identification book. An additional intervention dated 07/17/24 instructed staff to provide diversionary activities as needed and redirect when appropriate. Review of an incident log from May 2024 through July 2024 revealed Resident #158 had an elopement incident on 07/15/24 at 7:55 A.M. Review of a late entry nurse's note dated 07/15/24 at 9:45 A.M. and authored by RN/UM #467 on 07/16/24 revealed Resident #158 returned to facility at this time, full head to toe assessment completed, no skin impairments noted. Guardian notified of Resident #158's return. Review of historical weather data from www.wunderground.com revealed on 07/14/24 the high temperature was 87 degrees Fahrenheit (F) with a low temperature of 68 degrees F and on 07/15/24, the high temperature was 88 degrees F with a low temperature of 70 degrees F. Review of the facility's investigation regarding Resident #158's elopement revealed a root cause analysis meeting was conducted on 07/15/24 with the Administrator, DON, ADON/LPN/Risk #469, LPN/UM #464, LPN/UM #465 and RN/UM #467. The investigation revealed at approximately 1:00 A.M. Resident #158 left the facility unauthorized using an emergency exit door that was propped open by staff. The investigation documented Resident #158 walked to the Speedway gas station in Fairlawn and from there, called for a ride to FM #474's house in [NAME] (approximately 16 miles away). Resident #158 arrived at FM #474's house at approximately 4:00 A.M. FM #474 immediately called the facility and the police to notify them of Resident #158's whereabouts. Staff called a Code [NAME] (missing person) prior to FM #474 calling the facility. Contributing factors to the elopement included nurses and STNAs not completing rounds upon shift change. Review of a witness statement dated 07/15/24 and completed by the Administrator and the DON for FM #474 included the following information: Resident #158 walked out [of the facility], walked down the street (not named) and then somebody somewhere gave her a ride and dropped her off down the street (not named) then Resident #158 was walking on my door. Somebody (not named) picked her up from the gas station in Fairlawn Resident #158 called me from the gas station (time not given). Resident #158 arrived at my house at approximately 4:00 A.M. and she was happy and glad to be here and to see me. I tried calling the facility and police almost immediately. I tried calling the facility multiple times and it rang and rang. Resident #158 said she does not want to be at the facility and she wants to come home as she is confined to a small area and she wants to go out and participate in activities. Review of a witness statement dated 07/15/24 and completed by LPN/ADON/Risk #469 for Resident #158 included the following information: I wanted to see FM #474 because he doesn't eat home cooked meals and I worry about him. I want to go somewhere where I can lay out in the sun and not pace all day. Review of a witness statement dated 07/15/24 and authored by RN/UM #467 included the following information: I asked Resident #158 what she did while she was at FM #474's house and how she got there. Resident #158 stated she walked to FM #474's house. Review of a witness statement dated 07/15/24 and authored by STNA #341 included the following information: I got here at 6:30 A.M. and I got Resident #106 washed and dressed. My co-worker (not named) was getting Resident #14 washed and dressed. Breakfast trays came and we checked Resident #158's room and she was not there. Nursing was notified and a Code [NAME] was called. Review of a witness statement dated 07/15/24 and authored by Receptionist #451 included the following information: Call received from FM #474 at approximately 8:00 A.M. to 8:05 A.M. FM #474 asked where Resident #158 was at and I told him she was on her hall. FM #474 stated no, Resident #158 wasn't as she was at his home. FM #474 stated Resident #158 arrived around 4:00 A.M. and he had tried calling here, the DON and the police. FM #474 also stated that the door [on the Buckeye unit] was propped open. Review of a witness statement dated 07/15/24 and authored by LPN #471 included the following information: At 7:55 A.M. Buckeye nurse (not named) came to me and stated Resident #158 was missing. I immediately did a hall check, looked in all opened and unlocked doors and Resident #158 was not found. I called a Code Green, staff responded and a search was started. Receptionist #451 came back at 8:00 A.M. and said FM #474 just called and Resident #158 was at his house since 4:00 A.M. Code [NAME] was canceled and LG #472 was notified. Review of a witness statement dated 07/15/24 and authored by STNA #357 included the following information: I came in at 6:20 A.M., I checked the rooms and Resident #158 was not in her bed but the bathroom door was closed so I assumed she was using the bathroom. About an hour later we were passing breakfast trays and noticed Resident #158 was missing. Review of a witness statement dated 07/15/24 and authored by LPN #432 included the following information: I came in at 6:00 P.M. for my shift (6:00 P.M. to 6:30 A.M.). I passed before bed (HS) medications on the unit and Resident #158 was present. When I came back to Buckeye at approximately 12:00 A.M. the aide (not identified) was having a conversation with Resident #158 about the time and encouraging Resident #158 to try to go to sleep. That was the last time I had physically seen Resident #158. A text-message screen shot from LPN #432 dated 07/15/24 at 6:09 P.M. revealed the following information: I had heard a conversation with STNA #356 from Buckeye hall admitting to propping the door open with a wet floor sign as STNA #356 stated it was too hot and muggy in the dining room. STNA #356 also stated she was not owning up to it as she would get fired if she did. Review of a witness statement dated 07/15/24 and authored by LPN #413 included the following information: I did not know Resident #158 was missing. I never knew the door at the back of the unit was propped open. Review of a witness statement dated 07/19/24 and authored by LPN #413 included the following information: I was told by STNA #356 that she accidentally left the door open. Review of a text-message screenshot between the Administrator and STNA #356 on 07/19/24 revealed STNA #356 would not provide a statement. Review of a witness statement dated 07/15/24 and authored by LPN #431 included the following information: Average morning, nothing reported to me during shift change. Rounds made around 8:00 A.M. and noticed Resident #158 was not in her room. Complete check of the hall was done when we (not specified) noticed the back door was propped open with a wet floor sign. This was reported. Review of a [NAME] police report dated 07/15/24 at 8:35 A.M. revealed a call placed from RN/UM #467 regarding Resident #158 who was at FM #474's house but was supposed to be at the facility but had escaped. Resident #158 had a legal guardian identified as LG #472. Dispatch personnel had reached out to FM #474 who indicated Resident #158 was wearing a blue dress and had left his home but FM #474 was not sure where. LG #472 believed Resident #158 may have enough money to have gotten an Uber to leave the area. There is a history of FM #474 giving Resident #158 money as well as Resident #158 taking an Uber to Cleveland for a purchase. Resident #158 was with RN/UM #467 in the facility at 9:52 A.M. Review of STNA #356's personnel file revealed a date of hire dated 03/06/23. STNA #356's employment was terminated with the facility on 07/25/24 due to failure to cooperate with an investigation related to a serious resident incident. Interview on 07/29/24 at 3:56 P.M. with LPN #431 revealed on 07/15/24 she arrived at the facility to start her shift at 6:00 A.M. and received shift report from LPN #432 but nothing out of the ordinary had been reported to her. As Buckeye was her normal hall, she knew who to get up and reported that Resident #158 and her roommates all slept in, so she did not check on them. Between 7:45 A.M. and 8:00 A.M. she was in the dining room and the STNA (name not known) went to take Resident #158 her breakfast tray and Resident #158 was not there. LPN #431 acknowledged at this point she had not done rounds during her shift which had started at 6:00 A.M. LPN #431 stated a head count was done and only Resident #158 was missing. It was discovered at this time a folded up wet floor sign was propping the back door of the Buckeye unit open. LPN #431 stated she contacted LPN #471, and a Code [NAME] was called. Interview on 07/29/24 at 4:15 P.M. with Resident #158 revealed she was missing a book. This surveyor asked Resident #158 if she ever left the facility. Resident #158 stated yes, she left as the door was open and had left the facility between 10:30 P.M. to 11:00 P.M. but was unable to provide a date. Resident #158 said she went to [NAME] and had walked this way (pointed) then that way (pointed). Resident #158 stated the door had been left open two times but was unable to elaborate further. Interviews were attempted with STNA #356 on 07/30/24 at 11:37 A.M., 07/30/24 at 11:55 A.M. and 07/31/24 at 8:59 A.M. but were unsuccessful. Interview on 07/30/24 at 12:43 P.M. with LG #472 revealed she had been Resident #158's guardian for about two years. LG #472 stated FM #474 was to have no physical contact with Resident #158, but they were allowed to talk on the phone. LG #472 explained Resident #158 had psychogenic polydipsia and would drink fluids in excess and make herself sick so her fluid intake had to be monitored but FM #474 did not understand this and instead would give her drinks or money to buy drinks. LG #472 stated she was made aware of Resident #158's elopement from the facility and shared she was aware someone had left a wet floor sign in the secured door at the back of the unit and Resident #158 had observed people coming in and out of that door and had gotten out of the facility through that door sometime after 11:00 P.M. on 07/14/24. LG #472 stated Resident #158 told her and Resident #158's mother that she walked to [NAME] then a friend (not named) came to get her. LG #472 stated at the meeting with the facility, Resident #158 reported to them she had hitchhiked to [NAME]. LG #472 shared Resident #158 had a history of using Uber to go to Cleveland and reiterated Resident #158 required supervision and could not be out in the community alone. LG #472 shared at the meeting with the facility, a wander guard (device that would automatically lock doors upon approach) was discussed to be used for three or four weeks but stated she was unaware this had not been put in place for Resident #158. (Record review revealed no physician order for a wander guard device was noted and the resident resided on a unit that was not equipped with the wander guard system). Interview on 07/30/24 at 1:27 P.M. with LPN #471 revealed on 07/15/24, LPN #431 told her at 7:55 A.M. that Resident #158 was missing. They did a head count, and a Code [NAME] was called. While responding to the Code Green, Receptionist #451 came back to the unit to report FM #474 had just called the facility and told them Resident #158 had been at his house since 4:00 A.M. LPN #471 stated they cleared the code and did a facility-wide head count before working on obtaining witness statements from staff. LPN #471 shared Resident #158 was not an elopement risk for nursing but would not be safe outside of the facility as she had poor coping and decision-making skills and would not take her medications. LPN #471 revealed Resident #158 was independent with most of her activities of daily living and worked with therapy to do laundry for herself. Interview on 07/30/24 at 3:34 P.M. with LSW #410 revealed SSD #457 previously addressed any social service needs for Resident #158's unit but he no longer worked for the facility. LSW #410 explained the facility had three secured units: Buckeye and Hickory were on the first floor and were for behavioral management and Birch was on the second floor and was for dementia management. LSW #410 indicated a resident with elopement risk could reside on any of the three secured units. LSW #410 indicated nursing would decide if a resident required a wander guard. LSW #410 shared she had only limited interactions with Resident #158 but reported Resident #158 had a (legal) guardian, made a lot of delusional statements and was currently an elopement risk at the facility. Interviews were attempted with SSD #457 on 07/30/24 at 3:49 P.M. and 07/31/24 at 9:01 A.M. but were unsuccessful. Interview on 07/30/24 at 3:53 P.M. with Receptionist #451 revealed on 07/15/24 sometime between 8:00 A.M. and 8:30 A.M. FM #474 called and asked her where Resident #158 was. Receptionist #451 stated she told FM #474 that Resident #158 was on her unit and then FM #474 reported Resident #158 was at FM #474's house and had been there since 4:00 A.M. Interview on 07/31/24 at 5:04 P.M. with LPN #432 revealed Resident #158 was currently an elopement risk but was not at risk before. LPN #432 stated she worked the night shift starting on 07/14/24 at 6:00 P.M. and did before bed medication administration around 8:00 P.M. LPN #432 stated she last saw Resident #158 around 11:00 P.M. with STNA #337 and Resident #158 wanted coffee and STNA #337 was encouraging her to try to lay down. LPN #432 reported she rounded on the halls at 1:00 A.M., 3:00 A.M. and 5:00 A.M. but indicated she did not look in Resident #158's room at those times. LPN #432 explained there were certain residents who were an elopement risk, and those rooms were specifically checked during rounds. LPN #432 stated she completed shift report with LPN #431 and left the faciity on [DATE] around 6:30 A.M. but got a call around 8:00 A.M. from LPN #431 asking her where Resident #158 was and that was how she learned Resident #158 had left the facility. LPN #432 stated STNA #356 had worked until 10:00 P.M. on 07/14/24 and knew the back door code but she herself did not know that code. LPN #432 stated she went to school with LPN #431 and LPN #413 and LPN #413 had called STNA #356 to ask her about the back door and STNA #356 had admitted she had left the back door popped open but was concerned about losing her job. Interview on 07/31/24 at 5:48 A.M. with STNA #337 revealed she worked on 07/14/24 from 10:00 P.M. to 6:00 A.M. with LPN #432 and last saw Resident #158 on 07/15/24 around 1:00 A.M. when she asked for coffee. STNA #337 stated she did not check on Resident #158 at all after that time and left at the end of her shift around a little after 6:00 A.M. STNA #337 stated she was made aware the door to the unit had been propped open all night when LPN/ADON/Risk #469 called her later that morning but had not noticed this while on the unit. Interview on 07/31/24 at 8:06 A.M. with STNA #357 revealed she came in to work on 07/15/24 at 6:20 A.M. and was running behind but did her hall check around 6:40 A.M. When asked to elaborate what a hall check entailed, STNA #357 stated this was when she checked all the rooms on the hall to make sure all the residents were present and breathing. STNA #357 stated she went into Resident #158's room and noticed Resident #158 was not in her bed but the light was on in the bathroom and the door was shut so she assumed Resident #158 was in the bathroom. Around 8:00 A.M. they were passing breakfast trays, and it was at that point she realized Resident #158 was not in her room and stated she told LPN #431. STNA #437 reported Resident #158 told staff she left the faciity on [DATE] between 11:00 P.M. and 12:00 A.M. STNA #437 stated she did not think Resident #158 was an elopement risk prior to this event and stated staff would tell her who was at risk for elopement in addition to looking at the elopement book. Interviews were attempted with FM #474 on 07/31/24 at 8:23 A.M. and 07/31/24 at 11:16 A.M. but were unsuccessful. Interview on 07/31/24 at 9:38 A.M. with LPN #413 revealed she worked the night shift as a supervisor on 07/14/24 from 6:00 P.M. to 07/15/24 until 6:30 A.M. and shared she checked each unit that evening and they were fine, nothing out of the ordinary had occurred on night shift. LPN #413 explained the expectation was staff were to round every two hours on residents, but stated this process was not documented. Later that morning between 8:30 A.M. and 9:00 A.M. she was on her way to school and LPN #431 called her to ask if she knew Resident #158 was missing which she stated she did not. LPN #413 stated she did not know the code to the back door, but supervisors had a sheet with the door codes on them. LPN #413 stated she knew her staff and STNA #337 did not know the code so she called STNA #356 and STNA #356 confirmed to her that she had left the door open but would not divulge how long the door had been propped open for. LPN #413 stated Resident #158 was an elopement risk and there was a book at the nurses' station which listed residents at risk for [TRUNCATED]

Based on record review, self-reported incident (SRI) review, review of a police report, personnel file review, facility policy review and interviews, the facility failed to ensure Resident #161 was free from staff to resident physical abuse. This resulted in Immediate Jeopardy, the potential for actual physical harm and actual psychosocial harm on 07/24/24 at approximately 10:40 A.M. when Activity Aide (AA) #307 physically abused Resident #161 by jumping on and punching the resident after the resident hit AA #307 with his cane. Staff in the area told AA #307 to back away from Resident #161 but she did not. AA #307 then had to be restrained by Maintenance Technician (MT) #438 as she continued to kick and further assault Resident #161. Interview with Resident #161 on 07/30/24 at 4:18 P.M. revealed he did not feel safe at the facility due to the incident. This affected one resident (#161) of four residents reviewed for abuse and neglect. The facility census was 161 residents. On 08/01/24 at 2:37 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #475 were notified Immediate Jeopardy began on 07/24/24 at approximately 10:40 A.M. when AA #307 physically abused Resident #161, resulting in the potential for actual physical harm/injury and psychological harm. The Immediate Jeopardy was removed on 08/01/24 when the facility implemented the following corrective actions: On 07/24/24 at 10:30 A.M. AA #307 was witnessed in altercation with Resident #161. On 07/24/24 at 10:30 A.M. AA #307 was immediately removed from the building by witnessing staff member MT #438. On 07/24/24 at 10:37 A.M. Admissions Coordinator (AC) #309 called police and emergency medical services (EMS). On 07/24/24 at 10:44 A.M. EMS were on-site and assessed Resident #161, found no (physical) injury. No transfer to hospital required. On 07/24/24 at 10:45 A.M. Licensed Practical Nurse (LPN) #423 completed skin and pain assessments on Resident #161 and initiated neurological assessments. Neurological checks continued through 07/29/24 with no negative findings. Resident #161 found to be at baseline. Physician and Resident Representative notified of incident by LPN)/Assistant Director of Nursing (ADON)/Risk #469. On 07/24/24 at 10:49 A.M. police were on-site conducting staff interviews with the Administrator. On 07/24/24 at 11:30 A.M. the Administrator/Designee began all staff abuse/reporting education. Education completed same day. On 07/24/24 at 1130 A.M. LPN/Unit Manager (UM) #466, LPN/UM #464, LPN/UM#465, and RN/UM #467 interviewed all residents using the Centers for Medicare and Medicaid Quality Indicator Survey abuse tool to identify any additional concerns. On 07/24/24 at 12:06 P.M. the Administrator initiated a self-reported incident (SRI) related to the staff to resident abuse situation. On 07/24/24 (no time) the Administrator added Abuse Quality Assurance to Quality Assurance Performance Improvement (QAPI) process for July 2024. On 07/25/24 (no time) the police filed assault charges against AA #307. On 07/25/24 the Administrator notified AA #307 of termination of employment. On 07/25/24, 07/26/24 and 07/29/24 Licensed Social Worker (LSW) #410 followed up with Resident #161 for concerns regarding incident. LSW #410 to continue offering support to Resident #161 until Resident #161 feels safe. On 07/31/24 Resident #161 had a weekly skin check done and no new areas noted. Re-assessment on 08/02/24 revealed no new concerns. On 08/01/24, Resident #161 received counseling from in-house service. Counseling service to continue offering support to Resident #161 until Resident #161 felt safe. On 08/01/24 RDCO/RN #475 educated the DON and Administrator using Relias Handling Aggressive Behaviors with exit quiz for competency. On 08/01/24 the DON/designee provided Relias Handling Aggressive Behaviors education with exit quiz to demonstrate competency for all staff. (This training was initiated as a result of the facility's identification that the lack of behavioral health training likely contributed to the incident of staff to resident abuse involving Resident #161.) Education completed same day. Staff on vacation or leave to complete on return. At this time, two staff members were on leave and would receive this education upon return. On 08/02/24 the DON/Designee interviewed all residents, then would continue interviews with five residents weekly for four weeks regarding any abuse concerns. This would then continue randomly thereafter until compliance was confirmed. Starting on 08/02/24 Administrator/Designee would interview five staff members weekly for four weeks for any abuse concerns. This would then continue randomly thereafter until compliance was confirmed. Starting on 08/02/24 Administrator/Designee to audit five staff members weekly for four weeks for competency listing the warning signs of aggression and identifying ways to prevent and manage aggressive behaviors. On 08/02/24 the Psychiatrist #476 assessed Resident #161, who remained at baseline. On 08/02/24 the DON/Designee interviewed all residents for any abuse concerns. All non-interviewable residents received skin assessment. The facility implemented a plan for reported incidents to be reviewed by DON/Designee within 24 hours to ensure no other residents were affected. DON/Designee to address issues with reported incidents immediately upon identification. On 08/02/24, the DON/designee would re-educate facility staff on the abuse and neglect policy which would include: (a) What constitutes abuse and types of abuse and neglect; (b) Identification of signs and symptoms in residents and staff of potential abuse and abusers; (c) Actions to take when abuse is witnessed, suspected, or alleged; (d) Timely and appropriate reporting of witnessed, suspected, or alleged abuse to all responsible parties per facility policy; (e) Protection of resident while conducting a thorough investigation of alleged abuse; (f) Proper assessment of residents who have been or suspected to be abused; and (g) Prevention of future incidents of abuse from occurring. Staff on Leave or PTO to be educated upon return and prior to working. Two employees remain on leave and will be educated by the ED/Designee upon return. The facility implemented a plan for the DON/Designee to educate all new staff in Behavioral Health management. This would be ongoing as part of new hire orientation. The facility implemented a plan for the DON/Designee to interview five residents weekly for four weeks for any abuse concerns, then randomly thereafter until compliance was confirmed. The facility implemented a plan for the Administrator/Designee to interview five staff members weekly for four weeks for any abuse concerns, then randomly thereafter until compliance is confirmed. The Administrator or DON would monitor compliance with above in monthly QAPI meeting for three months then as needed for one year. All allegations of abuse would be reported to RDCO/RN #475 by the DON or Administrator as soon as the allegation was made. This would be ongoing. RDCO/RN #475 would monitor compliance during monthly visits for three months then on an as needed basis. On 08/05/24 from 1:40 P.M. to 2:00 P.M. interviews with LPN #425, RN #390, STNA #353 and STNA #319 confirmed they received education regarding abuse and behavior training. Although the Immediate Jeopardy was removed on 08/01/24 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 monitoring to ensure continued compliance. Findings include: Review of Resident #161's medical record revealed an admitted [DATE] with diagnoses including atrial fibrillation, type two diabetes mellitus, vitamin D deficiency, mixed hyperlipidemia, major depressive disorder, Alzheimer's disease with late onset, vascular dementia and osteitis deformans of multiple sites. Review of Resident #161's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #161 had moderate cognitive impairment, no behaviors coded and utilized a walker and a wheelchair. Review of Resident #161's plan of care dated 06/13/24 revealed the resident had impaired cognitive function due to dementia and Alzheimer's disease. A listed intervention also dated 06/13/24 indicated staff were to use resident's preferred name. Face resident when speaking to them. Reduce any distractions- turn off television, radio, close door et cetera. Use consistent, simple, directive sentences. Provide with necessary cues- stop and return if agitated. Review of Resident #161's progress notes revealed a note dated 07/24/24 at 10:45 A.M. and authored by Licensed Practical Nurse (LPN) #423 indicating he did not witness the incident (incident not specified) but was notified by staff. A full head to toe assessment was done and no areas found. Resident #161 stated he was in no pain at this time of care. Vitals were within normal limits, neurological checks (neuros) were put into place and the responsible party had been notified. Review of a facility self-reported incident (SRI) reported to the State Agency (SA) by the Administrator on 07/24/24 at 12:06 P.M. revealed an allegation of physical abuse between Resident #161 and Activity Aide (AA) #307 which was witnessed by Maintenance Technician (MT) #436, MT #438, LPN #427 and Admissions Coordinator (AC) #309. The SRI included Resident #161 was near the nurses' station on the first floor of the facility seated in his wheelchair and holding his cane. Resident #161 approached AA #307 regarding smoking and struck AA #307 with his cane several times. Staff in the area told AA #307 to back away from Resident #161 but she did not move and instead proceeded to strike Resident #161. AA #307 was removed from Resident #161 and police as well as Emergency Medical Services (EMS) were called. The facility found the allegation of physical abuse to be substantiated. AA #307 was terminated, and police were pursuing assault charges against AA #307 as a result of the facility's investigation. Review of a witness statement dated 07/24/24 and authored by MT #436 revealed the following information: On 07/24/24 at 10:40 A.M. I was walking down to the first-floor nurses' station and seen [Resident #161] hitting [AA #307] with the cane that he had, he hit her about five times and AA #307 said, you really [NAME][g] to hit me? AA #307 threw her papers on the floor and started to hit Resident #161 over and over until MT #438 pulled AA #307 off of Resident #161. AA #307 started kicking and swinging breaking stuff, screaming and saying stuff. Review of a witness statement authored by MT #438 revealed the following information: On 07/24/24 at 10:40 A.M. I was walking towards the main nurses' station when I noticed Resident #161 swinging his cane at AA #307. She put her papers down and hit Resident #161 in the head. I then grabbed AA #307 and escorted her out. A second witness statement authored by MT #438 revealed the following information: On 07/24/24 at 10:40 A.M. I was walking towards the main nursing station when I saw Resident #161 swinging his cane at AA #307. Resident #161 hit her at least three times in her arm. It might have knocked the papers out of her hand then AA #307 tried to hit Resident #161 back but then I grabbed AA #307 and escorted her outside. Review of a witness statement authored by LPN #427 revealed the following information: On 07/24/24 at 10:30 A.M. I witnessed AA #307 having a confrontation with Resident #161. Resident #161 hit AA #307 with his cane. I instructed AA #307 to back up so Resident #161 could not hit her, but AA #307 stood there and let Resident #161 continue to hit her. After being hit four to five times, AA #307 attacked Resident #161 hitting him in the face and head with her fist. AA #307 was restrained and removed away from Resident #161. Review of a witness statement dated 07/24/24 and authored by AC #309 revealed the following information: On 07/24/24 at 10:35 A.M. I was on the other side of the nurses' station when I heard two people yelling. I walked to the other side and saw Resident #161 strike AA #307 with his cane. Resident #161 took another swing and AA #307 yelled out, 'He's hitting me, y'all just going to let him hit me?' I, along with others (not named) told her to move away from Resident #161 as he was in a wheelchair. AA #307 continued to let Resident #161 strike her with the cane. AA #307 then put her paper and pen down and attacked Resident #161, punching him multiple times before we could get her off of him. MT #438 restrained AA #307. As MT #438 picked her up she kicked Resident #161 in the back and in his head. AA #307 was then removed from the area. I called 9-1-1 at 10:37 A.M. and EMS came to check Resident #161 out and reported no injuries. Review of a witness statement for AA #307 dated 07/25/24 and completed by the Administrator via phone revealed the following information: I told multiple people that [Resident #161] was going after me with his cane because I told him he couldn't smoke because of being sick. Ever since he was told he could not smoke, he has been behavioral towards me. He kept going at me with his cane. Resident #161 said he was going to call the police because [I] wouldn't give him his cigarette. Yesterday, Resident #161 hit me with his cane six different times .it does not matter where I got hit, I took six blows. I got on Resident #161 and hit him back and they (not specified) put me in the lobby and that was it. Review of a police report dated 07/24/24 at 10:37 A.M. revealed a call to the facility for assault listing AA #307 as a suspect and Resident #161 as a victim. AC #309 made the call and stated a female employee later identified as AA #307 physically assaulted Resident #161 and left the scene before officers arrived. Resident #161 stated he and AA #307 were involved in a verbal altercation regarding him smoking cigarettes. Resident #161 then stated AA #307 struck him with a closed fist multiple times in the head and kicked him multiple times in the legs. Resident #161 stated he then struck AA #307 with his cane but did not sustain any apparent injuries. AA #307 stated Resident #161 was aggravated that she would not give him a cigarette to smoke and he approached her while in his wheelchair. Resident #161 then struck her in the legs and arms five to six times with his metal cane. AA #307 stated she asked the staff for help when Resident #161 continued to strike her. In AA #307's written statement (not included with the report) she stated 'so I defended myself and put my hands on him.' AA #307 was placed under arrest for assault. Other staff at the facility by the names of MT #436, MT #438, LPN #427 and AC #309 all witnessed the altercation and stated AA #307 had to be restrained from continuing to assault Resident #161. Review of AA #307's personnel file revealed a hire date of 06/19/24 and background checks completed on 06/27/24 and 07/10/24. AA #307 signed off on reviewing the facility handbook which included abuse as well as the behavioral management video on 06/19/24. AA #307's employment was terminated with the facility on 07/25/24. Interview on 07/30/24 at 11:40 A.M. with AA #307 revealed on 07/24/24 around 10:30 A.M. in the morning there had been an incident with Resident #161. AA #307 stated she was the only activity staff in the facility due to the facility's COVID-19 outbreak. Around 8:00 A.M. on 07/24/24 Resident #161 had approached her outside wanting a cigarette, but she was told by staff (not identified) Resident #161 had COVID-19 and had to wait until a different smoke break time. AA #307 stated Resident #161 wanted to smoke with everyone else but could not as he was sick. Resident #161's aide, State tested Nursing Assistant (STNA) #323 gave him a cigarette then Resident #161 was telling people that she would not give him a cigarette. AA #307 stated she walked down the hallway and Resident #161 started whacking her arms and legs with his cane. AA #307 told the nurse (not named) to get Resident #161 as he had hit her five times. AA #307 reported she jumped on Resident #161 after the sixth time he had hit her but did not recall if she hit him or not. AA #307 became increasingly upset during the interview, then stated I did not assault that man, that (racial slur) hit me and assaulted me .they let that man beat my (expletive). AA #307 stated she was charged with assault the same date of the incident then ended the interview. Interview on 07/30/24 at 12:03 P.M. with the Administrator verified while the SRI was not yet completed as of the time of the interview, the allegation of staff to resident abuse was going to be substantiated. Interview on 07/30/24 at 2:24 P.M. with MT #436 revealed sometime on 07/24/24 after 10:00 A.M. he was coming down the [NAME] hall and saw Resident #161 in his wheelchair hit AA #307 with his cane five times and AA #307 just stood there. MT #436 stated Resident #161 and AA #307 had been going back and for the last few days but did not further elaborate on this matter. MT #436 continued that AA #307 told Resident #161, Are you going to hit me? and then AA #307 punched Resident #161 fast and more than once. MT #438 pulled AA #307 off of Resident #161, took her to the front desk and she left before the police came. MT #436 stated there was never an instance where hitting a resident was acceptable. Interview on 07/30/24 at 2:32 P.M. with MT #438 revealed on 07/24/24 between 10:30 A.M. and 10:45 A.M. he was coming down the [NAME] hall and AA #307 was coming to get four or five people for smoke break. MT #438 stated how AA #307 was walking, he felt they were about to fight. Resident #161 hit AA #307 with his cane four or five times. AA #307 did not do anything, but MT #438 did not think AA #307 would do anything to Resident #161. AA #307 told Resident #161 you gonna hit me? then yelled out he is hitting me. AA #307 put what was in her hands down then grabbed Resident #161's shirt collar and then went to swing at Resident #161. MT #438 stated he grabbed AA #307, and she was in his arms, kicking like a cat and he took her to the front lobby. MT #438 confirmed he witnessed AA #307 hit Resident #161 two times with an open hand slap. MT #438 also confirmed it was never acceptable to hit a resident. Interview on 07/30/24 at 4:18 P.M. with Resident #161 revealed he recalled the incident that had occurred with AA #307. The resident reported last week, AA #307 threw her stuff on the ground, he hit AA #307 one time with his cane then AA #307 hit the back of his head with her fist twice and a male staff (not identified) grabbed AA #307 and dragged her to the front of the facility. Resident #161 asked AA #307 why she did this but did not elaborate further during the interview. Resident #161 stated he did not feel safe at the facility as a result of the incident on 07/24/24. Interview on 07/31/24 at 8:28 A.M. with LPN #427 revealed last week during late morning, the newer activity staff, AA #307 got into a verbal altercation with Resident #161. LPN #427 stated Resident #161 told AA #307, get the (expletive) away from me, I am going to hit you with my cane. Resident #161 then hit AA #307 with his cane in her shoulder and face. LPN #427 reported he told AA #307 to back up and get away from Resident #161 and Resident #161 hit AA #307 again, hitting her three or four times. Then AA #307 began to beat the hell out of Resident #161, punching him in the face and body and one of the maintenance staff had to hold AA #307 in the air, with AA #307 still kicking Resident #161. AA #307 was taken to the lobby, and he had not seen her since. LPN #427 confirmed it was not ok to ever hit a resident. Interview on 07/31/24 at 8:38 A.M. with AC #309 revealed on 07/24/24 around 10:35 A.M. she was walking towards the Hickory hall from the Buckeye hall and saw Resident #161 hit AA #307 with his cane. AC #309 reported she told AA #307 to step away from Resident #161 as AA #307 said, You all gonna let him hit me? AC #309 stated AA #307 was not cornered by Resident #161 and was not stepping away from him. Resident #161 was striking AA #307 and maintenance staff (not specified) came up the hallway and words were exchanged with them and AA #307 but she could not recall what was said. AA #307 then put the pen and paper that was in her hands on the floor and she looked like she was going to attack and jumped on Resident #161 who was in his wheelchair and began to punch Resident #161. AA #307's arms were swinging so fast, and she made contact multiple times with a closed fist. MT #438 put his arms around AA #307 to lift her up and she kept trying to make contact with Resident #161 and did kick him in the back. AA #307 was taken to the lobby and was trying to get back into the facility. AC #307 stated she called 9-1-1 at 10:37 A.M. AC #307 confirmed it was never ok to hit a resident. Interview was attempted with STNA #323 on 07/31/24 at 9:04 A.M. but was unsuccessful. Interview on 07/31/24 at 3:47 P.M. with Medical Director (MD) #470 revealed he was aware of AA #307's employment and stated AA #307 had wanted to be a STNA. MD #470 stated he was made aware of the situation from last week where Resident #161 had tapped AA #307 on the leg with his cane and AA #307 proceeded to challenge Resident #161, put her belongings down and then attacked Resident #161, which was unacceptable, and the facility had no tolerance for that. Interview on 08/01/24 beginning at 10:02 A.M. with LPN/Assistant Director of Nursing (ADON)/Risk #469 and the Administrator revealed the facility determined the root cause of the (abuse) incident involving Resident #161 and AA #307 was due to AA #307's lacking behavioral health training. The administrative staff indicated moving forward the facility was going to utilize a competency packet with quiz for staff regarding behavioral health needs but stated they had not started this process as of the time of this interview. Review of the facility undated policy titled, Ohio Abuse, Neglect and Misappropriation, defined abuse as the willful infliction of injury, unreasonably confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and defined physical abuse as hitting, slapping, pinching, kicking or flicking with fingers or striking in any manner that is demeaning. It was the intent of this facility to prevent the abuse, mistreatment or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. All investigations of abuse, neglect and misappropriation would be reviewed by the Quality Assurance/Performance Improvement (QAPI) committee who would determine if the investigation was complete and if the action taken had resolved the issue or if a performance improvement plan was needed. Cases of sexual or physical abuse by staff or other residents always required tracking and corrective action by the QAA committee and this coordinated effort would allow the QAA committee to determine if there was further need for systemic action such as: insight on needed revisions to the policies and procedures that prohibit and prevent abuse/neglect/misappropriation and exploitation. This deficiency represents noncompliance investigated under Master Complaint Number OH00156356 and Complaint Number OH00155912.

Based on record review, self-reported incident review (SRI) and interview, the facility failed to ensure sufficient staff to prevent physical abuse for Resident #149. Harm occurred when Resident #149 sustained a nasal bone fracture, laceration requiring sutures and closed head injury. This affected one of five residents reviewed for abuse and one of 20 residents residing on the Birch secured unit. Facility census was 167. Findings include: Review of Resident #149's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #149's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem. Review of Resident #99's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #99's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of the SRI form dated 08/27/18 revealed at 7:45 P.M. staff reported an alleged physical altercation between Residents #99 and #149. Resident #149 entered Resident #99's room without permission and Resident #99 asked Resident #149 to leave. Resident #149 would not leave the room and was hit by Resident #99. Both residents resided on the Birch unit. Review of a witness statement dated 08/27/18 by Licensed Practical Nurse (LPN) #505 indicated Resident #149 was standing by the door with the STNA with blood running down his face. LPN #505 pulled a chair up for Resident #149 to sit down and started doing vital signs. The STNA explained that Resident #99 hit Resident #149 multiple times and dried blood was observed on Resident #99's right hand. Emergency services were called. Resident #99 indicated Resident #149 came in his room and he asked the resident to leave and the resident said a smart remark back so Resident #99 hit him multiple times. Resident #149 did not know what happened and denied pain. Resident #149 had a laceration on his eyebrow and a hematoma on the left side of his forehead. Review of Resident #149's progress note written by LPN #505 dated 08/28/18 at 5:00 A.M. indicated this nurse was downstairs finding the aide that was supposed to be on the hall. I found her by the back elevator. I came up the stairs and walked on the Birch secured unit to find Resident #149 standing by the door with the aide with blood running down his face. Review of Resident #149's progress note written by LPN #505 dated 08/28/18 at 6:40 A.M. indicated the resident arrived from the hospital at 4:00 A.M. with a laceration of the left eyebrow measuring 3.0 centimeters (cm) by 2.0 cm, a hematoma on the left forehead, a closed head injury and six sutures that closed the resident's eyebrow. X-rays showed a nasal bone fracture and the resident's face was discolored from the left forehead to the left cheek and eye. Resident #149's left eye was swollen shut and the resident denied pain. Interview on 10/01/18 at 4:18 P.M. with State tested Nursing Assistant (STNA) #506 indicated he was working on the Birch unit by himself and assisting another resident with care. STNA #506 indicated Resident #149 wandered into Resident #99's while he was in the other resident's room and no one else was on the unit to provide supervision or redirection. Interview on 10/02/18 at 8:40 A.M. with Physician #507 revealed Resident #99 would defend his territory, was very internally stimulated, would follow directions and was redirectable. Physician #507 indicated Resident #149 was a wanderer. Interview on 10/02/18 at 9:46 A.M. with STNA #508 indicated she was assisting another resident with a meal on another hall when she was instructed her assignment was changed to the Birch secured unit. STNA #508 revealed she did not arrive on the unit until after the altercation between Residents #99 and #149 occurred. Interview on 10/02/18 at 1:33 P.M. with LPN #505 indicated on 08/27/18 around 6:00 P.M. only STNA #506 was assigned to the Birch unit and the nurse attempted to secure additional staffing for the unit. LPN #505 indicated STNA #508 was re-assigned to the unit but did not arrive on the unit timely. LPN #505 left the Birch unit for ten to fifteen minutes to physically locate STNA #508 and found STNA #508 by the time clock returning from a smoke break. After returning to the Birch unit, LPN #505 observed Resident #149's face covered in blood. Review of Resident #149's computed tomography (CT) scan (x-ray measurements from different angles which produce cross-sectional images of a specific area) dated 08/27/18 at 11:23 P.M. revealed there was considerable left frontal temporal scalp, periorbital and premaxillary soft tissue swelling/hematoma and a [MEDICAL CONDITION] nasal spine. Review of the Ohio Abuse, Neglect and Misappropriation policy revised 09/02/16 indicated abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Under prevention, the policy indicated the facility established staffing based on census, acuity level, and needs. This deficiency substantiates Complaint Number OH 267.

Based on record review, self-reported incident review (SRI) and interview, the facility failed to prevent physical abuse for Resident #149 and Resident #152. Harm occurred when Resident #149 sustained a nasal bone fracture, laceration requiring sutures and closed head injury. This affected two (Residents #149 and #152) of five resident records reviewed for abuse. Findings include: 1. Review of Resident #149's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #149's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem. Review of Resident #99's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #99's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of the SRI form dated 08/27/18 revealed at 7:45 P.M. staff reported an alleged physical altercation between Residents #99 and #149. Resident #149 entered Resident #99's room without permission and Resident #99 asked Resident #149 to leave. Resident #149 would not leave the room and was hit by Resident #99. Both residents resided on the Birch unit. Review of a witness statement dated 08/27/18 by Licensed Practical Nurse (LPN) #505 indicated Resident #149 was standing by the door with the STNA with blood running down his face. LPN #505 pulled a chair up for Resident #149 to sit down and started doing vital signs. The STNA explained that Resident #99 hit Resident #149 multiple times and dried blood was observed on Resident #99's right hand. Emergency services were called. Resident #99 indicated Resident #149 came in his room and he asked the resident to leave and the resident said a smart remark back so Resident #99 hit him multiple times. Resident #149 did not know what happened and denied pain. Resident #149 had a laceration on his eyebrow and a hematoma on the left side of his forehead. Review of Resident #149's progress note written by LPN #505 dated 08/28/18 at 5:00 A.M. indicated this nurse was downstairs finding the aide that was supposed to be on the hall. I found her by the back elevator. I came up the stairs and walked on the Birch secured unit to find Resident #149 standing by the door with the aide with blood running down his face. Review of Resident #149's progress note written by LPN #505 dated 08/28/18 at 6:40 A.M. indicated the resident arrived from the hospital at 4:00 A.M. with a laceration of the left eyebrow measuring 3.0 centimeters (cm) by 2.0 cm, a hematoma on the left forehead, a closed head injury and six sutures that closed the resident's eyebrow. X-rays showed a nasal bone fracture and the resident's face was discolored from the left forehead to the left cheek and eye. Resident #149's left eye was swollen shut and the resident denied pain. Interview on 10/01/18 at 4:18 P.M. with State tested Nursing Assistant (STNA) #506 indicated he was working on the Birch unit by himself and assisting another resident with care. STNA #506 indicated Resident #149 wandered into Resident #99's room because there was not enough staff to provide the appropriate supervision. Interview on 10/02/18 at 8:40 A.M. with Physician #507 revealed Resident #99 would defend his territory, was very internally stimulated, would follow directions and was redirectable. Physician #507 indicated Resident #149 was a wanderer. Interview on 10/02/18 at 9:46 A.M. with STNA #508 indicated she was assisting another resident with a meal on another hall when she was instructed her assignment was changed to the Birch secured unit. STNA #508 revealed she did not arrive on the unit until after the altercation between Residents #99 and #149 occurred. Interview on 10/02/18 at 1:33 P.M. with LPN #505 indicated on 08/27/18 around 6:00 P.M. only STNA #506 was assigned to the Birch unit and the nurse attempted to secure additional staffing for the unit. LPN #505 indicated STNA #508 was re-assigned to the unit but did not arrive on the unit timely. LPN #505 left the Birch unit for ten to fifteen minutes to physically locate STNA #508 and found STNA #508 by the time clock returning from a smoke break. After returning to the Birch unit, LPN #505 observed Resident #149's face covered in blood. Review of Resident #149's computed tomography (CT) scan (x-ray measurements from different angles which produce cross-sectional images of a specific area) dated 08/27/18 at 11:23 P.M. revealed there was considerable left frontal temporal scalp, periorbital and premaxillary soft tissue swelling/hematoma and a [MEDICAL CONDITION] nasal spine. Review of the Ohio Abuse, Neglect and Misappropriation policy revised 09/02/16 indicated abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Review of Resident #152's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. depression, aortic aneurysm, and [MEDICAL CONDITION]. Review of Resident #152's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was alert and oriented and required limited assist of one person for bed mobility and dressing. Resident #152 required an extensive assist of one person for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of Resident #152's plan of care dated 04/20/18 revealed the resident had a behavior problem related to [DIAGNOSES REDACTED]. Interventions included assisting in developing more appropriate methods of coping and interacting; encouraging the resident to express feelings appropriately; caregivers to provide opportunity for positive interaction, attention; staff to stop stop and talk with him/her as passing by; educate resident, family/caregivers on successful coping and interaction strategies such as (specify); provide encouragement and active support by family/caregivers when resident utilized the strategies; if reasonable, discuss behaviors; explain/reinforce why behavior was inappropriate and/or unacceptable to resident; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention, and remove from situation and take to alternate location as needed. Review of Resident #152's nurses notes dated 09/30/18 (no time) revealed Resident #152 informed the nurse that his roommate (Resident #567) kept walking on his side of the room messing with the heater. Resident #152 stated When he told his roommate to stop, his roommate then got upset and hit him in the head with a fan. The nurse observed Resident #152 sitting on his bed with a 1.0 centimeter (cm) x 0.5 cm laceration above his right eye. Vital signs were within normal limits, neurological checks were initiated. The physician was notified. Resident #152 requested to go to the hospital stating I needed to be seen by a doctor right now. Resident #152's emergency contact was notified per resident request. Resident #152 was sent out to the hospital for evaluation. Interview with Resident #152 on 10/02/18 at 12:45 P.M. revealed he asked his roommate (Resident #567) to agree on a temperature for the bedroom. Both agreed to keep the room at around 72 degrees Fahrenheit. After an unidentified nurse changed the temperature to the agreed upon temperature, Resident #567 came back over to Resident #152's side of the room and according to Resident #152 stated you get your way all the time, but things are going to change. With that, Resident #152 stated Resident #567 went to his side of the room and turned on two fans and aimed the fans toward Resident #152's curtains which separated the two beds. This caused wind to circulate over to Resident #152's bed causing the resident to be cold. Resident #152 was lying in bed and had a flaccid right arm and was unable to get up without assist. Resident #152 stated Resident #567 unplugged a large window fan, picked it up and tried to hit Resident #152 in the head with the fan. Resident #567 stated he lifted his good arm to block his head and was able to keep the fan from hitting his head. Resident #152 stated he was able to knock the fan out of Resident #567's hand. This made Resident #567 angrier and the resident unplugged the smaller fan and threw it at Resident #152. The smaller fan struck Resident #152 on the right side of his head causing a laceration to the right eyebrow. Resident #152 stated he called for help and Resident #567 was removed from his room. Resident #152 stated he asked to go to the hospital because he had a head injury and wanted it evaluated. Resident #152 stated the police came and took Resident #152 out of his room. Resident #567 had not returned to the facility as of 10/02/18. Resident #152 stated when the resident came back he was going to press charges for assault. Interview with the Medical Director on 10/02/18 at 8:30 A.M. revealed he was surprised Resident #567 attacked Resident #152. The Medical Director stated Resident #567 was always polite when he spoke to the resident. The Medical Director stated he was not aware of a prior incident of a peer to peer altercation involving Resident #567. The Medical Director stated if Resident #152 was seated in his wheelchair the resident might be able to defend himself but if the resident was in bed he would not be able to defend himself from Resident #567. Interview with the Self-Reported Incident (SRI) investigator on 10/02/18 at 10:50 A.M. revealed he was in the beginning stages of investigating the incident between Resident #152 and Resident #567 on 09/30/18. He did not know the details, but reinforced all residents were resident to be free of abuse, including resident to resident abuse. Review of the facility's policy and procedure Ohio Abuse, Neglect and Misappropriation dated 10/07/14 (revised 02/01/17) revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict harm. This deficiency substantiates Complaint Number OH 267.

Based on medical record review, staff and resident interviews, observation of mechanical soft and pureed food preparation, observation of meal service, review of facility recipes and food preparation guidelines, review of in-service records, review of facility witness statements, and review of resident council meeting minutes, the facility failed to ensure residents with orders for pureed and mechanically altered diets were provided foods prepared at the correct texture to prevent choking and to meet their individual needs. This resulted in the potential for life threatening harm that is Immediate Jeopardy on 10/19/17 when Resident #1, who was ordered a mechanical soft diet, was found choking with watery eyes, blue lips, and not able to speak in the dining room. The resident required the [MEDICATION NAME] maneuver to expel a hard piece of French toast stick. The Immediate Jeopardy continued on 11/05/17 when Resident #152, who was to receive a pureed diet and was unable to communicate her needs, received foods that were a mechanical soft texture diet for lunch and was observed alone in her room with her meal. This affected two residents (Residents #1 and #152) who received foods that were not the correct texture to prevent choking while eating. This had the potential to affect 27 additional residents (Residents #3, #5, #7, #11, #13, #14, #17, #18, #25, #30, #37, #54, #55, #58, #59, #60, #62, #76, #84, #93, #100, #111, #128, #133, #140, #158, and #160) who were ordered mechanical soft diets, and 12 additional residents (Residents #9, #10, #12, #28, #38, #61, #68, #71, #81, #96, #120 and #150) who received a pureed diet due to chewing and/or swallowing impairment. On 11/07/17 at 12:15 P.M., the Regional Director of Clinical Services (RDCS) #101, Regional Registered Dietitian (RRD) #102, Regional Dietary Manager (RDM) #103, Dietary Account Manager (DAM) #104, and Mobile Director of Nursing (MDON) #105 were notified Immediate Jeopardy began on 10/19/17 when Resident #10, who was ordered a mechanical soft diet, was found choking in the dining room and required the [MEDICATION NAME] maneuver to expel a hard piece of a French toast stick. Afterward, there was no evidence the facility took measures to evaluate and monitor the food preparation of mechanical soft foods, and no evidence of any training with the cooks to assure mechanical soft and pureed foods were prepared correctly. Subsequently, on 11/05/17, Resident #152, who was to receive a pureed diet, was observed in an unsupervised meal setting with foods containing skins and chunks of vegetables and meat that was stringy in texture. The Immediate Jeopardy was removed on 11/09/17 when the facility implemented the following corrective action: · On 11/05/17, DAM #104 initiated puree audits at dinner which continued for each meal until breakfast on 11/08/17 when the audit tool was updated to include mechanical soft audits. The audits will continue for three meals a day for one week, then two meals a day for four weeks and one meal a day for eight weeks. · On 11/07/17, the Robot Coupe, a food processor/blender used to puree foods, was taken out of service and a new Robot Coupe was used. · On 11/08/17, RD #109 in serviced all 16 dietary employees, including Cooks #112, #113, #100 and Dietary Aides (DA) #114, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210 and #211, for puree food preparation which included correct consistency of a puree diet, how to prepare and present puree texture foods by using the right guidelines, recipes and equipment and where to find puree preparation guidelines for commercial thickener. · On 11/08/17, Speech/Language Pathologist (SLP) #111 in serviced all 16 dietary employees, including Cooks #112, #113, #100 and DA's #114, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210 and #211) on diet consistencies for puree and mechanical soft textures and the importance of providing accurate consistencies. · On 11/08/17, SLP #111 in-serviced all nursing staff on texture modified diets. · On 11/08/17, SLP #111 started tray audits for texture of mechanical soft and puree diets which will continue for three meals a week for four weeks. · On 11/08/17, RRD #102 in-serviced all 16 dietary employees on using the recipes during food preparation. · On 11/08/17, RRD #102 initiated audits for use of the recipes which will continue for three meals a day for one week, then two meals a day for four weeks, and then one meal a day for eight weeks. · On 11/08/17, RDM #103 in-serviced all 16 dietary employees on the operation of the Robot Coupe. · On 11/08/17, the DON or designee began auditing meals when served on the unit for the correct texture. The facility will audit three meals a week for four weeks to ensure staff are sending the appropriate foods and texture to the residents. · On 11/09/17, Maintenance Director #125 was in serviced by the RDM #103 on inspecting the Robot Coupe for proper functioning and blades to be sharpened monthly. Maintenance Director #125 will conduct audits for the operational functions of the Robot Coupe once a week for three months. The blades will be checked on a weekly basis for sharpness. · On 11/13/17, DAM #104 was observed preparing puree and mechanical soft foods to the correct consistencies. · On 11/13/17, interviews with DAM #104 and DA #114 revealed they received training and were knowledgeable on how to prepare proper food texture modifications; using the Robot Coupe; following the recipes to ensure proper consistency; and contacting Speech/Language Pathologist (SLP) #111 if had any questions on diet modifications. Although the Immediate Jeopardy was removed on 11/09/17, the facility remains out of compliance at severity level two that has the potential for more than minimal harm that is not Immediate Jeopardy, as they are in the process of evaluating their interventions and auditing staff performance in the provision of mechanical soft and pureed foods. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the State tested Nursing Assistant (STNA) Kardex, dated 02/06/15, revealed the resident was to be seated upright in a chair for each meal with her head in a neutral position; cut food up into bite size pieces, alternate solids to liquids at a three to one ratio; check the right side of her mouth every few bites for pocketed food, and encourage the resident throughout the meal to help her stay on task. A physician's orders [REDACTED]. Review of the nursing note dated 10/19/17 at 10:04 A.M. revealed Licensed Practical Nurse (LPN) #121 walked into the dining room during breakfast and observed the resident with watery eyes and blue discolored lips. The resident could not verbalize that she was choking. LPN #121 leaned the resident forward to cough up anything that was blocking her airway. STNA #122 assisted and performed the [MEDICATION NAME] maneuver giving her one thrust, and then the resident coughed. LPN #121 asked the resident to spit out the food but the resident swallowed it. There was no documented evidence that a STNA was assisting the resident with her alternating solids and liquids, and checking the right side of her mouth during this meal as ordered. review of the resident's medical record revealed [REDACTED]. On 11/06/17 at 4:55 P.M., interview with LPN #122, with MDON #105 present, revealed she was passing medications and went into the dining room, the STNA's were passing trays in the hall. She verified the resident did not look right and when she approached the resident. She saw her watery eyes and lips were blue. LPN #122 yelled for the STNA's, and STNA #122 performed the [MEDICATION NAME] and with one thrust a solid piece of a French toast stick came out. The resident did not want to spit it out and she swallowed it. LPN #121 verified she could only see part of the French toast stick. She verified the resident was not interviewable. 2. Resident #152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident spoke limited English. On 11/05/17 at 1:05 P.M., Resident #152 was observed in her room with her lunch tray in front of her with only a couple bites taken. The foods appeared to be a mechanical soft texture. According to the meal ticket on the tray the resident was to receive pureed foods. On 11/05/17 at 1:32 P.M., the surveyor asked MDON#105 to come into Resident #152's room to observe the resident's tray. Only a couple bites were taken from the meat, which appeared as a mechanical soft texture. Both MDON #105 and the surveyor attempted to communicate with the resident without success. The tray was taken to the nurse's station for better view. Registered Nurse (RN) #123, MDON #105, DAM #104, and RDM #103 were present and observed the meal ticket indicated the resident was to receive a pureed diet. Review of the plate included green vegetables (Capri blend including zucchini, squash and green beans). The mixed vegetables contained chunks and larger than pencil eraser size pieces of skin throughout. The meat was identified as pot roast, it had less than a tablespoon of gravy on top and the meat was stringy like pulled pork. All staff present at the observation verified the food served was not pureed texture. The pot roast served appeared to be a mechanical soft texture. RDM #103 verified he had only been at the facility for four days and informed someone (could not remember who) that the Robot Coupe was not functioning properly and the blade needed sharpened, and could not get the puree meals to the proper consistency. RDM #103 verified the kitchen continued to serve this improperly prepared pureed pot roast to the residents ordered a pureed diet. 3. Review of the list of dietary personnel revealed three staff were listed as cooks (Cook #100, Cook #112, and Cook #113). Interviews revealed Dietary Aide (DA) #106 and DA #114 also cooked. Review of their personnel files revealed only one dietary personnel (DA #114) had a signed job description for a cook position. Further review of their personnel files revealed no evidence of any type of orientation and/or training for Cooks #100, #112, #113, and DA's #106 and #114. Review of the new hire packet revealed it did not include any type of job specific training, including training on preparing pureed and mechanical soft foods. Review of the cook job description signed by DA #114 on 01/20/16 revealed the cook would prepare foods including texture modified and therapeutic diets, according to the facility menu and established policies and procedures; inspect special diet trays to ensure the correct diet was served; and attend in-service education and staff meetings as required. There was nothing specific to any training for the preparation of pureed or mechanically altered diets. On 11/05/17, review of the facility census and diet type records, there currently were 27 residents (Residents #3, #5, #7, #11, #13, #14, #17, #18, #25, #30, #37, #54, #55, #58, #59, #60, #62, #76, #84, #93, #100, #111, #128, #133, #140, #158, and #160) who were ordered mechanical soft diets, and 14 residents (Residents #1, #9, #10, #12, #28, #38, #61, #68, #71, #81, #96, #120, #150, and #152) who received a pureed diet due to chewing and/or swallowing impairment. Review of the facility policies and procedures revealed there was no policy for preparing mechanically altered diets including pureed and mechanical soft food items. Further review of the corporate recipes for pureeing foods revealed the instructions for preparing pureed foods was to measure the desired number of servings into the food processor and blend the items until smooth, adding liquid as needed for thinning. Commercial thickener may also be added to the product if it needs thickened. The instructions for preparing mechanical soft foods included measuring the desired number of servings into the food processor; grinding the product to the appropriate consistency; and if needed add gravy or broth for moistening. There were no descriptions or guidance provided that would tell the cook how much water and/or thickener to add to achieve the desired product, and what would be considered the appropriate consistency for serving pureed or mechanical soft foods. The only guidance readily accessible to the cooks was a paper on the wall that provided instructions on thickening steamed vegetables or meats with a thickener if needed. Review of the diet manual instructions for texture progression for pureed foods (undated) revealed this diet eliminated the need for chewing. All foods must be presented in a form that is homogenous and cohesive in nature. For example foods should have a pudding or mousse like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps. Vegetables must be without chunks, lumps, pulp or seeds. Meats that are tough or dry and cannot be pureed into a homogenous mousse like texture should not be used. Review of the diet manual instructions for mechanical soft diet revealed it consisted of ground meats, with soft fruits and vegetables, and most bread products. Vegetables that were not tender, or naturally large and in whole form, or are raw or crunchy were not permitted. French toast and pancakes were allowed if softened with syrup. Potatoes not allowed would include forms that were coarse when cooked or crispy deep fried. Review of the resident council meeting minutes dated August, 2017 revealed the residents' meal tickets were not being followed correctly. Further review of the resolutions revealed there was no documented evidence of a resolution. Regional Manager #118 observed dietary staff preparing meals between 10/25/17 ad 10/27/17. This resulted in a performance improvement plan and the discipline of DM #108 for failure to audit tickets/trays during tray line service to prevent the serving of wrong items, textures, and/or consistencies to the residents of the facility which has allowed for repeat errors and concerns. DM #108 was given 30 working days to conduct audits for a minimum of two meals each day to ensure accuracy of meal tickets, which was not done yet as DM #108 was still suspended at the time of the survey. 4. On 11/05/17 at 3:50 P.M., the surveyor entered the kitchen and DAM #104 was observed pureeing ham in a Robot Coupe borrowed from another facility. There were visible pieces of skin in the machine. She stated she just added a little water to the ham for pureeing and verified the skin was left on the ham. She stated she had only been helping out the facility for the past couple days. On 11/05/17 at 3:55 P.M., interview with DA #106 revealed he does cook but it had been over a month since he last cooked. He stated the cooks told him the blender (Robot Coupe) was not working right, something was wrong with the dicing or pulsating and it was not pureeing foods. On 11/05/17 at 4:00 P.M., interview with RDM #103 verified he did the pureed meat and vegetables for lunch and had to use a whisk because the Robot Coupe would not puree. He stated he added water and thickener to the vegetables. The mixed (capri style) vegetables included carrots, zucchini, squash and green beans. He stated he just added juice from the roast to the meat. On 11/05/17 at 4:10 P.M., phone interview with Cook #100 verified RDM #103 pureed the meat today. She stated the blender did not work very well. She verified she started as a cook for the first time about six weeks ago and the blender had not worked right since she started, it did not puree the foods, it just blended them. She stated she told her first manager (DM #107) but he was only here a couple days and left and never showed her how to puree the foods properly. She said the blender (Robot Coupe) only had one speed, so the mechanical soft and pureed diet textures were all the same consistency. On 11/05/17 at 4:30 P.M., interview with Registered Dietitian (RD) #109 verified she did not observe meals. She stated she heard the nursing staff were supposed to observe meals to ensure residents received what they needed. She verified the kitchen had some staffing concerns and she had worked on the tray line twice before today, last time being Friday (11/03/17). She stated they had to manually cut the broccoli into small pieces because the Robot Coupe was not able to do it for the mechanical soft diets. She verified she did not do any monitoring for food consistency or accuracy of trays. She stated she arrived on 11/05/17 after tray line was half way done and started assisting but not with the hot food. She verified herself and the DAM #104 were discussing the concerns with the Robot Coupe because it only had one setting; some have a puree setting and a mechanical soft setting. On 11/05/17 at 5:00 P.M., observation of the dinner puree ham with RDM #110 and DAM #104 verified it had separated with a large amount of excess water and clumpy ham pieces making it more of a consistency for mechanical soft. On 11/05/17 at 5:15 P.M., interview with MDON #105 verified the above observations. 5. On 11/06/17 at 7:15 A.M., interview with Cook #100 revealed eggs and bread were on the puree menu, and the bread was a mix where water is added. She verified she did not use recipes when preparing puree just added water and thickener if it was runny. She stated she had not worked in four days and was not aware of any concerns with the Robot Coupe. The surveyor asked what she did different when preparing mechanical soft versus puree foods. Cook #100 stated the only difference was she let the puree sit longer in the Robot Coupe to make it thinner. On 11/06/17 at 7:20 A.M., observation of the Robot Coupe in question revealed it was a R6024 series E 7 Quart. The machine only had an on and off button. Further observation of the blade with RDM #110 revealed he thought it could be sharpened but was not sure if the machine was malfunctioning. 6. On 11/06/17 at 10:30 A.M., interview with Speech/Language Pathologist (SLP) #111 verified she was concerned about the mechanical soft foods. She stated she said something to the kitchen a couple weeks ago because they gave potato chips and they are not appropriate or safe. She could not remember who she talked to in the kitchen, nor did she document her concerns and the conversation. SLP #111 verified she only had one or two residents on puree diets and did not usually see the meats because they were covered in gravy. She did have a concern with the pancakes because they were thicker than the rest of the breads and they get hard. She verified she did not express her concerns to the kitchen. She verified she had a concern with the French toast sticks because the ends got too hard for mechanical soft. SLP #111 verified she did not say anything to the kitchen because she did not want them to take the French toast sticks away from the residents because they liked them. She verified Friday (11/03/17) she was very concerned with the broccoli served as mechanical soft because it was almost raw and served in large pieces. SLP #111 stated nursing was aware of the concern with the broccoli so she did not go to the kitchen. She verified Resident #152 was on her case load but she had not observed any of her pureed foods. She just fed her oatmeal, bread, and yogurt. 7. On 11/07/17 at 2:30 P.M., interview with Cook #112 revealed she was hired in July, 2017. She said DM #115 was supposed to show her specifics of mechanically altered diets, but since she was a cook prior to working at the facility, she just started cooking and then DM #115 left the facility. She noticed a couple of weeks ago the Robot Coup had to run longer in order to get the food [MEDICATION NAME] and she had to add more liquid because the food was too thick. She said she told someone but did not remember who she told. Cook #112 said the consistency of the pureed food was to be like baby food, and a couple of weeks ago she had to let it run longer in order to get the food [MEDICATION NAME], and had to add more liquid because it was too thick. Cook #112 said she informed someone but cannot remember who she told. On 11/07/17 at 3:35 P.M., interview with RRD #102 and RDM #103 verified there was no documented evidence any of the dietary staff received orientation and/or in-service on cooking, and the only staff who had a signed cook job description was DA #114. RRD #102 and RDM #103 stated the training would be in the new hire packet. Review of the new hire packet revealed there was no evidence of training. RRD #102 stated they now have audits sheets for monitoring tray line including the mechanically altered foods. On 11/07/17 at 4:20 P.M., interview with Cook #112 revealed she was going to puree cheese ravioli, bread sticks and peas even though zucchini was on the menu, because that's what the spread sheet indicated. On 11/07/17 at 4:25 P.M., observation of Cook #112, with RRD #102, RDM #103, and RDM #110 present, revealed she put the cheese ravioli in a different Robot Coupe that had been borrowed by the facility. She had difficulty getting the Robot Coupe to operate. Cook #112 said she was not taught how to use the new Robot Coupe. The ravioli was pureed with sauce, no thickener was added, and it appeared runny and slid off the spoon as it was placed on tray line. Cook #112 then attempted to puree the peas by adding water and was having difficulty with the consistency. Cook #112 verified she needed some instruction for the use of the new equipment. On 11/08/17 at 6:20 A.M., interview with DA #114, with RDM #103 and RRD #102 present, revealed she was the cook for that day and breakfast was eggs, toast, and hash browns. She said she was the cook yesterday and had a different Robot Coupe to use and was not trained on how to use the machine. She said she was already done with the puree diets which were bread mix, eggs and instant mashed potatoes because they did not need pureed. On 11/08/17 at 6:35 A.M., interview with RDM #103, with RRD #102 present, verified on 11/03/17 the cook was DM #108, who no longer works at the facility. He verified they were short staffed and had staff from other buildings come in for the day. He said he was doing dishes and RD #109 was on tray line. He verified the broccoli was close to raw and being served in large portions and no one stopped the tray line to cook the broccoli properly for the mechanical soft diet. On 11/08/17 at 7:05 A.M., interview with RD #109 related to the uncooked broccoli served to residents on 11/03/17 revealed they ran out of broccoli about three-fourths of the way into tray line (the original broccoli was over cooked, soft and mushy) and had to cook more. She verified she was doing various things in the kitchen when she noticed the almost raw broccoli being served on tray line. She was not able to identify how many servings of broccoli left the kitchen but did stop tray line and had DM #108 cook the broccoli longer before serving the remainder of the residents. She verified she did not attempt to get the undercooked broccoli off of the trays that had been served. She verified the pieces of broccoli where larger than she was used to seeing, like the size of a golf ball and they were hard. She said there were staffing issues in the kitchen and staff came in from other facilities to help out. She was only helping because of this and did not usually go in the kitchen during tray line. She verified DAM #104 and RDM #103 were in the kitchen working and aware of the broccoli concern. The only thing she was aware of related to the Robot Coupe prior to 11/05/17 was DAM #104 having concerns there was only an on button on the machine, and not various buttons for desired types of consistency such as mechanical soft and puree. On 11/08/17 at 8:00 A.M., interview with RRD #102 and RDM #103 revealed there was no personnel file in the building for DM #108. They verified there was no documentation for this preparation cook position to show training was completed for preparing mechanically altered foods, or evidence that any of the cooks were trained. On 11/08/17 at 8:20 A.M., interview with RRD #102, with DCS #101 present, revealed in-services were completed on 08/15/17. Signatures of those in attendance were provided. There was no outline of the in-service but a recipe for pureeing bread was attached. She verified she was part of the in-service and she reviewed how to puree breads, where to locate the puree recipes, what the recipes looked like and how to read the recipes. The in-service was conducted because there were concerns about staff not reading puree recipes that were identified by DDM #116. On 11/08/17 at 12:05 P.M., phone interview with RM #118 verified he visited the facility from 10/25/17 to 10/27/17 to follow-up on some concerns, and identified the staff were not following the company's policies and procedures and there was a lack of leadership. RM #118 verified the facility management informed him of inconsistencies of textures and discrepancies with meal tickets but he did not observe tray line nor meal preparation. He removed the prior district manager and hired RDM #103 and DAM #104. On 11/08/17, RRD #102 in-serviced all 16 dietary employees regarding the use of recipes for preparation of pureed and mechanical soft foods. This included the use of the Robot Coupe. A new Robot Coupe was purchased and additional inservicing will be conducted with all dietary staff. On 11/08/17, interview with RDM #103 revealed he was responsible for overseeing the operation of this facility and following through with the outcome of the audits and correction of the deficient practice. DAM #103 was also hired for this facility to provide the managerial oversite and training, including training for the mechanically altered foods. On 11/09/17 at 10:20 A.M., interview with DCS #101 and RRD #102 verified the only directions currently available for the cooks were the thickening guidelines which were not being utilized, DCS #101 and RRD #102 verified they needed to ensure a consistent product, and each cook should have a guide to follow. On 11/13/17, DAM #104 was observed preparing puree and mechanical soft foods to the correct consistencies. On 11/13/17, interviews with DAM #104 and DA #114 revealed they received training and were knowledgeable on how to prepare proper food texture modifications; using the Robot Coupe; following the recipes to ensure proper consistency; and contacting Speech/Language Pathologist (SLP) #111 if had any questions on diet modifications. This deficiency resulted from incidental findings discovered during the investigation of Master Complaint Number OH 663 and Complaint Number OH 337.

Based on observation, interview and record review, the facility failed to ensure staff did not neglect to provide needed care to residents. This resulted in Actual Harm of a large blistered area to Resident #160's upper right thigh, and an open wound to Resident #176's right lower leg. This affected two (Residents #160 and #176) of four residents reviewed. Findings include: 1. Resident #160 had [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. The resident also had physicians orders beginning 11/01/10, to turn and reposition every two hours while in bed and while up in the wheelchair, and for a foam cushion to be placed in the geriatric chair when sitting in it to decrease pressure. Review of a physician telephone order dated 2/12/14 at 4:15 P.M. and signed by Certified Nurse Practitioner (CNP) #300 revealed Silver [MEDICATION NAME] Topical (a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. (Diagnosis: [REDACTED]. Review of notes written by CNP #300 on 02/12/14 at 4:20 P.M. revealed Resident #160 was seen for a new blistered area to the top of the right hip area, measuring 20 centimeters (cm) by 32 cm. The area was described as [DIAGNOSES REDACTED]tosus with scattered blisters with a mixed burned appearance. CNP #300's notes dated 02/12/14 at 5:30 P.M., revealed further discussion with the resident's physician and the team, as the team felt Resident #160 had not been exposed to a hot liquid spill. The treatment order was changed to an antibiotic ointment with a dry sterile dressing and a consultation with Wound Nurse Practitioner, CNP #301, was ordered. Review of a corrective counseling report dated 02/12/14 revealed State tested Nurse Aide (STNA) #200 reported a serious skin injury on Resident #160. When STNA #200 was questioned as to whether the injury was there earlier in the day, (STNA #200 worked 6:00 A.M. through 10:00 P.M. on 02/12/14) he indicated Resident #160 had been up and dressed at 6:00 A.M. when he arrived and STNA #200 admitted he had not checked the resident until 4:00 P.M. On 03/10/14 at 1:48 P.M. Resident #160 was observed in the second floor dining room in a geriatric chair with a blue foam support on the right side on which the resident was leaning. Interview with STNA #201 revealed the resident had an area on her right thigh that was discovered by STNA #200. She revealed that they used 2 people to change her now because the rash was very irritating to the resident at first. When asked if STNA #200 was at the facility, STNA #201 indicated he no longer worked at the facility. On 03/10/14 at 4:24 PM the wound nurse explained that Resident #160 ' s treatment had been completed earlier in the day. Observation of the open area to Resident #160's upper right thigh with the wound nurse revealed a large pink,and red open area rectangular in shape going from the right proximal medial thigh across the flank to the posterior thigh and hip area. Some dried yellow areas were scattered through the pink area. The wound nurse explained the yellow areas were where the pustules had reabsorbed. Some areas of white were where the treatment has not yet absorbed into the yellow areas. The wound edges were linear along the incontinence brief worn by the resident. A pink linear area on abdominal fold which was not open was noted above the incontinence brief. Interview with the director of nursing (DON) on 03/10/14 at 3:22 P.M. confirmed STNA #200's corrective counseling report and indicated she knew it was an issue. In addition, the DON had not reported the injury of unknown origin to the state agency nor had the DON reported the neglect to the state agency. Interview with STNA #200 via telephone on 03/10/14 at 4:12 P.M. revealed he had not checked Resident #160 from 6:00 A.M. through 4:00 P.M. when he found a "burn" on the resident and reported it to the nurse. Interview with the unit coordinator, Licensed Practical Nurse (LPN) #400, on 03/10/14 at 6:00 P.M. revealed she had interviewed STNA #200 regarding the incident. She indicated the facility knew that Resident #160 had been showered at 4:00 A.M., but did not know when or if the resident was checked again until 4:00 P.M. when the area was found. LPN #400 confirmed that it could have been almost 12 hours that the resident had been left in the same incontinence brief and she was supposed to be checked and changed at least every 2 hours. LPN #400 indicated STNA #200 was terminated because he did not take care of another resident. 2. Resident #176 had [DIAGNOSES REDACTED]. The resident's plan of care revealed the resident was at risk for skin breakdown due to requiring assistance with mobility, bowel incontinence, presence of [MEDICAL CONDITIONS], and dementia. The resident was to be turned and repositioned at least every 2 hours or more frequently if persistent redness was noted. The resident was to be transferred by 2 persons with a mechanical lift. Review of a witness statement dated 02/14/14 at 7:00 P.M. by STNA #200 revealed Resident #176 rubbed his right leg against his chair and got a cut and bruising. While getting him ready for bed he observed the injury and reported to the nurse. Review of a corrective counseling report dated 02/14/14 revealed STNA #200 failed to follow orders to lay a resident down in bed resulting in skin integrity issues. Review of a corrective counseling report dated 02/17/14 revealed STNA #200 was terminated for unacceptable work performance as he failed to lie a resident down between meals resulting in skin injury. Review of a witness statement written by the unit coordinator LPN #400 on 02/17/14 revealed she had looked at Resident #176's leg wound on that date after she had been informed of the area via the phone over the weekend. The wound was consistent with the resident rubbing the leg against the metal post on the Broda chair foot rest. LPN #400 called the resident's hospice provider to obtain a foot cradle for the foot rest. Resident #176 had a physician's orders [REDACTED]. Review of a wound evaluation report for Resident #176 dated 02/19/14 revealed the wound was an abrasion measuring 5.8 centimeters (cm) long by 3 cm wide by 0.1 cm deep with a moderate amount of serosnaguinous exudate, 30% granulation, 10% [MEDICATION NAME], with distinct wound edges outlined and attached and a pink wound base. Treatment: Staff noted area while giving routine care. Will cover with [MEDICATION NAME] and border gauze. Area superficial and should be self limiting. The evaluation was conducted by the certified nurse practitioner/certified wound specialist, CNP/CWS #301, who was an outside wound consultant that serviced the facility on a weekly basis. Interview with LPN #400 on 03/10/14 at 6:00 P.M. revealed she had interviewed STNA #200 regarding the injury to Resident #176. She indicated STNA #200 was terminated because he did the same thing to Resident #176 that he had done to Resident #160. He left the resident in his chair and did not check him for serveral hours. Resident #176 was put in his chair at about 11:30 A.M. for lunch and STNA #400 did not check him again until 7:00 P.M. when the injury to his leg was found. LPN #400 explained that the resident had contractures and his legs were always falling off of the footrests. When she interviewed STNA #200 regarding this injury, he admitted he had not checked the resident because the resident had a catheter and did not need checked. The resident was not provided care for more than 7 hours and sustained skin breakdown. This deficiency substantiates Complaint Number OH 897.

Based on clinical record review, resident and staff interviews, review of the facility's investigation of missing medication, and review of the facility's policy for administering medication, the facility failed to ensure Registered Nurse (RN) #165 immediately assessed Resident #40 after he became aware the resident had ingested 23 [MEDICATION NAME] 5 milligram (mg) tablets on 09/18/12. This resulted in Immediate Jeopardy for one resident (#40), who had a known history of drug seeking behavior. The medication cart was left unlocked and unattended by RN #165 on 09/18/12 at 7:00 P.M. and Resident #40 took the [MEDICATION NAME] tablets from the cart. The facility census was 162 residents. On 10/09/12 at 10:35 A.M. the administrator and director of nursing (DON) were notified that Immediate Jeopardy began on 09/18/12 at 7:00 P.M., when Resident #40 was observed by Resident #134 taking medication from an unlocked and unattended medication cart. Resident #134 reported the observation to RN #165, however, the nurse did not respond to Resident #134's allegation at that time. On 09/19/12 at 2:00 A.M., Resident #134 reported this again to LPN #170, who went to RN #165 and they checked the medication cart at 2:30 A.M. They then discovered that Resident #24's blister pack of [MEDICATION NAME] 5 mg tablets was missing from the cart, which was then found at 4:00 A.M. in the trash in Resident #40's room. On 09/19/12 at 4:45 A.M., Resident #40 admitted to RN #165 and LPN #170 that he took a narcotic medication blister pack from the medication cart on the evening of 09/18/12, and ingested 23 tablets by 09/19/12 at 12:00 A.M. RN #165 did not take the resident's vital signs and evaluate the resident's condition until 09/19/12 at 4:50 P.M. Resident #40 refused drug testing and hospital evaluation as ordered by the physician. The Immediate Jeopardy was removed on 09/20/12, when the facility implemented the following corrective actions: ? On 09/19/12, the facility suspended RN #165 and later terminated on 09/27/12. ? On 09/19/12, at 4:00 P.M., observation of all medication carts revealed they were locked, placed in the locked medication room, and were not accessible to residents. ? On 09/19/12 at 4:20 P.M., reconciliation of the narcotic medications with the DON and LPN #171, on the Maple unit where Resident #40 resided, revealed the narcotic counts were correct. ? On 09/19/12, the DON began in-services with 29 nurses on medication cart security, notification of physician, and resident head to toe assessment. All 36 nurses employed by the facility were in-serviced on medication cart security by 09/20/12. ? On 09/20/12, the narcotic drawer was removed from the medication cart and double locked in the medication cart storage area on the Maple unit where Resident #40 resided. ? On 09/20/12, interview with LPN #171, LPN #173, LPN #174, LPN #175, and RN #176 revealed training was provided to ensure the medication cart was locked at all times and not accessible to any resident in the facility, and they were aware of the proper measures to take for safe storage of medications. Although the Immediate Jeopardy was removed when the facility established systems to ensure medication carts were locked and not accessible to residents at all times, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility has not developed policies and procedures, or implemented their plans concerning police notification, narcotic thefts and evaluation of residents after ingestion of unsafe dosages of medications. Findings include: Resident #40's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial Minimum Data Set (MDS) assessment, dated 05/08/12, revealed he was alert, and required extensive assistance of one staff person for bed mobility, transfer, dressing and bathing. Resident #40 was independent with self-propelling his wheelchair in the facility. Review of Resident #40's initial plan of care dated 05/07/12, revealed the resident displayed behavioral symptoms of being non-compliant, manipulative, and was moody with attempted self-harm. Resident #40 also demonstrated drug seeking behavior and pretended to take medications, however would then save them to take at another time. The care plan indicated the resident was to be monitored for any behavior problems, increased depression, non-compliance, and the nurse was to check the resident's mouth when his medication intake was in question. The plan of care did not provide interventions related to drug seeking behavior or monitoring the resident when the medication pass was in process. According to nursing notes written by RN #165 dated 09/19/12 at 7:32 A.M. (late entry), on 09/18/12 at 7:00 P.M., Resident #134 told the nurse that she saw another resident take medications off the cart and place the medications in his shirt. RN #165 counted the narcotics in the box on 09/19/12 at 2:30 A.M. and discovered that the first narcotic card was missing. On 09/19/12 at 2:40 A.M., Resident #134 told RN #165 who the resident was that took the medications from the cart. At 2:50 A.M., RN #165 confronted Resident #40 with the allegation, however, Resident #40 denied taking any medications and said the nurse could search his room. At 3:00 A.M., RN #165 and State-tested Nurse Aide (STNA) #177 searched the smoking area for evidence of the medication, but found none. RN #165 then left the DON a message. At 4:00 A.M., RN #165 and STNA #177 changed Resident #40's dressing, and as STNA #177 was emptying the trash can, she discovered the missing narcotic card was inside a pizza box in the trash. At 4:45 A.M., RN #165, LPN #170, and LPN #182 asked Resident #40 about the narcotic card. At first, Resident #40 denied taking the medication, but then said he took them but he didn't have them on him. He said he took all of the pills in groups of five to eight pills, with the last taken at midnight. RN #165 took Resident #40's vital signs at 4:50 A.M. His pulse oxygenation was 95% on room air; blood pressure 105/59; pulse 110; and respirations 18. The resident showed no signs of being overdosed. At 5:00 A.M., RN #165 notified Clinical Manager (CM) #183 of the incident, and afterward told Resident #40 that he should be drug tested at a hospital. Resident #40 refused but said he would think about it. CM #183 was then notified of the residents' decision. RN #165 did not respond to Resident #134 when she notified him on 09/18/12 at 7:00 P.M. that Resident #40 took narcotic medications from the medication cart, did not complete a thorough medication and narcotic cart check, did not complete an assessment of Resident #40 after the allegation was made, and did not immediately report the allegation to the DON or the physician. According to nurse's notes written by LPN #178 dated 09/19/12 at 7:52 A.M., at 6:00 A.M. he went to see how Resident #40 was feeling. Resident #40 was sitting up in his wheelchair, working on his personal computer, and stated he was feeling good. Resident #40 did not appear sedated, was not slurring his words, and was very alert. LPN #178 asked Resident #40 if he wanted to go to the emergency room to be checked out, but the resident declined. LPN #178 told the resident that if he started to feel strange or too sedated and wanted to go to the hospital to let the nurse know. One-on-one supervision was started at that time, and STNA #181 was to stay with the resident and alert the nurse if Resident #40 had a change in his level of consciousness. There was no evidence that an assessment with vital signs and physician notification was completed by LPN #178. Review of the facility's self-reported incident (SRI) report, dated 09/19/12 at 12:50 P.M., revealed the facility reported an allegation of misappropriation of narcotics by a resident from another resident's supply to the Ohio Department of Health. The facility investigation was not attached to the SRI. Review of a police call report dated 09/20/12 at 4:40 P.M. revealed the police responded to a call placed by the facility on 09/20/12 at 4:45 P.M. of an allegation related to a resident stealing narcotics from the medication cart. According to the report, the officer arrived at 5:00 P.M. and left the facility at 5:34 P.M. No investigative details were available on this report. The police were notified 33 hours after the incident occurred. On 09/19/12 at 3:40 P.M., interview with the DON, with the administrator present, revealed she interviewed RN #165. RN #165 stated although Resident #134 told him she saw Resident #40 take the medication, RN #165 thought nothing about it because nothing was missing on top of the medication cart. Resident #134 told RN #165 she saw Resident #40 take the medication and hide it in his shirt. RN #165 did not take her seriously because of Resident #134's mental health [DIAGNOSES REDACTED]. According to the DON, RN #165 did not question, search, or assess Resident #40 about the allegation until 09/19/12 around 3:00 A.M. when Resident #134 told LPN #170 what she witnessed. LPN #170 then questioned RN #165 about the allegation. The DON stated at that time, RN #165 checked the medication cart and discovered the missing narcotic medication. When it was discovered, RN #165 and LPN #170 confronted Resident #40 about the missing medication. Resident #40 denied taking the medication, and told them to go ahead and search his room, but a room search was not completed. The DON stated the courtyard and parking lot were searched but the missing narcotic medication was not found. According to the DON, at approximately 4:00 A.M. to 4:30 A.M., RN #165 and STNA #177 completed Resident #40's dressing change. After the dressing change, STNA #177 found a pizza box in the trash can which contained the empty missing package for the [MEDICATION NAME] 5 mg tablets that belonged to Resident #24. According to the DON, at the time of discovery, Resident #40's vital signs were stable and he refused to go to the emergency room for drug testing and evaluation. According to the DON, Resident #40 had a history of [REDACTED]. On 09/19/12 at 4:40 P.M., observation of Resident #40 revealed he had to be awakened by the administrator. During a private interview with the resident, he held his eyes open to the size of quarters to focus on the surveyor. His speech was slow and understandable but it took Resident #40 at least one minute to respond to questions. Resident #40's untouched lunch had sat on his wheelchair since 11:30 A.M. According to Resident #40, on 09/18/12 around 7:00 P.M. he was sitting in his wheelchair near the medication cart when RN #165 left the cart and narcotic box unlocked. Resident #40 said RN #165 went into the area where the carts were stored and was gone approximately five minutes. Resident #40 said he opened the medication cart and then the unlocked narcotic box. He said he reached in and opened the narcotic box lid with his thumb and pulled out the first narcotic card he could reach. He then closed the narcotic box and medication cart drawers. He said he hid the medication in his shirt and went to his room. Resident #40 said RN #165 was still in the medication storage room when he left the area to go to his room. Resident #40 said he started taking five or six [MEDICATION NAME] tablets at a time at 8:00 P.M., then took more around 10:00 P.M., and finished the package of pills between 11:00 P.M. and 12:00 A.M. Resident #40 said he took 23 [MEDICATION NAME] 5 mg tablets within a four hour period. Resident #40 said the pills only made him sleep, and he denied suicidal thoughts when he took the medication. He said RN #165 and LPN #170 woke him up around 3:00 A.M. (on 09/19/12), asking him about the missing medication. He told them to search his room; they did not search his room however they searched the courtyard and parking lot. Resident #40 said RN #165 and STNA #177 found the empty medication pack in the pizza box in his trash can when RN #165 changed his dressing. Resident #40 said RN #165 took his blood pressure about 5:00 A.M., and wanted him to go to the hospital for drug testing and evaluation. Resident #40 said he refused to go because he did not want to be drug tested . On 09/20/12 at 9:47 A.M., interview with RN #165 revealed he had been employed by the facility since 07/10/12 and worked the 6:00 P.M. to 6:30 A.M. shift. On 09/18/12 he started his medication pass around 7:00 P.M. He needed to go to the medication storage area on the Maple unit to obtain a health drink. RN #165 said he thought the medication cart and narcotic box were locked when he went into the locked storage area. RN #165 said Resident #40 was seated in a wheelchair at the medication cart when he went into the locked storage area, and when he came out of the storage area, "nothing seemed amiss." He thought he was in the medication storage area approximately five to ten seconds. After about five minutes, Resident #134 came to him (RN #165) and said she saw Resident #40 take something off the top of the medication cart. RN #165 said he didn't think anything about it because nothing was missing on top of the cart. RN #165 said at that time, he did not check the inside of the medication cart or the narcotic box to see if anything was missing, and he didn't ask or check Resident #40 to see if the allegation was true. He did not call the supervisor about the allegation for further guidance. He continued his shift duties and around 2:30 A.M., LPN #170 asked him about Resident #134's allegation that medications were taken from the cart. RN #165 then looked into the allegation as Resident #134 had mentioned this to two nurses. RN #165 stated he then checked the medication cart and discovered that Resident #24's [MEDICATION NAME] was missing. RN #165 said he and LPN #170 went to Resident #134's room and woke her up around 3:00 A.M. to get the resident's name she saw taking the medication. RN #165 and LPN #170 then went to Resident #40's room, woke him up and asked him if he took the medication. Resident #40 denied taking the medication and told RN #165 and #170 to search his room. They did not search his room as they thought he may have taken, hid or destroyed the medication. They searched the courtyard and parking lot because Resident #40 would smoke in those areas, but the medication package was not found. RN #165 said he and STNA #177 went to Resident #40's room at approximately 4:00 A.M. to 4:30 A.M. to change his dressing, and STNA #177 found an empty medication package of [MEDICATION NAME] 5 mg tablets belonging to Resident #24 in an empty pizza box in the trash can of the resident's room. Resident #40 told RN #165 that he took all 23 [MEDICATION NAME] 5 mg tablets between 8:00 P.M. and 12:00 A.M. RN #165 took Resident #40's vital signs at that time and they were stable. RN #165 said he did not notify the physician of the incident but talked to LPN #178 about the incident around 5:30 A.M. to 6:00 A.M. RN #165 asked Resident #40 if he wanted to go the hospital, but Resident #40 refused to go to the emergency room for drug testing and evaluation. RN #165 said he didn't think he left the medication cart and narcotic box unlocked, but he must have for Resident #40 to take Resident #24's [MEDICATION NAME] from the narcotic box. On 09/20/12 at 11:45 A.M., interview with Licensed Social Worker (LSW) #180 revealed she was aware of Resident #40's history of drug seeking behavior. She said a plan of care was not developed to monitor the resident when the medication cart was in use. LSW #180 said she developed a contract if Resident #40 displayed the drug seeking behavior, but since the resident had previously not displayed this behavior, the contact was not signed by Resident #40 or implemented by LSW #180. Review of Resident #40's record revealed a plan of care was not in place to monitor the resident during medication pass. On 09/20/12 at 12:15 P.M., interview with Resident #134 revealed she witnessed Resident #40 take medication from the unlocked medication cart and unlocked narcotic box. Resident #134 said she told the male nurse (RN #165) about it, and he thanked her but did not believe her. Resident #134 said she told her nurse on second floor (LPN #170) about it and she thought the nurse told the "man" and they found the empty medication card with Resident #40. On 09/19/12 at 4:00 P.M., observation of the medication cart and narcotic box on the Maple unit was completed. The medication cart and narcotic box were locked and secured in the locked medication storage area. A narcotic count was conducted with LPN #171, the DON, and the surveyor. The narcotic count was correct. Observation of medication carts on all floors of the facility revealed the carts were locked, secure and non-accessible to residents. On 09/19/12, observation of Resident #24's pharmacy blister pack that was taken from the medication cart on 09/18/12 revealed the medication included in that pack was [MEDICATION NAME] 5 mg tablets. According to Nursing 2003 Drug Handbook, 23rd edition, Lippincott, Williams and Wilkins, the normal dosage of this medication was 5 mg every six hours or 10 mg every 12 hours. On 09/19/12 at 5:50 P.M., review of Resident #40's physician's progress notes dated 09/19/12 at 17:40 revealed the resident "got a hold of 23 Oxy IR 5 mg by theft last pm and took them per hx (history) between 8 P.M. and 11 P.M. Px (Patient) reportedly had an uneventful night and awoke with normal vital signs and oriented sensorium." The physician's note indicated the resident was awake all day without signs of disorientation. The resident seemed remorseful regarding the theft. The physician held the resident's morning dose of [MEDICATION NAME] as a precaution, and the resident's dose of [MEDICATION NAME] was also held. The physician's observations included the resident being "fluent, appropriate, alert, pupils equal EOM intact." The physician's assessment in this note indicated the resident had no sign of overdose, with none actually expected with the resident's "high tolerance." On 09/19/12 at 5:50 P.M., interview with Resident #40's physician's revealed the physician had known the resident since his admission to the facility on [DATE]. The physician stated he had just went through a process of tapering Resident #40 off of his narcotic pain medication when Resident #40 required hospitalization for an infection to his sacral pressure ulcer. The physician stated while Resident #40 was in the hospital, the resident was placed back on narcotic medication undoing everything he had accomplished while tapering the resident off the narcotic medication. The physician stated he completed an evaluation/assessment of Resident #40 and ordered the resident to provide urine for a drug test. The physician stated Resident #40 refused the drug test and refused to go to the hospital for evaluation. The physician confirmed Resident #40 told the physician he had consumed 23 [MEDICATION NAME] 5 mg tablets within four hours between 8:00 P.M. to 12:00 A.M. on 09/18/12. Review of the facility's policy and procedure Medication Administration NS-1197-00 (no date) revealed all medication will be administered only as prescribed and only by a licensed or authorized personnel. Never leave the medication cart unlocked. Never leave medication unattended. This deficiency substantiates Complaint Number OH 277.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to the survey. Based on staff and resident interviews, medical record review, personnel file review, and review of staff statements, the facility failed to ensure Resident #137 was protected from staff to resident abuse which caused bruising, skin tears and psychosocial distress. This resulted in Immediate Jeopardy for one (Resident #137) of 38 sampled residents. Facility census was 168. On 08/23/12 at 5:40 P.M. the director of nursing (DON) and administrator were notified Immediate Jeopardy began on 06/05/12 at 11:00 P.M., when State tested Nursing Assistants (STNAs) #4, #16 and #20 held down Resident #137 as Registered Nurse (RN) #3 administered a [MEDICAL CONDITION] (TB) test which Resident #137 had attempted to verbally and physically refuse. Resident #137 sustained skin tears on his arm and dark purple bruising from his wrist to his elbow. The Immediate Jeopardy was removed and the deficient practice was corrected on 06/07/12 when the facility took the following actions. ? RN #3, STNA #4, STNA #16 and STNA #20 were not allowed to return to work after the completion of their shifts on 06/06/12 and each was terminated on 06/11/12. ? On 06/06/12 at 1:30 P.M., Licensed Social Worker (LSW) #1 spoke with Resident #137 regarding his right to refuse care, medications and treatments. LSW #1 provided support and validation and asked Resident #137 if he wanted to press charges which he did not. Resident #137 verbalized that he was not afraid and felt safe. ? On 06/06/12, all staff present in the facility received in-servicing regarding resident rights and the facility's abuse policies and procedures. All staff not present in the facility on 06/06/12 received in-servicing prior to their return to work. ? On 06/06/12, staff completed 22 random resident interviews regarding dignity, involvement in decisions about daily care, abuse, privacy and sufficient staff. The 22 residents represented each nursing unit of the facility. No trends were identified. ? On 07/26/12, 28 facility incidents involving allegations of abuse and injuries of unknown origin were reviewed. No patterns were noted. All investigations were thorough and complete. ? On 07/26/12, interviews with five STNAs across all three shifts revealed each was knowledgeable regarding appropriate interventions for aggressive or catastrophic reactions and what, when, and to whom to report concerns. ? On 07/26/12, interviews with three front line supervisors who intervened with residents revealed they monitored provision of care and staff/resident interactions. Each supervisor voiced knowledge of the facility's abuse policy and procedures. Findings include: Medical record review revealed Resident #137 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly comprehensive assessment dated [DATE], revealed Resident #137 was able to make himself understood and had a clear comprehension of others. The assessment revealed Resident #137 did not have a history of rejection of care. Interview with Resident #137 on 07/26/12 at 8:35 A.M., revealed he was alert and oriented to time, person and place. His long and short term memory was intact. Resident #137 said that about one month ago at approximately 10:45 P.M., RN #3 told him she was going to administer a [MEDICAL CONDITION] (TB) test. Resident #137 told her no because he had already had one. The nurse returned with STNAs #16 and #20 and told him he had to have the TB test, he refused again. STNAs #16 and #20 then proceeded to hold his legs and RN #3 held his arm but Resident #137 would not remain still; he kept shaking his arm so RN #3 could not get the needle under his skin. RN #3 told the two STNAs holding his legs to get a man to help. One of the STNAs left and came back with STNA #4 who he said was much stronger than him. The two female STNAs held his legs but Resident #137 pulled his arms close to his body and turned into the mattress. However, STNA #4 was able to pull his arm out and push up his sleeve. As the sleeve was pulled up his skin tore and began to bleed. Resident #137 then conceded and RN #3 administered the TB test. Resident #137 said in addition to the skin tears he had dark purple bruising from his wrist to his elbow. Resident #137 said LSW #1 talked with him and the police were called. Resident #137 said he was he was going to leave the facility because of the incident. Observation of Resident #137's left forearm revealed two areas which were pink in color. Resident #137 said the areas were healed skin tears from the incident. A Skin Grid Non-Pressure Related Wounds document dated 06/07/12, revealed a skin tear/abrasion to the left proximal upper extremity measuring 6.5 centimeters (cm) x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of pink watery drainage. Date of wound onset was 06/05/12. Another Skin Grid Non-Pressure Related Wounds document dated 06/07/12 revealed a skin tear/abrasion to the left distal upper extremity measuring 2.5 cm x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of pink water drainage. Date of wound onset was 06/05/12. Interview with the director of nursing on 07/26/12 at 6:30 A.M., confirmed Resident #137, who was alert and oriented and his own responsible party, refused a TB injection on 06/05/12 at approximately 11:00 P.M., and he was forcefully administered the injection. RN #3 enlisted the help of three STNAs (STNAs #4, #16 and #20) who held the resident down while the injection was given. The police were called, but Resident #137 refused to press charges.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review and interview, the facility failed to ensure one alert and oriented resident's dignity was maintained by multiple staff members physically restricting his arms and legs and administering a treatment he had refused resulting in him conceding to the treatment. This affected one resident (Resident #137) of 28 self-reported resident incidents reviewed. The facility census was 168. Findings include: Medical record review revealed Resident #137 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly comprehensive assessment dated [DATE], revealed Resident #137 was able to make himself understood and had a clear comprehension of others. The assessment revealed Resident #137 did not have have a history of rejection of care. Interview with Resident #137 on 07/26/12 at 8:35 A.M,. revealed he was alert and oriented to time, person and place. His long and short term memory were intact. Resident #137 said that about one month ago at approximately 10:45 P.M., a nurse told him she was going to administer a [MEDICAL CONDITION] (TB) test. Resident #137 told her no because he had already had one. The nurse returned with two state tested nurse aides (STNAs) and told him he had to have the TB test and he refused again. The STNAs then preceded to hold his legs and the nurse held his arm but Resident #137 would not remain still; he kept shaking his arm so the nurse could not get the needle under his skin. The nurse told the two STNAs holding his legs to get a man to help. One of the STNAs left and came back with a male STNA who was much stronger then him. The two female STNAs held his legs but Resident #137 pulled his arms close to his body and turned into the mattress. However, the male STNA was able to pull his arm out and push up his sleeve. As the sleeve was pulled up his skin tore and began to bleed. Resident #137 then conceded and the nurse administered the TB test. Resident #137 said in addition to the skin tears he had dark purple bruising from his wrist to his elbow. Resident #137 said the social director talked with him and the police were called. Resident #137 said he was he was looking into leaving the facility because of the incident. Observation of Resident #137's left forearm revealed two areas which were pink in color. Resident #137 said the areas were healed skin tears. A Skin Grid Non-Pressure Related Wounds document dated 06/07/12, revealed a skin tear/abrasion to the left proximal upper extremity measuring 6.5 centimeters (cm) x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of serosanguinous (pink watery) drainage. Date of wound onset was 06/05/12. A Skin Grid Non-Pressure Related Wounds document dated 06/07/12 revealed a skin tear/abrasion to the left distal upper extremity measuring 2.5 cm x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of serosanguinous drainage. Date of wound onset was 06/05/12. This deficiency was removed and the deficient practice was corrected on 06/07/12 when the facility took the following actions. ? RN #3, STNA #4, STNA #16 and STNA #20 were not allowed to return to work after the completion of their shifts on 06/06/12 and each was terminated on 06/11/12. ? On 06/06/12 at 1:30 P.M., Licensed Social Worker (LSW) #1 spoke with Resident #137 regarding his right to refuse care, medications and treatments. LSW #1 provided support and validation and asked Resident #137 if he wanted to press charges which he did not. Resident #137 verbalized that he was not afraid and felt safe. ? On 06/06/12, all staff present in the facility received in-servicing regarding resident rights and the facility's abuse policies and procedures. All staff not present in the facility on 06/06/12 received in-servicing prior to their return to work. ? On 06/06/12, staff completed 22 random resident interviews regarding dignity, involvement in decisions about daily care, privacy and sufficient staff. The 22 residents represented each nursing unit of the facility. No trends were identified. ? On 07/26/12, 28 facility incidents involving allegations of abuse and injuries of unknown origin were reviewed. No patterns were noted. All investigations were thorough and complete. ? On 07/26/12, interviews with five STNAs across all three shifts revealed each was knowledgeable regarding appropriate interventions for aggressive or catastrophic reactions and what, when, and to whom to report concerns. ? On 07/26/12, interviews with three front line supervisors who intervened with residents revealed they monitored provision of care and staff/resident interactions. Each supervisor voiced knowledge of the facility's abuse policy and procedures.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review and interview, the facility failed to ensure one resident was free from physical restraint by multiple staff members during administration of a refused treatment resulting in bruising and skin tears. This affected one resident (Resident #137) of 28 self-reported resident incidents reviewed. The facility census was 168. Findings include: Medical record review revealed Resident #137 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly comprehensive assessment dated [DATE], revealed Resident #137 was able to make himself understood and had a clear comprehension of others. The assessment revealed Resident #137 did not have have a history of rejection of care. Interview with Resident #137 on 07/26/12 at 8:35 A.M., revealed he was alert and oriented to time, person and place. His long and short term memory were intact. Resident #137 said that about one month ago at approximately 10:45 P.M., a nurse told him she was going to administer a [MEDICAL CONDITION] (TB) test. Resident #137 told her no because he had already had one. The nurse returned with two state tested nurse aides (STNAs) and told him he had to have the TB test and he refused again. The STNAs then preceded to hold his legs and the nurse held his arm but Resident #137 would not remain still; he kept shaking his arm so the nurse could not get the needle under his skin. The nurse told the two STNAs holding his legs to get a man to help. One of the STNAs left and came back with a male STNA who was much stronger then him. The two female STNAs held his legs but Resident #137 pulled his arms close to his body and turned into the mattress. However, the male STNA was able to pull his arm out and push up his sleeve. As the sleeve was pulled up his skin tore and began to bleed. Resident #137 then conceded and the nurse administered the TB test. Resident #137 said in addition to the skin tears he had dark purple bruising from his wrist to his elbow. Resident #137 said the social director talked with him and the police were called. Resident #137 said he was he was looking into leaving the facility because of the incident. Observation of Resident #137's left forearm revealed two areas which were pink in color. Resident #137 said the areas were healed skin tears. A Skin Grid Non-Pressure Related Wounds document dated 06/07/12, revealed a skin tear/abrasion to the left proximal upper extremity measuring 6.5 centimeters (cm) x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of serosanguinous (pink watery) drainage. Date of wound onset was 06/05/12. A Skin Grid Non-Pressure Related Wounds document dated 06/07/12 revealed a skin tear/abrasion to the left distal upper extremity measuring 2.5 cm x 1.5 cm x 0.1 cm. The wound bed was pink/red with a small amount of serosanguinous drainage. Date of wound onset was 06/05/12. This deficiency was removed and the deficient practice was corrected on 06/07/12 when the facility took the following actions. ? RN #3, STNA #4, STNA #16 and STNA #20 were not allowed to return to work after the completion of their shifts on 06/06/12 and each was terminated on 06/11/12. ? On 06/06/12 at 1:30 P.M., Licensed Social Worker (LSW) #1 spoke with Resident #137 regarding his right to refuse care, medications and treatments. LSW #1 provided support and validation and asked Resident #137 if he wanted to press charges which he did not. Resident #137 verbalized that he was not afraid and felt safe. ? On 06/06/12, all staff present in the facility received in-servicing regarding resident rights and the facility's abuse policies and procedures. All staff not present in the facility on 06/06/12 received in-servicing prior to their return to work. ? On 06/06/12, staff completed 22 random resident interviews regarding dignity, involvement in decisions about daily care, privacy and sufficient staff. The 22 residents represented each nursing unit of the facility. No trends were identified. ? On 07/26/12, 28 facility incidents involving allegations of abuse and injuries of unknown origin were reviewed. No patterns were noted. All investigations were thorough and complete. ? On 07/26/12, interviews with five STNAs across all three shifts revealed each was knowledgeable regarding appropriate interventions for aggressive or catastrophic reactions and what, when, and to whom to report concerns. ? On 07/26/12, interviews with three front line supervisors who intervened with residents revealed they monitored provision of care and staff/resident interactions. Each supervisor voiced knowledge of the facility's abuse policy and procedures.