Based on observation, review of medical records, review of facility self-reported incidents (SRI), interviews with staff, interview with family, interview with the Wound Care Certified Nurse Practitioner (WCCNP), interview with the Medical Director (MD), review of timecard punches and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident physical and verbal abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 5:30 P.M., the facility failed to recognize and appropriately respond to an allegation of staff-to-resident abuse when Registered Nurse (RN) #500 was witnessed by State Tested Nursing Assistant (STNA) #465 and STNA #501 swearing and yelling at Resident #19. RN #500 removed Resident #19 from the dining room, took the resident to her room, slammed the door and remained alone in the room with Resident #19 for approximately 10 to 15 minutes. During this time, STNA #465 and STNA #501 heard RN #500 yelling and swearing at the resident and heard Resident #19 crying louder. No staff intervention occurred to protect the safety of Resident #19. After RN #500 exited Resident #19 ' s room, the resident was found by STNA #501 to be crying and holding up her arms, which had blood spots on the Geri sleeves she was wearing, and a bruise on her hand. Resident #19 had a total of nine wounds confirmed and measured by WCCNP #502. The facility failed to incorporate effective interventions to prevent further abuse from occurring when RN #500 was permitted to return to work with Resident #19, unsupervised, on 05/27/24. Additionally, a reasonable person in Resident #19's position would potentially have experienced severe psychosocial harm from the verbal and physical abuse/assault. This affected one (#19) of three residents reviewed for abuse. The facility census was 86. On 06/06/24 at 11:35 A.M., the Administrator, Regional Director of Operations (RDO) #503, and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on 05/19/24 at approximately 5:30 P.M. when Resident #19, a cognitively impaired resident residing on the memory care unit, was removed from the dining room by RN #500 who expressed frustration with the resident. RN #500 took Resident #19 to her room, slammed the door and RN #500 remained in the room with Resident #19 for approximately 10 to 15 minutes. During that time, STNA #465 and STNA #501 reported Resident #19 was heard screaming. RN #500 exited the room and STNA #501 entered and found Resident #19 crying, with blood noted on the Geri sleeves on her arms and bruising on her hand. STNA #501 got RN #500 to assess the injuries noted to Resident #19. STNA #501 reported RN #500 stated Wow. She is something else. She tried to get me, and we got into it. Resident #19 was subsequently seen on 05/22/24 by wound care for a total of nine identified wounds as a result of the incident on 05/19/24. The Immediate Jeopardy was removed on 06/07/24 when the facility implemented the following corrective actions: • On 05/19/24 at 9:40 P.M., RN #521 notified Resident #19's daughter/Power of Attorney (POA) of new skin tears and bruising to the resident's arms. • On 05/19/24 at 9:45 P.M., RN #521 notified Assistant Director of Nursing (ADON) # 522 Resident #19 had skin tears and bruising to bilateral arms. • On 05/19/24 at 10:00 P.M., ADON #522 notified the Administrator of the skin tears and bilateral bruising to the arms on Resident #19. • On 05/19/24 at 10:03 P.M., the Administrator notified RDCS #510 of Resident #19's skin tears and bilateral bruising to the arms. • On 05/19/24 at 10:05 P.M., the Administrator notified RDO #503 of Resident #19's injuries. • On 05/19/24 at 10:21 P.M., the Administrator opened an SRI for an injury of unknown origin. • On 05/19/24 at 10:30 P.M., the Administrator interviewed RN #521, via phone, regarding Resident #19's injuries. Per RN #521, STNA #465 and STNA #501 reported Resident #19 had bruising and blood on her Geri sleeves. RN #521 cleansed the resident ' s arms with normal saline (NS), applied Steri-Strips and xeroform dressing and wrapped the resident ' s arms in kerlix. RN #521 performed a skin assessment on Resident #19. • On 05/19/24 at 10:57 P.M., RN #521 notified CNP #524 of Resident #19's new skin tears and bilateral bruising to arms. New orders were obtained for bilateral x-rays of hands and arms. • On 05/20/24 at 9:00 A.M., the Director of Nursing (DON) interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 stated she took Resident #19 to her room, around dinner time, for approximately 10 minutes. RN #500 was suspended pending the outcome of the investigation. • On 05/20/24, Assistant Administrator (AA) #523 interviewed 12 random staff; STNA #602, STNA #627, STNA #609, STNA #620, STNA #515, STNA #631, STNA #671, STNA #673, STNA #675, STNA #676, STNA #619, and Licensed Practical Nurse (LPN) #632 regarding witnessing abuse or reporting abuse, with no findings. • On 05/20/24 beginning at 10:00 A.M. and completed on 05/24/24 at 8:30 P.M., ADON #522 initiated Residents Rights and Abuse Inservice for all staff. This was completed in person and via phone. • On 05/20/24 at 2:00 P.M., Resident #19 was seen by CNP #524. New orders were received for oxycodone for pain from skin tears and bruising and Keflex (antibiotic) for prevention of infection from skin tears. • On 05/20/24 at 3:00 P.M., CNP #524 ordered Resident #19 ' s assist rails be removed from the resident ' s bed to reduce risk of injury. The assist rails were removed from Resident #19's bed at 3:30 P.M. • On 05/21/24 at 7:00 A.M., laboratory (lab) orders, which included a Complete Blood Count (CBC) with differential, was completed for Resident #19. • On 05/21/24 at 12:30 P.M., Resident #19's lab results were received and reported to the physician. No new orders were received. • On 05/21/24 at 1:30 P.M., the Administrator and DON re-interviewed RN #500. No additional information was obtained. • On 05/21/24 at 4:27 P.M., an x-ray was completed for Resident #19's bilateral arms and hands. • On 05/22/24 at 8:00 A.M., Resident #19 was evaluated by WCCNP #502 for skin tears to bilateral arms. • On 05/22/24 from 10:30 A.M. until 11:30 A.M., ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe with no negative findings. • On 05/22/24 from 2:00 P.M. to 4:45 P.M., ADON #522 completed skin assessments of all residents on the memory care unit with no negative findings. • On 05/22/24 at 3:00 P.M., Resident #19 was evaluated by Medical Director (MD) #750. No bruising was noted to the resident ' s face at the time of the examination. A new order was received for referral to hematology. An appointment was scheduled for 05/30/24. • On 05/23/24 at 1:00 P.M., x-ray results of bilateral arms and hands received for Resident #19 with no fractures identified. • On 05/24/24 at 7:21 P.M., the SRI for injury of unknown origin was closed with an unsubstantiated finding. No abuse concerns were identified. • On 05/27/24 at 1:42 P.M., the DON informed RN #500 Resident #19's family requested, due to the incident on 05/19/24, she no longer work with the resident. RN #500 was offered the option to work on another unit. RN #500 refused the reassignment and immediately terminated her employment at the facility. • On 05/29/24 at 10:10 A.M., Resident #19 was seen by psychiatric services, Psychiatric CNP (PCNP) #700, with no negative findings. • On 05/30/24 at 8:00 A.M., Resident #19 was evaluated by hematology and no new orders were received. • On 06/06/24 at 11:50 A.M., the Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19 ' s injuries on 05/19/24. MD #750 indicated it was possible to sustain ecchymosis (bruising) with normal handling. • On 06/06/24 at 12:00 P.M., the Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 on 05/19/24 and abuse likely occurred. • On 06/06/24 at 12:15 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse. The QAPI meeting was attended by the Administrator, RDO #503, RDCS #510, Transportation Director (TD) #525, Activities Director Assisted Living (ADAL) #526, Activities Director (AD) #900, Housekeeping and Laundry Director (HLD) #527, Medical Records Clerk (MRC) #528, Chaplin #529, Central Supply (CS) #530, Marketing Director #531, Scheduler #515, Human Resources Director (HRD) #520, Minimum Data Set Coordinator (MDSC) #532, Business Office Manager (BOM) #533, Admissions/Social Services Designee (SSD) #535, Assistant Administrator (AA) #523, and Director of Maintenance (DOM) #540. • On 06/06/24 at 12:30 P.M., RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility ' s abuse policy and prevention, reporting and investigation of allegations of abuse. Additionally, education was provided related to SRI reporting categories. • On 06/06/24 at 2:35 P.M., the Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse on 05/19/24 involving RN #500. • On 06/06/24 at 2:45 P.M., the Administrator filed a police report with the local police department related to suspected staff-to-resident abuse on 05/19/24. • On 06/06/24 from 8:00 P.M. through 9:30 P.M., department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy. Staff who could not be reached for their education were left a voicemail message indicating they could not return to work until they received the education. • Interviews on 06/06/24 from 8:12 P.M. through 8:15 P.M. with STNA #671, STNA #609 and RN #521 verified each had received education on the facility's abuse prevention and reporting policies and procedures. • On 06/06/24 from 9:00 P.M. through 11:35 P.M., AA #523 completed interviews with all staff who worked on 05/17/24, 05/18/24 and 05/19/24, including STNA #465, STNA #600, STNA #501, STNA #601, STNA #602, STNA #603, STNA #604, STNA #605, STNA #606, STNA #607, STNA #608, STNA #609, STNA #470 and STNA #611, LPN #612, LPN #613, LPN #614, LPN #615 and LPN #616, RN #617 and RN #521, AD # 500, Occupational Therapist (OT) #618, MRC #528, CS #530, Marketing Director #531, TD # 525, HRD #520, DOM #540 and SSD #535. Voicemail messages were left for those staff who could not be reached, including STNA #619, STNA #620, STNA #621, STNA #622, STNA #623, STNA #624, STNA #625, STNA #626, STNA #627, STNA #628, STNA #629, STNA #630, STNA #631 and LPN #632, LPN #633 and LPN #634 to complete interviews. No new information or areas of concern were identified in the staff interviews. • On 06/06/24 at 9:35 P.M., RDCS #510, RDO #503 and the Administrator interviewed WCCNP #502 regarding Resident #19's injuries. • On 06/06/24 from 10:00 P.M. through 11:30 P.M., the DON and ADON #522 completed skin audits on all residents. No negative findings were identified. • Beginning on 06/06/24, the Administrator will review all potential SRIs with [NAME] President of Operations (VPO) #640 and [NAME] President of Clinical Services (VPCS) #641 to ensure the appropriate SRI category is filed and thoroughly investigated. • Beginning on 06/06/24, the Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff. The statement will be signed by the reporting staff and counter signed by the Administrator or designee. • Beginning on 06/06/24, VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks. • Beginning on 06/06/24, RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation was completed. • Beginning on 06/06/24, the Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed. • Beginning on 06/06/24, the DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse. • Beginning on 06/07/24, SSD #535 will meet with Resident #19 three times weekly for four weeks to assess psychosocial well-being and provide additional support. • Results of audits will be reviewed at the QAPI meeting weekly for four weeks, then monthly thereafter to determine on-going compliance. • Review of two (#34 and #62) additional open resident records revealed no concerns related to resident abuse. Although the Immediate Jeopardy was removed on 06/07/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review for Resident #19 revealed an admission date of 01/18/23. Diagnoses included neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder and Pseudobulbar affect (a medical condition that causes sudden and uncontrollable crying and or laughing). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #19 was severely cognitively impaired. Resident #19 used a wheelchair for mobility, required assistance with activities of daily living (ADLs) and the resident had no skin tears. Review of the care plan, dated 04/17/24, revealed Resident #19 had a behavior problem related to crying and yelling. Interventions included to anticipate and meet the needs of the resident and caregivers to provide opportunities for positive interactions, attention, and speak in a calm manner. Review of the Weekly Skin Assessments from 04/01/24 through 05/18/24 for Resident #19 revealed two weekly skin assessments were documented, one on 04/19/24 at 6:45 A.M. completed by LPN #702 and one on 05/03/24 at 6:18 A.M. completed by LPN #703. Each assessment revealed Resident #19 had no bruises, skin tears, lesions, cuts or abrasions noted. Review of the nursing progress notes from 04/01/24 through 05/18/24 revealed no documentation of incidents of bruises, skin tears, lesions, cuts or abrasions for Resident #19. Review of the shower sheets for Resident #19, dated 03/02/24, 03/06/24, 03/08/24, 03/13/24, 03/23/24, 04/27/24, 05/01/24, 05/04/24, 05/08/24, 05/11/24 and 05/15/24 revealed no skin tears or bruising to the arms or face. Review of a nursing progress note, dated 05/19/24 at 10:11 P.M. completed by RN #521, revealed the STNA reported Resident #19 developed skin tears during the day. RN #521 went into the room and observed the resident had multiple skin tears to bilateral upper extremities and new bruising to both hands. The skin tears were cleansed with normal saline, skin folded back over with Steri-Strips and a xerofoam dressing was applied and wrapped in kerlix. ADON #522 was updated, and the daughter was notified. A message was left for the on-call physician for MD #750, awaiting response. Review of a nursing progress note, dated 05/19/24 at 10:53 P.M. completed by RN #521, revealed Resident #19 had kerlix wrapped on her upper extremities before RN #521 cleansed the skin tears and rewrapped. RN #521 asked the STNA if Resident #19 had been wearing Geri sleeves during the day and the STNA confirmed Resident #19 had been wearing them. Review of the facility SRI revealed an injury of unknown origin was initiated by the Administrator for Resident #19, with a date of discovery of 05/19/24. Resident #19 complained of pain and the nurse medicated the resident. The nurse received report from staff that the resident was found with bruises and skin tears on bilateral arms. Resident #19 had a history of removing Geri sleeves and picking at skin. Staff became aware of the injuries on 05/19/24 at 9:45 P.M. The Administrator was notified at 10:00 P.M. by ADON #522, aids reported to the nurse and no other agencies were notified. Interventions included Geri sleeves were discontinued due to resident removing them causing injury. Review of the physician orders dated 05/20/24 revealed Resident #19 was ordered oxycodone oral tablet five milligrams (mg), give 2.5 mg by mouth every six hours as needed for moderate pain and Keflex oral capsule 250 mg give one tablet by mouth every six hours for seven days. Review of the Medication Administration Record (MAR) for Resident #19 for May 2024 revealed Resident #19 used the oxycodone oral tablet five mg tablet 11 times from 05/21/24 through 05/29/24 for pain. Review of a wound care note, dated 05/22/24 completed by WCCNP #502, revealed Resident #19 was being seen for initial consultation for wound care services in the setting of a skilled nursing facility. The note stated Resident #19 was weak and poorly mobile and lived on the memory care unit. Resident #19 was resting in bed and confused. Neurological assessment included positive for weakness and tremors or other involuntary movements. Musculoskeletal assessment included positive for stiffness, tenderness and limitation of motion. Resident #19 was alert and confused. Abnormal findings included traumatic lesion to the head and scattered bruising. Resident #19 was noted to have decreased bulk, tone, limited range of motion, stiffness, disoriented and decreased motor ability. Further review of the documentation revealed the following wounds: • Wound #1: left upper arm skin tear full thickness 4.2 x 3.5 x 0.1 centimeters (cm), scant bloody, ecchymotic (small bruise caused by blood leaking from broken blood vessels into the tissue of the skin or mucous membranes) with flaking skin, dry. Skin flap is partially adhered over wound bed, Steri-Strips intact. • Wound #2: left forearm skin tear full thickness 5.2 x 1.2 x 0.1 cm scant bloody, ecchymotic, dry Steri-Strips in place. The resident had mild transient pain during wound assessment which resolved post assessment. • Wound #3: left wrist skin tear full thickness 1.1 x 0.9 x 0.1 cm moderate bloody ecchymotic, dry. • Wound #4: left inner forearm skin tear full thickness 1.4 x 0.5 x 0.1 scant bloody ecchymotic, dry. Exposed tissue with a portion of dry scabbing, Steri-Strips intact. • Wound #5: left cheek abrasion, intact skin, 5.5 x 3.8 x 0 cm dry ecchymotic skin is flat with light purple and red ecchymotic discoloration. • Wound #6: right forearm skin tear, scabbed/crusted, 11.1 x 6.5 x 0 cm clustered wound, dry, ecchymotic. Scattered skin tears across dorsal side of right forearm. Four areas measured as one with dry intervening skin. Three skin tears located near right wrist (ulnar side), and one skin tear located on the dorsal/medial side of forearm. Steri-Strips intact with dry scabbing. • Wound #7: right chin abrasion, intact skin, 0.8 x 1.0 x 0 cm circular area dark purple, ecchymotic discoloration. • Wound #8: left chest abrasion ecchymosis 2.5 x 2.0 x 0 cm, intact skin. • Wound #9: right hand skin tear full thickness 1.7 x 1.2 x 0.1 cm scant bloody with no visible skin flap. Review of the daily schedule for 05/19/24 revealed from 2:30 P.M. through 6:30 P.M. a total of three staff members were scheduled for the unit/floor Resident #19 resided on. The three staff members scheduled were RN #500, STNA #465 and STNA #501. Observation on 06/03/24 at 1:50 P.M. of Resident #19 revealed the resident was sitting in a wheelchair in her room. Resident #19 was calm and did not respond to questions asked by the surveyor. Resident #19 had bilateral Geri sleeves on, and a visible dressing was located on the right hand, partially covered by the Geri sleeve. The left side of Resident #19 ' s face had three small red areas in a vertical line on the outer portion of her cheek. Resident #19 had a visitor who introduced herself as a sitter. Resident #19 ' s daughter called the sitter on the phone and inquired who was in the room. Concurrent interview with Resident #19 ' s daughter revealed she had a camera placed in the resident ' s room because Resident #19 was hurt by someone at the facility and received skin tears down her arms, a bruise to her right cheek and blood spots to the other side of her face. Resident #19's daughter revealed on 05/19/24 she received a phone call from RN #521, who stated two staff members reported there was an incident. Resident #19's daughter stated it was a nurse who caused the resident ' s injuries and she subsequently quit after being offered assignment on another floor and refused. Interview on 06/03/24 at 1:57 P.M. with STNA #607 revealed she worked on first shift (6:30 A.M. until 3:00 P.M.) on 05/19/24 with Resident #19. STNA #607 stated Resident #19 did not have any bruises or skin tears anywhere during her shift. STNA #607 revealed RN #500 was the nurse that shift, and Resident #19 was a two person assist for care. STNA #607 stated she heard RN #500 took Resident #19 to her room by herself and slammed the door. When the door opened Resident #19 had a bruised face with multiple markings, one on her chest, and multiple open areas to her arms. The family placed a camera in the resident ' s room after that. STNA #607 stated when Resident #19 was taken to her room, she was not beaten up, but when she came out, she was. STNA #607 stated Resident #19 was not able to tell anyone anything that happened. Additionally, STNA #607 stated on 05/22/24, AA #523 asked her questions about Resident #19, such as how she transferred and changed. STNA #607 stated she asked AA #523 why they called her in about the incident on 05/19/24 with Resident #19 when they did not talk to the two STNAs who were working. Interview on 06/03/24 at 4:49 P.M. and 06/04/24 at 4:42 P.M. with the DON confirmed the bruises on Resident #19's face were not mentioned in the SRI or in the nursing notes completed 05/19/24. The DON stated the bruises showed up a few days later and she did not know how Resident #19 got them because she did not investigate the cause. The DON revealed she concluded Resident #19 caused the bruises to her face and the skin tears to her arms herself from picking at the Geri sleeves. The DON confirmed there was no documentation in Resident #19's medical record from 04/01/24 through 05/19/24 of any picking at her Geri sleeves, causing self-inflicted skin tears or bruises. The DON stated Resident #19 had a low blood count, which could have caused the wounds. The DON confirmed Resident #19 received antibiotics (Keflex) for seven days to prevent an infection from the skin tears. Interview on 06/04/24 at 2:53 P.M. with STNA #465 revealed on 05/19/24 she started her shift at 6:30 A.M. and worked until 11:00 P.M. STNA #465 stated when she started her shift, Resident #19 had no skin tears or bruising. Resident #19 frequently cried her usual cry, which was normal for her. STNA #465 stated it was more of a weeping, with no tears, than an actual cry. STNA #465 stated RN #500 was frustrated with Resident #19 throughout the day and RN #500 was frustrated a lot with Resident #19 because of her whining. STNA #465 revealed she heard RN #500 tell Resident #19 to shut up (using profanity) and telling the resident she was so annoying. STNA #465 revealed she reported in the past to the DON that RN #500 would get angry, sear at, and tell Resident #19 to shut up but she was unaware of the DON following up on this. STNA #465 reported on 05/19/24, RN #500 was swearing at Resident #19 and around dinner time, approximately 5:30 P.M., RN #500 removed the resident from the dining room and states she could not take her whining anymore. STNA #465 stated RN #500 took Resident #19 to her room, slammed the door and then she heard the resident screaming louder and RN #500 was screaming at her to shut up, again using profanity towards Resident #19. STNA #465 stated prior to Resident #19 going in the room alone with RN #500, Resident #19 had no injuries to her arms. While Resident #19 had a history of picking her skin, STNA #465 denied the resident ever caused injuries like those she had after RN #500 left the resident ' s room, noting the wounds were horrible. STNA #465 stated while RN #500 was in the room with Resident #19, the resident was screaming a terrified scream. After about 10 to 15 minutes RN #500 exited the resident ' s room and Resident #19 remained in her room. STNA #465 stated STNA #501 went into Resident #19's room and called her to come to into the room to see Resident #19. STNA #465 stated Resident #19 was reaching out and crying real tears, saying look, look and pointing to her Geri sleeves. STNA #465 revealed Resident #19 ' s Geri sleeves were bloody. STNA #465 stated STNA #501 went to get RN #500 and they both went back into Resident #19 ' s room together. RN #500 wrapped Resident #19 ' s arms, but STNA #465 stated not very well. STNA #465 stated RN #500 came out of Resident #19's room and stated the resident had three new skin tears because they got into it and referred to Resident #19 in a derogatory manner. STNA #465 revealed Resident #19's face was red at the time and the bruises appeared the next morning. RN #521 came in at 6:30 P.M. and both STNA #465 and #501 told him he needed to look at Resident #19 because it was bad. RN #521 removed the bandages placed by RN #500 and reported it. STNA #465 confirmed she wrote a statement with all this information on 05/19/24, but no one ever interviewed her about the incident. Interview on 06/04/24 at 3:13 P.M. with STNA #501 revealed she started her shift at 2:30 P.M. on 05/19/24. Resident #19 was her assigned resident. STNA #501 revealed Resident #19 would make whining noises on and off daily, but never had tears. STNA #501 stated Resident #19 had no skin tears, bleeding, or bruising at the beginning of her shift on 05/19/24. Around dinner time, Resident #19 was in the dining room making whining noises. RN #500 was yelling this is enough and took Resident #19 to her room. STNA #501 stated she heard Resident #19 ' s door slam, with RN #500 remaining alone in the room with the resident. STNA #501 stated she heard Resident #19 screaming very loud and crying louder and louder. STNA #501 stated after RN #500 exited the resident ' s room she entered and found Resident #19 crying real tears, there was blood on her Geri sleeves and upper arms and bruising on her hand. STNA #501 stated she went to get RN #500 who stated Resident #19 was something else, she tried to get me, and we got into it. STNA #501 stated Resident #19 had a history of picking her skin, but she had never seen the resident cause wounds like those she had that day. STNA #501 stated when RN #521 came in for his shift, she reported the incident to him. Interview on 06/04/24 at 4:23 P.M. with the Administrator confirmed a police report was never made regarding the allegation made on 05/19/24 between RN #500 and Resident #19. Interview on 06/05/24 at 10:52 A.M. with WCCNP #502 revealed she visited residents at the facility weekly for wound assessment. WCCNP #502 revealed she had never visited Resident #19 prior to 05/22/24 and noted the resident had multiple skin tears during her assessment on 05/22/24. WCCNP #502 revealed bruising could occur easier with contact if the person had a low blood count and low platelets; however, WCCNP #502 confirmed Resident #19 ' s skin tears and abrasions were not consistent with low hemoglobin, and they were not consistent with self-picking. WCCNP #502 stated staff indicated Resident #19 could be combative, but the resident was not anxious during her examination. WCCNP #502 stated Resident #19 had no evidence of fingernail scratches, which would likely be seen if someone is self-picking their skin. Additionally, WCCNP #502 stated Steri-Strips were needed to reapproximate the skin flaps, also not consistent with skin picking. WCCNP #502 stated she did not believe Resident #19 ' s wounds were the result of skin picking or low hemoglobin levels. At the time of her examination, WCCNP #502 asked the nurse what happened, who stated she was unsure, but WCCNP #502 stated she wanted to get to the bottom of how Resident #19 sustained the wounds because they were bad. Lastly, WCCNP #502 stated all of the wounds happened at the same time, it was not a here and there and it was all one incident. Interview on 06/05[TRUNCATED]

Based on medical record review, review of self-reported incidents (SRI), interviews with staff, interview with the Medical Director (MD), interview with the Wound Care Nurse Practitioner (WCCNP), review of staff schedules, review of the facility investigation and review of the facility policy, the facility failed to ensure an allegation of staff-to-resident abuse was accurately reported and thoroughly investigated to protect residents from further potential abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 10:21 P.M. the Administrator filed an SRI for an injury of unknown origin after State Tested Nursing Assistant (STNA) #465 and STNA #501 alleged verbal and physical abuse of Resident #19 by Registered Nurse (RN) #500. Resident #19 sustained nine separate wounds as a result of the incident. The facility failed to accurately file an SRI, failed to interview staff witnesses (STNA #465 and STNA #501) and medical providers regarding the potential cause of Resident #19 ' s injuries, failed to validate staff witness statements, failed to file a police report and failed to notify the Ohio Board of Nursing of suspected staff-to-resident abuse. Furthermore, without thoroughly investigating the allegation, the facility permitted RN #500 to return to work with Resident #19, unsupervised, on 05/27/24. RN #500 subsequently terminated her employment with the facility after Resident #19's family requested she no longer work with the resident. This affected one (#19) of four residents reviewed for abuse investigations. The facility census was 86. On 06/06/24 at 11:35 A.M., the Administrator, Regional Director of Operations (RDO) #503, and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on 05/19/24 at 10:21 P.M. when the Administrator initiated an SRI for an injury of unknown origin for Resident #19 following an allegation of staff-to-resident abuse, where Resident #19 sustained nine separate wounds as a result of the incident. The facility failed to accurately identify and thoroughly investigate the allegation of staff-to resident abuse and RN #500 was permitted to return to work on 05/27/24, unsupervised, with Resident #19. The Immediate Jeopardy was removed on 06/06/24 when the facility implemented the following corrective actions: • On 05/19/24 at 10:21 P.M., the Administrator opened as SRI for an injury of unknown origin. • On 05/19/24 at 10:30 P.M., the Administrator interviewed RN #521, via phone, regarding Resident #19's injuries. Per RN #521, STNA #465 and STNA #501 reported Resident #19 had bruising and blood on her Geri sleeves. RN # 521 cleansed the resident's arms with normal saline (NS), applied Steri-Strips and xeroform dressing and wrapped the resident's arms in kerlix. RN #521 performed a skin assessment on Resident #19. • On 05/19/24 at 10:57 P.M., RN #521 notified Certified Nurse Practitioner (CNP) #524 of Resident #19's new skin tears and bilateral bruising to her arms. New orders were obtained for bilateral x-rays of the resident ' s hands and arms. • On 05/20/24 at 9:00 A.M., the DON interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 stated she took Resident #19 to her room, around dinner time, for approximately 10 minutes. RN #500 was suspended pending the outcome of the investigation. • On 05/20/24, Assistant Administrator (AA) #523 interviewed 12 random staff; STNA #602, STNA #627, STNA #609, STNA #620, STNA #515, STNA #631, STNA #671, STNA #673, STNA #675, STNA #676, STNA #619, and Licensed Practical Nurse (LPN) #632 regarding witnessing abuse or reporting abuse, with no findings. • On 05/20/24, beginning at 10:00 A.M. and completed on 05/24/24 at 8:30 P.M., Assistant Director of Nursing (ADON) #522 initiated Residents Rights and Abuse Inservice for all staff. This was completed in person and via phone. • On 05/21/24 at 1:30 P.M., the Administrator and DON re-interviewed RN #500. No additional information was obtained. • On 05/22/24, from 10:30 A.M. until 11:30 A.M., ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe, with no negative findings. • On 05/22/24 from 2:00 P.M. to 4:45 P.M., ADON #522 completed skin assessments on all residents on the memory care unit with no negative findings. • On 05/24/24 at 7:21 P.M., an SRI for injury of unknown origin was closed with an unsubstantiated finding. No abuse concerns were identified. • On 05/27/24 at 1:42 P.M., RN #500 was informed by the DON that Resident #19's family requested, due to the incident on 05/19/24, she no longer work with the resident. RN #500 was offered the option to work on another unit. RN #500 refused the reassignment and immediately terminated her employment at the facility. • On 06/06/24 at 11:50 A.M., the Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19 ' s injuries on 05/19/24. MD #750 indicated ecchymosis (bruising) could be caused by natural handling of residents. • On 06/06/24 at 12:00 P.M., the Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 on 05/19/24, and abuse likely occurred. • On 06/06/24 at 12:15 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse. The QAPI meeting was attended by the Administrator, RDO #503, RDCS #510, Transportation Director (TD) #525, Activities Director Assisted Living (ADAL) #526, Activities Director (AD) #900, Housekeeping and Laundry Director (HLD) #527, Medical Records Clerk (MRC) #528, Chaplin #529, Central Supply (CS) #530, Marketing Director #531, Scheduler #515, Human Resources Director (HRD) #520, Minimum Data Set Coordinator (MDSC) #532, Business Office Manager (BOM) #533, Admissions/Social Services Designee (SSD) #535, Assistant Administrator (AA) #523, and Director of Maintenance (DOM) #540. • On 06/06/24 at 12:30 P.M., RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility's abuse policy and prevention, reporting and investigation of allegations of abuse. Additionally, education was provided related to SRI reporting categories. • On 06/06/24 at 2:35 P.M., the Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse on 05/19/24 involving RN #500. • On 06/06/24 at 2:45 P.M., the Administrator filed a police report with the local police department related to suspected staff-to-resident abuse on 05/19/24. • On 06/06/24 from 8:00 P.M. through 9:30 P.M., department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy. Staff who could not be reached for their education were left a voicemail message indicating they could not return to work until they received the education. • Interviews on 06/06/24 from 8:12 P.M. through 8:15 P.M. of STNA #671, STNA #609 and RN #521 confirmed the facility provided education on the facility's abuse prevention and reporting policies and procedures. • On 06/06/24 from 9:00 P.M. through 11:35 P.M., AA #523 completed interviews with all staff who worked on 05/17/24, 05/18/24 and 05/19/24, including STNA #465, STNA #600, STNA #501, STNA #601, STNA #602, STNA #603, STNA #604, STNA #605, STNA #606, STNA #607, STNA #608, STNA #609, STNA #470 and STNA #611, LPN #612, LPN #613, LPN #614, LPN #615 and LPN #616, RN # 617 and RN #521, AD # 900, Occupational Therapist (OT) #618, MRC #528, CS # 530, Marketing Director #531, TD #525, HRD #520, DOM #540 and SSD #535. Voicemail messages were left for those staff who could not be reached, including STNA #619, STNA #620, STNA #621, STNA #622, STNA #623, STNA #624, STNA #625, STNA #626, STNA #627, STNA #628, STNA #629, STNA #630 and STNA #631 and LPN #632, LPN #633 and LPN #634 to complete interviews. No new information or areas of concern were identified in the staff interviews. • On 06/06/24 at 9:35 P.M., RDCS #510, RDO #503 and the Administrator interviewed Wound Care Certified Nurse Practitioner (WCCNP) #502 regarding Resident #19's injuries. WCCNP #502 indicated she could see how skin damage could be caused if staff were doing something with Resident #19 because the resident had thin, fragile skin and was elderly. • On 06/06/24 from 10:00 P.M. through 11:30 P.M., the DON and ADON #522 completed skin audits on all residents. No negative findings were identified. • Beginning on 06/06/24, the Administrator will review all potential SRIs with [NAME] President of Operations (VPO) #640 and [NAME] President of Clinical Services (VPCS) #641 to ensure the appropriate SRI category is filed and thoroughly investigated. • Beginning on 06/06/24, the Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff. The statement will be signed by the reporting staff and counter signed by the Administrator or designee. • Beginning on 06/06/24, VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks. • Beginning on 06/06/24, RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation is completed. • Beginning on 06/06/24, the Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed. • Beginning on 06/06/24, the DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse. • Results of audits will be reviewed at the weekly QAPI meeting for four weeks then monthly thereafter to determine on-going compliance. • Review of two (#34 and #62) additional open resident records revealed no concerns related to abuse reporting. Although the Immediate Jeopardy was removed on 06/06/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review for Resident #19 revealed an admission date of 01/18/23. Diagnoses included neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder and Pseudobulbar affect (a medical condition that causes sudden and uncontrollable crying and or laughing). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #19 was severely cognitively impaired. Resident #19 used a wheelchair for mobility, required assistance with activities of daily living (ADLs) and the resident had no skin tears identified. Review of the care plan, dated 04/17/24, revealed Resident #19 had a behavior problem related to crying and yelling. Interventions included to anticipate and meet the needs of the resident and caregivers to provide opportunities for positive interactions, attention, and speak in a calm manner. Review of the Weekly Skin Assessments from 04/01/24 through 05/18/24 for Resident #19 revealed two weekly skin assessments were documented, one on 04/19/24 at 6:45 A.M. completed by LPN #702 and one on 05/03/24 at 6:18 A.M. completed by LPN #703. Each assessment revealed Resident #19 had no bruises, skin tears, lesions, cuts or abrasions noted. Review of the nursing progress notes from 04/01/24 through 05/18/24 revealed no documentation of incidents of bruises, skin tears, lesions, cuts or abrasions for Resident #19. Review of the shower sheets for Resident #19, dated 03/02/24, 03/06/24, 03/08/24, 03/13/24, 03/23/24, 04/27/24, 05/01/24, 05/04/24, 05/08/24, 05/11/24 and 05/15/24 revealed no skin tears or bruising to the arms or face. Review of a nursing progress note, dated 05/19/24 at 10:11 P.M. completed by RN #521, revealed the STNA reported Resident #19 developed skin tears during the day. RN #521 went into the room and observed the resident had multiple skin tears to bilateral upper extremities and new bruising to both hands. Treatment was provided for the skin tears. RN #521 notified ADON #522 and the resident's daughter. A message was left for the on-call physician for MD #750, awaiting response. Review of a nursing progress note, dated 05/19/24 at 10:53 P.M. completed by RN #521, revealed Resident #19 had kerlix wrapped on her upper extremities before RN #521 cleansed the skin tears and rewrapped. RN #521 asked the STNA if Resident #19 had been wearing Geri sleeves during the day and the STNA confirmed Resident #19 had been wearing them. Review of the facility SRI revealed an injury of unknown origin was initiated by the Administrator for Resident #19, with a date of discovery of 05/19/24. Resident #19 complained of pain and the nurse medicated the resident. The nurse received report from staff that the resident was found with bruises and skin tears on bilateral arms. Resident #19 had a history of removing Geri sleeves and picking at skin. Staff became aware of the injuries on 05/19/24 at 9:45 P.M. The Administrator was notified at 10:00 P.M. by ADON #522, aids reported to the nurse and no other agencies were notified. Interventions included Geri sleeves were discontinued due to resident removing them, causing injury. Review of a wound care note, dated 05/22/24 and completed by WCCNP #502, revealed abnormal findings included traumatic lesion to the head and scattered bruising. Further review of the documentation revealed Resident #19 had six separate wounds, including skin tears and bruising, to her left upper arm, left forearm, left wrist, left inner forearm, right forearm, and right hand. Additionally, Resident #19 had a left cheek abrasion with bruising, right chin abrasion with bruising, and a left chest abrasion with bruising. Review of the daily schedule for 05/19/24 revealed from 2:30 P.M. through 6:30 P.M. a total of three staff members were scheduled for the unit Resident #19 resided on. The three staff members scheduled were RN #500, STNA #465 and STNA #501. Review of the facility investigation file revealed seven written staff statements. One from STNA #465, STNA #501 and STNA #607, two from RN #500, one from AD #900, and one from RN #521. STNA #607, AD #900 and RN #521 were not working during the time of the incident on 05/19/24. Review of a handwritten statement on lined notebook paper, dated 05/19/24 and untimed, revealed at mealtime, Resident #19 was yelling, screaming and was very disruptive. When STNA #501 removed the tray, she noticed blood on Resident #19's sleeves and reported this to the nurse. The nurse removed Resident #19 from the dining room and took her to her room. The statement included a cursive signature indicating STNA #465 signed the document. Review of a typed statement, dated 05/19/24 and untimed, revealed during dinner time, Resident #19 was making disruptive noises in the dining room. She was crying and screaming. While removing her dinner tray, blood stains were noted on her sleeves and the resident had bruising. STNA #501 reported this to the nurse, who removed Resident #19 and took her back to her room. The statement included a cursive signature indicating STNA #501 signed the document. Review of a typed witness statement, dated 05/20/24 and untimed, confirmed the DON completed a telephone interview with RN #500 related to the events on 05/19/24 with Resident #19. RN #500 indicated Resident #19 was aggressive toward her while attempting to administer medication. Review of a handwritten witness statement, completed by the Administrator and dated 05/21/24, revealed RN #500 was again interviewed over the phone, with the DON present, with no new information provided. Review of a typed statement, dated 05/19/24 and untimed, revealed the Administrator interviewed RN #521 via telephone. RN #521 stated he received in report Resident #19 had behaviors during the day and RN #500 had used derogatory language while speaking about the resident. The aides (STNA #465 and STNA #501) had reported Resident #19 had bruising and blood on her Geri sleeves. RN #521 provided treatment to the resident's arms and notified the Power of Attorney (POA), Certified Nurse Practitioner (CNP) and ADON #522 of new skin tears and bruising. Observation on 06/03/24 at 1:50 P.M. of Resident #19 revealed the resident was sitting in a wheelchair in her room. Resident #19 was calm and did not respond to questions asked by the surveyor. Resident #19 had bilateral Geri sleeves on, and a visible dressing was located on the right hand, partially covered by the Geri sleeve. The left side of Resident #19's face had three small red areas in a vertical line on the outer portion of her cheek. Resident #19 had a visitor who introduced herself as a sitter. Resident #19's daughter called the sitter on the phone and inquired who was in the room. Concurrent interview with Resident #19's daughter revealed she had a camera placed in the resident's room because Resident #19 was hurt by someone at the facility and received skin tears down her arms, a bruise to her right cheek and blood spots to the other side of her face. Resident #19's daughter revealed on 05/19/24 she received a phone call from RN #521, who stated two staff members reported there was an incident. Resident #19's daughter stated it was a nurse who caused the resident ' s injuries and she subsequently quit after being offered assignment on another floor and refused. Interview on 06/03/24 at 1:57 P.M. with STNA #607 revealed she worked first shift (6:30 A.M. until 3:00 P.M.) on 05/19/24 with Resident #19, who had no injuries during her shift. STNA #607 stated she was interviewed by AA #523 regarding the incident. STNA #607 stated she heard RN #500 caused Resident #19's injuries but she had no direct knowledge of the incident between RN #500 and Resident #19 and asked AA #523 why she was not talking to the staff who were there during that time. Interview on 06/03/24 at 4:49 P.M. and 06/04/24 at 4:42 P.M. with the DON confirmed the bruises on Resident #19's face were not mentioned in the SRI or in the nursing notes completed 05/19/24. The DON stated the bruises showed up a few days later and she did not know how Resident #19 got them because she did not investigate the cause. The DON revealed she concluded Resident #19 caused the bruises to her face and the skin tears to her arms herself from picking at the Geri sleeves. The DON confirmed there was no documentation in Resident #19's medical record from 04/01/24 through 05/19/24 of any picking at her Geri sleeves, causing self-inflicted skin tears or bruises. The DON stated Resident #19 had a low blood count, which could have caused the wounds. Interview on 06/04/24 at 2:53 P.M. with STNA #465 revealed on 05/19/24 she started her shift at 6:30 A.M. and worked until 11:00 P.M. STNA #465 stated when she started her shift, Resident #19 had no skin tears or bruising. STNA #465 confirmed she witnessed the incident on 05/19/24 at approximately 5:30 P.M. between RN #500 and Resident #19, in which RN #500 used derogatory language, removed the resident from the dining room, remained alone with the resident in her room and the resident subsequently had nine wounds. STNA #465 reported RN #500 stated the resident had three new skin tears because they got into it and referred to Resident #19 in a derogatory manner. STNA #465 stated RN #521 came in at 6:30 P.M. and both she and STNA #501 told him he needed to look at Resident #19 because her wounds were bad. RN #521 assessed Resident #19 and reported the incident. STNA #465 confirmed she wrote a witness statement on 05/19/24. Interview on 06/04/24 at 3:13 P.M. with STNA #501 revealed she started her shift at 2:30 P.M. on 05/19/24. Resident #19 was her assigned resident, and she had no skin tears or other injuries. STNA #501 verified she witnessed the incident between RN #500 and Resident #19 on 05/19/24, reporting around dinner time, RN #500 stated she had enough of Resident #19, removed her from the dining room, and was alone with the resident in her room. Resident #19 was heard screaming and after RN #500 exited the resident's room, the resident had blood on her Geri sleeves and upper arms and bruising on her hand. STNA #501 reported RN #500 stated Resident #19 was something else, she tried to get me, and we got into it. STNA #501 confirmed she reported the incident to RN #521 when he arrived for his shift at 6:30 P.M. and a handwritten witness statement was completed before she left that night. Review of the witness statement, handwritten on notebook paper and dated 05/19/24, on 06/04/24 at 4:35 P.M. with STNA #465, revealed the document signed with STNA #465's name was not the statement she had written on 05/19/24. STNA #465 further confirmed the handwriting and signature on the document was not hers, her statement was written on plain white paper (no lines) and the statement did not reflect her report of events on 05/19/24. STNA #465 stated her earlier interview with the surveyor was what she had written in her witness statement. STNA #465 had no knowledge of who wrote the statement that was included in the facility investigation and verified the facility administration never interviewed her regarding the incident on 05/19/24. Interview on 06/04/24 at 4:23 P.M. with the Administrator confirmed a police report was never filed regarding the incident on 05/19/24 between RN #500 and Resident #19, nor was RN #500 reported to the Ohio Board of Nursing for suspected abuse. Interview on 06/05/24 at 10:52 A.M. with WCCNP #502 revealed she had never visited Resident #19 prior to 05/22/24 and noted the resident had multiple skin tears during her assessment on 05/22/24. WCCNP #502 stated bruising could occur easier with contact if the person had a low blood count and low platelets. However, WCCNP #502 confirmed Resident #19's skin tears and abrasions were not consistent with low hemoglobin, and they were not consistent with self-picking. WCCNP #502 stated Resident #19 had no evidence of fingernail scratches, which would likely be seen if someone was self-picking their skin. Additionally, WCCNP #502 stated Steri-Strips were needed to reapproximate the skin flaps, also not consistent with skin picking. WCCNP #502 stated she did not believe Resident #19's wounds were the result of skin picking or low hemoglobin levels. WCCNP #502 confirmed she was not interviewed regarding her assessment findings and opinion regarding Resident #19's wounds. Interview on 06/05/24 at 12:27 P.M. with the DON verified RN #500 was permitted to return to work on Resident #19's unit on 05/27/24. RN #500 quit at approximately 1:42 P.M. that day, after Resident #19's family requested she not work with the resident following the incident on 05/19/24. The DON confirmed RN #500 was offered reassignment to another floor, but she refused, and terminated her employment that day. Review of the typed witness statement dated 05/19/24 and located in the facility's investigation file, on 06/05/24 at 3:23 P.M. with STNA #501 revealed the statement was not the handwritten statement she completed on 05/19/24, following the incident with RN #500 and Resident #19. STNA #501 stated she completed a handwritten statement, not typed. STNA #501 stated I wrote my own statement. I did not sign this. This is not mine. I have never seen this before. What I told you was accurate. That is my name, but I did not say that or sign that. Where is mine? STNA #501 verified she was not interviewed by the facility administration regarding the incident on 05/19/24. Interview on 06/05/24 at 3:40 P.M. with MD #750 confirmed he was the primary care physician for Resident #19. MD #750 revealed Resident #19's platelets were not low enough to cause spontaneous bleeding. MD #750 stated he was unaware of the extent of the incident involving RN #500 and Resident #19 and verified he had not been interviewed by the facility regarding the resident's injuries. Interview on 06/05/24 at 4:30 P.M. with the DON revealed STNA #465 and STNA #501's witness statements included in the facility's investigation file were placed under the Administrator's door. The DON stated she assumed both STNA #465 and STNA #501 wrote the statements themselves. The DON confirmed STNA #465 and STNA #501 were the only two staff members present during the incident and confirmed neither were interviewed. The DON stated she did not know where STNA #465 and STNA #501's written statements from 05/19/24 were and did not know where the two statements included in the investigation file came from. Interview on 06/05/24 at 4:34 P.M. with Administrator revealed she did not know if the witness statements included in the facility investigation from STNA #465 and STNA #501 were placed under the DON's door or hers after they were written. The Administrator stated she did not know who wrote or signed the witness statements and confirmed there were no other witness statements she had from STNA #465 or STNA #501. The Administrator verified she did not interview either STNA #465 or STNA #501, who were the only staff witnesses, regarding the incident. The Administrator stated she interviewed RN #500, who she thought was the important one to interview. The DON entered during the interview with the Administrator. Both the DON and the Administrator confirmed STNA #465 and STNA #501 were the only two witnesses and neither were ever interviewed regarding the incident on 05/19/24 between RN #500 and Resident #19. Additionally, the DON and Administrator confirmed neither WCCNP #502 nor MD #750 were interviewed regarding Resident #19's injuries. Both stated they suspected Resident #19's injuries were due to Resident #19 having a low platelet count and picking her own skin. Interview on 06/06/24 at 8:15 P.M. with RN #521 revealed on 05/19/24 he began his shift at 6:30 P.M. RN #500 gave him the nursing shift to shift report, using an explicative to describe Resident #19, and stated the resident had behaviors and got skin tears. RN #521 stated he notified the physician, family, and ADON #522 of the resident's wounds. RN #521 confirmed both STNA #465 and STNA #501 provided handwritten statements that night on plain white paper, and he placed them in the DON's mailbox. Review of the policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 11/01/19 revealed the facility will not tolerate Abuse, Neglect, Exploitation or the Misappropriation of Resident Property. Facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health (ODH). In cases where a crime is suspected, staff should also report the same to local law enforcement. The definition of abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. In the case of staff to resident abuse, the facility will follow the facilities procedure for discipline or dismissing an employee depending on the circumstances and results of the investigation. The investigation protocol included to interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee the day of the incident. This deficiency represents non-compliance investigated under Complaint Number OH00153215.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of medical records, interviews with staff, review of hospital records, review of the Certificate of Death, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, the facility failed to provide necessary care and services to prevent and subsequently promote healing and/or worsening of a facility acquired pressure ulcer. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death, when the facility failed to implement interventions to prevent the development of a facility acquired pressure ulcer, such as turning and repositioning and incontinence care for Resident #91, who was at risk for pressure ulcer development. Furthermore, the facility failed to timely and accurately complete skin assessments to identify the resident ' s pressure ulcer, failed to complete wound assessments and failed to provide the necessary care and treatments to promote healing and/or worsening of the wound. Consequently, on [DATE], Resident #91 was transferred to the hospital and admitted due to a fall and weakness secondary to Escherichia coli (E. Coli) bacteremia from an infected decubitus ulcer (pressure ulcer). Resident #91 subsequently died on [DATE]. The primary cause of death was E. coli sepsis (A life-threatening complication of an infection) due to an infected decubitus ulcer. Additionally, Actual Harm occurred to Resident #34, who was at risk for pressure ulcer development and dependent on staff for turning and repositioning and incontinence care, when Resident #34 was not provided weekly assessments of a stage three pressure ulcer, physician ordered pressure ulcer treatments were not completed as ordered, and the resident was subsequently admitted to the hospital on [DATE] with septic shock in setting of coccygeal wound. Lastly, the facility failed to provide care and services for the prevention, identification, and treatment of a pressure ulcer at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) for one (#40) additional resident reviewed for pressure ulcers. This affected three (#91, #34, #40) of four residents reviewed for pressure ulcers. The facility identified a total of 13 residents with pressure ulcers. The facility census was 86. On [DATE] at 1:49 P.M., the Administrator and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on [DATE] when Resident #91 when was identified to have a pressure wound to the right and left buttocks. Assistant Director of Nursing (ADON) #522 verified wound treatments to the right and left buttocks were not completed as ordered and could not verify Resident #91 received any care planned interventions for the prevention of pressure ulcers. On [DATE], the wound on the left and right buttock merged into one large wound to the sacrum, measuring 7.0 centimeters (cm) by 6.0 cm by 0.0 depth. The wound was noted with inflammation and induration (hardening of the skin and subcutaneous tissue, which may be secondary to infection). The wound had 10% granulation, 90% slough, moderate amount of serosanguinous drainage, and surgical debridement was provided. Resident #91 was not treated for any infection while at the facility. On [DATE], Resident #91 was sent to the hospital following a fall. The hospital notes indicated Resident #91 was admitted after a fall and weakness secondary to E. coli bacteremia from an infected decubitus ulcer. Resident #91 was subsequently discharged from the hospital to hospice care on [DATE] and died on [DATE]. Review of the death certificate revealed the immediate cause of death was E. coli sepsis due to an infected decubitus ulcer. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] between 2:09 P.M. and 5:49 P.M., Regional Minimum Data Set Coordinator (RMDSC) #914 and Minimum Data Set Coordinator (MDSC) #915 completed an assessment of all resident care plans to ensure they were updated with appropriate interventions to prevent and treat pressure ulcers. • On [DATE] between 2:20 P.M. and 8:10 P.M., Licensed Practical Nurse (LPN) #916, LPN #917 and ADON #522 completed a skin assessment on all residents. There were no new wounds noted on the whole house skin assessments. • On [DATE] at 2:45 P.M., a Root Cause Analysis was completed by RDCS #510, Regional Director of Operations (RDO) #503 and the Administrator. It was determined the Root Cause was the Director of Nursing (DON) and ADON #522 did not ensure preventative interventions and necessary care and treatments were in place to prevent, promote healing and/or worsening of Resident #91's wound. • On [DATE] at 2:58 P.M., RDCS #510 re-educated ADON #522 on the facility's Wound Care policy, Prevention of Pressure Ulcers/Injuries, and New Admission/re-admission Skin and Wound Care Best Practices Policy. RDCS #510 will provide the education to the DON prior to returning to work on [DATE]. • On [DATE] from 3:15 P.M. through 5:30 P.M., RDCS #510 provided in-service education for all licensed nurses, in person and via telephone, on the facility ' s Wound Care Policy, Prevention of Pressure Ulcers/Injuries, and New Admission/re-admission Skin and Wound Care Best Practices Policy. The following licensed nurses received the education: LPN #918, LPN #919, LPN #920, LPN #921, LPN #615, LPN #632, LPN #634, LPN #922, LPN #923, LPN #924, LPN #925, LPN #926, and Registered Nurse (RN) #521. Any licensed nurse who could not be reached will receive the education from ADON #522 or RDCS #510 prior to their next scheduled shift. • On [DATE] at 4:12 P.M., an AD Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, with Medical Director (MD) #750, to review the Immediate Jeopardy findings, discuss ensuring necessary care and treatments are in place to prevent and promote healing and/or worsening of wounds, and review facility polices related to prevention, identification, and investigation. Additional QAPI meeting attendees included RDO #503, RCDS #510, MDSC #915 (via phone), RMDSC #914 (via phone), and Assistant Administrator (AA) #523. • On [DATE] from 5:40 P.M. through 8:30 P.M., RDCS #510 provided wound care education, including policies and procedures, in person and via telephone, for State Tested Nursing Assistants (STNA) #932, STNA #933, STNA #934, STNA #608, STNA #627, STNA #609, STNA #501, STNA #935, STNA #936, STNA #602, STNA #625, STNA #911, STNA #624, STNA #628, STNA #607, STNA #622, STNA #937, STNA #938, STNA #620, STNA #939, STNA #604, STNA #629, STNA #940, STNA #673 and STNA #941. Any STNA who could not be reached will receive the education from the DON or designee prior to their next scheduled shift. • On [DATE] from 6:00 P.M. through 8:00 P.M., RDCS #510 completed a Braden Scale (assessment used for predicting pressure ulcer risk) audit for all residents. • Beginning on [DATE], the DON or designee will audit all new admissions, Monday through Friday, for four weeks to ensure skin prevention/treatment orders are in place, Braden Scale orders are in place and skin prevention and wound care interventions appropriately care planned. The audits will be completed within 48 hours of admission. • Beginning on [DATE], the DON or designee will audit all weekly skin assessments, Monday through Friday, for four weeks to ensure all assessments are completed accurately and any identified areas of concern are timely assessed and treated. • Beginning on [DATE], the DON or designee will visually validate all wound treatments are completed as ordered and audit the Treatment Administration Record (TAR) Monday through Friday for four weeks to ensure all treatments have been signed off on the TAR. • Beginning on [DATE], the DON or designee will audit all residents with wounds weekly for four weeks to ensure weekly wound assessments are completed, monitor for wound progress and ensure treatment orders and appropriate care plan interventions are in place for each wound. • Beginning on [DATE], the DON or designee will audit seven incontinent residents daily, Monday through Friday for four weeks to ensure incontinent residents were checked and changed and incontinence care provided. • Beginning on [DATE], the QAPI committee will meet weekly for four weeks, then monthly thereafter, to review all audit findings to ensure continued compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #91's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included fracture of unspecified part of neck of right femur, muscle weakness, and the need for assistance with personal care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was moderately cognitively impaired. Resident #91 had no impairment to the upper extremities and had impairment to one side of the lower extremities. Resident #91 was dependent for activities of daily living (ADLs), including toileting, bathing, dressing, bed mobility and transfers. Resident #91 was always incontinent of bowel and bladder, was at risk for pressure ulcers and had no pressure ulcers. Resident #91 had a surgical wound and skin tears and received surgical wound care. Review of the Admit Screener, dated [DATE] at 2:26 P.M. and completed by ADON #522, revealed Resident #91 was admitted from the hospital with an admitting diagnosis of fractured right hip, status post repair of the right hip fracture. Resident #91 ' s skin color was normal, temperature was warm, turgor was normal, and the resident had a right trochanter hip surgical incision and left forearm skin tear. The assessment indicated diffuse bruising to her bilateral arms, thighs and knees as well as the area surrounding the surgical site. Resident #91 was alert and oriented to person. Review of the Braden Scale, dated [DATE] at 2:24 P.M. and completed by ADON #522, revealed Resident #91 was at risk for pressure sores. Review of the care plan, dated [DATE], revealed Resident #91 had potential/actual impairment to skin integrity. Interventions included air mattress in place, encourage to turn and reposition with rounds every two hours and as needed and tolerated. Further review of the care plan revealed a focus area created on [DATE] to include Resident #91 had an ADL self-care performance deficit. Interventions included staff to turn and reposition in bed and as necessary, required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report changes to nurse. Additionally, Resident #91 had bladder incontinence. Interventions included to clean the peri area with each incontinent episode. Lastly, review of a care plan focus area created on [DATE] (six days after Resident #91's discharge), revealed the resident had an unstageable pressure ulcer to her sacrum related to immobility. Interventions included administer treatments as ordered and monitor for effectiveness, avoid positioning the resident on sacrum, assist to turn and reposition at least every two hours and more often as needed or requested. Review of the physician orders for Resident #91 revealed the following orders: initiated [DATE], pressure reducing mattress to bed; initiated [DATE] and discontinued [DATE], cleanse right buttocks open area with normal saline (NS) and pat dry, apply foam dressing daily and as needed (PRN); initiated [DATE] and discontinued [DATE], cleanse left buttock with NS and pat dry, apply collagen and foam dressing daily and PRN; initiated [DATE], air mattress to bed; initiated [DATE], cleanse sacral wound with NS and apply mesalt daily and PRN every night shift for wound management; initiated [DATE], cleanse sacral wound with NS and apply mesalt daily and PRN every night shift and as needed if soiled for wound management; and initiated [DATE], cleanse sacral wound with NS, apply mesalt and apply foam dressing daily and PRN. Further review of physician orders revealed Resident #91 had no orders for antibiotics during her stay at the facility. Additional review of Resident #91's medical record revealed no evidence of wound assessments, including measurements or description of the pressure ulcers identified in physician orders beginning on [DATE]. Review of the TAR for [DATE] revealed the wound care to Resident #91's left, and right buttocks was not documented as completed on [DATE] or [DATE]. Further review of the TAR for [DATE] revealed the wound care to Resident #91 ' s sacral wound was not documented as completed on [DATE] or [DATE]. Review of the Wound Weekly Observation Tool for Resident #91, dated [DATE] at 11:58 P.M. and completed by ADON #522, revealed Wound Care Certified Nurse Practitioner (WCCNP) #502 was in for initial evaluation of Resident #91 ' s wound. Family was notified on [DATE], resident is on turning and repositioning routine, wound to sacrum acquired, pressure 10% granulation 90% slough, moderate amount serosanguinous drainage, surgical debridement provided, wound measured 7.0 centimeter (cm) by 6.0 cm by 0.0 cm depth with inflammation and induration present. Review of WCCNP #502's visit note, dated [DATE], revealed Resident #91 was seen for an initial visit for wound care services. Resident #91 had a wound located on the sacrum. The wound was moderate in severity. The wound was an unstageable pressure ulcer with obscured full thickness skin and tissue loss. The wound measurement was seven cm in length by six cm in width with no measurable depth. The note further indicated the wound had a moderate amount of serosanguinous drainage, noted to have no odor. The peri wound did not exhibit signs and symptoms of infection. Lastly, the wound had 90% slough and 10% granulation tissue. Review of WCCNP #502's visit note, dated [DATE], revealed Resident #91 was being seen for a follow up visit for wound care services. Documentation included the unstageable pressure ulcer was full thickness with 20% granulation, 30% slough, 40% necrotic and 10% epithelial. There was moderate serosanguinous exudate and signs and symptoms of infection included odor. The wound was debrided to reduce bacterial load, will consider switching to Dakins next week if no improvement. Wound size was documented at 8.4 cm by 9.9 cm with an undetermined depth. Recommendations included a pressure reduction mattress per facility protocol and reposition per facility protocol. Interview on [DATE] at 1:58 P.M. and [DATE] at 11:30 A.M. with ADON #522 revealed Resident #91 had no pressure wounds on admission and developed a facility acquired stage three pressure ulcer. ADON #522 stated the wound started as two wounds, one on the right buttock and one on the left. ADON #522 confirmed there was no documentation to include the description of the wounds and measurements in the medical record for Resident #91's wounds to the right and left buttocks. ADON #522 revealed the two pressure wounds merged together as one sacral wound. ADON #522 stated she did not know if the staff were turning and repositioning Resident #91. ADON #522 further stated It was found at a stage three, it was bad when I looked at it, that shouldn't happen. ADON #522 revealed when she completed rounds, there were times she found wound dressings dated several days prior, indicating treatments had not been completed, but the nurses were still signing the TAR as completed. ADON #522 reviewed Resident #91 ' s TAR and confirmed there was no evidence the resident ' s treatments were completed on [DATE], [DATE], [DATE] or [DATE]. Additionally, ADON #522 verified there was no evidence in the medical record revealing when the resident transferred to the hospital or why. ADON #522 confirmed the resident was transferred to the emergency room (ER) on [DATE]. Interview on [DATE] at 10:57 A.M. with STNA #906 confirmed she worked with Resident #91 and remembered the resident. STNA #906 stated Resident #91's wound care dressings were not getting done consistently. STNA #906 stated Resident #91 would have a bowel movement and the stool would be impacted in the wound. STNA #906 revealed she would clean the stool out of the wound with wipes then saline and stated, Sometimes the nurses would not put the dressing back on, sometimes there was no dressing when I came on my shift and all day. A follow-up interview on [DATE] at 3:10 P.M. with ADON #522 revealed she initiated Resident #91's wound care on [DATE] and obtained the orders for the treatments to the right and left buttocks. ADON #522 confirmed she looked at the wounds, confirmed they were pressure wounds but did not measure the wounds, describe the wounds, or place any identifiable information describing the wounds in Resident #91's medical record. Review of the hospital admission note, dated [DATE], and an undated hospital physical examination at discharge, completed by Physician #907, revealed Resident #91 was admitted to the hospital after a fall and weakness secondary to E. coli bacteremia from an infected decubitus ulcer. Review of the Certificate of Death, dated [DATE] and signed by Registrar #908, revealed Resident #91's date of death was [DATE]. The immediate cause of death was E. coli sepsis due to an infected decubitus ulcer. 2) Review of Resident #34's medical record revealed an admission date of [DATE] and re-admission date of [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy and other skin ulcers, stage three pressure ulcer of sacral region, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was dependent for toileting, dressing, personal hygiene, and required substantial/maximal assistance for bed mobility. Resident #34 was always incontinent of bowel and bladder. Resident #34 was at risk for pressure ulcers and had one stage three pressure ulcer that was present upon admission and received pressure ulcer care. Review of the care plan, dated [DATE], revealed Resident #34 was always incontinent of bowel. Interventions included: checking the resident every two hours and assisting with toileting as needed. Additionally, Resident #34 had one pressure ulcer wound on the sacrum (stage three). Interventions included: to provide treatments as ordered and to educate the resident, family, and caregivers as to causes of skin breakdown including transfer/positioning requirements and frequent repositioning. Record review of Resident #34's monthly physician orders for [DATE] and [DATE] revealed orders for: Cleanse sacral wound with NS, pat dry and apply collagen to the wound bed. Cover with bordered foam dressing daily and PRN. The order was discontinued [DATE]; initiated on [DATE] and discontinued on [DATE], cleanse sacral wound with NS, pat dry, apply collagen to the wound bed followed by calcium alginate and cover with bordered foam dressing daily and PRN every night shift for wound management; initiated [DATE], cleanse sacral wound with NS, pat dry, apply Medi honey to the wound bed followed by calcium alginate and foam every night shift; and initiated [DATE], turn and reposition every two hours as tolerated while in bed. Review of the Wound Weekly Observation Tool dated [DATE] at 10:33 P.M. and completed by ADON #522 revealed WCCNP #502 onsite to follow up. Resident #34's sacral wound noted to be 80% granulation, 10% slough 10% epithelial and measured 1.4 cm in length by 0.6 cm in width by 1.0 cm in depth. The wound was unchanged. Further review of the medical record revealed there were no further Wound Weekly Observation Tools completed for Resident #34 in the medical record until [DATE]. Review of the TAR from [DATE] through [DATE] revealed both night shift wound treatment orders (cleanse sacral wound with NS, pat dry, apply collagen to the wound bed followed by calcium alginate and cover with bordered foam dressing daily and as needed every night shift initiated [DATE] and cleanse sacral wound with NS, pat dry, apply Medi honey to the wound bed followed by calcium alginate and foam every night shift initiated [DATE]) were both signed as completed on [DATE] and [DATE]. Review of the progress note dated [DATE] at 7:18 P.M. and completed by LPN #616 revealed Resident #34 returned from dialysis early due to leg/buttocks pain. Resident #34 was feeling blah today, complained of not being able to grab things with her left hand. Resident #34 was encouraged not to keep holding her cell phone in her left hand for long periods of time. Vital signs stable. Plan of care continues. Review of the change in condition evaluation, dated [DATE] at 7:53 A.M. and completed by LPN #616, revealed Resident #34's blood pressure was 94/40, pulse was 64, respirations 20 and temperature was 97.5 degrees Fahrenheit (F). Review of a progress note dated [DATE] at 1:12 P.M. and completed by LPN #616 revealed at 7:30 A.M., Resident #34 complained of dropping things from her left hand. The on-call Nurse Practitioner (NP) was called, and new order received to send resident to the emergency department (ED) for an evaluation. Resident sent to ED this morning. Review of a progress note, dated [DATE] at 1:12 P.M. and completed by LPN #616, revealed the nurse called the ED for a status update on Resident #34. Resident #34 was being admitted to the Intensive Care Unit (ICU) for septic shock. Review of the Nursing Re-admit Assessment completed [DATE] at 11:45 P.M. and completed by LPN #894, revealed Resident #34 was readmitted from the hospital with an admitting diagnosis of septic shock. Review of the hospital Discharge summary, dated [DATE] and completed by Physician #891, revealed Resident #34 was admitted to the ICU and transferred to the medical floor following stabilization. Resident #34 was treated for septic shock in setting of both coccygeal wound and possible proctitis (inflammation of the rectum). Resident #34 was treated with linezolid (antibacterial) and Zosyn (antibiotic) during hospitalization. Review of the re-admission physician orders for Resident #34's wound care to the coccyx included: sacrum: Cleanse with NS, pat dry, apply Dakins ' s wet to dry, cover with ABD (abdominal dressing) and secure with paper tape every day shift. The order was initiated [DATE] and discontinued [DATE]. Further review of physician orders revealed on [DATE], a new order was initiated to cleanse the sacral wound with NS, apply Medi honey, calcium alginate and cover with foam dressing daily and PRN every night shift for wound management. The order was discontinued on [DATE]. Review of the TAR for Resident #34 from [DATE] through [DATE] revealed both treatments were signed off daily from [DATE] through [DATE]. Wound care to the coccyx was not documented as being completed on [DATE] or [DATE]. On [DATE], the cleanse sacral wound with NS, apply Medi honey, calcium alginate, cover with foam dressing daily treatment was initialed. Interview on [DATE] at 10:45 A.M. with Resident #34 revealed she had a sacral pressure ulcer. Resident #34 revealed the staff were supposed to change her wound dressing every day, but they did not. Resident #34 stated she was supposed to be turned every two hours but was only turned once a day. Resident #34 revealed the last time she was changed for incontinence was at 4:00 A.M. and needed changed now but the STNAs did not have time. Observation on [DATE] at 11:13 A.M. of incontinence care provided by STNA #460 for Resident #34 revealed Resident #34 had a large bowel movement (stool). The stool was partially dried on Resident #34's skin. Resident #34 had a boarder dressing to the sacral area. The dressing was partially lifted at the bottom and there was visible stool under the dressing. STNA #460 revealed this was the first time on this day she was able to assist Resident #34 with incontinence care (nearly five hours after her shift began). STNA #460 stated there were not enough staff and too many residents who required total care. STNA #460 revealed residents were usually provided incontinence care at least once per shift, some were changed twice per shift and expressed she could not reposition Resident #34 every two hours as there was just not enough staff, and she could not do it all. STNA #460 stated, Oh, that must be poop (referring to the contents under the dressing located on Resident #34's sacrum). While cleaning the stool from Resident #34's buttocks, STNA #460 removed the dressing from Resident #34's sacrum. STNA #460 then took the same washcloth and cleaned the stool from the wound while rubbing the wound with the soiled washcloth. STNA #460 stated she would apply another dressing to the wound bed if there was one in the room. STNA #460 reported the STNAs reapplied wound dressings when residents were incontinent and had stool on them. STNA #460 then began looking around the room for a wound dressing to apply. The wound to the sacrum was exposed, the wound bed had visible slough, the surrounding tissue was red with visual remnants of stool that remained on the wound bed. STNA #460 revealed there was not another dressing and left the room revealing she would get the nurse to apply the dressing. A nurse did apply a new dressing after the surveyor left. Review of the Wound Care assessment, completed by WCCNP #502 and dated [DATE] at 9:45 A.M., revealed Resident #34 was seen for a follow up visit for wound care services. The resident ' s wound had declined. Treatment order changed to include applying hydrogel to wound bed to help absorb wound exudate along with alginate silver to prevent buildup of new bacteria. If dressing gets soiled, change as needed. The fully updated treatment order included cleanse wound with NS, pat dry, apply hydrogel followed by silver nitrate to the wound bed and cover with bordered foam dressing. Change/apply treatment daily and as needed. Interview on [DATE] at 11:18 A.M., with WCCNP #502 revealed Resident #34's sacral wound was worsening. WCCNP #502 confirmed sitting with stool on a wound would worsen the wound and could cause infection. WCCNP #502 revealed she assessed Resident #34 wounds weekly and had seen the resident frequently soiled with urine and stool. WCCNP #502 revealed she asked the staff to start cleaning residents prior to her visit. WCCNP #502 confirmed the STNAs should not be applying a new dressing or cleaning the wound and revealed she has seen dressings dated for days prior to when the wounds should have been changed. Review of the Wound Weekly Observation Tool dated [DATE] at 3:39 P.M. and completed by ADON #522, revealed Resident #34's wound to the sacrum was worsening with the wound having tunneling and/or undermining. The document included new treatment orders including to cleanse the coccyx wound with NS, apply hydrogel followed by silver alginate to the wound bed and cover with bordered foam dressing. Interview on [DATE] at 1:41 P.M. with ADON #522 stated she and WCCNP #502 had asked the STNAs to clean residents before rounds because they were frequently saturated with urine and/or stool. ADON #522 confirmed, during rounds, she had found wound dressings that were dated two or three days prior to when the wound treatments should have been done, which was daily. ADON #522 verified nurses were signing the wound care as completed on the TAR without completing treatments. ADON #522 revealed she talked to the nurses about it but hasn't had time to write them up yet. ADON #522 revealed the nurses were not completing their weekly skin assessments either. Review of the physician orders for Resident #34 revealed the order given by WCCNP #502 on [DATE] was not placed in the medical record and initiated until [DATE]. Review of the [DATE] TAR for Resident #34 confirmed the wound care treatment ordered on [DATE] was not initiated until [DATE]. Interview on [DATE] at 10:22 A.M. with the DON confirmed Resident #34 had overlapping wound care orders. The DON verified she did not know which treatments were completed for Resident #34. The DON confirmed old treatment orders should be discontinued when new orders were written. Interview on [DATE] at 11:04 A.M. with ADON #522 confirmed on [DATE] WCCNP #502 provided new treatment orders for Resident #34's sacral wound. ADON #522 verified the order was not placed in the resident's orders until [DATE] and not initiated until [DATE], stating she did not get to it because she had to work the floor. ADON #522 confirmed when new orders for treatments were written, the old wound care orders should be discontinued. ADON #522 confirmed when new wound treatment orders for Resident #34 were initiated [DATE], the previous order initiated [DATE] should have been discontinued and the wound care order dated [DATE] should have been discontinued on [DATE], when the new order started, resulting in overlapping orders and nurses signing the TAR as completing both treatments. ADON #522 could not confirm what wound care treatments Resident #34 received. 3) Review of Resident #40's medical record revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus, chronic kidney disease, overactive bladder, muscle weakness, and abnormalities of gait and mobility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was dependent for toileting, personal hygiene, and required substantial/maximum assistance with transfers. Resident #40 used a wheelchair and was dependent for mobility. Resident #40 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #40 was at risk for pressure ulcers and had two stage three pressure ulcers. Resident #40 had a pressure reducing device to her chair. Review of the care plan, dated [DATE], revealed Resident #40 was at risk for alteration in elimination related to episodes of incontinence. Interventions included to check resident every two hours and assist with toileting as needed and monitor for skin redness and irritation and notify nursing. Resident #40 was also at risk for alteration in skin integrity related to impaired mobility, medication, episodes of incontinence and fragile skin. Interventions included turning and repositioning Resident #40 every two hours as tolerated. Review of Resident #40's [DATE] physician orders revealed the following orders: Initiated [DATE], Roho like cushion (pressure relieving) when up in wheelchair, check inflation every shift; initiated [DATE], wound care: cleanse right buttock wound with NS, pat dry, apply silver alginate to wound bed and apply foam dressing daily and as needed on day shift; initiated [DATE], wound care: cleanse right lower buttock abscess with NS daily and as needed, leave open to air scheduled every day shift; and initiated [DATE], encourage resident and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews with facility staff, review of an incident report, review of the emergency medical technician (EMT) report, review of the hospital computed tomography scan (CT), review of the hospital emergency room (ER) documentation, and review of the facility policy titled Falls and Fall Risk, Managing, the facility failed to provide adequate supervision and ensure care planned interventions to prevent falls were consistently implemented for one resident (#86) to prevent a fall with injury in the facility. This resulted in Immediate Jeopardy on [DATE] when Resident #86, who was admitted to the facility with a comminuted and mildly displaced fracture of the left greater trochanter and was assessed as a fall risk, was not provided adequate supervision to prevent an unwitnessed fall and as a result sustained an acute intracranial hemorrhage (bleeding in the brain). Additionally, a second resident (#07) was placed at risk for the potential for more than minimal harm that was not Immediate Jeopardy when care planned interventions to prevent falls were not implemented appropriately by staff during a transfer from the bed to the recliner chair by one staff utilizing the appropriate assistive device, the resident ' s knee ' s buckled, and the resident had to be lowered to the floor. This affected two (Residents #07 and #86) of three residents reviewed for falls. The facility census was 85. On [DATE] at 12:53 P.M., [NAME] President (VP) of Operations #129, VP of Clinical Operations #130, Director of Nursing (DON) #125 and Regional Registered Nurse (RRN) #126 were notified Immediate Jeopardy began on [DATE] when Resident #86 had an unwitnessed fall in the dining room and per the EMT report, no one was on the scene who could provide the EMT with a patient medical history or details of the fall other than the resident arrived at the facility 48 hours ago and had a do not resuscitate comfort care arrest code status (DNRCCA), which allows lifesaving treatments before the patient ' s heart or breathing stops, which could not be furnished. The resident was subsequently transported to the hospital following the fall where she was diagnosed with an acute intracranial hemorrhage (bleeding in the brain) which included bilateral predominately frontal lobe scattered subarachnoid hemorrhages, left frontal parenchymal hematoma/contusion and intraventricular hemorrhage noted with layering blood along the septum pellucidum and left trigone. Resident #86's responsible party declined treatment and the family decided to initiate hospice services and Resident #86 was transferred to a hospice care facility from the hospital where she ultimately expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 1:15 P.M., DON #125, Licensed Practical Nurse (LPN)/Unit Manager (UM) #119 and LPN/UM #111 completed fall risk assessments on all residents to identify all residents who were high risk for falls. • On [DATE] at 2:15 P.M., new policies were developed including Routine Resident Check Policy and High Fall Risk Common Area Policy. • On [DATE] at 2:30 P.M., an Interdisciplinary Team (IDT) meeting was held with all department heads on the new policies that were developed including Routine Resident. • Check Policy and High Fall Risk Common Area Policy as well as education by VP of Clinical Operations #130. Department heads in attendance included: the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/Minimum Data Set (MDS) Coordinator #131, Chaplain #132, LPN/Assisted Living (AL) DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Assistant Administrator #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, Human Resources (HR) Director #140 and Activities Director #141. • On [DATE] at 3:34 P.M., education on the facility ' s Routine Resident Check Policy and High Fall Risk Common Area Policy were provided to all healthcare staff members by department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140 and Activities Director #141. • On [DATE] at 3:35 P.M., a point of care (POC) high fall risk safety check task was placed in each resident ' s electronic medical record who was assessed as a fall risk by VP of Clinical Operations #130 for the staff to provide documentation for the additional safety checks as stated in the Routine Resident Check Policy and High Fall Risk Common Area Policy. • On [DATE] at 3:44 P.M., education binders were created by VP of Operations #129 for oncoming agency staff. • On [DATE] at 4:50 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held by the Administrator with the Medical Director via telephone and the Immediate Jeopardy plan was reviewed. The QAPI meeting was attended by DON #125, LPN/UM #119, VP of Operations #129, VP of Clinical Operations #130, RRN #126, Human Resources #140, LPN/AL DON #133, Assistant Administrator #124, and LPN/MDS #131. • On [DATE] at 5:26 P.M., all tasks were entered in POC for each resident who was at high risk for falls by RRN #126. • On [DATE] at 5:45 P.M., a list of high-risk for fall residents was created to place in the common areas and dining rooms, nursing stations, and medication carts by VP of Clinical Operations #130. • On [DATE] at 6:15 P.M., LPN/MDS Coordinator #131 updated all care plans of residents who were assessed as high risk for falls. • On [DATE] at 6:30 P.M., education was completed to all healthcare staff on the new policies including the Routine Resident Check Policy and the High Fall Risk Common Area Policy by facility department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140, and Activities Director #141. • The DON or designee will audit the High Risk Fall List five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. • The DON or designee will audit the Resident Safety Checks five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. • All Audit findings will be submitted weekly for four weeks to the QAPI committee for review and recommendation. • Interviews were conducted on [DATE] to verify staff were educated on the new fall policies and were able to articulate the Routine Resident Check Policy and the High Fall Risk Common Area Policy. Staff interviewed included LPN #112, RN #120, Transportation Coordinator #139, State Tested Nursing Assistant (STNA) #142, Housekeeping Staff #143, STNA #144, LPN #145, Director of Rehabilitation #146, Certified Occupational Therapy Assistant (COTA) #147, and RN #148. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #86's medical record revealed the resident was admitted to the secured memory care unit (SMCU) assisted living facility (ALF) on [DATE] with diagnoses including repeated falls, muscle weakness, and unspecified dementia. Review of Resident #86's ALF St. Louis University Mental Status (SLUMS) Examination form dated [DATE] revealed the resident scored a seven which was identified as having dementia. Resident #86's medical record revealed the resident was hospitalized on [DATE] with an admitting diagnosis of a fall. Review of Resident #86's hospital documentation dated [DATE] revealed the family elected for no invasive treatment, just medical management, due to advanced Alzheimer ' s dementia, and osteoporosis who presented to the ER from the ALF with recurrent falls. Radiological studies showed a comminuted and mildly displaced fracture of the greater trochanter. The resident hit her head and required stitches to her left eyebrow. Orthopedics had evaluated the resident and recommended no surgery at this time, pain control and toe-touch weight bearing to the left leg. Review of Resident #86's medical record revealed the resident was admitted to the skilled nursing facility (SNF) on [DATE] with diagnoses including a displaced fracture of the greater trochanter of the left femur, laceration of the left eyelid, and unspecified dementia. Resident #86's Minimum Data Set (MDS) assessment, dated [DATE], documented she needed limited assistance of two staff members for transfers, ambulation, and extensive assistance of two staff members for locomotion on and off the nursing unit, and dressing. Review of Resident #86's Fall Scale form dated [DATE] revealed the resident was at high risk for falls. Review of Resident #86's Interim Care Plan form dated [DATE] revealed the resident was cognitively impaired, required a mechanical lift for transferring and total dependence for ambulating, dressing, personal hygiene, and toilet use as well as assistance with eating and the resident used an assistive device for walking. Review of Resident #86's progress note dated [DATE] at 1:54 A.M. documented the resident arrived on [DATE] at approximately 10:00 P.M. and was alert to self. A laceration was noted above the left eyebrow measuring two centimeters (cm) which was scabbed over, and she had a left greater trochanter hip fracture with a transdermal gauze. Resident #86's plan of care, initiated on [DATE], documented a behavior problem related to noncompliance with her weight bearing status of the fractured left hip, had impaired cognition and had a risk for falls. Interventions on the plan of care included to anticipate and meet Resident #86's needs, provide cueing, re-orienting and supervision as needed, and be sure Resident #86's call light was in reach, and encourage Resident #86 to ask for assistance and promptly respond to requests. Review of Resident #86's fall incident report, dated [DATE] at 1:10 P.M., documented Resident #86 had an unwitnessed fall in the dining room. The incident report stated Resident #86 needed supervision and was agitated and attempted to stand alone without staff assistance, use of assistive device, or use of a call light. Resident #86 was found on the floor. Resident #86 sustained a laceration to the right eye and pressure was applied. Resident #86 was sent to the hospital and the incident report documented the facility would reassess her safety needs upon her return to the facility. Review of Resident #86's EMT report, dated [DATE], documented a dispatch was initiated for a report of a female who fell. On contact, the resident was unresponsive to verbal stimuli. Her skin was pink, warm, and dry and her respirations were equal and unlabored. The fall was unwitnessed, and no one was on the scene who could provide the EMT with a patient medical history or details of the fall other than the resident arrived at the facility 48 hours ago and had a do not resuscitate comfort care arrest code status (DNRCCA) which allows lifesaving treatments before the patient ' s heart or breathing stops, which could not be furnished. Review of Resident #86's hospital CT scan (diagnostic imaging procedure to produce images of the inside of the body) of the head without contrast for a trauma protocol dated [DATE] revealed an acute intracranial hemorrhage including bilateral predominately frontal lobe scattered subarachnoid hemorrhages, left frontal parenchymal hematoma/contusion measuring one cm, intraventricular hemorrhage noted with layering blood along the septum pellucidum and left trigone. Review of Resident #86's hospital emergency room documentation, dated [DATE], documented the resident had a history of Alzheimer ' s, who was on Plavix, was sent over from the nursing home for a fall. It was unclear how long the resident had been down. She was found on the ground in the dining hall. Per the EMT, the nursing home was unable to provide any other history. The resident was recently sent back there from the hospital after she had a fall and had a left hip fracture. The left hip fracture was nonoperative. The resident had a hematoma to the left forehead, would open her eyes to name and would not follow commands. Upon discussion with the family, the family had elected for the resident to be comfort care and she would be admitted . During an interview on [DATE] at 9:25 A.M., the DON stated Resident #86 had a fall in the assisted living facility prior to her admission to the long-term care facility. Resident #86 had fractured her hip and due to her advanced Alzheimer's disease, the family decided to transfer her to the long-term care facility for increased supervision. The DON stated Resident #86 had sustained a fall in the long-term care facility while in the dining room and was sent to the hospital for evaluation. The family decided to initiate hospice services and Resident #86 was transferred to a hospice care facility from the hospital and did not return to the facility. During an interview with STNA #114 and STNA #113 on [DATE] at 8:30 A.M and 8:36 A.M. respectively, both stated Resident #86 was very confused and known to attempt to stand unassisted and try to ambulate. Both STNAs stated Resident #86 needed close supervision to prevent a fall. During an interview on [DATE] at 9:12 A.M., LPN/UM #111 stated staff were already in the dining room assessing Resident #86 when she got to the dining room following the resident ' s fall. She could not remember who the STNAs were at the time but stated the nurse was RN #120. LPN/UM #111 stated Resident #86 was observed trying to get out of bed by the DON on [DATE] around 9:00 A.M. and that was why the resident was put in a reclining chair in the common area at that time. LPN/UM #111 stated around 1:10 P.M. (after lunch) the resident was observed by Dietary Aide #122 walking from the reclining chair and falling approximately 20 feet away in the main dining room on the third floor. LPN/UM #111 stated the resident was observed on her side with her arm over her eye and a small amount of blood was observed on the back of her hand. During an interview on [DATE] at 9:24 A.M., LPN #112 stated she was the nurse for Resident #86, but she was in a room passing medications to another resident, two doors down from the dining room. LPN #112 stated she was informed Resident #86 fell but she did not directly assess the resident and instead obtained anything RN #120 and LPN/UM #111 might need as they were assessing the resident. During an interview on [DATE] at 10:14 A.M., RN #120 stated she assessed Resident #86 when she was on the floor. She took vital signs and assessed the resident. She stated the resident was alert and awake and was moaning but would not answer questions. RN #120 stated the resident did not say anything coherent. The resident was lying on her left side with her arm and leg up (bent). She confirmed she was sitting at the desk of the nursing station which had a wall which obstructed the view of the dining room at the time the resident sustained the fall. During an interview on [DATE] at 10:20 A.M., STNA #121 stated she noticed Resident #86 was on the floor and remembered getting the nurse. She observed her chair was still parked at the lunch table and she must have walked to where she had fallen but she did not witness the fall. She remembered a dietary aide had come to inform them of Resident #86's fall and it took approximately one minute to get to the resident. During an interview on [DATE] at 11:15 A.M., Dietary Aide #122 stated she was in the dining room at the steam table when Resident #86 was observed getting up from the reclining chair at the table and walking. She stated she did not think anything of it and turned to finish her work at the steam table. Dietary Aide #122 stated she heard a loud bang and a thump and turned to find Resident #86 had fallen to the floor. Dietary Aide #122 stated no other nursing staff were in the dining room or near the dining room providing supervision to Resident #86, who was at risk for falls. She stated she went down to LPN/UM #111's office to inform her of the fall and then returned to her work. She was unaware of what occurred after she informed LPN/UM #111. A second interview on [DATE] at 11:25 A.M. with LPN/UM #111 confirmed Dietary Aide #122 told her Resident #86 sustained a fall in the dining room. During a telephone interview on [DATE] at 12:21 P.M., Resident #86's responsible party stated he was questioned by the hospital about his mother's care, and he did not know the extent of the injuries. He stated his mother was not alert when he visited her in the hospital. He could not understand how his mother walked across the dining room and fell with a broken hip. During an interview on [DATE] at 12:57 P.M., the DON stated they had put interventions in place for falls for Resident #86 upon admission including keep in common areas for additional staff supervision and call light in reach even though it was not documented on the immediate needs care plan. She also stated she was unaware Dietary Aide #122 had observed Resident #86 walking without assistance. She stated the dietary personnel would not know the resident's fall risk and interventions because of HIPAA (Health Insurance Portability and Accountability Act - a federal law that protects sensitive patient health information from being disclosed without the patient ' s consent or knowledge). The DON stated Resident #86 was not provided one-to-one supervision, but staff would monitor the resident as she was in the common lounge/dining area. The DON confirmed no nursing staff were in the common area providing supervision to Resident #86 when she stood up from her reclining chair and walked across the common lounge/dining area and subsequently sustained a fall with fracture requiring hospitalization. During a telephone interview on [DATE] at 1:45 P.M. with the DON present, the EMT stated Resident #86 was initially not responsive on [DATE] when they found her on the floor and then she started moving around. The resident was transported to the hospital. During an interview on [DATE] at 11:21 A.M., Hospice Staff #127 stated they received Resident #86 as an inpatient for hospice services on [DATE] and she expired on [DATE]. During an interview on [DATE] at 11:50 A.M., STNA #128 stated she had observed Resident #86 in the dining room in her reclining chair on [DATE]. She stated she felt she had observed her within a couple of minutes of her fall but could not remember the exact details. She could not remember if any other staff members were in the dining room at the time of the observation and stated the nursing staff do chart right off the dining room. 2. Resident #07 was admitted on [DATE] with diagnoses including chronic severe kidney disease, depression, anxiety, anemia, osteoarthritis, hyperthyroid, lumbar disc degenerative disease of the vertebrae, gastric ulcer with a history of repeated falls, lack of coordination, muscle weakness, and need for personal assistance with personal care. A review of Resident #07's MDS assessment dated [DATE] indicated extensive assistance of two staff members was needed for bed mobility, transfers, ambulation, and locomotion. Resident #07's most recent fall assessment indicated she had a high risk for falls. Resident #07's plan of care initiated upon admission to the facility revealed a risk for falls related to impaired mobility, impaired balance, medication, incontinence and past medical history of falls. Resident #07 had a diagnosis of a fracture, anxiety, depression, chronic kidney disease, low back pain, and intervertebral disc degeneration of the lumbar region. Interventions on the plan of care revised on [DATE] documented to use a gait belt and on [DATE] to perform transfers with the use of a gait belt and two staff members. Resident #07's nursing progress note dated [DATE] revealed Resident #07 was transferred from the bed to the recliner chair by one staff member. Resident #07's knees buckled, and she was lowered to the floor. Resident #07's fall investigation report dated [DATE] indicated State Tested Nursing Assistant (STNA) #117 transferred Resident #07 from the bed to the recliner chair using a walker when Resident #07's knee became weak and STNA #117 lowered Resident #07 to the floor. The result of the investigation was to train staff to use a gait belt and two staff members for transfers. During an interview on [DATE] at 1:30 P.M., STNA #117 verified the above information and stated she was not informed Resident #07 needed two staff members and use of a gait belt for transfers. Review of the facility policy titled Falls and Fall Risk, Managing, dated 2001, revealed the policy statement was based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent residents from falling and try to minimize complication from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). Monitoring subsequent falls and fall risk revealed the staff would monitor and document each resident's response to interventions or recommend whether the measures were still needed if the problem that required the intervention had resolved. If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. This deficiency represents non-compliance investigated under Compliant Number OH00146589.