**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104. This affected one resident (#104) of three residents reviewed for activities of daily living. The facility census was 120. Actual Harm occurred on 04/22/24 when Resident #104, who was admitted on [DATE] with severe cognitive impairment and was known to use contact lenses, developed right eye redness and pain and was diagnosed with conjunctivitis (pink eye) which required antibiotic treatment due to a lack of routine eye care for the resident. Findings include: Review of the medical record for Resident #104 revealed an admission date of 11/03/23 with diagnoses including dementia with psychotic disturbance, aphasia (inability to understand and express language), restlessness and agitation, psychotic disorder with delusions, anxiety, and bipolar disorder. Review of Resident #104's plan of care initiated 11/06/23 revealed no focus on eye care or the care of contact lenses. There was a focus on behavior which indicated Resident #104 refused taking her contacts out for regular washing. Interventions included to educate on non-compliance with treatment or care and reapproach with resistance to activities of daily. Review of the nursing progress note dated 11/07/23 revealed Resident #104's family reported Resident #104 wore contacts but had not utilized them since the hospital admission about one month prior and had a history of refusing contacts. Resident #104's family was advised the facility offered house eye exams and eye glass services if needed in the future. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had severe cognitive impairment with no use of corrective lenses. Review of the nurse practitioner progress note dated 11/27/23 indicated Resident #104 was examined with no concerns related to the eyes. The note indicated a contact lens remained within the right eye. Review of Resident #104's physician orders for November 2023 revealed no orders related to eye care or the care of contact lenses. Review of the eye physician's progress note date 12/04/23 revealed Resident #104 was examined and had an air optic color contact lens in the right eye which was removed on this date. Staff were instructed to not let Resident #104 wear contact lenses. Resident #104 was scheduled to return for a follow-up in 12 to 15 months or in six to nine months for a retina evaluation. Review of the nursing progress note dated 01/15/24 indicated Resident #104 placed a contact lens into the right eye. Staff made several attempts to remove the contact lens but Resident #104 continued to refuse. The family was made aware. There was no evidence the resident's physician or nurse practitioner were notified at this time. Review of a social service progress note dated 01/25/24 revealed Resident #104's family decided to allow Resident #104 to wear contact lenses despite education on the risks of leaving contact lenses in place for lengthy time periods and not removing for routine washing. Nursing staff were made aware. There was no documented evidence that the physician or nurse practitioner were notified. There was no documented evidence nursing staff followed through with the information provided by social services or that the resident's care plan was updated related to the use of contact lenses. Review of Resident #104's physician orders and progress notes from 01/25/24 through 04/21/24 revealed no care or assessments related to Resident #104's use of contact lenses was completed during this time period. In addition, there were no changes to the resident's care plan during this time period or evidence of ongoing resident or family education related to the use of the contact lens. Review of the nursing progress note dated 04/22/24 revealed Resident #104's eye was red, and the resident complained of eye pain. The previous shift reported attempts to remove the right eye contact lens without success. Nursing would request the nurse practitioner to assess Resident #104 on this date. Interview on 04/22/24 at 6:37 P.M. with Resident #104's family revealed a concern Resident #104 had a blue contact lens in the right eye which had been left in place for almost one year. The family member stated it was noticeable because the resident's left eye was green, her natural color, and the right eye was blue, the color of the contact lens. The family indicated staff explained they could not get it out, but stated the eye looked swollen now and it was concerning because the contact lens had been in for too long. Resident #104's family stated the contact lenses were brought in a while back but could not state a time frame. During the interview, the family revealed staff had spoken to the resident's son in January 2024 but not to the resident's first emergency contact. The family member interviewed denied any education or information being provided to him related to the risk of the contact lens use for the resident. Interview on 04/24/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #584 verified Resident #104 had used a contact lens since admission and currently only had one contact lens in the right eye which had been there for a while. LPN #584 confirmed the right eye was now reddened, and the nurse practitioner was supposed to look at the eye, but nothing was provided in report, so LPN #584 was uncertain if anything was done about Resident #104's right eye. LPN #584 further stated staff do try to get the contact lens out of the right eye but Resident #104 would not allow it. LPN #584 indicated personally attempting it over the previous weekend but was unsuccessful. Record review revealed no documentation had been completed to reflect this. Interview on 04/24/24 at 9:02 A.M. with Unit Manager LPN #607 verified Resident #104 had a right eye contact lens in place. LPN #607 revealed Resident #104 was admitted with a contact lens in the right eye. Resident #104 was encouraged to remove the contact lens but refused. The eye doctor had come to the facility and removed it. Social services told the family that due to Resident #104's dementia, it was not best to wear contacts and it was agreed but additional contact lenses were brought in which resulted in Resident #104 placing another contact lens in the right eye. There was never a contact lens in the left eye. Resident #104 would not allow staff to remove it or touch the eye. The family was asked to assist in getting the contact lens out but they had not. The LPN revealed the lens needed to be removed. The LPN also indicated the nurse practitioner was aware of it but not sure what was done about it. Observation on 04/24/24 at 9:15 A.M. with Unit Manager LPN #607 of Resident #104's eyes revealed the left eye was green in color with no abnormal findings. The right eye was blue in color and had some swelling and redness. There was a red raised area on the mid lower lid, and Resident #104 complained of right eye pain. Interview on 04/24/24 at 9:18 A.M. with Nurse Practitioner (NP) #610 revealed the NP had knowledge of Resident #104 wearing contact lenses and wearing one in the eye at one time but was not aware of Resident #104 wearing the same contact lens for months. NP #610 indicated it was not a good idea for contact lenses to be worn for long periods because it could lead to complications like infection. NP #610 further indicated she had not been previously made aware of Resident #104's right eye being swollen, red, and painful but stated she would look at it on this date. Interview on 04/24/24 at 11:19 A.M. with Unit Manager LPN #607 revealed the eye physician last examined Resident #104 on 12/04/23, and the resident was scheduled to see the eye doctor on each visit thereafter to remove the right contact lens. Review of the nurse practitioner progress note dated 04/24/24 revealed Resident #104 was examined for complaint of right eye pain. Resident #104 was unable to state when it started. The right eye contained a contact lens and now the eye was reddened. The right upper eye lid was swollen and the lower eyelid had a small bump. It was uncertain how long ago the contact lens was placed. Staff reported the family was to come in and assist in removal of the lens and attempts to remove the lens were unsuccessful. Resident #104 previously had a right contact lens removed by the eye doctor but placed a new lens in after removal. The resident had a diagnosis of acute right eye conjunctivitis with a plan to start Besifloxacin antibiotic eye drops (used for the treatment of bacterial conjunctivitis) for seven days and warm compresses to the right eye. Review of the nursing progress note dated 04/24/24 revealed Resident #104's family planned to visit in approximately one week to change the contact lens in the right eye. An additional review of Resident #104's plan of care (initiated 11/06/23), revealed a new focus area was added on 04/25/24 (following surveyor intervention) for the resident's risk of injury related to infection due to use of contact lenses and refusing to allow staff to assist with inserting and removing. Interventions included administer antibiotic as ordered; apply warm compress as ordered; arrange eye care practitioner consult as required; document all refusals to allow staff to assist with contact lens; family would assist with placement and cleaning of contact lenses; keep spouse informed of refusal of assistance with contacts; monitor for, document and report as needed any signs and symptoms of acute eye problems; and per ophthalmology appointment on 12/04/23 Resident #104 not to wear contacts. Review of the eye doctor visits to the facility from 12/04/23 to current revealed the eye doctor was present in the facility on 01/29/24 and 03/25/24. The resident was not seen on either of these dates. Interview on 04/25/24 at 10:15 A.M. with Assistant Social Services Director #605 indicated the eye doctor sets up the visit list and staff add on any resident who needed seen and if residents refused, staff kept re-adding the resident to the next visit list. Resident #104 was known to put contact lenses back into the eyes and staff like it taken out and cleaned, so Resident #104 was on the list routinely for every eye visit. Review of email communication between the facility and eye physician dated 04/25/24 revealed Resident #104's last eye physician examination was on 12/04/23 with a follow-up scheduled for June 2024. Resident #104 could be seen on the next visit scheduled 05/20/24 if desired and all following visits thereafter. Interview on 04/25/24 at 2:06 P.M. with the Director of Nursing verified the above findings and confirmed the facts were accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #101 revealed an admission date of 04/18/23. Diagnoses included muscle weakness, abnormalities of gait and mobility, severe protein-calorie malnutrition, and reduced mobility. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #101 had impaired cognition and had no falls since admission or the prior assessment. Review of the fall risk evaluation dated 03/07/24 revealed a score of nine. Per instructions a total score of 10 or greater, the resident should be considered high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the nurses' note dated 03/31/24 at 8:04 A.M. revealed Resident #101 was observed kneeling on the floor next to the bed holding onto the side rails. Resident #101 stated he was attempting to pick up a pill that he dropped. Resident #101 had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A voicemail was left for the resident's niece. The physician and hospice were notified. Review of the interdisciplinary team (IDT) noted dated 04/01/24 at 11:00 A.M. revealed the IDT team met this morning regarding Resident #101's fall that occurred on 03/31/24. The resident was observed kneeling on the floor next to the bed holding onto the side rails. The resident stated he was attempting to pick up a pill that he dropped. The resident had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A voicemail was left for the resident's niece. The physician and hospice were notified. Risk factors included but were not limited to muscle weakness, communicating hydrocephalus, repeated falls, and reduced mobility. Intervention was to keep bed in lowest position at all times. The care plan and [NAME] were updated. Review of the care plan revised on 04/01/24 revealed Resident #101 was at risk for falls related to antidepressant use, history of falls, weakness, episodes of incontinence, balance problem. Interventions included bed in lowest position at all times, and floor mat to left side of the bed while in bed. Observation on 04/22/24 at 3:04 P.M. of Resident #101 in the bed with the bed in the high position with the floor mat folded in corner. Interview at this time with Resident #101 stated he had no concerns with care. Observation on 04/24/24 at 10:55 A.M. of Resident #101 in his room in bed with the bed in high position and no mat to floor. Resident #101 was observed watching tv. Observation on 04/29/24 at 9:42 A.M. of Resident #101 in his room in bed; the bed was not in the lowest position, and there was no mat to the floor next to his bed. Observation on 04/29/24 at 9:58 A.M., with STNA #514 of Resident #101's with the bed not in the lowest position and no floor mat to the floor next to the bed. Interview at this time with STNA #514 verified the observation and pointed to the mat folded in corner near the resident's dresser. Review of the facility policy titled Falls/Accidents/Incidents, revised 07/17/23, revealed the intent of this requirement is to ensure the facility provided an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazards and risks; evaluating and analyzing hazards and risk; implementing interventions to reduce hazards and risk; and monitoring for effectiveness and modifying interventions when necessary. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. Based on observation, record review, policy review and interview the facility failed to provide adequate assistance, supervision and/or assistive devices to prevent falls and consistently implement fall interventions for Resident #57 and Resident #101. Actual harm occurred on 04/14/24 when Resident #57, who was moderately cognitively impaired and required two staff assist with bed mobility, sustained a fall out of bed when being provided hands on care by only one staff member. The resident sustained a right shoulder fracture as a result of the fall. This affected two residents (#57 and #101) of three residents reviewed for falls. The facility census was 120. Findings Include: 1. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), depression, diabetes, high blood pressure, osteoporosis, and anxiety. A new diagnosis of right shoulder fracture was added on 04/14/24. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was moderately cognitively impaired and was dependent on staff for personal care. Review of Resident #57's falls care plan, initiated on 07/24/19, revealed the resident was at risk for falls due to impaired mobility, impaired decision making, impaired cognition, and impaired safety awareness. The care plan was revised on 01/23/23 to indicate the resident was at increased risk for injury related to osteoporosis. The resident sustained a fall on 01/23/23. An intervention initiated on 01/27/23 was for the resident to have two person assist with care with one on each side of the bed. Review of Resident #57's [NAME] (a form which indicates care needs a resident requires) revealed the resident required staff assist of two for bed mobility and hands on care while in bed. Review of Resident #57's progress note revealed on 04/14/24 at 10:15 A.M. Registered Nurse (RN) #602 was called to the resident's room due to the resident rolling out of bed during patient care. The resident rolled over while getting changed and rolled off the bed onto the floor. Resident #57 had an injury to his right elbow and a right knee abrasion. RN #602 notified the physician and an order for an x-ray of the right elbow was given. The x-ray indicated the resident sustained a right shoulder fracture. On 04/18/24 Resident #57 saw the orthopedist who ordered the resident to wear a sling at all times and apply ice to the shoulder for 20 minutes three times a day. A follow-up appointment was scheduled for 05/17/24. Review of the facility's fall investigation for Resident #57's 04/14/24 fall revealed the facility determined the root cause of the fall was he was getting changed. Following the incident the Interdisciplinary Team (IDT) implemented a new fall intervention to obtain a wider bed for the resident and add grab bars to the bed. State Tested Nursing Assistant (STNA) #516's written statement regarding the incident dated 04/14/24, revealed she was providing resident care and she rolled Resident #57. STNA #516 said she thought the resident was holding on to the side rail, but he rolled off the bed. STNA #516 stated she first checked the resident and then went and got RN #602. On 04/15/24 STNA #516 was educated on accessing the [NAME] and reviewing the resident's mobility status. Interview with Regional Clinical Manager (RCM) #609 on 04/24/24 at 10:15 A.M. regarding Resident # 57's fall on 04/14/24 revealed STNA #516 should have been providing care with another staff member when the resident fell out of bed. The [NAME] indicated he was to have an assist of two staff while performing care in bed. Interview with STNA #516 on 04/24/24 at 10:30 A.M. revealed she was the person who was providing care to Resident #57 when he fell out of bed. STNA #516 said the bed was at a normal height. It was not in the high position or the low position. She stated she was changing the resident's fitted sheet when he rolled off the bed. STNA #516 said she had been keeping one hand on him during care except when he rolled over and that was when he fell. She confirmed Resident #57 was supposed to have two staff assist with care while the resident was in bed. STNA #516 confirmed she did not follow the [NAME] instructions for care. She said the reason she provided the care alone for the resident was because there was no one available to help her. On 04/24/24 at 10:40 A.M. an observation of Resident #57 revealed he was in bed with a sling to his arm. An interview with the resident at the time of the observation revealed he exhibited confusion and smiled a lot, nodding his head to questions. When asked if he had any pain from the fall he had sustained, the resident stated he was fine. Review of the facility Falls/Accidents/Incidents policy, last revised 07/17/23, revealed the intent of the policy was to ensure the facility provided an environment that was free from accident hazards over which the facility had control and provide supervision and assistive devices to each resident to prevent avoidable accidents. No information was provided on how the facility would accomplish this goal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, facility policy and procedure review, Self-Reported Incident (SRI) review and facility investigation review, the facility failed to ensure residents were properly transferred, as per their plan of care and/or physician's order to prevent actual injury and/or potential injury. Actual Harm occurred on [DATE] when Resident #125 who was dependent on staff for activities of daily living (ADL) and required a mechanical lift (device used to transfer a person from one place to another) of two staff assist for transfers was transferred by only one staff, State Tested Nursing Assistant (STNA) #614 without a mechanical lift from his bed to his wheelchair. The resident was again transferred on [DATE] by STNA #680 and STNA #685 without a mechanical lift from his wheelchair to his bed. After breakfast on [DATE] STNA #637 pulled back the covers for Resident #125 and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region and yellow tinted bruising to his left rib cage area. STNA #637 revealed the resident was grunting, clenching his teeth and voiced a sound like ouch displaying signs of significant pain. The resident was transferred to the hospital, and diagnosed with a displaced intertrochanteric fracture to his left femur. The injury was determined to have occurred as a result of not being transferred with the mechanical lift on [DATE]. This affected four residents (#15, #33, #80 and #125) of four residents reviewed for accidents/proper transfers. The facility identified 41 residents (#1, #7, #9, #15, #19, #21, #22, #23, #29, #32, #33 #36, #39, #48, #50, #55, #57, #58, #59, #63, #64, #67, #68, #69, #71, #74, #79, #80 #81, #85, #90, #96, #97, #99, #100, #102, #103, #109, #115, #116 and #125) who were dependent on staff or required (staff) assistance with transfers. The facility census was 119. Findings include: 1. Review of the closed medical record for Resident #125 revealed an admission date of [DATE]. The resident passed away at the facility on [DATE]. Resident #125 had diagnoses including dementia, hypertension, polymyalgia rheumatica (syndrome with pain or stiffness to neck shoulders and extremities), and fracture of head of left femur diagnosed on [DATE]. Review of the care plan dated [DATE] revealed Resident #125 required assistance with activities of daily living (ADL) related to weakness as he required extensive to total staff assistance with ADL. Interventions included a mechanical lift with two staff assist for transfers and monitor and report changes in physical functioning. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 was cognitively impaired. The assessment revealed the resident was dependent on staff for ADL care including to move from sitting to lying position, and chair to bed/ bed to chair transfers. Review of the undated task bar revealed Resident #125 was to be transferred with a mechanical lift by two staff assist. Review of Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of [DATE] physician's orders revealed Resident #125 had an order dated [DATE] to be transferred with a mechanical lift with two staff assist. He also had an order for Hospice due to Alzheimer's disease dated [DATE]. Review of weight record revealed on [DATE] Resident #125's weight was recorded as 159.6 pounds. Review of nursing note dated [DATE] at 7:12 A.M. and completed by Licensed Practical Nurse (LPN) #629 revealed Resident #125 had purple areas to his left foot near his great toe measuring three centimeters (cm) in length by four cm in width and another area measured two cm in length by one cm in width. The note revealed both areas were blanchable, and the areas were cleansed with normal saline and covered. Primary Care Physician (PCP) #900 was called and a message was left. Review of nursing note dated [DATE] at 9:20 A.M. completed by Registered Nurse (RN) #689 revealed staff had called her to Resident #125's room due to reddened area to his left hip, left pelvis, and left rib cage area. The note revealed the resident was in pain. PCP #900 was notified and ordered to obtain x-rays of the areas. Review of the Bath/ Shower Skin Inspection Sheet dated [DATE] and completed by RN #689 revealed Resident #125 had bruises to his left hip, left side of his pelvis, left side of his ribs, right foot, and right great toe. Review of facility SRI, tracking number 239869 and dated [DATE] revealed the Administrator submitted an SRI for injury of unknown source. The SRI noted on [DATE] Resident #125 had redness near his leg hip, rib, and pelvis area and that he was dependent on staff with mobility. Resident #125 was found to have a closed displaced intertrochanteric fracture of his left hip. The SRI revealed during the investigation the facility concluded the resident was possibly not transferred correctly per care plan, but abuse was not suspected. The facility unsubstantiated the SRI. Review of the nursing note dated [DATE] at 11:01 A.M. and completed by RN #689 revealed the x-ray company was unable to obtain x-rays and PCP #900 was notified and ordered to send Resident #125 to the hospital emergency room. Review of the After Visit Summary dated [DATE] revealed emergency room (ER) Physician #708 had evaluated Resident #125 and noted in the summary the reason of the visit was due to a fall. The resident had a closed displaced intertrochanteric fracture of his left femur. He was to follow up with Physician #709 and received orders for pain medications. Review of the nursing note dated [DATE] at 6:49 A.M. completed by LPN #704 revealed at approximately 8:00 P.M. the hospital called and reported Resident #125 was returning to the facility with a new diagnosis of left femur fracture. The note revealed no intervention would be done because the resident was contracted per the orthopedic physician at the hospital. The note revealed Resident #125 was nonverbal throughout the night but grimaced in pain while transferring from gurney to bed. PCP #900 was notified and ordered pain medication, and his family was notified. Review of the Skin Observation Tool dated [DATE] and completed by RN #670 revealed Resident #125 had bruising to his left trochanter area that measured 16 cm in length by 5.2 cm in width. The area was described as redness noted with dark purple area to center of his boney prominence. Review of the nursing notes dated [DATE] at 11:28 A.M. and completed by Social Service Director (SSD) #622 revealed Resident #125's daughter had spoken with PCP #900 and they both agreed to have Hospice services initiated due to his decline in health. Review of the Witness Statement dated [DATE] and completed by STNA #680 revealed she had come on duty on [DATE] at approximately 8:30 P.M. to 9:00 P.M. and STNA #685 asked for assistance to transfer Resident #125 to his bed as he was not on a Hoyer sling (designed to be suspended from a swivel bar on a mechanical lift to transfer a person) in his wheelchair. The statement revealed that this had happened several times. The statement revealed the only available Hoyer sling was not suitable for the current mechanical lift. The statement revealed she and STNA #685 armed and leg him into his bed and then she left the room. Review of the Witness Statement dated [DATE] and completed by STNA #615 revealed she had gotten Resident #125 up on [DATE] and that she was not aware he was to be transferred with a mechanical lift. Review of nursing notes dated [DATE] at 8:15 A.M. and completed by RN #670 revealed Resident #125 had expired at the facility. Interview on [DATE] at 2:39 P.M. with RN #689 revealed (on [DATE]) at approximately 9:00 A.M. STNA #637 notified her Resident #125 had something on his left hip. She revealed she immediately evaluated and noted a softball size red hard area to his left hip over his boney prominence. She revealed he also had bruising to his left pelvic area, and on his left rib cage. She revealed she notified PCP #900, and he ordered an in-house x-ray, but the x-ray company was unable to obtain good imaging due to the resident's contractures. She revealed PCP #900 ordered the resident to be sent to the hospital for an evaluation. Interview on [DATE] at 2:44 P.M. with STNA #630 revealed she worked day shift on [DATE] and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. Interview on [DATE] at 3:05 P.M. with STNA #665 revealed she had worked on [DATE] on day shift and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. She revealed she had seen this happen a few times before as well. She revealed Resident #125 was to be transferred by a mechanical lift and did not know how staff were transferring him without use of a mechanical lift as he was contracted, heavy, and not able to assist by bearing any weight. Interview on [DATE] at 3:20 P.M. with STNA #685 revealed on [DATE] she had worked 7:00 P.M. to 7:00 A.M. and when she came in, Resident #125 was sitting in his wheelchair without a Hoyer sling underneath him. She revealed she told LPN #629 the resident was not on a Hoyer sling as this had happened several times before. She revealed LPN #629 stated that she would communicate again that staff were still getting him up without a Hoyer sling. She revealed she and STNA #680 got on each side of him and transferred him by getting under his arms and grabbing the back of his pants. She revealed she felt the transfer was completed in a safe manner. She revealed he already had a gown on and that she just removed his sweat pants. She revealed since he had a urinary catheter and was not incontinent of bowel that she did not remove his incontinent product and/or lift his gown. She revealed she did not notice any bruising. Attempts to interview STNA #615 on [DATE] at 3:36 P.M. and on [DATE] at 8:42 A.M. were unsuccessful as she did not return the calls. Interview on [DATE] at 3:38 P.M. with STNA #680 revealed on [DATE] she came in at 7:00 P.M. and noticed Resident #125 was not on a Hoyer sling. She revealed she went to laundry to retrieve a sling to place underneath him, but there was only one available. She verified she had not notify LPN #629 that he was not on a Hoyer sling and that she was unable to locate a sling to transfer him with. She revealed she and STNA #685 were strong and transferred him under his arms and grabbed his pants. She verified she did not utilize a gait belt during the transfer. She revealed she left the room after the transfer but felt the transfer was done in a gentle manner. During the interview, she revealed first shift staff continued to get up residents , including Resident #81 and #119 without a mechanical lift as she frequently came in and they did not have a Hoyer sling underneath them despite orders to be transferred with a mechanical lift. Interview on [DATE] at 3:42 P.M. with LPN #629 revealed she was the nurse on duty [DATE] from 7:00 P.M. to 7:30 A.M. but was not notified by the staff that Resident #125 did not have a Hoyer sling underneath him and/or that they transferred him without a mechanical lift. She revealed on [DATE] she was completing the treatment on his foot and noticed he had new dark purple areas to the inside of his right foot. She revealed she did not know if the areas were pressure and/or bruise and passed on the areas in report. Interview on [DATE] at 3:48 P.M. with STNA #637 revealed she worked on [DATE] and after breakfast she pulled back Resident #125's covers and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region, and yellow tinted bruising to his left rib cage area. She revealed he was grunting, clenching his teeth together, and voicing a sound like ouch showing he was in significant pain. She revealed RN #689 was notified. She revealed she had worked on [DATE] and felt STNA #615 had gotten Resident #125 up all by herself as she was working the same hall as her, and she had not asked her to help transfer him. Interview on [DATE] at 4:12 P.M. with [NAME] President (VP) of Clinical Services #711 verified STNA #615 revealed during the investigation that she had gotten Resident #125 up by herself without a mechanical lift on [DATE]. She also verified that the facility only had a policy regarding transfer with a mechanical lift but did not have a policy regarding one or two persons transfer assistance. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #125 was to be transferred with a mechanical lift with two staff assist per his physician order dated [DATE]. Also, they verified on [DATE] STNA #615 had transferred him by herself without the use of a mechanical lift from his bed to his wheelchair and on [DATE] STNA #680 and #685 had transferred him without a mechanical lift from his chair to his bed. They verified per STNA #680's witness statement she had stated the only available Hoyer sling was not suitable for the mechanical lift so they armed and leg transferred him. 2. Review of the medical record for Resident #33 revealed an admission date of [DATE] with diagnoses including congestive heart failure, lymphedema, and morbid obesity. Review of the care plan dated [DATE] revealed Resident #33 required assistance with ADL related to weakness and morbid obesity. Interventions included he was to be transferred by use of mechanical lift and two staff assist. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #33 was cognitively impaired as his Brief Interview for Mental Status Score (BIMS) was a 12. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the [DATE] Physician Orders revealed no orders regarding utilizing a mechanical lift to transfer. Review of the weight record revealed on [DATE] Resident #33's weight was 335.2 pounds. Review of the Kardex as of [DATE] revealed Resident #33 was to utilize a mechanical lift with two staff assist with transfers. Interview on [DATE] at 7:38 A.M. with Resident #33 revealed he was to be transferred with a mechanical lift in and out of bed but that it was hard as sometimes staff would not transfer him back into bed when he wanted as there was not enough staff. He revealed this caused him to sit up in his wheelchair for a long time causing his legs and buttocks to hurt. He revealed staff sometimes had no choice but to only use one staff to transfer him back to bed as he stated there were not enough staff. He revealed there was one aide and described the aide: African American and that she had told him she was [AGE] years old but could not remember her name had gotten him up and put him back to bed with the mechanical lift by herself on several occasions. He revealed it was not her fault as there just were not enough staff. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #33 was to be transferred utilizing a mechanical lift with two staff. 3. Review of medical record for Resident #15 revealed an admission date of [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, and major depression. Review of the care plan dated [DATE] revealed Resident #15 was at risk for falls related to impaired mobility. Interventions included transfer by use of a mechanical lift and two staff assistance. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. Review of annual MDS assessment dated [DATE] revealed Resident #15 had significant cognitive impairment. Review of the [DATE] physician orders revealed Resident #15 had an order dated [DATE] to be transferred with a mechanical lift by two staff. Review of the Kardex dated as of [DATE] revealed Resident #15 was to be transferred using a mechanical lift and two staff assist. Observation on [DATE] at 7:26 A.M. revealed STNA #600 and STNA #710 transferred Resident #15 with a mechanical lift with no concerns. She was unable to be interviewed due to cognitive ability. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. 4. Review of the medical record for Resident #80 revealed an admission date of [DATE] with diagnoses including unspecified psychosis, abnormalities with gait and mobility, osteoporosis, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed she was cognitively intact and required extensive assist of two staff with transfers. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on all the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 3:09 P.M. with Resident #80 revealed she was unsure how and how many staff usually assisted in transferring her to her bed to chair and/or her chair to her bed. Review of the Kardex dated [DATE] Resident #80 was to be transferred with two staff assist. Observation on [DATE] at 10:02 A.M. revealed STNA #632, and STNA #665 transferred Resident #80 with no issues. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the facility policy labeled; Mechanical Lift, dated [DATE], revealed the purpose of the policy was to transfer a dependent resident safely. The policy revealed to confirm a mechanical lift was to be used. There was nothing in the policy regarding how many staff were to assist during a transfer with a mechanical lift. Review of the undated policy labeled, Freedom from Abuse and Neglect revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, and emotional stress. This deficiency represents non-compliance investigated under Complaint Number OH00147411. This deficiency is an example of continued non-compliance from the survey completed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat potentially contagious/communicable rashes per physician orders, failed to timely implement transmission-based precautions to prevent spreading the rash to other residents, failed to implement exposure control measures, failed to educate and in service staff on infection control relative to preventing the spread of potentially contagious/communicable rashes, failed to report the outbreak to the local health department, and failed to prohibit State Tested Nursing Assistant (STNA) #373, who exhibited signs of a potentially communicable/contagious rash, from direct resident contact. Actual Harm occurred on 07/26/23 when Resident #61, who was evaluated for a body rash by his Primary Care Physician (PCP) #400 on 07/25/23 and ordered permethrin cream (a topical treatment used to treat scabies caused by the itch mite Sarcoptes scabiei which is a highly contagious skin condition) to be administered on 07/26/23 to treat the body rash, did not get the treatment of permethrin cream as ordered by the physician until the permethrin cream was reordered on 08/03/23. This resulted in seven residents (#26, #36, #54, #61, #62, #96 and #103) developing a rash with resulting severe itching, intense scratching, bleeding of rash areas, severe discomfort with statements including but not limited to feeling like their skin was on fire, felt she was dying, it is miserable, it is burning demonstrating psychosocial harm due to anxiety, disrupted routine sleep and/or hospitalization to the emergency room for worsening rash symptoms. Additionally, the facility did not exclude STNA #373 from providing direct resident care after she told a nurse on duty she had developed the rash to her arms, legs, and abdomen approximately one week ago. Instead, the nurse gave her permethrin cream to use and had her continue to work her shift. On 08/25/23 STNA #373 revealed she went to Physician #901 and was diagnosed with scabies. This affected 20 residents (Residents #12, #17, #19, #26, #27, #31, #36, #42, #45, #48, #50, #54, #62, #63, #69, #96, #102, #103, #104 and #118) who developed a rash, and/ or received permethrin treatment out of 41 residents (Resident #5, #6, #9, #12, #17, #19, #24, #26, #27, #31, #36, #40, #42, #45, #46, #48, #50, #54, #55, #57, #60, #61, #62, #63, #69, #76, #78, #82, #80, #87, #88, #90, #96, #102, #103, #104, #108, #111, #115, #117, #118) residing on the secured unit and had the potential to affect all 117 residents residing at the facility as STNA #373 had worked other units other than the secured unit in the last two weeks. Findings included: 1. Review of the medical record for Resident #61 revealed an admission date of 01/13/23 and diagnoses included psychosis, dementia, and chronic obstructive pulmonary disease. Resident #61 lived on the secured unit of the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/23, revealed Resident #61 was cognitively impaired. He required supervision only with bed mobility, transfers, and ambulation. Review of a nursing note dated 07/21/23 at 11:27 A.M. and completed by Licensed Practical Nurse (LPN) #341 revealed Resident #61 complained of dry, itchy skin to arms and legs. The note revealed PCP #400 was notified and ordered [NAME] lotion (an anti-itch lotion). Review of a nursing note dated 07/25/23 at 7:05 P.M. and completed by LPN #341 revealed Resident #61 was seen per Primary Care Physician (PCP) #400 due to re-occurring rash to body and she referred to dermatologist and ordered permethrin treatment. Review of the July 2023 Medication Administration Record (MAR) revealed Resident #61 had an order to receive permethrin external cream five percent apply all over body topically one time on 07/26/23 for re-occurring rash and shower off on 07/27/23. The MAR was blank on 07/26/23 indicating the treatment was not completed as ordered by the physician. Review of the July 2023 Treatment Administration Record (TAR) revealed Resident #61 was placed on contact isolation precautions from 07/27/23 through 07/31/23 when the contact precautions were discontinued. There was no evidence on the TAR to indicate Resident #61 was placed on contact isolation precautions on 07/25/23 when PCP #400 ordered the permethrin treatment and there was no evidence of contact isolation precautions on 07/26/23. Review of the August 2023 MAR and TAR revealed on 08/03/23 at 10:38 P.M. Resident #61 received permethrin cream five percent topically all over his body due to re-occurring rash. This was his first treatment of permethrin cream, since it had not been given on 07/26/23 per physician order. There was no order for Resident #61 to be on contact isolation precautions from 08/01/23 to 08/03/23 per the TAR. Review of nursing notes dated from 07/25/23 to 08/03/23 revealed there was no documentation PCP #400 was notified Resident #61 had not received his one-time permethrin cream ordered for 07/26/23 and he had not received the treatment until 08/03/23. Review of nursing notes also revealed no evidence Resident #61 was on contact isolation on 07/25/23 and 07/26/23 after PCP #400 had ordered permethrin for potential scabies on 07/25/23. There was also no documentation per the nursing notes that he was on contact isolation from 08/01/23 to 08/03/23. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #61 had a red rash to his body. The assessment revealed PCP #400 was notified and ordered permethrin cream to be applied and then to repeat the treatment in one week. Review of the resident census revealed Resident #61 received a roommate (Resident #9) on 07/28/23 and continued to live as roommates despite Resident #61 not receiving the permethrin cream (scabies treatment) as ordered for 07/26/23. Review of Physician Progress Note dated 08/01/23 and completed by PCP #400 revealed Resident #61 continued to have an itchy rash to arms, neck, abdomen, and he was treated with permethrin and had a dermatology appointment. There was no documentation PCP #400 was aware Resident #61 missed his permethrin treatment on 07/26/23. Interview and observation on 08/23/23 at 11:34 A.M. with Resident #61 revealed he had a rash in his groin, around his legs and just about everywhere. He revealed it itched especially all night which kept him up at night. He stated, it is miserable. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing (DON) verified Resident #61's permethrin cream was not documented as given on 07/26/23 as well as he was not on contact isolation for the entire duration of the rash after the permethrin cream was ordered on 07/25/23 until it was finally given on 08/03/23. Review of Dermatopathology Report, dated as collected on 08/15/23 and reported on 08/22/23, revealed Resident #61 had a biopsy to left forearm showing irregularly acanthotic and spongiotic epidermis with dermal inflammatory reaction. The report's comments section documented a medication reaction and spongiotic dermatitis were not ruled out. It is to be noted the biopsy was completed after permethrin cream was administered to Resident #61 on 08/03/23. 2. Review of the medical record for Resident #62 revealed an admission date of 07/19/22 and diagnoses included dementia, and hypertension. Review of the annual MDS dated [DATE] revealed Resident #62 was cognitively impaired and required supervision with most her activities of daily living. Review of Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review dated 07/26/23 and completed by Unit Manager/ LPN #344 revealed Resident #62 had a rash to her bilateral arms and legs with scabs. Review of Skin Observation Tool dated 07/28/23 and unauthored revealed Resident #62 had a dry rash to her body with some scabbed areas. Review of July MAR and TAR for Resident #62 revealed she had an order for contact precautions dated to start 07/27/23 at 7:00 P.M. and was treated with permethrin external cream for her rash on 07/28/23. There was no evidence contact precaution started on 07/26/23 when on the shower review it was documented she had a rash (as well as other residents in the secured unit had a rash and being treated with permethrin cream). Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. Interview and observation on 08/23/23 at 3:01 P.M. of Resident #62 revealed she was sitting in the lounge and a visible red splotchy rash noted to her bilateral arms with dry flaky skin. She was unable to provide any information during the interview except that she had a rash. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim DON verified the facility had no documentation Resident #62 was placed on transmission-based precaution before 07/27/23. 3. Review of medical record for Resident #54 revealed an admission date of 05/29/23 and diagnoses included dementia, and hypertension. Review of quarterly MDS dated [DATE] and revealed she had impaired cognition. Review of July 2023 physician orders revealed Resident #54 had an order dated 07/21/23 for [NAME] lotion as needed to apply to itchy skin. She then had orders dated 07/26/23 to be placed on contact isolation and permethrin external cream. Review of nursing notes dated 07/21/23 at 5:50 P.M. and completed by LPN #343 revealed PCP #400 was in facility and notified of new red itchy areas and new orders were received. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed Resident #54 had a rash to her stomach area that was acquired on 07/26/23. The assessment revealed PCP #400 ordered permethrin and to repeat the cream in one week. Interview and observation on 08/22/23 at 7:54 P.M. revealed Resident #54 sitting in her chair in her room and when asked if she had a rash she stated, it was burning and was red. She then proceeded to show this surveyor a rash to her chest and arms as she pulled down her shirt. She revealed the rash just does not go away. She revealed the rash was uncomfortable and that it does keep her up at night as the rash was itchy. She revealed she had the rash a long time but was unable to provide details to how long and was unsure if she seen a physician for the rash as she stated that was why she was at the facility as she was unable to remember things. Review of nursing notes dated from 07/27/23 to 08/22/23 revealed no other documentation regarding her rash and/ or physician notification that the rash continued as observed on 08/22/23. 4. Review of medical record for Resident #96 revealed an admission date of 12/20/22 and her diagnoses included Alzheimer's disease, hypertension, and diabetes. Review of quarterly MDS dated [DATE] revealed Resident #96 had impaired cognition and required supervision only with most her activities of daily living. Review of the Wound Observation Tool dated 07/27/23 and completed by Unit Manager/ LPN #344 revealed on 07/26/23 Resident #96 had a rash to her body. PCP #400 was notified and ordered permethrin cream topically and repeat in one week. Interview and observation on 08/22/23 at 7:58 P.M. with Resident #96 revealed she had a rash all over but mainly her back. She revealed it itched all the time. She showed this surveyor her bilateral arms and a red rash with scratch marks noted to her bilateral arms. She revealed the rash itched and sometimes woke her up at night causing her not to sleep well. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed several residents had rashes on the secured unit and recently Resident #96 was in her room when she was passing out the mail and she was digging and scratching hard at her leg intensely causing her leg to bleed all over. She revealed she felt bad as she seemed very uncomfortable as well as several other residents. 5. Review of medical record for Resident #103 revealed an admission date of 07/21/23 with diagnoses including Alzheimer's disease, diabetes, anxiety, and hypertension. A diagnosis of scabies on 08/10/23 was added to her medical diagnosis list. Review of care plan dated 07/21/23 revealed Resident #103 was at risk for actual and/ or potential skin impairment as on 07/27/23 she was receiving treatment due to roommate's rash. Intervention included treatment as ordered, skin check weekly, and observe skin during care. Review of unauthored Skin Observation Tool dated 07/25/23 revealed a second skin check was completed and skin was intact with no areas noted. Review of Skin Monitoring: Comprehensive CNA Shower Review dated 07/26/23 completed by Unit Manager/ LPN #344 revealed skin was clear. There were no additional skin observations noted as completed from 07/25/23 to 08/10/23. Review of July 2023 MAR revealed Resident #103 received permethrin external cream five percent apply to neck to toes topically times one dose and then shower and remove on 07/27/23. Review of nursing notes dated 07/27/23 to 08/23/23 revealed no documentation regarding Resident #103's rash and/ or notification to the Power of Attorney (POA) regarding the permethrin cream ordered on 07/27/23. Review of nursing note dated 08/08/23 at 4:53 P.M. and completed by LPN #343 revealed staff notified the nurse that Resident #103 felt itchy on her thighs and small raised areas were noted. The note revealed Resident #103 denied pain just felt itchy. The note revealed PCP #400 was notified and ordered [NAME] (anti-itch moisturizing lotion) lotion five percent as needed for areas. Review of nursing note dated 08/10/23 at 2:32 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103's daughter was in concerned about the itchy areas to her inner thighs. The note revealed her daughter wanted her sent to the emergency room (ER) for an evaluation. Review of nursing note dated 08/10/23 at 4:35 P.M. and completed by Unit Manager/ LPN #338 revealed Resident #103 returned from the emergency room with a diagnosis of scabies and new orders. Review of After Visit Summary dated 08/10/23 and completed by ER Physician Assistant #900 revealed Resident #103 was seen due to rash. Resident #103 was provided information regarding scabies and nonspecific rash. She was ordered hydrocortisone ointment 2.5 percent to apply to affected areas twice a day for `14 days and permethrin five percent to apply to affected area times one dose for pruritic (itchy) rash. Observation on 08/22/23 from 7:30 P.M. to 8:25 P.M. revealed Resident #103 was unable to be interview due to cognitive ability and no signs of a rash were visibly seen. 6. Review of the medical record for Resident #36 revealed an admission date of 03/27/23 and diagnoses included dementia, anxiety, and diabetes. Review of the significant change MDS dated [DATE] revealed she was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of a nursing note dated 07/26/23 at 7:15 P.M. and completed by Unit Manager/ LPN #344 revealed Resident #36's power of attorney (POA) was notified she received permethrin cream as preventative and had a possible exposure to scabies and was asked if the resident was itching or had a rash and the POA stated not at this time. Review of nursing notes dated 08/08/23 at 1:39 P.M. and completed by LPN #341 revealed during Resident #36's shower she had small red spots/ rash noted to lower back along with some scratch marks. The note revealed she stated it itched sometimes. The note revealed PCP #400 was notified and ordered [NAME] anti-inch lotion since she was treated with the permethrin cream on 07/26/23. Interview on 08/22/23 at 7:30 P.M. with Resident #36 revealed she had a rash as well as all the residents on the unit had a rash. She revealed her rash was on her chest and she had the rash for two to three weeks. She revealed she felt it was caused by staff washing all their clothes together and not keeping it separate. Observation revealed during the interview she was itching her bilateral arms and the sides of her abdomen. 7. Review of medical record for Resident #26 revealed an admission date of 02/11/22 and diagnoses included psychosis, bipolar disorder, and dementia. Review of the quarterly MDS dated [DATE] revealed Resident #26 had cognitive impairment. Review of August 2023 Physician Orders and TAR revealed no evidence Resident #26 was placed on contact isolation after she was found to have a rash on 08/13/23 and was ordered to be treated with permethrin cream. Review of a nursing note dated 08/13/23 at 12:37 P.M. with LPN #377 revealed Resident #26 was complaining of itching and the nurse examined noting a rash to her torso and extremities. PCP #400 was notified and ordered permethrin cream and repeat the cream in seven days. Observation on 08/22/23 at 7:36 P.M. revealed Resident #26 was in her room without a shirt on attempting to make her bed. She was observed with a red rash covering her back, chest, abdomen, and bilateral arms and had multiple scratch marks that were scabbed from previous scratching. She was observed to intensely dig at her back making red marks and removing previous scabbed scratches causing areas to bleed. While scratching she was observed making facial grimaces as she was trying to reach the middle of her back. She was unable to be interviewed due to cognitive ability. Interview on 08/24/23 at 9:45 A.M. with Administrator and Interim Director of Nursing verified no evidence Resident #26 was placed on transmission-based precautions. 8. Interview on 08/24/23 at 3:35 P.M. and 4:18 P.M. with STNA #373 revealed she worked 5:00 P.M. to 5:00 A.M. usually on the secured unit but floated to other units in the facility. She revealed approximately one week ago she got a rash to her arms, legs, and abdomen that looked like what the residents had on the secured unit. She revealed she told a nurse (but did not want to get the nurse in trouble so would not provide her name) about her rash and the nurse gave her permethrin cream to apply to the rash and the nurse had stated the rash was scabies. She revealed she remained on duty and worked having direct contact with the residents despite having the rash, as the nurse did not send her home. She revealed she was upset as she felt the facility should have told the staff the rash was contagious and what should have been done to prevent the rash from spreading amongst the staff. She revealed she was concerned bringing the contagious rash home to her family. She revealed she felt this was a contamination issue especially because she worked on other units and with how many residents had the rash on the secured unit, she was concerned about spreading to the other units. She revealed she did not tell the interim DON instead she told the nurse on duty. STNA #373 explained she knew the interim DON was aware, as the interim DON had contacted her today (08/24/23) and told her she needed to repeat the permethrin treatment. STNA #373 revealed she was not sure how the interim DON thought she would get the cream but probably the interim DON assumed she would get it from the nurse who gave it to her the first time. She then revealed the interim DON called her back later and told her she was being removed from the schedule until she got a doctor's release. Interview on 08/25/23 at 3:56 P.M. with STNA #373 revealed she went to Physician #901 today (08/25/23) and she was diagnosed with scabies. She revealed the physician had told her she had burrowing to her skin which was a classic sign of scabies. She revealed she was ordered permethrin cream to be applied and was to remain off work until 08/27/23. She revealed she was notifying the facility. Review of the staffing schedule and interview on 08/24/23 at 8:31 A.M. with Scheduler/ STNA #372 revealed the following staff from 08/07/23 to 08/20/23 had worked the secured unit as well as other units in the facility during this time frame including STNA #373 as well as LPN #377, STNA #319, #322, #335, #340, #349, #351, #358, #365, #367, and #375. 9. Interview on 08/22/23 at 7:22 P.M. with STNA #351 revealed on the secured unit there was tons of residents with rashes. She revealed she usually worked on the secured unit but today, 08/22/23, she was on a different unit. She revealed just more and more residents keep getting it and nobody seems to be doing anything about it. She revealed she felt bad as the residents constantly are itching and scratching at their skin and seemed to be uncomfortable. She revealed she was concerned about what the rashes were as she had heard it was scabies, but that management was not telling the staff. She revealed she had never received any in services regarding the rashes and precautions to take. Interview on 08/22/23 at 7:39 P.M. with STNA #375 revealed he routinely worked the secured unit and there were several residents with rashes on the unit. He revealed the rashes were bad as residents were itching so bad it felt like they cannot take it anymore as the residents had the rashes a long time approximately two months it seemed. He revealed management had not communicated what the rashes were and/ or given any training regarding precautions they should be doing. Interview on 08/22/23 at 7:42 P.M. with STNA #402 revealed she routinely worked the secured unit and was upset as nobody had told the staff what the rashes were, and she felt the staff had a right to know especially that so many residents had rashes and that more keep on getting a rash. She revealed she was giving Resident #62 a shower recently and during the shower Resident #62 stated, her skin was on fire, she felt she was dying. She revealed all the residents scratch all the time and cannot get a good night sleep. She revealed Resident #61 always complained and appeared in a lot of discomfort. She revealed she had not received any training regarding the rashes and/ or precautions to take. She revealed staff member, STNA #373, now had the rash and stated most likely because nobody was telling them what the rashes really were and any special instructions that they should be taking to prevent the spread. Interview on 08/22/23 at 8:25 P.M. with Agency STNA #403 revealed several residents had rashes on the secured unit. She revealed she had not received any in-services regarding the rashes and/ or precautions to take. Interview on 08/23/23 at 9:37 A.M. with the Interim DON verified per the list the facility submitted there were 17 residents currently with rashes on the secured unit. She verified all 17 residents appeared to have the same type of rash and revealed I am assuming it is contagious because one person is getting it then the next person also getting it. She revealed the facility could not state the rash was scabies but verified PCP #400 was ordering permethrin cream which was a treatment to treat scabies. She was asked what infection control plan the facility had initiated, and she revealed once the rash was found on a resident, the resident was placed on contact isolation and permethrin cream was ordered and applied and then washed off after 12 hours. When the Interim DON was asked if any further plans regarding the outbreak, she stated why would I have to have any other plan or such, we see the rash, we call the doctor, we get the cream, and they wash it off. She verified the facility had not contacted the local health department regarding the outbreak of rashes. She was asked if she felt the facility was having an outbreak of rashes and she stated yes. She verified the facility did not have any formal training of staff regarding infection control measures regarding the outbreak of rashes and then asked, what am I supposed to educate on a rash?. She verified the facility completed only one skin sweep on 07/26/23 and revealed if the staff find a rash, they already know they were to report it but verified she had no education evidence she educated the staff regarding reporting of rashes. Interview on 08/23/23 at 10:38 A.M. with Local Health Department Epidemiologist #405 revealed they had not been contacted by the facility regarding the outbreak of rashes that potentially may be scabies since the physician was treating the rashes with permethrin cream. He revealed anytime there was two or more cases including rashes that they needed to be reported by the facility. He revealed if they have 17 rashes or possibly more confined to one unit this was a contagious outbreak and needed to be reported. He revealed the local health department would try to figure out the exact diagnosis and/ or confirm if it was scabies, work with the medical team at the facility, implement isolation exposure guidelines as usually they would send the facility immediate guidelines to implement and coordinate a host of infection control measures to stop and prevent further spread/ outbreak. Interview on 08/23/23 at 12:03 P.M. with Activities Director #342 revealed she was upset as the facility does not share anything about what the rashes were and what the staff should do. She revealed the facility had not in serviced and/ or provided any education regarding precautions to take. She revealed she was concerned as she did not want to take anything home to her kids so felt the facility should educate especially since almost all the residents on the secured unit have the rash. Interview on 08/23/23 at 3:38 P.M. with PCP #400 revealed about a month ago Resident #61 started to have a rash as she felt he was the first resident on the secured unit to have. She revealed at first, she treated with triamcinolone cream as she felt it was allergic dermatitis. She revealed the rash did not improve and the rash looked like possibly scabies. She revealed she ordered him to be treated with permethrin cream and had referred him to a dermatologist. She revealed she seen him recently and felt his rash had improved and felt it was because he had received permethrin cream for the scabies. She revealed she had received further calls regarding other residents having the same type of rash, so she instructed them to treat as well with permethrin cream and repeat the cream in one week. She revealed she also ordered the facility to treat the resident's roommate as well as precaution. She revealed she did not realize there was currently 17 total residents with rashes as she stated, not aware of 17 did not think that many but that she received a lot of calls so could be that many as she did not keep track. She revealed there were only a few contagious rashes with severe itching with scabies being one of them and that was why she treated the rashes with permethrin cream. Review of a list provided by the facility on 08/22/23 of residents with current rashes on the secured unit included 17 residents: Resident #9, #12, #17, #19, #26, #36, #42, #45, #48, #54, #61, #62, #63, #69, #96, #103, and #104. Review of Infection Control Log from 07/01/23 to 08/22/23 revealed the following 20 residents on the secured unit currently or had rashes and/ or were treated with permethrin cream: on 07/26/23 Residents #12, #17, #31, #54, #96, on 07/27/23 Resident #36, #42, #50, #62, on 08/08/23 Resident #19, #27, #48, #102, on 08/09/23 Resident #63, #69, #118, on 08/10/23 Resident #103, on 08/13/23 Resident #26, and on 08/20/23 Resident #45, and #104. Review of Know Your ABC's: A Quick Guide to Reportable Infectious Disease in Ohio dated 08/01/19 included the facility would report an outbreak, unusual incident, or epidemic of other disease such as histoplasmosis (fungal infection, pediculosis (lice), scabies) by the end of the next business day to the local health department. Review of facility policy labeled, Scabies identification, Treatment and Environmental Cleaning dated August 2016 revealed the purpose of this procedure was to treat residents infected with and sensitized to scabies and to prevent the spread of scabies to other residents and staff. The policy revealed scabies was an itching skin irritation caused by a microscopic human mite which burrows into the skin's upper layers and eventually causes itching, tiny red lines just above the skin and an allergic rash. The incubation period was two to six weeks and persons who had been previously infected develop more rapid symptoms one to four days after re-exposure. The policy revealed symptoms include severe itching which worsens at night and spreads by skin-to-skin contact or through contact with bedding, clothing, privacy curtains and furniture. Residents should remain on contact precaution 24 hours after the treatment and any staff members should report any rashes that developed on their bodies to the Infection Preventionist or Director of Nursing. The policy revealed during a scabies outbreak the Infection Preventionist or committee would coordinate an effective treatment program. The policy revealed infected employees can return to work after treatment was completed but should use gowns and gloves for direct resident care to prevent reinfestation until all control measures for affected areas have been completed. This deficiency represents non-compliance investigated under MASTER Complaint Number OH0000145650, Complaint Number OH00145621, OH00145594, OH00145593, OH00145536, OH00145524, and OH00145303 and is an example of continued noncompliance from the survey dated 07/20/23.