**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, resident family interview, and policy review, the facility failed to provide a resident and the resident representative a written bed-hold notice at the time of hospitalization. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 90. Findings included: Review of Resident #44's medical record revealed an admission date of 03/07/25. Diagnoses included complication of left knee internal orthopedic prosthetic devices, left artificial knee joint, and multiple sclerosis. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition. Review of Resident #44's most recent care plan revealed the resident may need assistance to coordinate community resources for discharge planning. Interventions included to provide written and verbal instructions at the resident's level of understanding, verbally explain instructions to the resident and family prior to discharge, and provide the resident/family with a written copy. Review of Resident #44's contact information revealed the resident was her own responsible party. The resident's wife was the first emergency contact and representative for care conferences, and Resident #44's sister was the second emergency contact. Review of Resident #44's hospital notes dated 03/19/25 revealed the resident had worsening necrotic tissue of her lower extremity and would require a debridement the following week of the left knee. The resident was admitted to the hospital on [DATE]. Review of Resident #44's progress note dated 03/26/25 revealed the nurse received a telephone call from Resident #44's sister indicating the hospital was admitting the resident until 03/28/25, and the resident would be returning with a wound vacuum to the left knee. Review of Resident #44's social service note dated 03/31/25 revealed telephone contact was made with the resident, and she wanted to confirm her room would be held until her return from the hospital. The Social Worker responded that Resident #44 would return to the same room as her sister agreed to a bed hold. The resident would sign the bed hold form at that time. Review of Resident #44's late entry social service progress note, written by Assistant Heath Care Administrator #658 and dated 04/03/25, revealed on 03/26/25 he spoke with Resident #44's sister in regard to completing a bed hold and the sister stated she would do anything they have to keep her room. Review of Resident #44's bed hold agreement document dated 03/26/25 revealed a telephone interview with the resident's sister revealed the sister agreed to the bed hold policy and expenses. Review of a social service note dated 04/03/25 revealed Resident #44 returned to the facility. Interview with Resident #44 on 04/07/25 at 10:04 A.M. revealed she was not notified she was past her 20 days of paid care and was paying out of pocket. The resident was hospitalized and stated she had to have a wound vacuum applied to her knee. Her sister called the facility and spoke to Assistant Health Care Administrator #658 and was never informed of the expenses incurred in a bed hold. Resident #44 stated she was never informed verbally nor in writing of the bed hold policy and had incurred a large amount of out-of-pocket money owed to the facility. The resident stated she was her own person, and her sister was not the one to make financial decisions for her. Interview with Resident #44's sister on 04/07/25 at 10:04 A.M. verified she was not informed of the bed hold policy. Interview with the Administrator on 04/07/25 at 1:25 P.M. verified the facility failed to inform Resident #44 in writing of the bed hold policy on 03/26/25. Review of the undated facility policy titled, Out of Residence Policy, revealed the facility will ascertain from the resident or responsible party either prior to or during the absence if the resident intends to return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident family member and staff interview, medical record review, review of staff meeting documents and education materials, facility policy review, and review of a facility job description for certified medication aides (CMAs), the facility failed to ensure staff were working within their scope of practice related to CMAs administering as needed medications. This affected one (#64) of two residents reviewed for pain. The facility census was 90. Findings include: Review of the medical record for Resident #64 revealed she was admitted on [DATE] with diagnoses of congestive heart failure (CHF), diabetes mellitus type two, anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed she was cognitively impaired. At the time of medical record review for Resident #64 an MDS assessment was in progress for a significant change for admission to hospice services. Review of the care plan initiated April 2025 for Resident #64 revealed a care plan for pain with interventions to assess affects of unrelieved pain and notify the physician for pain medication adjustment, assess complaints of sudden/unusual/worsening pain and report to physician, assess the need to change as needed pain medication to a routine if resident was having difficulty anticipating pain medication needs, assist with position changes for comfort, and non-pharmacological methods of comfort. Review of the current physician orders dated April 2025 for Resident #64 revealed she was prescribed the pain medication Tylenol 650 milligrams (mg) every six hours pro re nata (PRN, meaning as needed) for pain or fever. The order was prescribed and in place since admission and admission to hospice services on 04/07/25. Review of Resident #64's nursing progress notes dated 04/04/2025 at 10:54 A.M. revealed the resident was crying out in pain and PRN Tylenol was administered and the overseeing nurse was notified. Review of the pain assessment documentation for Resident #64 revealed she had documented pain on 04/04/25 at 10:55 A.M. Further review of the pain assessment documentation for Resident #64 revealed following administration of Tylenol her pain was rated as a seven and the Tylenol was ineffective. Review of the nursing note dated 4/4/2025 at 10:55 A.M., generated by the electronic medication administration record (eMAR) for Resident #64 revealed Tylenol was administered for pain and the pain was rated at a six. Review of the nursing progress note dated 4/4/2025 at 2:28 P.M., generated by the eMAR for Resident #64, revealed the Tylenol was not effective and the follow-up pain was rated at a seven. Observation on 04/07/25 at 10:18 A.M. of Resident #64 revealed she was laying in bed on her back, moaning, and her breathing had a gurgling sound. Resident #64's daughter-in-law was at the bedside. Concurrent interview with Resident #64's daughter-in-law stated Resident #64 had been declining and the family was asked to consider hospice care. Resident #64's daughter-in-law stated the resident's family decided yesterday (04/06/25) and notified the facility on which hospice provider they chose, and were now waiting for hospice to come for their assessment and possible admission. Resident #64's daughter-in-law further stated she arrived at approximately 9:15 A.M. on 04/07/25 and the nurse communicated the nurse practitioner had been in to evaluate Resident #64 earlier that morning and ordered medication for comfort. Observation on 04/07/25 at 11:49 A.M. of Resident #64 revealed she was laying in bed, with the head of bed elevated, and had a wash cloth to her forehead. Resident #64 moved her head side-to-side and was breathing out of her mouth with non-labored shallow breaths with continued gurgling sound during breathing. Resident #64 had continuous oxygen running at two liters by way of nasal cannula and her family remained at the bedside. Interview on 04/08/25 at 2:52 P.M. with Licensed Practical Nurse (LPN) #612 stated if a certified medication aide (CMA) reported ineffective pain control the expectation would be for the overseeing nurse to conduct an assessment and attempt non-pharmacological methods of pain control such as repositioning. LPN #612 verified there was no documentation for a nursing assessment for pain control, no further treatment for pain, and no notification to the physician for uncontrolled pain for Resident #64. Further interview with LPN #612 stated the CMA that provided care on 04/04/25 for Resident #64 was CMA #584 and LPN #597 was assigned to oversee CMA #584 on 04/04/25. Interview on 04/08/25 at 3:35 P.M. with LPN #597 verified she worked on 04/04/25 and was not notified of uncontrolled pain for Resident #64 by CMA #584. Interview on 04/09/25 at 10:39 A.M. with the Director of Nursing (DON) stated on 04/04/25 the Tylenol administered to Resident #64 was by CMA #584 and it was out of her scope of practice to assess for pain. The DON further stated when a CMA was working and PRN medication was warranted, the CMA was required to notify the overseeing nurse for an assessment and direction for administration of the PRN medication. The DON further stated she interviewed the staff, and LPN #597 reported she was not notified of Resident #64's uncontrolled pain; and interview with CMA #584 reported she administered Resident #64 Tylenol before notifying the overseeing nurse. Further interview with the DON stated the CMA regulations were recently updated and included duties CMAs could now practice which included administration of insulin via an insulin pen only, administration of narcotics, and administration of PRN medications. The DON further stated the facility reviewed these updated regulations for CMAs, and the facility chose to allow for CMAs to administer insulin by way of insulin dial pen only with training and the facility policy continued to prohibit CMAs from administering narcotic medications and PRN medications without the assessment from the overseeing nurse first. Review of the staff meeting conducted on 03/17/25 for all nurses and CMAs to review the expectation of the nurse and the CMAs and update on the facility policy regarding the recent regulation changes for CMAs. Review of the sign-in sheet of this meeting revealed CMA #584 was present at the meeting and received the updated facility policy. Review of the presentation material revealed CMAs, per facility policy, were not permitted to administer PRN medications without a nurse assessment and narcotics continued to not be permitted for administration by a CMA. Interview on 04/10/25 at 7:54 A.M. with CMA #584 verified she was working on 04/04/25 and caring for Resident #64 when she was in calling out in pain and was different than her usual behavior of yelling. CMA #584 verified she administered the PRN Tylenol to Resident #64 on 04/04/25. Review of the undated facility job description for CMA revealed a certified medication aide will have their tasks delegated by their supervising LPN or registered nurse (RN). In addition to passing medication, CMAs will also monitor resident conditions, document, and report any condition changes, and monitor for drug reactions. CMAs are only allowed to observe and notify the nurse of any change in condition, and may not administer any PRN medication without notifying a nurse of the observation and need and the nurse completing the assessment and giving verbal consent to administer a PRN medication. Review of the facility policy titled, Pain Management, dated June 2024, revealed staff will observe for non-verbal and verbal indicators which may indicate the presence of pain and report to the overseeing nurse. The facility will use the pain assessment tool. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team such as nurse practitioners, physicians, nurses, or pharmacists. Review of the facility policy titled, Provision of Quality of Care, dated January 2023, revealed the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. All employees are responsible for following established policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure physician orders for pain were maintained to provide effective pain management. This affected one (#86) of two residents reviewed for pain. The facility census was 90. Findings included: Review of Resident #86's medical record revealed an admission date of 01/31/25. Diagnoses included malnutrition and acute renal disease. Review of Resident #86's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident required scheduled pain medication and opioid use for pain control daily. Review of Resident #86's current care plan revealed she had the potential for pain related to chronic pain, osteoarthritis, and low back pain. Interventions included listening to the resident's concerns, advise the resident to request pain medication before pain becomes severe, and assess complaints of pain and report to the medical doctor. Review of Resident #86's nurses note dated 03/16/25 revealed she was readmitted to the facility after a laminectomy (a surgical procedure on the spinal cord). Review of Resident #86's physician order dated 03/16/25 revealed the resident was ordered the pain medication acetaminophen oral tablet 325 milligrams (mg) with instructions to give two tablets by mouth every four hours as needed for pain. Review of Resident #86's physician order dated 04/01/25 revealed the resident was ordered hydrocodone-acetaminophen (opioid pain medication) tablet 5-325 mg to be administered as needed for pain once daily related to diseases of the spinal cord. The end date for the order was indefinite. Review of Resident #86's skilled evaluation dated 04/07/25 at 12:05 A.M. revealed the resident complained of pain in her medial back (spine) with a level of seven on a 10-point pain scale. Relaxation techniques were encouraged and the resident's position was changed. Further review revealed non-medication interventions were not effective and as needed medication was provided. Review of Resident #86's medication administration record (MAR) for April 2025 revealed acetaminophen 325 mg was administered on 04/08/25 at 1:15 A.M. and at 8:43 A.M. for a pain rating of seven. Hydrocodone-acetaminophen was administered not administered on 04/08/25. Interview with Resident #86 on 04/08/25 at 7:20 A.M. revealed the resident had requested pain medication at 5:15 A.M. on 04/08/25 and received no medication. She rated her back pain as eight to nine out of 10. The resident stated staff informed her they could not obtain the medication from the locked medication dispensing system. Interview with Licensed Practical Nurse (LPN) #594 on 04/08/25 at 7:25 A.M. revealed Resident #86 did receive acetaminophen on 04/08/25, but there was not a current order for hydrocodone-acetaminophen. LPN #594 stated the physician was due to round anytime and they would ask for an updated prescription at that time. Review of the facility policy titled, Pain Management, dated June 2024, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to address dementia care and treatment. This affected one (#23) of one residents reviewed for dementia related daily care and stimulation. The facility census was 90. Findings include: Review of Resident #23's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, dementia, coronary artery disease, hypertension, anxiety disorder, chronic pain, osteoporosis, anemia, major depression, type II diabetes mellitus, atrial fibrillation, and chronic kidney disease stage four. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was assessed with moderately impaired cognition, utilized a walker and wheelchair for mobility, required supervision or touching assistance with activities of daily living (ADLs), was continent of bowel and bladder, received a mechanically altered diet, was not at risk for development of pressure ulcers, and received insulin injections, antipsychotic medication, antidepressant medication, anticoagulation medication, and diuretic medication. Review of a nursing plan of care dated 08/11/24 was revised to address Resident #23's risk for fluctuating cognitive state/progressive cognitive deficit related to dementia and Alzheimer's disease. Interventions included to administer medication to help address the resident's cognitive deficit per physician order; monitor for side effects/adverse reaction and notify the physician if these are suspected or observed; encourage the resident to attempt simple tasks unassisted as able; encourage to speak about pleasant memories as needed; gently redirect the resident in the event that he/she makes an inappropriate choice; give cues/supervision for daily decision-making; give medications as ordered; intervene for unsafe decisions; monitor for changes in cognitive status and notify the physician if these are observed or suspected; notify family for material needs; physician consultation as needed; provide reorientation as needed during daily care activities; and provide simple explanations prior to initiating or assisting with care and reminders as needed. Further review revealed no resident individualized or specific interventions were documented. In addition on 08/12/24 a plan of care was initiated to address Resident #23's psychosocial well-being and activities which noted Resident #23 had a need for interpersonal interaction, established own goals, had a strong identification with past roles, lost roles, new to the facility, and withdrawal from activities of interest. The resident voiced she it was more difficult to do some activities she once enjoyed, such as reading and baking. Interests include reading when feeling up to it, watching television, and resting. She voiced having little pleasure or interest in doing things. Interventions included to allow the resident to vent/express thoughts, needs, and feelings; talk with the resident during care to provide socialization and reorient as needed; encourage the resident to attend activities and praise for doing so; and encourage the resident to maintain current level of independence in all simple choices. There were no resident specific points of interest were listed or alternative examples of sensory stimulation were provided. Observation on 04/08/25 at 9:29 A.M. noted Resident #23 in bed with the lights off, eyes closed, and the room quiet. There was no stimulation or activity was being provided. At 11:51 A.M., Resident #23 was seated in a recliner at the bedside with no radio, television, books, or stimulation observed. On 04/09/25 at 10:26 A.M., Resident #23 was seated in a recliner with her feet to the floor. There was no meaningful stimuli or activity being provided and the room was silent with the lights off. At 12:07 P.M., the resident was in her room and reclined in a chair with her eyes closed. There was no meaningful stimuli or activity engagement provided. On 04/10/25 at 8:00 A.M., Resident #23 was observed in bed with her eyes closed and the room was quiet with the lights off. On 04/08/25 at 1:50 P.M., interview with Activity Assistant (AA) #622 stated Resident #23 spent much of her time in her room, sleeping. AA #662 stated the resident was provided with one-on-one visits once weekly and was not aware of any residents specific activity or stimulation engagement for Resident #23. On 04/10/25 at 8:10 A.M. interview with Activity Director (AD) #626, during a review of Resident #23's activity interest, verified no documentation was available indicating activities or related engagement that were provided. On 04/10/25 at 9:22 A.M., additional interview with AD #626 stated Resident #23 was spoken to following the previous interview and noted Resident #23 had interest in various types of music, movies, reading, and the walls in the resident's room also lacked pictures or visual stimuli.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of a menu, review of a meal ticket, and review of the facility policy, the facility failed to offer alternate food choices when the resident did not eat well from the offered meal. This affected one (#42) of three residents reviewed for dining observation. The facility census was 90. Findings include: Review of the medical record for Resident #42 revealed an admission date of 04/26/16 with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 revealed the resident was severely cognitively impaired and required set-up for eating. Review of the current physician orders dated April 2025 for Resident #42 revealed she was ordered a fortified regular diet and for staff to check the refrigerator for homemade meals provided from family, and if food was available from family, please offer the homemade food during mealtime. Review of the care plan revised March 2025 for Resident #42 revealed she was at risk for poor oral intake with interventions in place for a fortified regular diet and needed assistance with eating. Review of the menu for 04/07/25 revealed the lunch served was Salisbury steak, roasted potato wedges, and peas and carrots. Review of the meal ticket for Resident #42 revealed no documented dislikes. Observation on 04/07/25 at 12:28 P.M., during dining observation, revealed Resident #42 was not offered substitute foods when she did not eat well for lunch. Continued observation during lunch for Resident #42 revealed she was assisted by Certified Nurse Aide (CNA) #530 and CNA #541, and neither of them offered a substitute when Resident #42 did not eat well. Review of the certified nurse aide (CNA) documentation for Resident #42 dated 04/07/25 revealed her meal intake for lunch on 04/07/25 was documented as zero percent (0%), which indicated Resident #42 ate between 0 and 25 of her meal. Interview on 04/07/25 at 1:06 P.M. with CNA #541 verified she did not offer an alternate meal or tried any other source of intake for Resident #42 for lunch. CNA #541 verified Resident #42 ate less than 25% of her meal for lunch. Review of the facility undated staff guidelines titled, Dining Room Expectations, revealed staff are to offer substitute meals for any unwanted items or food uneaten.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were stored in a manner to prevent spoilage and spoiled foods were discarded. This had the potential to affect all residents receiving food from the kitchen with the exception of one (#244) resident the facility identified that received nothing by mouth. The facility census was 90. Findings include: Observation on 04/07/25 from 7:50 AM to 8:10 A.M. revealed the walk-in cooler contained four containers of fresh strawberries with a whitish fuzzy growth on them, a bag of baby carrots that were open, unlabeled, and undated, and a tray of pastries and brownies that were uncovered, unlabeled, and undated. The tray of pastries and the tray of browns were thrown away and were hard when they were moved on the tray to throw in the garbage can. Interview on 04/07/25 at 7:56 A.M. with Assistant Dietary Manager (ADM) #700 verified strawberries contained mold, and confirmed the opened, unlabeled, and undated bag of baby carrots and the tray of pastries and brownies. ADM #700 further stated the pastries and brownies were from meals the previous day. Review of the facility policy titled, Food and Supply Storage, revised January 2025, revealed staff must cover, label, and date unused portions or open packages, and sort produce daily and remove spoiled pieces.

Based on observation, medical record review, and staff interview, the facility failed to assisted residents with dining in a dignified manner. This affected three (#2, #21, and #28) of eight residents observed eating in the South dining room. The census was 77. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 11/26/19. Diagnoses included dysphagia, adjustment disorder with mixed anxiety and depressed mood, chronic kidney disease, bradycardia, and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, completed 07/12/22, revealed Resident #2 was assessed as cognitively intact and required extensive one person physical assist with eating. Review of a nutritional care plan dated 12/02/19 revealed an intervention Resident #2 needed assistance with eating. 2. Review of Resident #21's medical record revealed an admission date of 07/02/15. Diagnoses included Alzheimer's disease with late onset, dementia without behavioral disturbances, dysphagia, hypothyroidism, and essential hypertension. Review of the most recent MDS assessment, completed 05/14/22, revealed Resident #21 was assessed with severely impaired cognitive skills for daily decision making and required extensive one person physical assist with eating. Review of a nutritional care plan dated 07/17/15 revealed an intervention that Resident #21 needed assistance with eating. 3. Review of Resident #28's medical record revealed an admission date of 10/01/18. Diagnoses included dementia with behavioral disturbances, diabetes mellitus type II, major depression, anxiety, and Alzheimer's disease. Review of the most recent MDS assessment, completed 05/25/22, revealed Resident #28 was assessed with severely impaired cognitive skills for daily decision making and required extensive one person physical assist with eating. Review of a nutritional care plan dated 10/03/18 revealed an intervention that Resident #28 needed assistance with eating. Observation on 08/02/22 at 5:07 P.M. revealed State Tested Nurse Aide (STNA) #413 was feeding three residents (#2, #21, and #28) in the South dining room. Further observation revealed all three residents were seated at the same table and STNA #413 was standing feeding one of the residents. There was one empty chair at the table not being used by anyone at this time. Continual observation was made, on 08/02/22 between 5:08 P.M. and 5:25 P.M., and revealed STNA #413 stood beside one of the residents and offered a bite of food or drink, and then walked to the next resident to offer food and drink, and walked to the last resident to offer food and drink. STNA #413 moved in a clockwise fashion from resident to resident seated at the table, while standing and when walking around the table. STNA #413 offered no more than one bite of food or one drink to each resident during each turn throughout the entire observation. STNA #413 walked around the entire table and offered food and drink to each of the three residents at least five times during this observation. Observation on 08/02/22 at 5:26 P.M. revealed 14 empty chairs in the South dining not being utilized by any resident, visitor, or staff member. Interview on 08/02/22 at 5:28 P.M. with STNA #413 verified the three residents she was assisting with feeding were Resident #2, #21, and #28 and verified they all required staff assistance with eating. STNA #413 stated she started feeding all three residents around 5:00 P.M. on 08/02/22 and verified she was standing, walking, and feeding all three residents at the same time.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to timely notify the physician when a resident experienced a change in condition that required a new treatment. This affected one (#62) of two reviewed for changes in condition. The census was 77. Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive assistance of at least two staff with bed mobility, was dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan, dated 07/01/22, revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment, dated 07/01/22, revealed Resident #62 was assessed with a suspected deep tissue injury to the right heel measuring 3.5 centimeters (cm) long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no documentation of a physician or nurse practitioner being notified of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 07/10/22, or 07/11/22. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nurse practitioner visit note, dated 07/12/22, revealed Resident #62's wound vacuum was in place and functioning with no concerns. The nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for pressure wound debriedment (removal of dead or damaged tissue) and was started on antibiotics. Resident #62 was also noted to have a small wound and erythema (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Review of the Notification of Changes, dated 03/30/22, revealed the facility must inform the resident, consult with the resident's physician and or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included a need to alter treatment, this may include a new treatment or discontinuation of a current treatment, and a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include life-threatening conditions or clinical complications. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. This deficiency substantiated Complaint Number OH000134422.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and resident interview, the facility failed to ensure residents were assessed for the appropriate use of a restraint and free from use of an unnecessary restraint. This affected one (#53) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, delirium, and overactive bladder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #53 had mild cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of fall risk assessments dated 05/24/22, 07/06/22, and 08/06/22 revealed Resident #53 was at moderate risk for falls. Review of the care plan for Resident #53 revealed the risk for falls due to Resident #53's decreased safety awareness. Interventions for Resident #53 included the use of a chair alarm when resident in chair and a bed alarm when Resident #53 was in bed. Review of restrictive device consent, signed 05/28/22, revealed Resident #53 was to use a bed alarm when in bed and a chair alarm when in any chair. The consent was signed by family after the resident had a fall which required a hospital assessment during which a urinary tract infection was identified. Review of the social service notes dated 05/30/22 revealed Resident #53 mentioned she felt she had lost her independence because of the chair and bed alarms. Review of the physician orders dated 06/29/22 revealed an order for an alarm to the chair and to the bed to alert staff of unassisted attempts to rise per self due to resident unable realize own limitations secondary to dementia. The record contained no assessment for the use of the bed and chair alarm. Interview with Resident #53 on 08/01/22 at 2:35 P.M. revealed Resident #53 felt she had lost independence due to the use of the chair and bed alarms. Observation on 08/02/22 at 9:06 A.M. Resident #53 ambulated to the bathroom with a wheeled walker and the chair alarm was sounding. Two staff responded immediately. Observation on 08/03/22 at 8:52 A.M. revealed Resident #53 was in her room sitting in the recliner with the chair alarm in place. At 1:51 P.M. Resident #53 standing with the walker in hand in front of the recliner with the chair alarm sounding. Staff in hallway outside of the room responded. Observations on 08/04/22 at 8:50 A.M., 12:07 P.M., and 4:08 P.M. revealed Resident #53 was her room sitting in the recliner with the chair alarm in place. Interview with the State Tested Nursing Assistant (STNA) #431 on 08/04/22 at 8:50 A.M. revealed knowledge that Resident #53 did not like the chair alarm and did not want the alarms for either the bed or chair. Interview on 08/04/22 at 1:53 A.M. with Social Work #376 revealed the family for Resident #53 requested the use of the alarms due Resident #53's increased falls. Social Worker #376 stated Resident #53 was not afraid of the alarm and continues to get up without the assistance of staff. Interview on 08/04/22 at 3:50 P.M. with the Director of Nursing revealed no specific resident evaluations are completed either initially or ongoing for the use of bed alarms or chair alarms. If the family requests the use of an alarm the facility will place one on the resident. Review of the policy titled Restraint Free Environment, dated 10/12/21, revealed residents are to be treated with respect and dignity, which included the right to be free of any physical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical symptoms. A physician's order alone is not sufficient to warrant the use of a physical restraint and the facility is responsible for the appropriateness of the determination to use a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policies, the facility failed to ensure residents with hearing impairments were assisted with placement of hearing aides as care planned and as ordered. This affected one (#25) of one residents reviewed for vision and hearing. The facility identified 23 residents in the facility with hearing aides. The census was 77. Findings include: Review of Resident #25's medical record revealed an admission date of 03/06/20. Findings included Alzheimer's disease with late onset, orthostatic hypotension, diabetes mellitus type II, dementia without behavioral disturbances, major depression, anxiety, and atrial fibrillation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed with severely impaired cognitive skills for daily decision making, was assessed with minimal hearing difficulty, and wore hearing aids. Review of the Care Area Assessment (CAA) Summary for communication revealed Resident #25 had minimum hearing difficulty and staff were to assist with hearing aids, adjust the tone, and repeat as needed. The facility indicated Resident #25's communication deficits would be care planned. Review of the most recently completed MDS assessment dated [DATE] revealed Resident #25 continued to be assessed with severely impaired cognitive skills for daily decision making, was assessed with minimal hearing difficulty, and wore hearing aids. Review of a care plan dated 03/19/20 revealed Resident #25 was alert with clear speech, and minimal hearing difficulty with hearing aids. Review of an intervention dated 03/19/20 revealed Resident #25 had bilateral hearing aids available and in use. Review of a physician order dated 07/28/21 revealed Resident #25 was to have her hearing aids put in her ears before breakfast and removed at night. Resident #25's hearing aids were to be stored in the nurse's cart. Review of the August 2022 medication administration record (MAR) revealed Resident #25's hearing aids were documented as not placed in her ears on 08/01/22 and 08/02/22. Observation on 08/01/22 between 9:00 A.M. and 2:30 P.M. revealed Resident #25 did not have her hearing aids in her ears throughout the day. Observation on 08/02/22 at 12:38 P.M., at 1:40 P.M., at 3:00 P.M., and at 5:08 P.M. revealed Resident #25 did not have hearing aids in her ears. Observation on 08/03/22 at 7:58 A.M. revealed Resident #25 sitting in her reclining chair in her bedroom eating breakfast. Resident #25 did not have her hearing aids in her ears at this time. Subsequent observations on 08/03/22 at 8:59 A.M. and at 9:48 A.M. revealed Resident #25 continued to not have her hearing aids in her ears. Interview on 08/03/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #417 verified she was the nurse providing care to Resident #25 on 08/03/22 and verified Resident #25's hearing aids were kept in the medication cart. Observation on 08/03/22 at 10:35 A.M., with LPN #417, revealed both of Resident #25's hearing aids were inside of a case and stored in the medication cart at that time. Interview on 08/03/22 at 10:35 A.M. with LPN #417 verified Resident #25 did not have her hearing aids in her ears and stated she thought Resident #25's family did not want her to have her hearing aids in unless they said to put them in, but could not identify where or when she discovered that information. Observation on 08/03/22 at 11:27 A.M. revealed Resident #25 remained with no hearing aids in her ears. Review of a facility policy titled Activities of Daily Living (ADLs), revised 11/22/21, revealed based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for all ADLs including using speech, language, or other functional communication systems. Review of a facility policy titled Care and Use of Hearing Aids, revised 03/29/22, revealed it is the practice of the facility to assist residents in using their hearing aides, and to provide care to the hearing aides to ensure they are clean and protected from loss and breakage when not being worn.

Based on observation, medical record review, staff interview, review of State Tested Nurse Aide (STNA) bowel tracking documentation and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with nail care. This affected one (#177) of two residents reviewed for activities of daily living (ADLs). The facility census was 77. Findings include: Review of the medical record for Resident #177 revealed an admission date of 07/23/22. Diagnoses included cerebral infarction, myocardial infarction, aphasia, multiple fractures of ribs, fracture of nasal bones, chronic obstructive pulmonary disease (COPD), hypertension, and retention of urine. Review of the Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #177 had short and long term memory problems, was severely cognitively impaired, and required extensive assistance with bed mobility, dressing, and personal hygiene. Additionally, Resident #177 was occasionally incontinent of bowel. Review of the plan of care, initiated 07/23/22, revealed Resident #177 had a potential/actual deficit with activities of daily living (ADLs). Interventions included allow ample time for participation, assist with ADLs as current needs required, encourage Resident #177 to participate in ADLs, encourage rest periods as needed, and monitor for changes in functional ADL ability. Review of STNA documentation from 07/24/22 through 08/04/22 revealed Resident #177 had bowel movements on 07/26/22, 07/30/22, 07/31/22 and 08/04/22. Review of a nursing progress note dated 07/31/22 revealed Resident #177 had a bowel movement and smeared feces over self and bed. Observation on 08/01/22 at 1:34 P.M. of Resident #177 revealed a dark substance was present under the Resident's left hand fingernails. Additional observations on 08/02/22 at 8:03 A.M. and 8:49 A.M. revealed Resident #177 had a dark substance was present his left hand fingernails. Interview on 08/02/22 at 9:00 A.M. of Licensed Practical Nurse (LPN) #417 verified Resident #177 had a dark substance was present under his left hand fingernails. Interview on 08/02/22 at 9:06 A.M., STNA #418 confirmed Resident #177 had a dark substance under his left hand fingernails. STNA #418 stated Resident #177 was incontinent of bowel and would remove the brief and get feces on his hands. STNA #418 stated she believed Resident #177 had feces under his left hand fingernails and she planned to clean them today. STNA #418 stated Resident #177 did not have a bowel movement yet today on her shift, which began at 6:00 A.M. STNA #418 confirmed resident's bowel movements were documented and tracked in the electronic medical record with the Resident's last documented bowel movement being 07/31/22. Additional observations on 08/02/22 at 10:36 A.M. and 12:07 P.M. of Resident #177 revealed the dark substance was remained under his left hand fingernails. Observation on 08/02/22 at 2:39 P. M. revealed Resident #177's fingernails had been cleaned. Observation on 08/04/22 at 8:37 A.M. of Resident #177 revealed a dark substance was present under the resident's left hand fingernails. Interview on 08/04/22 at 10:23 A.M., STNA # 390 revealed Resident #177 had a bowel movement that morning and the resident stuck his hand in the feces. STNA #390 stated he cleaned Resident #177 up after the bowel movement but did not clean his fingernails. Additional observations on 08/04/22 at 10:25 A.M., 11:19 A.M. and 1:07 P.M. revealed Resident #177 continued to have debris under his left hand fingernails. Follow up interview on 08/04/22 at 1:07 P.M., STNA #390 confirmed Resident #177 only had one bowel movement that day which was earlier in the morning. Interview on 08/04/22 at 2:45 P.M., STNA #424 verified Resident #177 had debris under his left hand fingernails. STNA #424 stated she would take care of cleaning the Resident's fingernails. Review of facility policy titled Activities of Daily Living (ADLs), dated 11/22/21, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility polices, the facility failed to ensure wounds were assessed and treated in a timely manner and failed to ensure compression garments were applied as ordered. This affected one (#62) of one residents reviewed for non-pressure skin impairments and one (#52) of one residents reviewed for edema. The facility identified three residents in the facility with non-pressure skin impairments. The census was 77. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive two-plus persons assistance with bed mobility, was totally dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan dated 07/01/22 revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with a suspected deep tissue injury to the right heel measuring 3.5 centimeters (cm) long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no assessment of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 07/10/22, or 07/11/22. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nurse practitioner visit note dated 07/12/22 revealed the nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for pressure wound debriedment (removal of dead or damaged tissue) and was started on antibiotics. Resident #62 was also noted to have a small wound and erythema (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound and did not order any treatments for the wound. NP #500 stated the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hypertension, hypothyroid, aphasia, vitamin D deficiency, weakness, transient ischemic attack, and a cerebral infarct. Review of the MDS assessment dated [DATE] revealed Resident #52 was cognitively intact and required extensive assistance with dressing. Review of physician orders revealed orders dated 12/15/21 for amlodipine besylate 10 milligram (mg), one tablet daily and 12/01/21 for monthly weights. An order dated 03/07/22 revealed the nurse was to measure Resident #52 for knee high compression stockings and the compression stockings were to be applied in the morning and removed at bedtime. An order written on 06/20/22 for Lasix 20 mg once daily for bilateral lower extremity edema. Review of progress note dated 07/19/22 revealed chronic bilateral lower extremity edema with left lower extremity greater than the right lower extremity. Observations on 08/02/22 at 9:13 A.M., 08/03/22 at 8:29 A.M. and on 08/04/22 at 12:48 P.M. revealed swelling and edema to Resident #52's bilateral lower extremities with the edema to the left lower extremity greater than the edema to the right lower extremity. Compression stockings were not observed in place. Interview on 08/03/22 at 2:16 PM with State Tested Nursing Assistant (STNA) #431 revealed Resident #52 was not wearing compression stockings. STNA #431 stated she was unaware Resident #52 was to wear compression stocking and added Resident #52 does not have compression stockings. Interview on 08/03/22 at 2:20 P.M. with Registered Nurse (RN) #443 verified Resident #52 did have an order for compression stockings. RN #443 was unsure if Resident #52 had been wearing the compression stockings. RN #443 stated she measured and ordered the compression stockings. Review of facility policy titled Physician Orders dated 11/22/2, revealed the physician must provide written or verbal orders for the residents' immediate care and needs. The orders allow staff to provide essential care to the resident and provide information to maintain or improve the resident's functional status. This deficiency substantiates Complaint Number OH00134422.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed timely assess pressure ulcers. This affected one (#62) of six residents reviewed for pressure ulcers. The facility identified 10 residents in the facility with pressure ulcers. The census was 77. Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of hospital documents dated 05/20/22, prior to Resident #62's admission to the facility, revealed Resident #62 was admitted with chronic osteomyelitis due to uncontrolled diabetes mellitus, had multiple extensive pressure ulcers with necrotizing fascitis (flesh-eating infection), and three separate infectious organisms discovered in her wounds. Resident #62's wound infections were treated with two antibiotics and consideration was made for a surgical consultation. Resident #62's wounds initially got better but then deteriorated rapidly to a necrotizing state. Review of a wound progress note dated 06/27/22 revealed Resident #62 had a stage three (full-thickness skin loss) pressure ulcer to the right heel which measured 3.0 centimeters (cm) long by 4.0 cm wide with no depth and 75 percent (%) to 100% of the wound covered with eschar (dead tissue); a stage four (full-thickness skin and tissue loss) to the right ischium (on the curvature of the posterior pelvic bone) measuring 9.0 cm long by 2.5 cm wide by 0.1 cm deep; and a stage four pressure ulcer to the coccyx (bone structure at the base of the spine) measuring 8.5 cm long by 14.5 cm wide by 1.0 cm deep. Review of a physician note dated 06/29/22 revealed Resident #62 would be discharged to a nursing facility within the next 24 to 48 hours and Resident #62 had arranged follow up with care with a plastic surgeon to look at the sacral and ischial wounds. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive assistance of two staff for bed mobility, was dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Resident #62 had interventions with pressure reduction to the bed and chair, turning and repositioning, pressure ulcer care, and application of non-surgical dressings. Review of the Care Area Assessment (CAA) Summary for pressure ulcer and injury revealed Resident #62 was able to voice needs and required extensive assistance with bed mobility to reduce friction. Resident #62's skin was observed with care and weekly skin checks completed. Staff provided treatments and monitored for changes as needed. Review of a care plan dated 07/01/22 revealed Resident #62 had actual skin breakdown with pressure ulcers on admission. Care plan interventions included provide treatments as ordered and monitor for changes, observe skin daily with care, and weekly wound management. Review of an assessment used to predict pressure ulcer development dated 07/01/22 revealed Resident #62 was assessed at moderate risk. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with a suspected deep tissue injury to the right heel measuring 3.5 cm long by 4.0 cm wide, a suspected deep tissue injury to the right lateral ischium measuring 2.0 cm long by 2.0 cm wide, a stage four pressure ulcer to the right ischium measuring 8.5 cm long by 3.5 mc wide by 0.1 cm deep, a stage four pressure ulcer to the sacrum measuring 13.0 cm long by 8.0 cm wide by 2.0 cm deep, and a stage four pressure ulcer to the left sacrum measuring 3.5 cm long by 2.0 cm wide by 2.0 cm deep. Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted. Resident #62's pressure ulcers were assessed on 07/03/22 and were as followed: Resident #62's deep tissue injury to the right heel measured 3.8 cm long by 3.5 cm wide by 0.1 cm depth; Resident #62's deep tissue injury to the right lateral ischium measured 2.0 cm long by 2.0 cm wide by 0.2 cm deep; Resident #62's stage four pressure ulcer to the left ischium measured 3.5 cm long by 2.2 cm wide by 0.5 cm deep; Resident #62's stage four pressure ulcer to the right ischium measured 7.5 cm long by 3.5 cm wide by 2.0 cm deep; and Resident #62's stage four pressure ulcer to the sacrum measured 13.0 cm long by 9.0 cm wide by 4.0 cm deep. Review of the July 2022 TAR revealed Resident #62's deep tissue injury to the right heel was assessed on 07/10/22 and measured 3.5 cm long by 3.0 cm wide with no depth; however, none of Resident #62's other pressure ulcers were assessed or measured on 07/10/22. Review of nursing progress notes and assessments dated between 07/04/22 and 07/12/22 revealed no documentation of Resident #62's wounds on her right lateral ischium, left ischium, right ischium, and sacrum assessed or measured after 07/03/22. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum change and reapplication were held for day shift. The nursing note indicated with the complexity level it was felt it would take two staff to manage it appropriately and the unit manager was notified. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum was changed with the canister noted to have brownish-red drainage and a foul odor. The pressure ulcers were observed to be beefy red with increased necrotic tissue to the wound perimeter. There were no measurements obtained of these wounds and the wounds were not staged. The wound vacuum was applied and sealed with no leaks. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 underwent surgical debridement of the pressure ulcers on her left and right ischium and sacrum to remove necrotic tissue. Resident #62's wounds were not significantly bigger and did not change stages. Interview on 08/04/22 at 4:55 P.M. with Director of Nursing (DON) verified Resident #62's wounds were assessed in the facility on 07/01/22, on admission, and on 07/03/22. DON stated Resident #62's wounds were scheduled to be assessed on 07/10/22; however, the wound vacuum was in place and the wounds could not be observed. DON verified Resident #62's wound vacuum was changed on 07/11/22 and verified Resident #62's wounds wound have been visible and able to be assessed at that time but the facility did not assess them. DON verified Resident #62's pressure ulcers on her right lateral ischium, left ischium, right ischium, and sacrum were not assessed after 07/10/22 as Resident #62 was sent to the hospital on [DATE]. Review of a facility policy titled, Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. This deficiency substantiates Complaint Number OH00134422.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#13) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, major depressive disorder, orthostatic hypotension, osteoporosis, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and locomotion, and had two or more falls. Review of the plan of care, revised 10/29/20, revealed Resident #13 was at risk for falls. Interventions included assist resident getting in and out of bed, a scoop mattress to bed to define bed parameters, and keep wheelchair at bedside while in bed for safety. Review of the Fall Risk Assessment, dated 06/10/22, revealed Resident #13 was at moderate risk for falls. Review of a physician order, dated 02/01/22, revealed a scoop mattress to bed to define bed parameters due to resident's decreased awareness of own physical limitations. Observation on 08/01/22 at 3:01 P.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Observation on 08/02/22 at 7:30 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Interview on 08/02/22 at 11:18 A.M. with State Tested Nurse Aide (STNA) #434 confirmed Resident #13 did not have a scoop mattress to the bed. Additionally, STNA #434 stated it was not typical for Resident #13's wheelchair to be left at bedside when the Resident was in bed. STNA #434 was unaware of the fall interventions for Resident #13 to have a scoop mattress or for her wheelchair to be placed bedside when Resident #13 was in bed. STNA #434 stated Resident #13 did attempt to get up on her own sometimes and had a history of falls at the facility. STNA #434 confirmed Resident #13 was dependent on staff for all care, including safe transfers. Observation on 08/03/22 at 8:08 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress and her wheelchair was located on the wall opposite her bed, in front of the window. Review of facility policy titled Fall Prevention Program, revised 06/23/22, revealed each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care and staff were to be aware of interventions in the electronic medical record and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure physician ordered fluid restrictions were followed and failed to ensure appropriate mechanisms were used to alert staff to residents on fluids restrictions per the policy. This affected one (#45) of one residents reviewed for hydration. The census was 77. Findings include: Review of Resident #45's medical record revealed an admission date of 09/20/20. Diagnoses included Alzheimer's disease with late onset, epilepsy, dementia without behavioral disturbances, hypo-osmolality and hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone, flaccid neuropathic bladder, hallucinations, anxiety, congestive heart failure, and aphasia. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was assessed with moderately impaired cognitive skills for daily decision making and required supervision for eating. Review of Resident #45's most recently completed basic metabolic panel (a laboratory test that measures electrolyte balance) revealed Resident #45's sodium and potassium levels were within normal range. Review of a nutrition care plan dated 10/05/21 revealed Resident #45 had an intervention for no water pitcher at the bedside. Review of a consulting dietician recommendation document dated 07/07/22 revealed Resident #45 was ordered a regular diet with small portions and a fluid restriction consisting of no water pitcher at the bedside. Review of a physician order dated 07/12/22 revealed Resident #45 was ordered a fluid restriction with no water pitcher at the bedside. There was no physician order to monitor Resident #45's fluid intake. Review of a dietary communication form dated 07/1/522 revealed Resident #45 was to have no water pitcher at the bedside. Review of nurse aide documentation dated between 07/10/22 and 08/08/22 revealed only one fluid intake documented on 07/10/22 and revealed Resident #45 had 20 milliliters of fluid intake. Observation on 08/02/22 at 3:10 P.M. and 5:11 P.M. revealed Resident #45 sitting in her reclining chair in her bedroom with a large white Styrofoam cup sitting on the bedside table, with fluid in the cup, to the right of Resident #45 within her reach. There was no signage to identify Resident #45 was on a fluid restriction outside or inside the room. Observation on 08/03/22 at 7:22 A.M. revealed Resident #45 was up sitting in her reclining chair eating breakfast. There was a large white Styrofoam cup on the bedside table near her food tray that contained fluids with the date of 08/03/22 written on the outside of the cup. Resident #45 was eating and drinking independently. Subsequent observations on 08/03/22 at 9:03 A.M. and 9:48 A.M. revealed Resident #45 remained in her reclining chair with a large white Styrofoam cup with fluid inside with her reach on the beside table. There remained no signage indicating Resident #45 was on a fluid restriction outside or inside the room. Interview on 08/03/22 at 7:48 A.M. with Resident #45 stated she was not aware she was on a fluid restriction and when asked what she drank from when she was thirsty, Resident #45 lifted her large white Styrofoam cup full of fluid. Interview on 08/03/22 at 10:02 A.M. with State Tested Nurse Aide (STNA) #456 stated residents received large white Styrofoam cups as their water pitchers and the third shift staff were responsible for getting the residents new cups every day and filling them with fresh ice water. STNA #456 stated each Styrofoam cup could hold 20 ounces of water. Observation on 08/03/22 at 10:25 A.M., with STNA #456, verified Resident #45 had a large white Styrofoam cup within her reach that contained fluid and no signage identifying Resident #45 was on a fluid restriction. Interview on 08/03/22 at 10:25 A.M. with STNA #456 stated she was not aware Resident #45 was on a fluid restriction and was not to have a water pitcher at the bedside. A telephone interview was completed on 08/08/22 at 8:49 A.M. with Dietician #550 who verified Resident #45 was ordered to have no water pitcher at the bedside. Dietician #550 stated Resident #45 had a history of low sodium levels and as a first line of intervention to prevent low sodium, he ordered the fluid restriction for no water at the bedside. Dietician #550 stated Resident #45 was moderately to severely cognitively impaired and was physically capable of drinking independently, and by having no water pitcher at the bedside, it eliminated the readily available source of water for Resident #45 to drink. Review of a a facility policy titled Hydration, last revised 08/03/22, revealed the resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Signage will be placed in individual resident rooms alerting staff to resident specific needs, such as thickened liquids, no water at bedside, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of visitor screening logs, review of resident vaccination status, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were followed for visitor screening and source control to prevent the spread of COVID-19 with the potential to affect 13 (#1, #6, #11, #13, #15, #17, #24, #29, #31, #50, #58, #67 and #76) of 13 residents in the Special Care Unit (memory care). Additionally, the facility failed to ensure clean linen was transported in a sanitary manner with the potential to affect 10 (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) of 10 residents on the rehabilitation unit. Lastly, the facility failed to ensure sanitary conditions for one Resident (#61) of three residents reviewed who had a catheter. The facility census was 77. Findings include: 1. Interview on 08/01/22 at 8:00 A.M. of the Administrator revealed the facility was in COVID-19 outbreak status until 08/07/22. Observation on 08/02/22 at 11:33 A.M. of the Special Care Unit dining room revealed Resident #11 sitting at a table with three visitors, a male, a female and a toddler who was sitting on Resident #11's lap. The male visitor had his facemask hanging from his left ear, the female visitor had her facemask below her chin, and the toddler was unmasked. Each visitors' mouth and nose were exposed. Resident #6 approached the table and sat with Resident #11 and the three visitors. Both residents and all visitors were within arms reach of each other. Neither Resident #11 or Resident #6 were wearing facemasks. Additional observation revealed Residents #1, #13, #17, #24 and #50 were also sitting in the dining room, unmasked, and at adjacent tables from Resident #11, Resident #6 and the three visitors. Review of the facility resident COVID-19 vaccination list revealed Resident #11 was not vaccinated for COVID-19 and Resident #6 was not up-to-date with COVID-19 vaccinations. Review of the facility COVID-19 kiosk screening log, dated 08/02/22, revealed Resident #11's three visitors did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/02/22 at 11:35 A.M. with State Tested Nurse Aide (STNA) #434 confirmed visitors were to wear facemasks during visits and were to social distance to potentially limit transmission of COVID-19 to residents. STNA #434 stated the visitors were family of Resident #11. STNA #434 verified the visitors were not properly wearing facemasks to cover their mouth and nose and Residents #1, #6, #11, #13, #17, #24 and #50 were in the dining room with the visitors, in close proximity, and the residents were also unmasked. STNA #434 stated she had asked the family many times to put their facemasks on correctly but they refused and she was not sure what else she could do about it. Interview on 08/02/22 at 12:20 P.M. with the Administrator confirmed visitors were expected to wear facemasks, especially in common areas of the facility. If visitors refused to wear the proper personal protective equipment (PPE) staff were expected to contact someone in administration for assistance. Interview on 08/04/22 at 10:31 A.M. with the Administrator and Director of Nursing (DON) verified on 08/02/22 Resident #11's three visitors were not screened for COVID-19 signs and symptoms on the facility kiosk prior to visiting the Special Care Unit. The Administrator stated the visitors may have screened in through the connected assisted living entrance, which was a paper screening. Follow-up interview on 08/04/22 at 11:38 A.M. with the Administrator revealed a family member of Resident #11 screened for signs and symptoms of COVID-19 through the assisted living entrance. The paper screening document was dated 08/01/22 and 08/02/22. Each specific visitor entry was undated, including the date Resident #11's family member screened for signs and symptoms of COVID-19. Review of the facility assisted living paper COVID-19 screening log, dated 08/01/22 and 08/02/22 revealed Resident #11's three visitors in the facility on 08/02/22 did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/04/22 at 11:40 A.M. with STNA #434 confirmed Resident #11's family member who screened for signs and symptoms of COVID-19 on the assisted living paper screening log dated 08/01/22 and 08/02/22 was not one of the three visitors observed visiting on the Special Care Unit on 08/02/22. STNA #434 identified the family member on the screening form to be Resident #11's daughter, who had visited at a different time. STNA #434 confirmed Resident #11's visitors on 08/02/22 were the Resident's son, granddaughter and great granddaughter. STNA #434 verified their names were not on the assisted living paper screening log. Follow up interview on 08/04/22 at 11:41 A.M. with the Administrator verified the facility had no evidence Resident #11's family, who were observed not practicing COVID-19 source control on 08/02/22, were screened by the facility for signs and symptoms of COVID-19. Review of facility policy titled COVID-19 Visitors-Vendors-Others, revised 06/22/22, revealed all individuals and personnel must be screened for COVID-19 each time they enter the facility. In addition to the screening questions, visitors were to wear masks before entering the facility or have the necessary PPE on. Unvaccinated residents, where possible, should wear a face covering during the visit. Staff will observe the visitors to ensure correct donning of PPE and appropriate hand hygiene. Additionally, visitations will not be allowed for those visitors who refuse to wear a face covering, whether visiting a vaccinated or unvaccinated resident, and all visitors are to facilitate social distancing. 2. Observation on 08/02/22 at 8:08 A.M. of the rehabilitation unit revealed a three tier cart sitting in the hall outside of Resident #180 and #183's rooms. Both Resident doors were closed, a PPE cart was placed outside of each door and signs were hanging on the room doors identifying Resident #180 and #183 were on transmission based precautions. Further observation revealed there were 14 folded personal clothing items on the top shelf of the uncovered cart. Continued observations on 08/02/22 at 8:22 A.M., 8:48 A.M. and 8:57 A.M. revealed the three tiered cart remained in the hall outside of Resident #180 and #183's rooms, with the personal clothing items on the top shelf, uncovered. Interview on 08/02/22 at 8:57 A.M. with Licensed Practical Nurse (LPN) #417 verified the uncovered cart located in the hall outside of Resident #180 and #183's rooms had uncovered resident personal clothing on the top shelf of the cart. LPN #417 stated the personal clothing was waiting to be delivered to residents. LPN #417 confirmed Residents #180 and #183 were on transmission based precautions due to being on COVID-19 quarantine. Additional observation on 08/02/22 at 9:06 A.M. revealed the three tier cart remained in the hall outside of Resident #180 and #183's room, with uncovered personal clothing on the top shelf. Interview on 08/02/22 with State Tested Nurse Aide (STNA) #418 verified the cart had clean, uncovered, resident personal clothing on the top shelf. STNA #418 stated some of the clothing was labeled and other items were unlabeled so she would have to figure out who they belonged to. STNA #418 stated she did not know why the uncovered cart with clean clothing was left in the hall. STNA #418 moved the cart into the clean linen closet. Review of facility policy titled Handling Clean Linen, dated 05/31/22, revealed clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during loading, transport and unloading. Guidelines for the storage of clean linen included clean linen shall be delivered to resident care units on covered linen carts with covers down. The facility identified 10 residents (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) on the rehabilitation unit. 3. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, pneumonia, hypertension, atrial fibrillation, and urinary retention. Review of the Minimum Data Set 3.0 assessment, dated 07/18/22, revealed Resident #61 had mild cognitive impairment and required extensive assistance with toilet use and personal hygiene. Resident #61 was continent of bowel and bladder and had a urinary tract infection in the last thirty days. Review of physician orders revealed an order written on 07/01/22 for the antibiotic cephalexin 500 milligrams (mg), one tablet, twice daily for seven days. Review of urine culture dated 07/06/22 revealed evidence of a urinary tract infection with pseudomonas greater than 100,000 colony forming units per milliliter (CFU/ml). Review of physician orders dated 07/14/22 included the antibiotic amoxicillin 200 mg, one tablet twice a day for seven days. Additional orders written on 07/14/22 included catheter irrigation as needed for occlusion, catheter drainage bag to be changed weekly and the tubing changed weekly every Wednesday night, catheter leg bag when Resident #61 was up, and catheter care every shift. Observation on 08/02/22 at 2:13 P.M. revealed the catheter bag folded onto itself resting on the floor next to the right side of the bed. Interview on 08/02/22 at 2:23 P.M. with STNA #551 verified the catheter bag for Resident #61 was touching the floor. STNA #551 further added catheter bags are not to be on the floor. STNA #551 readjusted the catheter bag to ensure the catheter bag no longer sat on the floor. Observation on 08/03/22 at 2:05 P.M. revealed Resident #61's catheter bag hanging off the handle of the recliner, resting on the floor. Interview on 08/03/22 at 2:08 P.M. with STNA #390 verified Resident #61's catheter bag was resting on the floor and further verified the catheter bag should not touching the floor. STNA #390 repositioned the catheter drainage bag to prevent it from touching the floor. Review of the facility policy titled Catheter Care, dated 03/08/21, revealed residents with catheters should receive appropriate catheter care and further stated catheter drainage bags should be always covered when in use.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents wheelchairs were kept clean. This affected one resident, Resident (#71) of two residents reviewed for environmental concerns. The facility identified 56 residents who required assistance with ambulation or assistive devices. The facility census was 93. Findings included: Review of Resident #71's medical record revealed an admission date of 06/03/19. Diagnoses included abnormalities of gait, osteoarthritis, asthma, insomnia, major depressive disorder, unsteadiness on lack of coordination, dysphagia, type II diabetes, hyperlipidemia, spinal stenosis, and osteoarthritis. Review of Resident #71's Minimum Data Set (MDS) assessment, dated 07/04/19, revealed Resident #71 was moderately cognitively impaired. Resident #71 required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. Observation on 08/12/19 at 2:12 P.M. of Resident #71's wheelchair found a build up of food crumbs, dust, and debris around the edges of Resident #71's wheelchair seat cushion. A dried piece of what appeared to be brown and white bread was wedged between the arm rest and wheel support of the wheelchair. Interview on 08/12/19 at 2:15 P.M., Resident #71 removed the dried bread from her wheelchair and reported it must have gotten in there yesterday during breakfast. Resident #71 reported it looked like the bread she had with breakfast on 08/11/19. The bread was dry and crumbled in Resident #71's hand when she pushed on it. Interview on 08/12/19 at 2:20 P.M., State Tested Nursing Assistant (STNA) #105 verified stale bread was found in Resident #71's wheelchair and Resident #71's wheelchair needed to be cleaned. STNA #105 reported all resident wheelchairs were cleaned on third shift so they had time to dry while residents were sleeping. STNA #105 reported she was not aware of when Resident #71's wheelchair was last cleaned. Observation on 08/13/19 at 8:43 A.M. found Resident #71 seated in her wheelchair in her room. Resident #71's wheelchair continued to have food crumbs, dust, and debris around the edges of the seat cushion. Interview at this time with Resident #71 revealed no one had cleaned her wheelchair. Interview on 08/13/19 at 2:02 P.M., STNA #110 revealed Resident #71 was able to make her needs known but required physical assistance with transfer and mobility. STNA #110 reported Resident #71 required a wheelchair for mobility and the facility was responsible for cleaning all resident's wheelchairs and equipment. STNA #110 stated there was a schedule for when equipment to be cleaned. The schedule had wheelchairs cleaned on third shift so there was time for the wheelchair to dry overnight. STNA #110 reported there was no documentation completed related if equipment was cleaned as scheduled. Observation on 08/13/19 at 2:12 P.M., Resident #71's wheelchair continued to have food crumbs, dust, and debris around the edges of the seat cushion. Review of the facility policy titled Wheelchair/Walker Cleaning Schedule, dated 07/26/18, revealed to clean wheelchairs on night shift per unit as scheduled. In between scheduled cleanings staff shall remove and clean visible matter from all wheelchairs and walkers on an as needed basis daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Self-Reported Incident (SRI), medical record review, facility policy review and satff interview, the facility failed to implement the abuse policy on reporting allegations of abuse. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 revealed Resident #9 was named in the allegation of physical abuse. Review of the facility investigation of the SRI revealed on 04/14/19 at 11:30 A.M., Resident #9 reported that she was beat up on 4/13/2019 in the evening by three girls, STNA #150 who immediately reported this to the charge nurse. The investigation initiated and was submitted on 04/15/19 at 8:56 A.M. and closed on 04/16/19. Review of the staff statements revealed STNA #160 stated she assisted Resident #9 with care and transfers on 04/13/19. STNA #160 reported that approximately 8:45 Pm to 9:00 P.M., Resident #9 put on her call light. When STNA answered her call light. Resident #9 told her that three girls took her into the bathroom and beat her up. STNA #170's statement revealed on 04/13/19 at bedtime she toileted Resident #9 and gave her bedtime snack when Resident #9 mentioned that she was upset because three girls came in and hit her. Interview and review of the incident investigation with Director of Nursing (DON) on 08/14/19 at 9:46 A.M., verified the incident was reported to her on 04/14/19 at approximately 11:30 A.M. The DON verified two STNAs (#160 and #170) were aware of the incident on 04/13/19. STNA #160 was aware between 8:45 P.M. and 9:00 P.M. STNA #170 was aware on 04/13/19 at bedtime. The DON verified the alleged abuse was not reported to management by STNA #160 or #170 and the SRI was not submitted until 04/15/19 at 8:56 A.M. The DON verified the alleged abuse was not reported immediately as required and per the faciltiy policy. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). All abuse incidents or allegations must be reported to the Administrator immediately. If the event that caused the allegation involves abuse it should be reported to ODH immediately but not later than two hours after the allegation is made. The Administrator will notify ODH of all alleged violations involving abuse as soon as possible but in not event later that 24 hours from the time the incident/allegation was made known to the staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Self-Reported Incident (SRI), medical record review,facility policy review and staff interview, the facility failed to timely report an allegation of abuse by a resident. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 revealed Resident #9 was named in the allegation of physical abuse. Review of the facility investigation of the SRI revealed on 04/14/19 at 11:30 A.M., Resident #9 reported that she was beat up on 4/13/2019 in the evening by three girls, STNA #150 who immediately reported this to the charge nurse. The investigation initiated and was submitted on 04/15/19 at 8:56 A.M. and closed on 04/16/19. Review of the staff statements revealed STNA #160 stated she assisted Resident #9 with care and transfers on 04/13/19. STNA #160 reported that approximately 8:45 Pm to 9:00 P.M., Resident #9 put on her call light. When STNA answered her call light. Resident #9 told her that three girls took her into the bathroom and beat her up. STNA #170's statement revealed on 04/13/19 at bedtime she toileted Resident #9 and gave her bedtime snack when Resident #9 mentioned that she was upset because three girls came in and hit her. Interview and review of the incident investigation with Director of Nursing (DON) on 08/14/19 at 9:46 A.M., verified the incident was reported to her on 04/14/19 at approximately 11:30 A.M. The DON verified two STNAs (#160 and #170) were aware of the incident on 04/13/19. STNA #160 was aware between 8:45 P.M. and 9:00 P.M. STNA #170 was aware on 04/13/19 at bedtime. The DON verified the alleged abuse was not reported to management by STNA #160 or #170 and the SRI was not submitted until 04/15/19 at 8:56 A.M. The DON verified the alleged abuse was not reported immediately as required and per the faciltiy policy. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). All abuse incidents or allegations must be reported to the Administrator immediately. If the event that caused the allegation involves abuse it should be reported to ODH immediately but not later than two hours after the allegation is made. The Administrator will notify ODH of all alleged violations involving abuse as soon as possible but in not event later that 24 hours from the time the incident/allegation was made known to the staff member.

Based on medical record review, observation, facility policy review and staff interviews, the facility failed to follow the physician orders for treatment of a non-pressure skin condition. This failed practice affected one (#87) of one resident reviewed for non-pressure skin conditions. The facility census was 93. Findings include: Review of the medical record for Resident #87 revealed an admission date of 01/02/19, with diagnoses of Parkinson's disease, dementia, repeated falls, depression, anxiety, heart disease, diabetes, hallucinations, seborrheic dermatitis and bulbous pemphigoid (a medical condition which causes blistering of the skin). Review of the nurse progress note dated 08/03/19 at 7:58 A.M., revealed Resident #87 had a new blister located below the left knee. Blister was fluid filled and resident was not showing signs of discomfort at this time. Review of the current physician orders revealed to wash bulbous pemphigoid blister to left knee with soap and water or normal saline and pat dry. Leave open to air, every shift ordered on 08/13/19. Observation on 08/15/19 at 10:19 A.M., with Licensed Practical Nurse (LPN) #220, revealed the resident had a skin lesion below his left knee approximated 2.5 centimeters round, scabbed and no drainage noted. LPN #220 commented she was not aware Resident #87 had the lesion at his left knee. As observations continued, LPN #220 did not cleanse the wound. LPN #220 applied Mupirocin Ointment 2 % to the area. Interview after the observation, with LPN #220 verified the lesion was a bulbous pemphigoid blister which had opened and was now dry and scabbed. After reviewing the physician orders LPN #220 verified the order was to wash the area with soap and water then leave it open to air. LPN #220 stated she thought the order was for Mupirocin ointment. LPN #220 stated there was no order to apply Mupirocin ointment to the left knee wound. LPN #220 verified she had not reviewed the physician orders prior to completing the wound treatment and verified she had not followed the physician order in regard to the left knee treatment. LPN #220 stated she could call the physician at this time to obtain an order to apply the Mupirocin ointment. Interview on 08/15/19 at 4:40 P.M., with LPN #400 stated there was a physician order for Mupirocin ointment and provided copies of additional information for review. Review of the physician orders revealed two orders, both dated and printed on 07/25/19. The first order was: Mupirocin Ointment 2 %. Apply to open sores to trunk topically every day shift for bulbous pemphigoid. The second order was nearly identical to the first with the addition of application of the ointment to the face. The second order was: Mupirocin Ointment 2 %. Apply to open sores to face/trunk topically every day shift for bulbous pemphigoid. Neither order included application to the knee. Additionally, LPN #400 verified LPN #220 had called the physician to obtain a new order to apply Mupirocin Ointment 2 % to the knee on 08/15/19 at 11:23 A.M., after the observation when she failed to complete the treatment per the current and active physician order which was to wash bulbous pemphigoid blister to left knee with soap and water or normal saline and pat dry. Leave open to air, every shift ordered on 08/13/19. Review of the facility policy titled Pressure Ulcer/Skin Breakdown Clinical Protocol revised March 2014 revealed the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings and application of topical agents if indicated for the type of skin alteration.

Based on medical record review, pharmacist and staff interview, the facility failed to attempt two gradual dose reductions (GDR)of psychoactive medications with in the first year of implementation. This affected one (#67) of five residents reviewed for unnecessary medications. The facility identified 58 residents who receive psychoactive medications. The census was 93. Findings include: Review of Resident #67's medical record revealed an admission date of 08/01/18. Diagnoses included Alzheimer's disease, diabetes mellitus type II, major depression, unspecified psychosis, unspecified mood disorder, anxiety, congestive heart failure, and essential hypertension. Review of a physician order dated 08/01/19 revealed Resident #67 was ordered the antidepressant Zoloft 100 milligrams (mg) by mouth daily and the antidepressant Trazodone 100 mg by mouth every 24 hours as needed. Review of a physician order dated 08/02/19 revealed Resident #67 was ordered the antipsychotic medication Abilify 15 mg by mouth at bedtime. Review of monthly medication regimen reviews for Resident #67 completed on 08/07/18, 09/11/18, 10/17/18, 11/21/18, 12/18/18, 01/28/19, 02/11/19, 03/21/19, 04/29/19, 05/20/19, 06/17/19, and 07/30/19 revealed a GDR for Resident #67's Abilify was recommended on 03/21/19. No other GDR were recommended between 08/07/19 and 07/30/19. Review of a consultant pharmacist document dated 03/20/19 revealed a recommendation to decrease Resident #67's ordered Abilify to 10 mg at bedtime. The documented contained Resident #67's other orders for Trazodone and Zoloft, however, did not recommend a dose reduction of these medications. A nurse practitioner reviewed the GDR recommendation and agreed to reduce Resident #67's Abilify to 10 mg at bedtime on 03/26/19. Review of a physician order dated 03/28/19 revealed Resident #67 was ordered Abilify 10 mg by mouth at bedtime and the original order from 08/02/19 was discontinued. This order remained active as of 08/15/19. Review of the most recently completed Minimum Data Set (MDS) assessment revealed Resident #67's last GDR was on 03/28/19. Review of progress notes completed by a behavioral health practitioner on 08/17/18, 08/23/18, 09/06/18, 09/20/18, 10/11/18, 10/25/18, 11/20/18, 11/29/18, 11/30/18, 01/25/19, and 05/03/19 revealed no documentation of an attempt to reduce Resident #67's Abilify of Zoloft. GDR recommendations were made for Resident #67's Trazodone in August 2018 and May 2019, and the orders were processed for the recommendations on 08/17/18 and 05/05/19. Review of physician progress notes dated between 08/01/18 and 08/15/19 revealed no documentation of an attempt to GDR Resident #67's psychoactive medications. Interview on 08/15/19 at 11:48 A.M. with Registered Nurse (RN) #300 verified there was no documentation in Resident #67's medical record for any GDR of her Zoloft with an order date of 08/01/19, and only one GDR of her Abilify with an original order date of 08/02/19, and a GDR on 03/28/19, within the first year of Resident #67 being ordered both medications. Telephone interview on 08/15/19 at approximately 1:30 P.M. with Pharmacist #500 stated when conducting GDR recommendations he was under the impression if one psychoactive medication was recommended for a GDR it covered all psychoactive medications that particular resident was ordered, and there was no need to address each psychoactive medication individually. Pharmacist #500 also stated he was under the impression when a GDR was accepted and the medication was ordered with a different dose, the calendar year was reset to the new date of the new order.

Based on observation, medical record review, review of facility policy and staff interview, the facility failed to ensure residents who required mechanically altered diets received the proper nutrition. This affected the two residents (#28 and #78) of two residents the facility identified as receiving pureed diets. The facility census was 93. Findings Include: Observation on 08/13/19 at 8:52 A.M., of the kitchen found the dietary staff were preparing cold sub sandwiches as was indicated on the regular lunch menu. Observation on 08/13/19 at 8:56 A.M., of the kitchen found Dietary Staff (DS) #201 completing the pureed lunch meals. Coinciding interview with DS #201 revealed the facility currently had two residents who received a pureed diet, Resident #28 and #78. DS #201 was observed following the recipe to puree two sub sandwiches. DS #201 added two portions of buns, two portions of ham and turkey, and two portions of cheese into a clear glass blender. DS #201 added 1/4 cup water and pork broth per serving to soften the sub components to puree properly. After the subs were pureed properly, DS #201 was observed following the recipe and portioned two four ounce servings (two #8 scoops) into two separate containers. DS #201 held up the blender and a good sized portion of the pureed sub sandwich was noted to still be in the blender. Interview on 08/13/19 at 9:04 A.M. with DS #201 verified she had a lot of the pureed food left over. Observation of the blender found 12 ounces of pureed food remained in the blender. DS #201 discarded the left over pureed food, covered, dated, labeled, and stored the two portions of pureed subs. Interview on 08/13/19 at 3:38 P.M. with Dietician #250 revealed the calculations for the portion size was incorrect for the pureed sub sandwich. Dietician #250 verified the scoop size did not provide the same nutrition as the regular sub sandwich. Dietician #250 stated the pureed food should have been divided into two equal portions. Review of Resident #28's medical record revealed an admission date of 04/20/19. Diagnoses included stroke and Alzheimer's disease. Review of Resident #28's physician orders revealed an order dated 10/04/18 for Resident #28 to receive a regular diet, pureed texture and thin consistency. Review of Resident #78's medical record revealed an admission date of 12/25/17. Diagnoses included dysphagia and Alzheimer's disease. Review of Resident #78's physician orders revealed an order dated 10/04/18 for Resident #78 to receive a regular diet, pureed texture, and nectar thick consistency. Review of the facility policy titled, Texture and Consistency- Modified Diets, revised 2017 revealed the food and nutrition services department were responsible for preparing and serving the diet texture and fluid consistency as ordered. Care was to be taken to serve the foods and fluids as ordered on the consistency altered diets.

Based on observation, review of facility and the staff interview, the facility failed to ensure outdoor garbage dumpster areas were kept in a safe and sanitary manner. This had the potential to affect 93 of 93 facility residents. The facility census was 93. Findings include: Observation on 08/12/19 at 9:39 A.M. of the outside garbage storage area revealed a large puddle of liquid on the ground around the dumpster. The liquid had a strong, foul, odor that smelled like decomposing garbage. A nine volt battery, used disposable latex gloves, pieces of plastic, and other unidentifiable debris were observed in the liquid. Interview on 08/12/19 at 9:44 A.M. with Dietary Manager (DM) #210 verified the area around the outdoor garbage dumpster had not been cleaned. DM #210 reported it was the maintenance staff's responsibility to ensure the area was kept clean. Review of the facility policy titled, Garbage/Recycling Area Cleaning Schedule dated 08/14/18 revealed the facility would maintain a clean waste environment in the facility's receiving/loading dock area where the garbage dumpster/compactor is located.