**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of facility policy, the facility failed to ensure Resident #11's family were notified of a change in condition. This affected one resident (Resident #11) of three residents reviewed for notification of change. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses including chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Resident #11 was not responsible for herself, and her sister was listed as her responsible party. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of a weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed Resident #26 hit Resident #11 in the face resulting in a bruise above her left eyebrow. Both Certified Nursing Assistant (CNA) #856 and #900 witnessed the incident and revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and Assistant Director of Nursing (ADON) #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed Certified Nursing Assistant (CNA) #801 was present during the alleged incident. Observation of three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/19/24 at 2:15 P.M. with ADON #849 confirmed and verified Resident #11 had bruising above her left eyebrow related to being hit by Resident #26 on 11/04/24 and the incident was not reported t0 Resident #11's family member. Interview on 11/20/24 at 10:17 A.M. with Resident #11 sister revealed staff did not inform her of the incident of physical abuse between Resident #11 and Resident #26 that occurred on 11/04/24. Resident #11 sister revealed she visited Resident #11 between 11/10/24 and 11/16/24 and another staff member who she could not recall informed her of the incident of physical abuse and explained the bruising to Resident #11's forehead. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, and the incident was not reported to Resident #11 sister. Review of the facility document titled Resident Change in Condition Policy revised 06/27/24, revealed the facility had a policy in place to recognize and intervene in the event of a change in condition and the physician and family and/or responsible party would be notified as soon as the nurse had identified the change in condition and the resident was stable. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #11 and #26 were free from abuse. This affected two residents (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: 1. Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of the weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye and to the left scapula area. Review of the progress note in Resident #11's medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to physical abuse. Review of the progress note dated 11/18/24 at 1:27 P.M. in Resident #11 medical record revealed the interdisciplinary team (IDT) met and reviewed the allegation of abuse and an investigation was initiated. Review of the progress note revealed Resident #11 received a head-to-to-toe observation with no negative findings. Review of the progress note revealed the documented head-to-toe assessment was incorrect as an observation of Resident #11 on 11/19/24 at 8:43 A.M., one day later, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. 2. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had a BIMS score of 10 that indicated he was alert and oriented with cognition impairment. Review of the MDS assessment revealed he was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 04/27/24 revealed Resident #26 was at risk for altered mood and behaviors related to bipolar and depression with interventions that included providing 15-to-30-minute checks or one-on-one as needed. Review of the physician orders dated 08/31/24 revealed Resident #26 had an order in place to protect other residents from harm. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview on 11/19/24 at 8:34 A.M. with Licensed Practical Nurse (LPN) #872 revealed she worked 7:00 A.M. to 2:00 P.M. on the day the alleged physical abuse occurred between Resident #11 and Resident #26. LPN #872 revealed the physical altercation occurred after she her shift ended, and she had left for the day. LPN #872 revealed she seen the bruise located on Resident #11 forehead above her left eye. LPN #872 revealed she did not document, report or complete an assessment due to being informed that another staff member had completed it on the day it occurred. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/19/24 at 2:15 P.M. with ADON #849 revealed she was in the building on the day, 11/04/24, the alleged abuse occurred but she was not aware of the physical altercation that took place. ADON #849 revealed Resident #11 and Resident #26 had a history of not getting along and had behavior contracts in place to stay away from each other. ADON #849 revealed she was not aware of any bruising to Resident #11 face and did not observe any bruising to her face on 11/04/24 and the days after. ADON #849 revealed [NAME] Regional Nurse (SRN) #879 informed her of Resident #11 bruising to her face. ADON #849 revealed she did not recall the day it was brought to her attention. ADON #849 confirmed and verified Resident #11 bruising related to being hit by Resident #26. ADON #849 verified a timely investigation did not occur immediately after the incident between Resident #11 and #26. Interview on 11/19/24 at 2:22 P.M. with the Administrator revealed Resident #11 and Resident #26 had a physical altercation on 11/04/24 and it was reported late to the Ohio Department of Health. Administrator also revealed there was no documentation of the incident and staff present did not follow the abuse procedures and protocols. Interview on 11/19/24 at 2:28 P.M. with SRN #879 revealed she observed an old bruising to Resident #11 face on 11/14/24 and reported it to the Administrator and DON. SRN #879 revealed Resident #11 had discoloration near her left eye and told her that Resident #26 hit her. Interview on 11/20/24 at 8:39 A.M. with LPN #803 revealed she was aware of Resident #11 bruising located above her left eyebrow. LPN #803 revealed when she saw the bruising, approximately 10 days ago, it appeared to not be fresh. LPN #803 revealed the bruise appeared in the shape of a C and was an old, faint, purple, yellow brown in color and was near the end and resolving. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed Resident #11 approached Resident #26 and a verbal altercation began, and as a result, Resident #26 punched her in the head. The Administrator revealed both residents had behavior contracts in place in which they were to remain away from each other and staff were to monitor for compliance with the contracts. The Administrator revealed CNA #900 and LPN #901, who were unavailable for interview, both were present at the time of the incident. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate all allegations, suspicions, and incidents of abuse. Physical abuse involves hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Review of the policy revealed the facility staff, which included, but not limited to, employees, consultants, contractors, volunteers and other caregivers who provide care and services to the residents on behalf of the facility, were to immediately report all such allegations to the Administrator. Review of the policy revealed the facility would monitor residents with a history of aggressive behaviors or behaviors and needs that may lead to conflict. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure the abuse policy was implemented for an incident of abuse involving Resident #11 and #26. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, staff did not follow the abuse policy and protocol, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate and immediately report all allegations, suspicions, and incidents of abuse. Physical abuse was defined as hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the State Agency. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, staff did not follow the abuse policy and protocol, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate and immediately report all allegations, suspicions, and incidents of abuse. Physical abuse was defined as hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly and timely investigated for Resident #11 and Resident #26. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: 1.Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of the weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye and to the left scapula area. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation resulting in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the progress note dated 11/18/24 at 1:27 P.M. in Resident #11's medical record revealed the interdisciplinary team (IDT) met and reviewed the allegation of abuse and an investigation was initiated. Review of the progress note revealed Resident #11 received a head-to-to-toe observation with no negative findings. 2.Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10 that indicated he was alert and oriented with cognition impairment. Review of the MDS assessment revealed he was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 04/27/24 revealed Resident #26 was at risk for altered mood and behaviors related to bipolar and depression with interventions that included providing 15-to-30-minute checks or one-on-one as needed. Review of the physician orders dated 08/31/24 revealed Resident #26 had an order in place to protect other residents from harm. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse incident dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed CNA #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview on 11/19/24 at 8:34 A.M. with Licensed Practical Nurse (LPN) #872 revealed she worked 7:00 A.M. to 2:00 P.M. on the day the alleged physical abuse occurred between Resident #11 and Resident #26. LPN #872 revealed the physical altercation occurred after she her shift ended, and she had left for the day. LPN #872 revealed she seen the bruise located on Resident #11 forehead above her left eye. LPN #872 revealed she did not document or complete an assessment due to being informed that another staff member had completed it on the day it occurred. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and Assistant Director of Nursing (ADON) #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed Certified Nursing Assistant (CNA) #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI and investigation was initiated late. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to immediately investigate all allegations, suspicions, and incidents of abuse. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on record review, interview and review of facility policy, the facility failed to ensure Resident #75's physician ordered laboratory services were completed and reported to the physician as required. This affected one resident (Resident #75) of one resident reviewed for laboratory services. The facility census was 65. Findings Include: Review of the medial record for Resident #75 revealed an admission date of 10/02/24. Diagnoses included cirrhosis of liver, obesity, chronic pain, heart failure and pulmonary edema. Review of a progress note on 10/17/24 at 6:21 P.M. revealed the Nurse Practitioner (NP) #883 was in to see Resident #75 regarding congestions and not feeling well. She ordered Stat (immediately) Basic Metabolic Panel (a blood test which provides information about body fluid balance and metabolism) and a chest x-ray. Review of the labs drawn on 10/17/24 at 1:20 P.M. for the basic metabolic panel (BMP) revealed the specimen hemolyzed (break down of red blood cells causing the specimen to be unusable) so the facility was to reschedule the BMP. Interview on 11/21/24 at 10:27 A.M. with NP #883 revealed she ordered a stat BMP on 10/17/24 for Resident #75. NP #883 verified that the facility should have checked on the Stat BMP and rescheduled the test if the sample was not adequate. Interview on 11/21/24 at 10:35 A.M. with the Director of Nursing (DON) verified Resident #75 had orders for a stat BMP and due to the specimen being hemolyzed the lab was not completed. The nursing staff should have followed up on the lab and reschedule for the lab to be redrawn. Review of the facility policy Resident Change in Condition policy, dated 06/27/24 revealed the nurse would address any emergency care required given the situation and gather information and the most recent labs to the provide/physician. This deficiency identified non-compliance during investigation of Complaint Number OH00159522.

Based on observations, interview and policy review the facility failed to ensure resident rooms were clean and sanitary for Resident #36, #1, #34, #59 and #50. This affected five residents (#36, #1, #34, #59 and #50) out of eight residents reviewed for physical environment. The facility census was 65. Finding Include: Observation on 11/20/24 at 11:41 A.M. of Resident #36's room revealed a black grimy buildup on the floor showing wheelchair tracks all over the floor, and tables and tops of furniture were dusty. Resident #36 stated they don't clean his room every day and he would like the room cleaned. Observation on 11/20/24 at 11:54 A.M. of Resident #1's room revealed the floor was not swept as there was a build up on dirt in the corners with pieces of paper on the floor and footprints on the floor. Resident #1 stated her room was not cleaned on a daily basis. Interview on 11/20/24 at 12:00 P.M. with Resident #34 revealed housekeeping did not clean her room since she had been there. Observation of her room revealed a build up of dust and dirt around the edge of wall and in corners. Observation on 11/20/24 at 12:03 P.M. of Resident #59's room revealed a plastic bag, paper towels, and an empty wipes container on the floor, and under the bed was food with various debris on the floor in front of bed. Observation on 11/20/24 at 1:06 P.M. of Resident 50's room revealed dried food and drink in front of his bed on the fall matt, food was around the wheels of his bed caked on the floor and in front of his recliner there was dried food stuck to the floor. Resident #50 stated housekeeping would come in but did not really clean and they never clean his bathroom. Observation of the bathroom revealed brown wet liquid around the base of toilet with a brown paper towel in front of toilet soaking up the wetness. The toilet seat was covered with hair and around the base of the toilet was dry brown substance and dust on top of it. Observation was conducted on 11/20/24 at 3:15 P.M. with the Administrator and Director of Nursing (DON) who verified the above findings and verified housekeeping was to clean rooms daily. Interview on 11/21/24 at 10:55 A.M. with Housekeeping Manager (HM) #834 revealed resident rooms were to be cleaned daily. Rooms should be swept and mopped, all high touch areas cleaned, and bathrooms cleaned daily. Deep cleaning was done with room moves and discharges. HM #834 stated there was only one housekeeper working yesterday and there was no second shift housekeeper but the nurse aides could clean any area needing cleaned when the housekeepers are not working. Review of the facility policy Environmental Services: Housekeeping, dated 08/30/22 revealed removal of soiled/used items, clean surfaces with saturated cleaning cloth any soiled surfaces around the room, clean bed rails, overbed table, bedside stand, resident chair, call light devices. Clean sink, bath, shower area and high touch surfaces with disinfectant. Clean toilet bowl with designated cleaner. Sweep and mop floor. This deficiency represents noncompliance identified during investigation of Complaint Number OH00159532.

Based on record review, resident interview, staff interview, and review of witness statements, the facility Administrator failed to treat Resident #21 in a dignified and respectful manner. This affected one resident (#21) of three reviewed. The facility census was 56. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/12/20 with diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/07/24, revealed Resident #21 had no cognitive impairment. On 08/28/24 at 9:06 A.M., an interview with Resident #21 stated the Administrator yelled at her and argued with her, which Resident #21 felt was inappropriate. On 08/28/24 at 9:55 A.M., an interview with Licensed Practical Nurse (LPN) #214 confirmed they witnessed the Administrator yelling at Resident #21, gesturing at her with her hands and pointing a finger at her. LPN #214 stated this incident occurred in the middle of the building by the nurses station. On 08/28/24 at 3:53 P.M., an interview with Regional Registered Nurse (RN) #242 stated the Administrator was verbally inappropriate with Resident #21, threatening to kick Resident #21 out of the building. Review of Resident #21's signed statement, dated 08/28/24, indicated the Administrator told Resident #21 that she was in charge and she would kick Resident #21 out. Review of LPN #214's signed statement, dated 08/28/24, confirmed the Administrator yelled at Resident #21 and the Administrator told Resident #21 that she could kick Resident #21 out of the facility. LPN #214 further stated it was a bad choice of words and uncalled for. This deficiency represents non-compliance investigated under Complaint Number OH00155871.

Based on record review, resident interview, staff interview, and review of witness statements, the facility failed to ensure allegations of abuse were reported by staff in a timely manner, which led to a delay in the investigation of the alleged incident. This affected one resident (#21) of three reviewed. The facility census was 56. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/12/20 with diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/07/24, revealed Resident #21 had no cognitive impairment. On 08/28/24 at 9:06 A.M., an interview with Resident #21 stated the Administrator yelled at her and argued with her, which Resident #21 felt was inappropriate. On 08/28/24 at 9:55 A.M., an interview with Licensed Practical Nurse (LPN) #214 confirmed they witnessed the Administrator yelling at Resident #21, gesturing at her with her hands and pointing a finger at her. LPN #214 stated this incident occurred in the middle of the building by the nurses station a few weeks ago and they reported it to the former Director of Nursing (DON). On 08/28/24 at 2:05 P.M., an interview with Regional Registered Nurse (RN) #242 denied knowledge of anyone accusing the Administrator of verbal abuse. On 08/28/24 at 3:53 P.M., an interview with Regional RN #242 stated it was never reported to the regional team that a resident or staff member had alleged verbal abuse incidents against the Administrator. Regional RN #242 confirmed that the Administrator was verbally inappropriate with Resident #21, threatening to kick Resident #21 out of the building. Review of Resident #21's signed statement, dated 08/28/24, indicated the Administrator told Resident #21 that she was in charge and she would kick Resident #21 out. Review of LPN #214's signed statement, dated 08/28/24, confirmed there was an incident a couple weeks ago when the Administrator yelled at Resident #21 and the Administrator told Resident #21 that she could kick Resident #21 out of the facility. Review of the facility's policy titled Ohio Resident Abuse Policy, dated 07/11/24, revealed facility staff must immediately report all allegations of abuse to the Administrator or Abuse Coordinator. The policy further indicated that all investigations must be completed within five working days of the alleged occurrence. This deficiency represents non-compliance investigated under Complaint Number OH00155871.

Based on record review and staff interview, the facility failed to notify the physician of residents not receiving medications as physician ordered. This affected five (Residents #1, #3, #8, #24, and #55) of 13 residents receiving insulin in the facility. The facility census was 63. Findings include: 1. Review of the medical record for Resident #1 revealed an admission dated 04/25/24. Diagnoses included type II diabetes mellitus and end stage renal failure. Review of the medication administration record (MAR) for May 2024 revealed on 05/05/24 at 9:30 P.M., Resident #1 did not have his blood sugar check and did not receive any insulin as physician ordered. At the bottom of the MAR under reasons not administered on 05/05/24 at 9:30 P.M. stated drug/item unavailable. There was no documentation in the medical record that the physician was notified that Resident #1's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #1 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 2. Review of the medical record for Resident #3 revealed an admission date of 10/13/23. Diagnosis included type II diabetes mellitus. Review of Resident #3's physician orders for 03/28/24 revealed Humalog KwikPen Insulin (short acting insulin) 100 unit/milliliter (ml) give eight units subcutaneous (SQ) before meals and Lantus Soloster U-100 insulin (long-acting insulin) 100 unit/ml, give 18 units SQ at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at 9:00 P.M., Lantus 18 unit/ml was not administered, and blood glucose was not checked. On 05/06/24 at 7:30 A.M. glucose sugar was not checked, and insulin was not administered. At the bottom of MAR under reason not administered on 05/06/24 at 7:30 A.M. stated no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #3's insulin and blood sugar check were not administered as physician ordered on 05/05/24 and 05/06/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #3 did not receive insulin two times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 3. Review of the medical record for Resident #8 revealed an admission date 02/02/24. Diagnosis included type II diabetes mellitus. Review of Resident #8's physician orders dated 03/30/24 revealed an order for insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at bedtime (8:00 P.M. to 10:30 P.M.), Resident #8 did not have his blood glucose taken and no insulin was administered. There was no notation for the reason not administered. There was no documentation in the medical record that the physician was notified that Resident #8's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #8 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 4. Review of the medical record for Resident #24 revealed an admission date of 07/29/20. Diagnosis included type II diabetes mellitus. Review of Resident #24's physician order dated 03/30/24 revealed insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/04/24 at bedtime (7:00 P.M.-11:00 P.M.,) on 05/05/24 at morning (6:00 A.M. to 7:00 A.M.) and the bedtime (7:00 P.M.-11:00 P.M.) and on 05/06/24 at morning (6:00 A.M. to 7:00 A.M.), Resident #24's blood sugar was not checked, and no insulin was administered. Insulin was given at other scheduled times and blood glucose was checked. At the bottom of the MAR under reason not administered on 05/06/24 at morning (6:00 A.M. - 7:00 A.M.) stated no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #24's insulin and blood sugar check were not administered as physician ordered on 05/04/24, twice on 05/05/24 and on 05/06/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #24 did not receive insulin four times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 5. Review of the medical record for Resident #55 revealed an admission date on 03/27/24. Diagnosis included type II diabetes mellitus. Review of Resident #55's physician orders dated 04/01/24 revealed an order for insulin lispro (short acting insulin) 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at dinner (4:00 P.M.) and bedtime (9:00 P.M.), Resident #55 did not have their blood sugar checked and was not administered insulin. At the bottom of MAR under on 05/05/24 at 4:00 P.M. stated reason not administered was no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #55's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #55 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. Interview on 05/13/24 at 8:41 A.M. with Licensed Practical Nurse (LPN) #306 verified she did not notify the physician that the residents did not receive their insulin as physician ordered. This was an incidental finding during the course of the complaint investigation.

Based on record review, observation, and resident and staff interview, the facility failed to administer medications as physician ordered, resulting in significant medication errors. This affected five (Resident #1, #3, #8, #24 and #55) of thirteen residents reviewed for insulin. The facility census was 63. Findings include: 1. Review of the medical record for Resident #1 revealed an admission dated 04/25/24. Diagnoses included type II diabetes mellitus and end stage renal failure. Review of Resident #1's physician order for May 2024 revealed Humalog (insulin) U-100 100 unit per milliliter (ml) before meals and at bedtime. Review of the medication administration record (MAR) for May 2024 revealed on 05/05/24 at 9:30 P.M., Resident #1 did not have his blood sugar check and did not receive any insulin as physician ordered. At the bottom of the MAR under reasons not administered on 05/05/24 at 9:30 P.M. stated drug/item unavailable. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #1 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 2. Review of the medical record for Resident #3 revealed an admission date of 10/13/23. Diagnosis included type II diabetes mellitus. Review of Resident #3's physician orders for 03/28/24 revealed Humalog KwikPen Insulin (short acting insulin) 100 unit/milliliter (ml) give eight units subcutaneous (SQ) before meals and Lantus Soloster U-100 insulin (long-acting insulin) 100 unit/ml, give 18 units SQ at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at 9:00 P.M., Lantus 18 unit/ml was not administered, and blood glucose was not checked. On 05/06/24 at 7:30 A.M. glucose sugar was not checked, and insulin was not administered. At the bottom of MAR under reason not administered on 05/06/24 at 7:30 A.M. stated no testing strips available. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #3 did not receive insulin two times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 3. Review of the medical record for Resident #8 revealed an admission date 02/02/24. Diagnosis included type II diabetes mellitus. Review of Resident #8's physician orders dated 03/30/24 revealed an order for insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at bedtime (8:00 P.M. to 10:30 P.M.), Resident #8 did not have his blood glucose taken and no insulin was administered. There was no notation for the reason not administered. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #8 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 4. Review of the medical record for Resident #24 revealed an admission date of 07/29/20. Diagnosis included type II diabetes mellitus. Review of Resident #24's physician order dated 03/30/24 revealed insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/04/24 at bedtime (7:00 P.M.-11:00 P.M.,) on 05/05/24 at morning (6:00 A.M. to 7:00 A.M.) and the bedtime (7:00 P.M.-11:00 P.M.) and on 05/06/24 at morning (6:00 A.M. to 7:00 A.M.), Resident #24's blood sugar was not checked, and no insulin was administered. Insulin was given at other scheduled times and blood glucose was checked. At the bottom of the MAR under reason not administered on 05/06/24 at morning (6:00 A.M.-7:00 A.M.) stated no testing strips available. Interview on 05/09/24 at 10:04 A.M. with Resident #24 stated one time the nurse was not able to administered their insulin due to her not having any glucometer strips to test their blood sugar. Later, they must have found the strips because the nurse checked my blood sugar and administered insulin per sliding schedule. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #24 did not receive insulin four times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. 5. Review of the medical record for Resident #55 revealed an admission date on 03/27/24. Diagnosis included type II diabetes mellitus. Review of Resident #55's physician orders dated 04/01/24 revealed an order for insulin lispro (short acting insulin) 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at dinner (4:00 P.M.) and bedtime (9:00 P.M.), Resident #55 did not have their blood sugar checked and was not administered insulin. At the bottom of MAR under on 05/05/24 at 4:00 P.M. stated reason not administered was no testing strips available. Observation on 05/09/24 at 9:30 A.M. of the medication storage room and the 100-Hall, 200-Hall and 400-Hall medication carts revealed plenty of insulin needles and glucometer strips. Interview on 05/09/24 at 1:25 P.M. with Administrator stated on 05/05/24, Licensed Practical Nurse (LPN) #306 called to yell at her and stated she was going to the police station to turn her keys in. She stated there was no glucose strip in the building. The Administrator told LPN #306 to look in the medication room or storage room. The Administrator stated she told LPN #306 to go look in the supply room and call her back if she did not find any glucometer strips. The Administrator stated the nurse did not call her back. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #55 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. Interview on 05/13/24 at 8:41 A.M. with LPN #306 revealed she worked on 05/05/24 and she was told by the day shift nurse that there were no glucometer strips in the building so blood sugar could not be taken, and she was trying to reach management all day. LPN #306 stated she tried to call the Administrator and there was no answer. The Administrator called back after she called the police to report she did not have supplies to do her job safely and was going to bring the medication cart keys to them. LPN #306 stated the Administrator was upset and told her to check central supply and medication room for glucometer strips and she could not take the keys to the police station, or she would report her to the board of nursing for abandonment. LPN #306 stated she could not find the glucometer strips. This deficiency represents non-compliance investigated under Complaint Number OH00153676.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #65's medications were administered as ordered. This finding affected one (Resident #65) of five residents reviewed for medication administration. Findings include: Review of Resident #65's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, other psychoactive substance abuse and multiple fractures. Review of Resident #65's physician orders revealed an order dated 07/01/23 for Lexapro (antidepressant) give 10 mg (milligrams) by mouth one time a day for depression due at 9:00 A.M.; Ferrous Sulfate (iron) 325 mg by mouth two times a day for anemia due at 08:00 A.M. and 08:00 P.M.; and Lovenox injection (anticoagulant) 30 mg/0.3 ml (milliliters) give one vial subcutaneously two times a day for health maintenance due at 08:00 A.M. and 08:00 P.M Review of Resident #65's medication administration records (MARS) from 08/01/23 to 08/21/23 revealed no evidence the resident's Lexapro, iron and Lovenox anticoagulant medications were administered as ordered. Interview on 04/17/24 at 10:21 A.M. with Licensed Practical Nurse (LPN) #813 confirmed she did not administer Resident #65's morning medications as ordered. Review of the General Dose Preparation and Medication Administration policy revised 01/01/13 indicated the facility staff should verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time and for the correct resident. This deficiency represents non-compliance investigated under Complaint Number OH00152414.

Based on record review, observation and interview the facility failed to develop a comprehensive, person-centered care plan for needed care and services to maintain the highest practicable well-being for Resident #48. The affected one resident (Resident #48) of three residents reviewed for care plans. The census was 58. Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/23/23. Resident #48's diagnoses included hypertension, hyperlipidemia, other chronic osteomyelitis, atherosclerotic heart disease, peripheral vascular disease, hypotension, cognitive communication deficit, muscle weakness, history of falling, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/30/23, revealed she was cognitively intact, required extensive physical assistance of one staff for personal hygiene and was totally dependent on one staff for toilet use. Review of Resident #48's care plan revealed it did not identify any area of concern specifically related to Resident #48 refusing nail care or digging in her brief after having a bowel movement nor was there a plan for cleaning her hands/fingernails after digging in her brief after a bowel movement. The care plan did mention she could refuse care, but there was no plan or intervention related to her fingernail care for her habit of digging in her own stool. Observation on 04/28/23 at approximately 4:20 P.M. revealed Resident #48 sitting in her wheelchair, talking with multiple members of her family. Observation of both hands and under her fingernails revealed a dry, brown colored substance under eight of the ten fingers. Interview with Resident #48 on 04/28/23 at 4:22 P.M. confirmed she had a dry, brown substance underneath her fingernails. She wouldn't say what was underneath the nails, but said she would like her hands cleaned more often. Resident #48 explained the facility staff offered and completed a bed bath almost every day, but she confirmed her fingernails were still dirty and not being cleaned by staff. Interview with Resident #48's family members present at the bedside on 04/28/23 at 4:25 P.M. revealed Resident #48 had a habit of digs in her brief and the substance underneath her fingernails was more than likely feces. The family stated Resident #48 had a habit of doing this, but the facility staff did not have a schedule or plan to have her hands cleaned after each time she dug in her feces. Family also confirmed Resident #48 would refuse a bath/shower when offered, but felt the facility should have a plan in place to clean under Resident #48's fingernails, especially since it was known she will dig in her brief when she has been incontinent of bowel. Interview with State Tested Nursing Aide (STNA) #101 on 04/28/23 at approximately 4:50 P.M. verified Resident #48 digs in her brief when she has been incontinent of bowel and the substance under her nails was likely feces. She confirmed Resident #48 does this multiple times per day. STNA #101 explained staff try to clean her up as soon as possible, but there were times she would refuse to allow them to clean her fingernails or that Resident #48 claimed she did not care that she digs in her brief. STNA #101 confirmed there was no care plan or plan of action for the staff to follow when Resident #48 digs in her brief and got feces on her hands. STNA #101 also confirmed there was no plan in place to assist the staff in determining what to do when Resident #48 refused to allow them to clean her hands after she got feces on them so STNA #101 explained she did not know what to do after Resident #48 continually refused to get her hands cleaned. This deficiency represented non-compliance investigated under Complaint Number OH00141978.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Resident #38 with an appropriate fitting bed and mattress to prevent his feet from dangling off the end of the bed. This affected one resident (#38) of three residents reviewed for appropriate fitting beds. The facility census was 60. Findings include: Record review for Resident #38 revealed an admission date of 01/15/20. Diagnosis included dementia, muscle weakness, and pervasive developmental disorder (delays in development of social and communication skills). Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. Resident #38 required extensive one-person physical assistance for bed mobility and transfers. Observation on 04/03/23 at 12:48 P.M. revealed Resident #38 was lying in bed. There was no footboard at the end of Resident #38's bed. Resident #38's head of his bed was elevated approximately 30 degrees. Both of Resident #38's feet were dangling off the end of the bed from above the ankles down. The mattress was several inches shorter than the bed frame. There was a blue mattress extender at the end of the mattress that was several inches lower than the mattress and Resident #38's feet. Observation on 04/05/23 at 9:00 A.M. revealed Resident #38 was lying in bed. There was no footboard at the end of Resident #38's bed. Resident #38's head of his bed was elevated approximately 30 degrees. Both of Resident #38's feet were dangling off the end of the bed from above the ankles down. Observation on 04/06/23 at 2:50 P.M. with Assistant Director of Nursing (ADON) #338 confirmed Resident #38 was lying in bed, and Resident #38's feet were dangling off the end of the bed. The bed frame was several inches longer than the mattress, and there was no footboard. A bed extender was at the end of the mattress lying flat but with the head of the bed elevated as the resident normally had, the extender was lower than the mattress causing Resident #38's feet and ankles to dangle at the end of the mattress. ADON #338 confirmed the resident's feet should not be dangling off the end of the mattress. Observation on 04/06/23 at 2:57 P.M. with Certified Occupational Therapy Assistant (COTA) #602 confirmed Resident #38's feet were dangling off the end of the bed above the ankles. COTA #602 confirmed there was a bed extender at the end of the mattress, but it was significantly lower than the mattress and she would want to see an extender at the end of his bed appropriately fitted for positioning to prevent his feet from dangling over the end of the mattress. Observation on 04/06/23 at 3:06 P.M. with Maintenance Director #336 confirmed Resident #38's mattress was much shorter than the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy the facility failed to provide nail care and shaving for Residents #21, who was dependent on staff for personal care. This affected one resident (#21) of four residents reviewed for morning care. The facility census was 60. Findings include: Review of the medical record for Resident #21 revealed an admission date of 08/01/2016 with diagnoses including schizophrenia, cerebral infarction, dysphagia, hypertension, weakness, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 required extensive assistance from one-staff for dressing and personal hygiene. Review of Resident #21's care plan dated 01/23/23 revealed a self-care deficit with history of syncope and collapse at home, weakness, and decreased mobility. Resident #21 was to receive bathing and hygiene with the assistance from one person. Review of Resident #21's task sheet in the Electronic Medical Record (EMR) for March and April 2023 revealed Resident #21 received personal hygiene daily. Staff documented Resident #21 required extensive assistance and total dependence for care. There was no documented evidence of Resident #21 refusing personal hygiene. Observation and interview on 04/03/23 at 9:51 A.M. revealed Resident #21 had long dirty fingernails and facial hair was overgrown. Resident #21 stated he preferred to be shaved, but staff would not always do it. Interview on 04/05/23 at 9:55 A.M. with Licensed Practical Nurse (LPN) #343 verified Resident #21's fingernails nails were dirty and needed trimmed, and his facial hair was overgrown. Review of the policy and procedure titled Morning Care/AM Care revealed morning care would be offered each day to promote resident comfort. Procedure #9 stated fingernail care was to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply physician ordered creams to Resident #5. This affected one resident (#5) of three residents reviewed for physician ordered treatments. The facility census was 60. Findings include: Record review for Resident #5 revealed an admission date of 07/14/21. Diagnosis included osteoarthritis, morbid obesity, and weakness. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had mildly impaired cognition. Resident #5 required extensive assistance of one person for bed mobility, toilet use, and personal hygiene. Resident #5 was always incontinent of bowel and bladder. Resident #5 was at risk for pressure ulcer injuries and received applications of ointments. Review of the care plan dated 01/09/23 revealed Resident #5 was always incontinent of bowel and bladder related to diabetes, urinary urgency, impaired mobility, and weakness. Interventions included providing incontinence care as needed and administering medications per the physician's orders. Review of the physician orders revealed Resident #5 had orders for zinc oxide to buttocks two times a day written 04/03/23 and an order for barrier cream every shift and as needed to peri area that nursing assistants may apply for each incontinence episode written 02/08/23. Interview on 04/03/23 at 11:54 A.M. with Resident #5 revealed her concern that she was supposed to get zinc oxide to her buttocks twice a day, but the staff had been telling her for the last several days that they were out of the zinc oxide. Observation on 04/04/23 at 9:29 A.M. of medication storage located in the medication storage room with Assistant Director of Nursing (ADON) #338 revealed multiple new tubes of zinc oxide. Interview on 04/04/23 at 4:38 P.M. with Resident #5 revealed staff had still not applied the zinc oxide as ordered. Observation on 04/05/23 at 4:25 P.M. with State Tested Nurse Aides (STNAs) #372 and #373 providing incontinence care to Resident #5 revealed no cream or ointment was applied to Resident #5's buttocks after the incontinence care was completed. There was an undated border foam dressing to Resident #5's coccyx/sacral area. STNA #373 revealed she had been Resident #5's STNA throughout the day, and over the past two weeks, the dressing had been on Resident #5's buttocks when she worked. STNAs #372 and #373 confirmed neither STNA applied creams or ointments to Resident #5's buttocks over the past two weeks because the dressing was there. STNA #373 searched Resident #5's room and verified Resident #5 did not have the zinc oxide or the barrier cream in her room. STNA #373 revealed the creams were usually kept in the residents' rooms when the STNAs were to apply the creams. Record review of the physician orders, nurses' notes, and the Treatment Administration Record (TAR) for resident #5 revealed there was no order or documentation for the border foam gauze. Review of the TAR revealed the barrier cream was to be applied to Resident #5 at 7:00 A.M. and 7:00 P.M. The zinc oxide order was written on 04/03/22 and was to be applied at 8:00 A.M. and 8:00 P.M. On 04/05/22 the time was changed on the TAR for the zinc oxide to be applied at 7:00 A.M. and 7:00 P.M. The TAR was signed each shift revealing the zinc oxide and the barrier cream were both applied per the physician's orders. Interview and observation on 04/05/23 at 5:30 P.M. with ADON #338 revealed the STNAs were to apply the barrier cream, and the nurses were to apply the zinc oxide to Resident #5's buttocks. ADON #338 revealed the barrier cream would be kept in the resident's rooms and the zinc oxide would be kept in the treatment cart with the resident's name on it. Observation of the treatment cart with ADON #338 revealed Resident #5 did not have an assigned tube of zinc oxide for her use in the treatment cart. ADON #338 confirmed there were multiple tubes of zinc oxide available in the storage room and someone just needed to grab one for Resident #5. Interview on 04/05/23 at 5:34 P.M. with ADON #338 and Resident #5's charge nurse, Licensed Practical Nurse (LPN) #343, revealed LPN #343 confirmed she did not apply the zinc oxide to Resident #5's buttocks at 7:00 A.M. or at all. LPN #343 confirmed she signed off the TAR confirming the zinc oxide and barrier cream were applied because she assumed the STNA's did it. LPN #343 revealed she asked STNAs #372 and #373 if they had applied it, and they said they did. Interview on 04/05/23 at 5:38 P.M. with ADON #338, LPN #343, STNAs #372 and #373 revealed STNAs #372 and #373 confirmed LPN #343 did not ask either of them (who were the assigned STNA's to Resident #5 during the shift) if they applied the barrier cream or the zinc oxide. STNAs #372 and #373 confirmed they did not apply either cream to Resident #5's buttocks during the shift. LPN #343 confirmed she did not ask any STNA's if they applied the creams, she just assumed they did and signed the TAR that it was completed. Observation on 04/05/23 at 5:42 P.M. with ADON #338 confirmed Resident #5 had a border foam dressing on her coccyx sacral area. ADON #338 removed the dressing and confirmed there was no open area under the dressing. ADON #338 confirmed she did not know when or who put the dressing on Resident #5. ADON #338 confirmed Resident #5 did not have an order for the dressing and confirmed there was no documentation in Resident #5's medical record regarding the foam dressing. Interview on 04/06/23 at 10:19 A.M. with ADON #338 revealed she spoke to the previous nurses who documented zinc cream had been applied to Resident #5's buttocks from 04/03/23 through 04/05/23. ADON #338 revealed the nurses confirmed they did not apply the zinc cream, they assumed the STNAs did.

Based on observations, interview, and record review, the facility failed to provide a communication device to maintain independence and accommodate physical limitation in accordance with the plan of care. This affected one resident (Resident #1) out of five sampled residents. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admission date of 03/31/22. Diagnoses included multiple sclerosis, quadriplegia (paralysis of all four limbs), and dysphagia (difficulty swallowing). Review of the Comprehensive Minimum Data Set assessment, dated 04/07/22, revealed Resident #1 had intact cognition, clear speech, limited range of motion, and was able to participate in her care planning. Resident #1 required extensive assistance of staff for all activities of daily living and one person physical assist with eating. Review of the plan of care dated 04/07/22 revealed Resident #1 had difficulty communicating related to disease process. Interventions included eye contact, speech therapy evaluation, and use of alternative device including communication board and electronic devices. Review of physician orders dated April 2022 identified orders for Speech Therapy to evaluate and treat. Review of the Speech Therapy Progress Report dated from 04/01/22 to 04/21/22 revealed Resident #1 was evaluated for swallow function and discharged on 04/21/22 with diet modification and swallow techniques. Review of the physician orders dated 10/24/22, revealed Resident #1 had orders for a blow call light. Interview on 11/01/22 at 10:00 A.M. with Licensed Social (LSW) #100 stated she was unaware Resident #1 requested a communication device. Interview on 11/01/22 at 10:15 A.M. with Resident #1 revealed she was unable to communicate by way of telephone with her family or case manager. Resident #1 further stated she had spoken with LSW #100 and requested an adaptive device for communication in April 2022. Resident #1 further stated she had voiced concern regarding not having received an adaptive device for communication as requested in April to her brother, case managers, and again with LSW #100 on 08/31/22 at a facility meeting. Observation of Resident #1 on 11/01/22 at 10:30 A.M. revealed Resident #1 was physically unable to place or receive a phone call. Interview on 11/03/22 at 9:15 A.M. with Supervisor #110 and Case Manager (CM) #120, from Resident #1's waiver program, revealed they had attended a meeting on 08/31/22 with LSW #100 and Resident #1. Resident #1 requested a communication device and LSW #100 agreed to provide a hands free communication device. Interview on 11/03/22 at 9:30 A.M. with Case Manager (CM) #130 revealed she was unable to communicate with Resident #1 by way of telephone. Interview on 11/03/22 at 10:20 A.M. with Speech Therapist (ST) #600 confirmed Resident #1 was not evaluated for a communication device. ST #600 stated she was unaware Resident #1 was unable to communicate by way of the telephone. Interviews on 10/31/22 and 11/03/22 between 8:00 A.M. and 5:00 P.M. with State tested Nurse Assistants #10, #40, and #80, revealed staff dialed the telephone, then propped the receiver next to Resident #1's ear. STNAs #10, #40, and #80 stated LSW #100 was aware Resident #1 was unable to dial or hold the telephone. This deficiency represents noncompliance investigated under Complaint Number OH00136971.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consider residents preference for hot dogs as a meal choice. This affected four (Residents #19, #21, #36, and #54) of five residents reviewed for food choices. The facility census was 58. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, obesity, anxiety disorder, and abnormal posture. The quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was alert and oriented to person, place and time (A&Ox3). She only required help with setting up to and supervision to eat. She had no problems with swallowing and no dental issues. Physician orders indicated her diet order was for a regular diet and regular texture. A review of dietary progress notes from 01/16/18 through 10/31/19 revealed the registered dietician had no concerns with the resident's nutritional intake. Interview on 10/28/19 at 2:39 P.M. with Resident #19 revealed she really wanted to be able to have a hot dog for a meal now and then. She stated the facility did not allow hot dogs as a meal because they were a choking hazard. 2. Resident #21 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, abnormal posture, and diabetes. The quarterly MDS assessment dated [DATE] revealed the resident was A&Ox3. He only required help setting up and supervision to eat. He had no problems with swallowing and no dental issues. Physician orders indicated his diet order was for a regular diet and regular texture. A review of dietary progress notes from 07/18/17 through 10/31/19 revealed the registered dietician had no concerns with the resident's nutritional intake. Interview on 10/28/19 at 12:14 P.M. with Resident #21 revealed he really wanted to be able to have a hot dog. He grew up watching sports and eating hot dogs. He stated the facility did not allow hot dogs as a meal because they were a choking hazard. 3. Resident #36 was admitted to the facility on [DATE] with diagnoses including heart failure, gastro-esophageal reflux disease (GERD), and major depressive disorder. The quarterly MDS dated [DATE] revealed the resident was A&Ox3. He only required help setting up and supervision to eat. He had no problems with swallowing and no dental issues. physician orders indicated his diet order was for a regular diet and regular texture. A review of dietary progress notes from 07/26/18 through 10/31/19 revealed the registered dietician had no concerns with the resident's nutritional intake. Interview on 10/31/19 at 12:24 P.M. with Resident #36 revealed he had been asking about being able to eat hot dogs as a meal for several months in the Resident Council meetings. He stated the facility did not allow hot dogs as a meal because they were a choking hazard. 4. Resident #54 was admitted to the facility on [DATE] with diagnoses including dysphagia, heart disease, diabetes, and anxiety. The quarterly MDS dated [DATE] revealed the resident was A&Ox3. She only required help setting up to eat and was independent to eat. She had no problems with swallowing and no dental issues. Her diet order was for a regular diet and regular texture. A review of dietary progress notes from 07/25/17 through 10/31/19 revealed the registered dietician had no concerns with the resident's nutritional intake. Interview on 10/28/19 at 3:32 P.M. with Resident #54 revealed she really wanted to be able to have a hot dog for a meal because the food is horrible. She had a friend who used to bring her hot dogs but does not anymore. She stated the facility did not allow hot dogs as a meal because they were a choking hazard. On 10/30/19 at 4:37 P.M. Licensed Practical Nurse (LPN) #500 verified Residents #19, #21, #36 and #54 had no physical reasons why they could not safely chew and swallow food, including hot dogs. Review of Resident Council Minutes from 07/31/19 revealed the residents asked if they would be able to have hot dogs as a meal if they signed a waiver. No follow up action was found for the request. Review of Tubular Shaped Meats-Limited Service and Slicing Procedure, dated 02/20/19, asserts the facility allows service of hot dogs, kielbasa, link sausages and other tubular shaped meats in a limited capacity. The facility may only serve such tubular shaped meats at Facility-sanctioned events, such as a food related event with the activity department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for three (Residents #6, #8 and #208) of 17 residents reviewed for assessments. The facility census was 58. Findings include: 1. Resident #6 was admitted to the facility on [DATE]. Diagnoses included hemiplegia, muscle wasting, dementia, depression, and cerebral infarct. Review of the progress note dated 02/25/19 revealed Resident #6 had a fall from her bed. Review of the Incident Log between 02/01/19 and 10/30/19 revealed Resident #6 had an unwitnessed fall on 02/25/19 at 10:00 P.M. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question has the resident had any falls since admission/entry or reentry or the prior assessment. Review of the MDS schedule for Resident #6 revealed her prior assessment was dated 01/12/19. Licensed Practical Nurse (LPN) #500 was interviewed on 10/31/19 at 09:31 A.M. and verified Resident #6's MDS assessment was not accurately coded regarding falls. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included diabetes, muscle weakness, repeated falls, polyneuropathy, dementia, and depression. Review of the physician orders for Resident #8 revealed an order dated 06/12/19 for trazodone 50 milligrams (mg), one-half tablet at bedtime. The trazodone order was discontinued on 07/16/19. The physician orders further revealed an order dated 01/09/19 for tramadol 50 mg every six hours as needed for pain. Review of progress notes for Resident #8 between 05/20/19 and 07/17/19 revealed the resident had four falls. The progress notes further revealed the four falls occurred on 05/24/19, 06/09/19, 07/14/19 and 07/15/19. Review of the Incident Log between 02/01/19 and 10/30/19 revealed Resident #8 had unwitnessed falls on 05/24/19 at 1:36 P.M., 06/09/19 at 1:14 A.M., and 07/14/19 at 5:15 P.M. The Incident Log revealed Resident #8 had a witnessed fall on 07/15/19 at 9:45 A.M. Review of the July 2019 Medication Administration Record (MAR) for Resident #8 revealed between 07/11/19 and 07/17/19 he received trazodone, an antidepressant medication, five times and tramadol, a narcotic, one time. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had one fall between 05/20/19 and 07/17/19. The MDS 3.0 assessment also revealed Resident #8 received antidepressant medication seven times and no narcotic medications between 07/11/19 and 07/17/19. LPN #500 was interviewed on 10/31/19 at 09:15 A.M. and verified Resident # 8's MDS assessment was not accurately coded regarding falls and medications. 3. Resident #208 was admitted to the facility on [DATE]. Diagnoses included diabetes, muscle spasms, chronic respiratory failure, end stage renal disease, depression, and anxiety. Review of the progress note dated 10/10/19 revealed Resident #208 had a fall when getting out of bed. Review of the Incident Log between 02/01/19 and 10/30/19 revealed Resident #208 had an unwitnessed fall on 10/10/19 at 1:00 A.M. Review of the admission MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question has the resident had any falls since admission/entry or reentry or the prior assessment. LPN #500 was interviewed on 10/31/19 at 09:34 A.M. and verified Resident #208's MDS assessment was not accurately coded regarding falls.

2. Review of the medical record for Resident #36 revealed an admission date of 08/02/17 with diagnoses that included bilateral inguinal hernias, hydrocele (swelling in the scrotum), uropathy (urinary blockage) and urinary tract infection. Review of the physician order dated 09/27/19 revealed Resident #36 was to receive Bactrim DS 800-160 mg, one tablet every twelve hours, for a urinary tract infection. Review of the MAR revealed Resident #36 received Bactrim each day between 09/27/19 and 10/04/19. Review of Resident #36's care plan dated 09/27/19 revealed no care plan that addressed the urinary tract infection or the administration of the antibiotic. LPN #501 was interviewed on 10/31/19 at 9:22 A.M. and verified there was no care plan for the antibiotic started 09/27/19 or the urinary tract infection for Resident #36. Based on record review and interview the facility failed to update resident care plans related to antibiotic use. This affected two (Resident #20 and Resident #36) of 17 residents reviewed for revision and accuracy of care plans. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 08/08/19. Diagnoses included muscle weakness, diabetes mellitus, morbid obesity and major depressive disorder. Review of physician orders dated 10/21/19 through 10/28/19 revealed Resident #20 was ordered Flagyl (antibiotic) 500 milligrams (mg) every 12 hours for a yeast infection. Review of the care plan dated 10/21/19 revealed no care plan was created related to Resident #20 having an infection and or receiving an antibiotic. Review of the Medication Administration Record (MAR) revealed Resident #20 received Flagyl twice a day between 10/21/19 and 10/28/19. On 10/31/19 at 8:37 A.M. Licensed Practical Nurse (LPN) #501 verified that no care plan was created related to Resident #20 receiving an antibiotic for an infection.