Based on interview and record review the facility failed to ensure a resident received his medical records in a timely manner. This affected one resident (Resident #75) our of three residents reviewed for medical record access. The facility census was 152. Findings include: Interview on 03/03/25 at 3:32 P.M. with Resident #75 revealed he requested his medical records and it took a while to receive them. Interview on 03/04/25 at 10:08 A.M. with Designated Social Worker (DSW) #431, with administrator present per her request, revealed Resident #75 provided her with a medical records request form on 02/04/25 and she contacted the case manager and scheduler to see who takes care of the request. DSW #431 couldn't remember what they said. Interview on 03/04/25 at 11:02 A.M. with Administrator verified the medical request form submitted by Resident #75 on 02/04/25 was not submitted to attorneys for approval until 02/24/25. Administrator reported they hired a new medical record staff person, Medical Records #383, who started on 02/03/25 and started her vacation on 02/04/24 and didn't' return until 02/20/25. Interview on 03/05/25 at 1:22 P.M. with Medical Records #383 revealed she returned from vacation on 02/20/25 and spoke with Resident #75 regarding his request for medical records on 02/04/25. Medical Records reported he paid the fee on 02/24/25 and she submitted the request and delivered the records to him on 02/24/25. Review of the medical records form, HIPAA Privacy Authorization Form revealed Resident #75 requested medical records on 02/04/25. Review of the medical records form, Record Request Invoice, dated 02/24/25 revealed cash was received on this date for the medical records. Review of facility policy, Medical Record Request, undated revealed purpose to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) and to afford our patients the right to inspect and obtain a copy of health information about themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy, the facility failed to ensure Resident #129 received proper incontinence care. This affected one resident (Resident #129) of three residents reviewed for incontinence. The facility census was 152. Findings include: Review of the medical record for Resident #129 revealed an admission date of 03/14/24. Diagnosis included but were not limited to COVID-19, dysphagia, cirrhosis of Iver, nontraumatic intracerebral hemorrhage, hemiplegia affecting right dominant side, and sickle-cell disease. Review of the Care Plan dated 12/10/24 revealed Resident #129 had bladder and bowel incontinence. Interventions included offer to toilet resident upon waking, before and after meals, at bedtime and as needed (PRN) and provide peri-care after each episode of incontinence. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #129 had severely impaired cognition. Review of the bladder and bowel section revealed Resident #129 was always incontinent of bladder and bowel. Observation on 03/05/25 at 08:07 A.M. of perineal (peri) care (incontinence care) for Resident #129 revealed Wound Nurse # 581 gathered supplies, provided privacy, washed hands in bathroom and applied gloves. Wound Nurse #581 positioned Resident #129 on her right side and removed her brief. Wound Nurse #581 began to clean her buttocks area first with a warm washcloth with soap and water. When she removed the washcloth there was a small amount of stool on the washcloth after wiping. Wound Nurse #581 got another soapy washcloth and cleansed buttocks, then a rinse wash cloth, and then she patted area dry. Wound Nurse #581 removed the dressing to Resident #129's sacrum for the Wound Nurse Practitioner (NP) #700 to measure a pressure ulcer. After Wound NP #700 measured the pressure area Wound Nurse #581 did the pressure ulcer treatment. After completion of wound treatment Wound Nurse #581 then applied new brief, repositioned resident and ensured call light was in reach. Before leaving the room Wound Nurse #581 removed her gloves and washed her hands. Resident #129's front genital area was not cleansed. Interview on 03/05/25 at 8:24 A.M. with Wound Nurse #581 verified she provided peri-care/incontinence care incorrectly. Wound Nurse #581 reported she forgot to cleanse Resident #129's front genital peri area and she was to provide peri care to the front first then do the buttocks. Interview on 03/05/25 at 8:53 A.M. with Director of Nursing (DON) revealed procedure for peri care is to clean the front peri area first then the buttocks. DON verified Wound Nurse #581 performed peri care incorrectly. Review of facility policy, Perineal Care, dated August 2009, revealed the purpose of the procedure is to provide cleanliness and comfort. For female residents wash perineal area then wash the rectal area thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00161455.

Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one resident (Resident #136) out of three residents reviewed for secured medications. The facility census was 152. Findings include: Review of Resident #136 medical record revealed the following medications were due for administration the morning of 03/04/25: Amiodarone Hydrochloric Acid (HCI) 200 milligram (mg) give one by mouth (po) once a day (qd) for heart rate, Jardiance 25 mg give 1 tablet po for diabetes mellitus, Metoprolol Succinate extended release (ER) 24 hour 25 mg, give ½ tablet 12.5 mg PO qd for blood pressure, Potassium Chloride ER 20 milliequivalent (MEQ) give 1 tablet po qd for hypokalemia, sodium chloride oral tablet give 1 gram qd po for supplement, Vitamin C 500 mg give 1 tablet qd for anemia, and Acyclovir 400 mg give 1 tablet twice a day (BID) for prevention. Observation and interview on 03/04/25 at 11:52 A.M. with Resident #136 revealed a medicine cup on the overbed tray with 6 ½ pills in the cup. Resident #136 reported the nurse left the medications there for them to take. Resident#136 verified these were his morning medications. Interview and observation on 03/04/25 at 12:03 P.M. with supervisor LPN #583 confirmed a medicine cup with 6 ½ medications were left in Resident #136's room on his over the bed tray. LPN #583 verified medications are not to be left in a resident room. LPN #583 confirmed there were 6 ½ pills in the medicine cup and removed the medicine cup, with medications. Interview on 03/04/25 at 12:15 P.M. with Director of Nursing (DON) verified mediations were not to be left unattended in a residents room. Interview on 03/04/25 at 12:26 P.M. with LPN # 322 verified she left the medications at Resident #136's bedside. LPN #322 confirmed medications were not to be left at bedside. LPN #322 confirmed the medications were his morning medications and there were 6 ½ pills in the medicine cup. Review of facility policy, Medication Administration, dated 09/14/20 revealed to provide guidance for medication administration and administer medications as ordered and stay with until consumed/refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure Resident #201's medical record accurately reflected confirmation of the resident's death. This affected one resident (Resident #201) out of three resident reviewed for death in the facility. The facility census was 152. Findings include: Review of the medical record for Resident #201 revealed an admission date of [DATE] with diagnosis including but not limited to malignant neoplasm of nasopharynx, respiratory failure, severe protein-calorie nutrition, congestive heart failure, history of transient ischemic attack (TIA), adult failure to thrive, tracheostomy status, gastrostomy, and mood affective disorder. Resident #201 expired at the facility on [DATE]. Review of the progress note dated [DATE] at 12:00 A.M. authored by Licensed Practical Nurse (LPN) #579 revealed LPN #579 checked on Resident #210 and was unable to obtain vital signs. Resident #201 did not respond to verbal and tactile stimuli. Nursing supervisor was made aware, family and physician notified. LPN #579 contacted the funeral home where they received the body at 11:50 P.M. Interview on [DATE] at 8:54 A.M. with LPN #579 revealed she found Resident #201 deceased and checked for vital signs, and he didn't have any. LPN #579 reported she informed Nursing Supervisor Registered Nurse (RN) #706 and she came and verified no vital signs. Interview on [DATE] at 9:40 A.M. with Director of Nursing (DON) confirmed Resident #201's medical record did not contain documentation of the RN confirming the resident's death. Review of facility policy, Death of a Resident Documenting, undated, revealed all information pertaining to a resident's death (i.e. date, time of death, the name and title of the individual pronouncing the resident death, etc.) must be recorded on the nurses' noted. Review of the facility policy, Charting/Documenting Policy, undated, revealed the purpose of the guidelines is to ensure complete comprehensive and timely document and timely documentation of the resident's/patient's care, treatment, response to care, signs, symptoms, change of condition as well as the progress of the resident/patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #146, who was dependent on staff assistance for activities of daily living (ADL), received adequate and proper assistance for dressing, personal hygiene, and incontinence care. This affected one resident (#146) of three residents reviewed for ADL. The facility census was 166. Findings include: Review of Resident #146's medical record revealed an admission date of 01/22/24 and a reentry date of 01/26/24. Resident #146's diagnoses included bradycardia, type two diabetes mellitus, vascular dementia, moderate, with psychotic disturbance, and Alzheimer's disease. Review of Resident #146's care plan dated 01/22/24 included Resident #146 had an activity of daily living (ADL) self-care performance deficit related to urinary tract infection, Alzheimer's disease, bradycardia and incontinence. The goal developed was for Resident #146 to maintain, improve current level of function through the review date. Interventions included Resident #146 required the staff assistance of one person for transfers. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 was rarely, never understood and dependent (on staff) for bathing, toileting hygiene, and putting on and taking off footwear. Resident #146 required substantial to maximal assistance with upper and lower body dressing, for chair, bed-to-chair transfer and sitting to standing. Resident #46 was always incontinent of urine and bowel. Review of Resident #146's care plan dated 11/14/24 included Resident #146 had a urinary tract infection. The goal developed was for Resident #146's urinary tract infection to be resolved without complications by the review date. Interventions included to check Resident #146 at least every two hours for incontinence and wash, rinse and dry soiled areas. Resident #146 had bladder incontinence related to Alzheimer's disease, weakness, impaired mobility. The goal developed was for Resident #146 to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to provide peri-care after each episode of incontinence. Observation on 11/18/24 at 8:03 A.M. of Resident #146 with Certified Nursing Assistant (CNA) #400 revealed Resident #146 was sitting in a wheelchair in the hall of the nursing unit he resided on. Resident #146 was not wearing socks, had one shoe on his bare right foot, no show on his left foot, the shoelaces of the shoe on the right foot were not tied and were dragging on the floor. Resident #146's bare left foot was resting directly on the floor and a Band-Aid could be seen on Resident #146's left toe. Resident #146 had black athletic pants on and was wearing an incontinence brief which was observed to be full of urine with the fullness observed even with the athletic pants covering the incontinence brief. CNA #400 stated the night shift aide told her Resident #146 needed his incontinence brief changed. Resident #146's black athletic pants were covered in what appeared to be dried food and drink stains. CNA #400 confirmed Resident #146's pants were dirty, he did not have socks on, only one shoe, and the shoelaces were dragging on the floor. CNA #400 also confirmed Resident #146's incontinence brief was full of urine and needed changed. CNA #400 pushed Resident #146's wheelchair into the common area shower room and bathroom and attempted to stand him up and transfer him to the toilet, but Resident #146 was unable to assist with the transfer and CNA #400 left the bathroom to find another staff member to assist her. CNA #400 came back to the bathroom with Licensed Practical Nurse (LPN) #401. LPN #401 observed Resident #146 only had one shoe on, and his bare left foot was resting on the bathroom floor, and left the bathroom to find his other shoe before providing incontinence care. LPN #401 entered the bathroom and stated she could not find Resident #146's other shoe, but brought non-skid socks and put them on Resident #146's feet. LPN #401 and CNA #400 transferred Resident #146 to the toilet with great difficulty. Resident #146 was unable to use his legs to assist with the transfer and CNA #400 and LPN #401 had great difficulty transferring him to the toilet. Resident #146's pants were removed and CNA #400 identified and confirmed the entire back of his pants was soaked with urine, and the incontinence brief was soaked with urine. CNA #400 and LPN #401 assisted Resident #146 to stand up and CNA #400 provided incontinence care. CNA #400 washed Resident #146's buttocks and anal area using a wash cloth and when she was finished with the buttocks and anal area she folded the wash cloth and used the same wash cloth to cleanse Resident #146's perineal area. After folding the wash cloth CNA #400 proceeded to wash Resident #146's perineal area, and cleaned Resident #146's penis last with the soiled wash cloth used for the buttock and anal area. CNA #400 picked up a towel, wet one end of the towel with water, and used the end of the towel to rinse Resident #146's buttocks, penis and perineal area and used the dry end to dry his buttocks, penis and perineal area. CNA #400 confirmed she used the same wash cloth and washed Resident #146's buttocks and anal area before she cleaned his perineal area and penis. CNA #400 stated she only had one wash cloth, and she should have washed his perineal area and penis before washing Resident #146's buttocks and anal area. After finishing Resident #146's incontinence care, CNA #400 and LPN #401 assisted Resident #146 back to the wheelchair without wiping the urine off the wheelchair seat cushion with disinfectant cloths. CNA #400 and LPN #401 confirmed the cushion was not wiped with disinfectant cloths and it should have been. CNA #400 and LPN #401 were assisting Resident #146 out of the bathroom and when asked if they helped Resident #146 wash his hands after sitting on the toilet and receiving incontinence care they confirmed they did not help him wash his hands and pushed him back to the sink and assisted him to wash his hands. Further observation revealed Resident #146's fingernails were about a half inch long. LPN #401 confirmed the length of Resident #146's fingernails and stated they should have been trimmed on his shower day. CNA #400 and LPN #401 confirmed they had a difficult time transferring Resident #146 on and off the toilet and CNA #400 stated Resident #146 might need a sit-to-stand or mechanical lift. Interview on 11/18/24 at 10:30 A.M. of the Director of Nursing (DON) confirmed CNA #400 and LPN #401 told her Resident #146's incontinence care was not done properly. The DON confirmed she was notified Resident #146's transfer to the toilet was difficult and stated sometimes Resident #146 could help with transfers more than other times. Review of Resident #146's medical record revealed a care plan revision, dated 11/18/24 indicating Resident #146 required staff assistance of one to two persons for transfers. Resident #146's care plan was revised on 11/19/24 and included Resident #146 required the use of a stand up lift with two staff. Review of the facility policy titled Perineal Care revised 08/2009 included the purposes of the procedure were to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for special needs of the resident. After assembling supplies for a male resident wet washcloth and apply soap or skin cleansing agent and wash the perineal area starting with the urethra and working outward, continue to wash the perineal area including the penis, scrotum, and inner thighs. Thoroughly rinse the perineal area in the same order using fresh water and a clean washcloth. Gently dry the perineum using the same sequence. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks, dry area thoroughly. Promptly respond to a resident's request for toileting assistance. Review of the facility policy titled Activities of Daily Living (ADL), Supporting revised 03/2018 included residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination (toileting), dining and communication. A resident's ability to perform ADLs would be measured using clinical tools including the MDS. This deficiency represents non-compliance investigated under Complaint Number OH00159838.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to implement adequate and necessary interventions to address Resident #146's constipation through implementation of the facility bowel protocol. This affected one resident (#146) of three residents reviewed for constipation. Findings include: Review of Resident #146's medical record revealed an admission date of 01/22/24 and a reentry date of 01/26/24. Resident #146's diagnoses included bradycardia, type two diabetes mellitus, vascular dementia, moderate, with psychotic disturbance, and Alzheimer's disease. Review of Resident #146's care plan dated 01/22/24 included Resident #146 had an activities of daily living (ADL) self-care performance deficit related to urinary tract infection, Alzheimer's disease, bradycardia and incontinence. The goal developed was for Resident #146 to maintain, improve current level of function through the review date. Interventions included Resident #146 required the staff assistance of one person for toileting. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 was rarely, never understood and dependent (on staff) for bathing, toileting hygiene, and putting on and taking off footwear. Resident #146 required substantial to maximal assistance with upper and lower body dressing, for chair, bed-to-chair transfer and sitting to standing. Resident #46 was always incontinent of urine and bowel. Review of Resident #146's electronic medical record aide charting dated 11/14/24 through 11/18/24 revealed the resident did not have a bowel movement for five days. Review of Resident #146's progress notes dated 11/14/24 through 11/18/24 revealed no evidence the resident had a bowel movement during this time period. The medical record did not contain evidence the resident's bowel sounds, pain, tenderness, and firmness of the abdomen were assessed during this time period. Review of Resident #146's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 11/14/24 through 11/18/24 revealed he regularly received Polyethylene Glycol 3350 powder 17 grams (gm) by mouth one time a day for constipation but he did not receive any other medications or treatment related to not having a bowel movement during these five days. Observation on 11/18/24 at 8:03 A.M. of Resident #146 revealed the resident was sitting in a wheelchair and his incontinence brief was observed to be full and the resident needed to be changed. Certified Nursing Assistant (CNA) #400 and Licensed Practical Nurse (LPN) #401 assisted Resident #146 to the toilet in the common area shower room and bathroom to provide incontinence care. While Resident #146 was on the toilet CNA #400 asked Resident #146 if he needed to have a bowel movement and Resident #146 stated no. There was no bowel movement observed during the incontinence care. Interview on 11/19/24 at 11:03 A.M. with CNA #402 revealed the aides charted bowel movements in a resident's electronic record. CNA #402 stated if a resident had diarrhea or was constipated she reported it to the nurse, and if a resident was on the facility bowel protocol it popped up on her computer screen. CNA #402 reviewed the list of residents on the bowel protocol and revealed Resident #146 was on the list of residents who were on the bowel protocol. CNA #402 stated she was assigned to care for Resident #146 today, and was unaware Resident #146 was on the bowel protocol and did not tell the nurse he was on the bowel protocol. CNA #402 stated even though she did not tell the nurse Resident #146 was on the bowel protocol, the nurses also had the residents who were on the bowel protocol pop up on their computer screen. CNA #402 stated Resident #146 required total assistance with care. Interview on 11/19/24 at 11:10 A.M. with LPN #403 revealed Resident #146 popped up on her computer screen to implement a bowel protocol. LPN #403 stated she did not know before now Resident #146 was on the bowel protocol because she had not looked at residents' on the bowel protocol since she arrived for work at 7:00 A.M. LPN #403 indicated a resident popped up on the clinical alert area on the dashboard of the electronic record when they did not have a bowel movement for three days (six shifts). Interview on 11/19/24 at 11:20 A.M. with Unit Manager (UM) #404 revealed she was the unit manager for the nursing unit Resident #146 resided on and stated Resident #146 was on the bowel protocol list from the weekend. UM #404 stated nurses could check the dashboard in the electronic record to check if any residents were on the bowel protocol. UM #404 stated as a back-up measure for residents on the bowel protocol she usually checked the list every morning and alerted the nurses which residents were on the bowel protocol. UM #404 stated yesterday (11/18/24) she was too busy to check the list and she did not get to the list today. UM #404 indicated on 11/18/24 she told the nurses to check the dashboard for residents on the bowel protocol, but she did not know if the nurses checked the bowel protocol list after she told them to do it. UM #404 confirmed Resident #146 did not have a documented bowel movement for five days. Review of the facility undated policy titled Bowel Protocol revealed nursing staff should maintain a record of bowel evacuation on each resident in POC (electronic record). A bowel elimination protocol was initiated by nursing staff when the resident had no recorded results after six shifts, or per resident's pattern. When the BM record shows no bowel elimination by the third day or six shifts, the 7:00 A.M. to 7:00 P.M. charge nurse initiated the bowel protocol unless contraindicated by resident condition or physician (or the resident had existing orders for constipation); the first step was on the third day or after six shifts, the charge nurse gave resident 30 cubic centimeters (cc's) of Milk of Magnesia in the morning; the second step was if the Milk of Magnesia was ineffective, the second shift nurse may administer Dulcolax Suppository 10 mg rectally, consult with physician or the Nurse Practitioner for Dulcolax tablets; if there were no results from the suppository or oral tablets a Fleets type enema (sodium phosphate) was administered by the nurse; bowel routine may be started at any time, but preferable in the morning. Bowel routine may be recorded on the 24 hour report, clinical record, and verbally communicated to oncoming shifts, in report. Note bowel sounds, pain, tenderness, and firmness of the abdomen. Notify physician if bowel routine was ineffective. This deficiency represents non-compliance investigated under Complaint Number OH00159838. This deficiency is also an example of continued non-compliance from the survey dated 11/08/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #126 revealed an admission date of [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, dependence on renal dialysis, type one diabetes mellitus with kidney complications and retinopathy, chronic diastolic congestive heart failure, dysarthria, anxiety disorder, acquired absence of kidney, and neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders revealed an order dated [DATE] for Resident #126 to be transported to Centers for Dialysis Care (CDC) every Monday, Wednesday, and Friday to receive dialysis related to end stage renal disease. Review of the care plan dated [DATE] revealed Resident #126 required dialysis every Monday, Wednesday, and Friday at CDC related to renal failure. Interventions included monitoring and reporting complications related to dialysis. Review of the progress notes from [DATE] through [DATE] revealed no indication Resident #126 did not receive her scheduled dialysis treatment on [DATE] or that any medical provider was notified she had not received dialysis on [DATE]. Interview on [DATE] at 3:18 P.M. with Resident #126 confirmed she did not receive her ordered dialysis that day because the transportation company responsible for taking her to the appointment never showed up. During the interview, Resident #126 stated she had missed a previous dialysis appointment due to the lack of transportation, but she was unable to provide detail as to the date it had occurred. Interview on [DATE] at 11:48 A.M. with Unit Secretary #681 confirmed Resident #126 did not go to dialysis on [DATE] due to the lack of transportation and the appointment had to be rescheduled for [DATE]. Further interview confirmed Unit Secretary #681 called the nurses station on [DATE] to inform them Resident #126 had missed her dialysis appointment but she was unable to recall who she spoke with. Unit Secretary #126 also confirmed Resident #126 was transported to the hospital prior to the rescheduled dialysis appointment. Interview on [DATE] with Registered Nurse (RN) #814 confirmed Resident #126 missed her dialysis appointment on [DATE] and that she was supposed to receive dialysis three times a week. RN #814 further explained when a resident misses a scheduled dialysis appointment, the protocol was to reschedule the appointment for the next day, unless the resident refuses. During RN #814's explanation of missed dialysis appointment protocols, physician or provider notification was not mentioned. Interview on [DATE] at 12:05 P.M. with CDC Representative #840 confirmed Resident #126 did not receive her scheduled dialysis on [DATE]. Interview on [DATE] at 12:45 P.M. with Nurse Practitioner (NP) #839 confirmed she was supposed to be notified when dialysis residents did not receive their scheduled dialysis. NP #839 further confirmed she was not notified Resident #126 did not receive dialysis on [DATE]. During the interview, NP #839 revealed that had she been informed, she would have ordered Resident #126 to have a chest x-ray and labs to make sure there were no concerns related to fluid overload due to the missed dialysis treatment. Review of the policy titled End-Stage Renal Disease, Care of Resident with revised [DATE] revealed the facility was to communicate dialysis concerns with the dietician, staff, and medical provider. This deficiency represents non-compliance investigated under Complaint Number OH00158529. Based on interview, medical record reivew, and facility policy review, the facility failed to ensure the physician was notified in a timely manner for a change in condition for Resident #162 and for Resident #126. This affected two Residents (#126 and #162) of two reviewed for notification of change. The facility census was 166. Findings include: 1. Review of the closed medical record for Resident #162 revealed an admission date of [DATE] and discharge date of [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, generalized muscle weakness, difficulty in walking, repeated falls, and history of fractures including right femur, left tibia, T9-T10 (thoracic spine) vertebra, and right clavicle. Review of the plan of care initiated on [DATE] revealed Resident #162 was at risk for falls related to history of falls with fracture and weakness. Interventions included Dycem (non-slip self-adhesive strip) to wheelchair, ensure call light in reach, encourage use of call light, wear appropriate footwear when ambulating, follow facility fall protocol, evaluate and treat as needed, and offer to toilet resident every two hours and as needed. Review of the Un-Witnessed Fall incident report dated [DATE] at 4:22 P.M. revealed Resident #162 had an unwitnessed fall in her room. It was noted Certified Nurse Practitioner (CNP) #833 was notified on [DATE] at 4:12 P.M. and Resident #162's brother was notified on [DATE] at 4:21 P.M. Review of the progress note dated [DATE] at 4:31 P.M. revealed Resident #162 was found on the floor in her room and was complaining of pain in the lower extremity. An X-ray was ordered, CNP notified, and voicemail left for Resident #162's brother. Resident #162's vitals were stable. Review of the Radiology Results Report dated [DATE] at 11:47 P.M. revealed bilateral hip X-rays with two to three views on each side. The left hip results showed no evidence of acute fracture or dislocation. The right hip results showed near anatomic alignment of the intertrochanteric right femur post fixation and no dislocation. Review of the witness statement dated [DATE] for Licensed Practical Nurse (LPN) Unit Manager #787 stated he called CNP #833 and requested another X-ray of the knee and lower leg. An order was obtained and X-ray company was contacted. Review of Nursing Progress Note dated [DATE] at 3:31 P.M. revealed a call was placed to CNP regarding hip X-rays being negative by LPN Unit Manager #787. Increased swelling to right knee and lower leg was noted with new order for X-ray to right knee and lower leg. Review of Nursing Progress Note dated [DATE] at 4:31 A.M. revealed X-ray results were received and revealed an acute mildly displaced fracture of the distal femur and tri-compartmental degenerative changes in the knee. It was noted nurse attempted to notify physician of X-ray result however was awaiting response. Review of Nursing Progress Note dated [DATE] at 5:35 A.M. revealed upon medication pass Resident #162 was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and continued until Emergency Medical Services (EMS) arrived. EMS pronounced Resident #162 deceased at 5:52 A.M. The nurse on call notified physician via urgent message and was awaiting response. Resident #162's family was contacted several times however was awaiting return call. Review of Nursing Progress Note dated [DATE] at 6:37 A.M. revealed numerous attempts were made to contact the physician without success by Agency LPN #827. Review of Nursing Progress Note dated [DATE] at 7:12 A.M. revealed a message was left for physician without successful contact by Assistant Director of Nursing (ADON). CNP was notified at this time by phone and notified Resident #162 had expired. Review of Nursing Progress Note dated [DATE] at 7:28 A.M. revealed the physician retuned call to ADON and was notified of the x-ray result from [DATE] and Resident #162 had expired. Physician to call the coroner's office. Review of the undated facility Investigation Timeline revealed Resident #162 had fall on [DATE]. On [DATE] at 3:31 P.M. it was noted Resident #162 had swelling to knee and an x-ray to the area was ordered. Results were received via fax and in electronic medical record (EMR) at 9:15 P.M. on [DATE]. The facility identified X-ray results were located at approximately 4:00 A.M. on [DATE]. Resident #162 was found unresponsive at approximately 5:30 A.M. on [DATE] and CPR started, EMS arrived at approximately 5:40 A.M, and Resident #162 was pronounced deceased at 5:52 A.M. LPN Night Supervisor #608 notified ADON at 6:03 A.M. NP #833 was notified via text by ADON at 7:10 A.M. and returned call at 7:12 A.M. Physician #832 was notified via text by ADON at 7:28 A.M. and returned call at 8:10 A.M. It was noted Physician #832's contact information was inaccurate on the face sheet. All nurses were educated on notification of change and to call the medical director if no response was received within one hour and checking the fax machine every four hours. Interview on [DATE] at 11:34 A.M. with Director of Nursing (DON) and ADON revealed they had completed an investigation into Resident #162's fall, fracture, and subsequent death. DON and ADON confirmed the radiology results came through on the fax machine at 9:15 P.M. on [DATE] and were not identified by nursing staff until [DATE] at approximately 4:00 A.M. DON and ADON confirmed Agency LPN #827 had not called the correct number for Physician #832 when attempting to make notification. DON indicated Agency LPN #827 had used the number on the face sheet which was the office phone number for Physician #833 and not a line that was monitored 24 hours per day. DON indicated Physician #833's direct line had to be updated into the face sheets following the incident. Interview on [DATE] at 7:56 A.M. with Agency LPN #827 via phone revealed on [DATE] she had been assigned to care for Resident #162 on night shift. Agency LPN #827 indicated during report at the beginning of her shift the previous nurse had notified her there was a pending X-ray result for Resident #162. Agency LPN #827 indicated she questioned the other nurse on floor about how to receive lab and radiology reports at about 12:00 A.M. on [DATE]. Agency LPN #827 confirmed she did not locate the X-ray results for Resident #162 until approximately 4:00 A.M. on [DATE]. Agency LPN #827 reported she attempted to reach the physician on the results at approximately 4:41 A.M. on [DATE]. Agency LPN #827 confirmed on [DATE] at approximately 5:30 A.M. Resident #162 was found unresponsive, required CPR, and was pronounced deceased at 5:52 A.M. by EMS. Agency LPN #827 confirmed she was unable to contact the physician or family prior to the end of her shift. Interview on [DATE] at 2:30 P.M. with CNP #833 confirmed she had been notified when Resident #162 fell on [DATE]. CNP #833 indicated she was again notified on [DATE] by LPN Unit Manager #787 that Resident #162 was complaining of knee pain. CNP #833 reported she was not required to be on call throughout the night. CNP #833 stated at about 8:00 A.M. on [DATE] the ADON called her to inform her of Resident #162's passing and the fracture. CNP #833 indicated the results came through on fax and was unsure what the delay was in results being reported. CNP #833 indicated had she been notified of the fracture at a reasonable hour Resident #162 would have been sent out to the hospital for evaluation. Interview on [DATE] at 4:04 P.M. with Physician #832 revealed she had not been notified of Resident #162's fall on [DATE]. Physician #832 indicated when she questioned why she had not been notified she was not given an answer and just told they were trying to figure out what had happened. Physician #832 stated if she had been notified, she would have ordered an X-ray and for a fracture she would have sent Resident #162 to the hospital. Physician #832 stated she was on call at night and was able to be reached directly on her cell phone. Physician #832 stated she was not notified of Resident #162's fracture or passing until approximately 6:00 A.M. on [DATE]. Review of facility policy Change in a Resident's Condition or Status, undated revealed The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there was an accident involving the resident, significant change to the resident's physical or mental condition, a need to alter the resident's medical treatment significantly, and a need to transfer the resident to a hospital or treatment center.

Based on record review and interview with staff the facility failed to follow-up with grievances involving Resident #167 in a timely manner. This affected one resident (#167) of three residents reviewed for grievances. The census was 166. Findings include: Review of the closed medical record for Resident #167 revealed an admission date of 12/16/19 and a discharge date of 01/19/24. Diagnoses included heart failure, dysphagia and dementia without behavioral disturbance. Review of the concern log revealed an entry on 01/04/24 from the family of Resident #167 regarding issues including missing dentures and request for medical records. The notes indicated the team met with the family regarding concerns and gave a consent to be seen by the dentist for replacement dentures. It stated the Administrator discussed replacement options. Review of the email dated 01/08/24 at 1:30 P.M. from the son to the Administrator revealed the son typed he had left five voicemails in the past ten days for Medical Records department. He was asking for a response by the next day. Review of the email dated 08/23/24 at 1:01 P.M. from the daughter to the Administrator revealed the subject line was marked as Dentures- IMPORTANT (time sensitive). Attached to the email was an itemized receipt for the dentures. The daughter requested a response by 08/30/24. Interview on 10/30/24 at 10:30 A.M. with the Administrator revealed he was aware of Resident #167's missing dentures and acknowledged they had a meeting with family who also requested medical records. The Administrator verified he received the email dated 01/08/24 stating he forwarded the request for medical records and sent the son a request form to be completed. He stated he never heard from him again regarding the medical records. A follow-up interview at 5:16 P.M. with the Administrator revealed the resident was put on the list to be seen by the dentist however Resident #167 was discharged prior to the visit stating he lost touch with the son after that. He stated the facility was not going to pay for the dentures but wanted to see if they would be covered under insurance. A subsequent interview on 11/04/24 at 9:30 A.M. with the Administrator revealed he denied receiving the email dated 08/23/24 regarding reimbursement for dentures but verified it was the correct email address for him as it changed with new ownership. He denied having any further interaction after Resident #167 was discharged on 01/19/24. This deficiency represents non-compliance investigated under Complaint Number OH00159071, OH00158529 and OH00158389.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #79 revealed an initial admission date of 12/24/17 and a re-entry date of 06/05/23. Diagnoses included epilepsy, hypertensive heart with heart failure, gastrostomy status, type two diabetes mellitus, hyperlipidemia, primary hypertension, unspecified protein-calorie malnutrition, anemia, neuromuscular dysfunction of bladder, vascular dementia, major depression, schizoaffective disorder, and oropharyngeal phase dysphagia. Review of the quarterly MDS 3.0 assessment completed on 10/06/24 revealed Resident #79 had moderate cognitive impairment with no behaviors or rejection of care. Further review of the MDS revealed Resident #79 required partial to moderate feeding assistance, had a history of holding food in her mouth or cheeks, coughed or choked during meals or with medication administration, complained of swallowing difficulty, was on a mechanically altered diet and received 51 percent or more of her nutrition through a feeing tube. Review of the physician order revealed a diet order dated 08/13/24 for a regular diet with pureed texture and mildly thick (nectar) consistency liquids with no straw related to oropharyngeal dysphagia. Review of the care plan dated 07/02/19 to 01/06/25 revealed Resident #79 had the potential for weight and hydration issues related to variable oral intake, mechanically altered diet, and varying ability to feed herself. Interventions included assisting Resident #79 to eat per Occupation Therapist (OT) recommendation and providing enteral feeds per physician orders. The care plan also indicated a deficit in activities of daily living (ADL) self-care deficit. Interventions included directions for staff to feed Resident #79 at all meals and indicated she was a full feed with no straws. Review of the Speech-Language Pathology (SLP) dated 10/14/24 revealed Resident #79 had minimum to mild progress toward maintaining ability to consume pureed solids and nectar thick liquids to maximize nutritional intake and enhance hydration to reduce risk of aspiration, penetration, malnutrition, and weight loss by exhibiting minimal to mild oropharyngeal impairment. Review of the point of care feeding assistance response history from 09/12/24 (date the care plan was last updated to reflect Resident #79 was a full feed) through 11/04/24 revealed one date, 09/25/24, when Resident #79 was unavailable, and 52 days she was available for meals. During that time, Resident #79 had documentation indicating limited feeding assistance was provided zero days, extensive assistance was provided for at least one meal on two dates (09/19/24 and 11/04/24), and total assistance was provided for at least one meal on eight dates (09/12/24, 09/13/24, 09/16/24, 09/19/24, 09/20/24, 10/08/24, 10/24/24, and 10/30/24). Documentation from all other dates in that time span indicated no assistance was provided or supervision only was provided. Review of the pre-printed [NAME] 2 Assignment sheet for the CNAs revealed Resident #79 was on a mechanical soft, thin liquid diet. There was no mention of her requiring feeding assistance. This was confirmed by LPN #787 on 11/05/24 at 11:15 A.M. Review of the [NAME] 2, South 1 preprinted assignment sheet for unit nurses revealed Resident # 79 took pills crushed and was on a mechanical soft diet. There was nothing regarding Resident #79's need for feeding assistance. It was confirmed during an interview with LPN #787 on 11/05/24 at 11:15 A.M. that the assignment sheet did not indicate Resident # 79 needed feeding assistance. Interview on 10/28/24 from 10:36 A.M. to 10:45 A.M. with Resident #79 revealed she felt she never got help to eat as she asked the surveyor to help feed her. At the time of this interview, a breakfast tray was observed on the bedside table alongside the left side of the bed, out of reach from the resident with lids and plate cover intact and silverware undisturbed. At 10:45 A.M., Resident #79 placed her call light on to request staff assistance with breakfast. Observation on 10/28/24 at 10:52 A.M. revealed Certified Nursing Assistant (CNA) #841 brought a rewarmed tray of breakfast food to Resident #79, set-up the tray, in front of Resident #79, and exited the resident's room. Interview with CNA #79 at this time confirmed Resident #79 had not received assistance with her breakfast earlier that morning so she just rewarmed the food and completed meal set-up prior to exiting the room just then. CNA #841 further confirmed Resident #79 was left to eat alone and that as per the report she received, Resident #79 only needed assistance with the set-up for meals and not hands-on feeding assistance or supervision. Observation on 10/31/24 at 9:31 A.M. revealed the tube feeding pump beeping and a breakfast tray set-up in front of Resident # 79. At the time of the observation, no staff were providing feeding assistance, and a towel was noted over Resident #79's chest with food dropped on it and a small amount pureed food was noted on the left side of her mouth. An interview with Resident #79 at the time of this observation confirmed that staff set her tray up and placed it in front of her about 15 to 20 minutes earlier and did not offer to help her eat, which she reiterated happened frequently. She stated she tried to eat on her own and was too tired to continue. Interview on 10/31/24 at 9:41 A.M. with CNA #842 confirmed she received report from the nurse or off going CNA at the change of shift and was only informed of one of her assigned residents (Resident #98) who needed feeding assistance. She further confirmed Resident #79 was one of her assigned residents and she received assistance with meal set-up. During the interview, CNA #842 pulled an assignment sheet from her pocket and verified that Resident #79 was not listed as requiring feeding assistance. Observations continued from the hallway on the unit on 10/31/24 until 10:11 A.M. which revealed no staff had entered the room of Resident #79 to offer assistance with breakfast. Interview on 10/31/24 at 10:23 A.M. with Dietitian #711 confirmed Resident #79 had pretty poor oral intake of meals and that she relied on tube feedings as her primary source of nutrition. During the interview, Dietitian #711 confirmed that Resident #79's level of feeding assistance was inconsistent but staff were to provide assistance with meals. Interview on 11/04/24 at 3:07 P.M. with CNA #843 revealed she arrived at the unit at 11:30 A.M. and Resident #79 still had her breakfast tray beside her bed which was untouched. She further confirmed Resident #79 did not eat anything from her lunch tray on this date and received no feeding assistance because she was unaware Resident #79 required any assistance. During this interview, another CNA was present (CNA #749) who confirmed she was unaware Resident #79 received meals and thought she was only fed through a feeding tube. Interview on 11/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) Unit Manager #787 confirmed if a resident required feeding assistance, it should be noted on the staff assignment sheets. LPN Unit Manager #787 also revealed he was aware staff do not like to use the new assignment sheets, but nurses still were required to give a run-down of resident needs to CNAs in morning change of shift report, which should include residents needing feeding assistance. Interview on 11/05/24 at 11:35 AM with Director of Therapy (DOT) #658 revealed Resident #79 was currently on a functional maintenance program with the SLP to ensure she maintains safety with her current diet. DOT #658 further confirmed Resident #79 needed cues to maintain safe eating strategies, which included small bites and sips, alternating liquids and solids, time between bites, and double swallows. Review of the policy titled Assistance with Meals last revised March 2022 revealed staff were to help feed residents who needed assistance with eating. The policy further revealed residents were to be fed with attention to safety, comfort, and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00159168 and OH00158529. Based on observation, record review and interview the facility failed to ensure Resident #62, Resident #108 and Resident #79 were assisted with eating their meal. This affected three residents (#62, #108 and #79) out of seven residents reviewed for activity of daily living (ADL) assistance. The facility census was 166. Findings include: 1. Resident #62 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), osteoarthritis, and hyperlipidemia (high cholesterol). Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. Resident #62's physician order dated 09/14/24 revealed the nurse was to ensure Resident #62 was fed all her meals. If Resident #62 pushed her food away then re-approach Resident #62 with food. A review of Resident #62's plan of care revised 12/19/22 indicated an activity of living deficit related to cognition and ability. Interventions on the plan of care indicated she required one person to feed her meals and required two-person assistance for toileting, transfers, and assistance with bathing, showering, bed mobility, dressing, personal hygiene and oral care. An observation of the meal service on 10/30/24 from 12:30 P.M. to 2:00 P.M. revealed Resident #62 was assisted to the dining room in her wheelchair at 12:40 P.M. At 1:15 P.M. Resident #62 was served her lunch by Certified Nursing Assistant (CNA) #900. CNA #900 set the meal tray in front of Resident #62 and repositioned Resident #62 in an upright position, uncovered her meal plate and set-up the tray for Resident #62 and then walked away to continue to serve the meal trays to the other residents in the dining room. At 1:19 P.M. Licensed Practical Nurse (LPN) #763 walked over and fed Resident #62 a few bites of her meal while standing next to her. LPN #763 walked away from Resident #62 and left the dining room. Resident #62 sat in front of her meal tray and tried to eat a few bites of her meal. At 1:48 P.M. Resident #62's meal tray was removed from the table and CNA #900 assisted Resident #62 back to the common area in the nursing unit. Resident #62 ate approximately 10% of her meal. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not fed at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNAs assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Resident #108 was admitted on [DATE] with diagnoses including osteoporosis, vitamin D deficiency, and hemorrhagic thrombocytopenia. A review of Resident #108's nursing ADL functional assessment dated [DATE] indicted she needed assistance with setting up her meal and encourage her to be out of bed for all of her meals. Resident #108's plan of care revised on 02/07/24 indicated an activity of daily living self-care performance deficit. Interventions on the care plan indicated Resident #108 needed assistance with setting up her meal and supervision when eating her meal. An interview with Resident #108 on 10/28/24 at 10:42 AM revealed she needed assistance with getting out of bed and had to wait a long time in the morning for assistance. Resident #108 stated the staff had not offered to assist her out of bed yet today. An observation on 11/04/24 at 10:16 A.M. revealed CNA #841 delivered Resident #108 her meal tray. CNA #841 repositioned Resident #108 in her bed, raised the head of the bed and placed the meal tray on the over-the-bed tray across her lap while lying in bed. CNA #841 set up the meal for Resident #108 and left the room. Resident #108 was not encouraged to get out of bed or supervised during the meal. An interview with CNA #841 on 11/04/24 at 10:16 A.M. verified the above findings and stated the only time Resident #108 was assisted out of bed was when her daughter visited and assisted with feeding her meal. CNA #841 stated Resident #108 did not need supervision during meals and verified the staff were unable to supervise Resident #108 for her meals when she was eating in bed. Review of the facility policy and procedure titled Meal Assistance revised March 2022 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of the medical record, the facility failed to ensure residents received prescribed treatments or application of appliances as prescribed to maintain or prevent a decline in range of motion (ROM). This affected one resident (Resident #27) of one resident reviewed for ROM/mobility. The facility census was 166. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/07/24 with diagnoses including chronic obstructive pulmonary disease (COPD), depression, primary hypertension, osteoarthritis, muscle weakness, pain in left shoulder, and hemiplegia or hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 10/13/24 revealed Resident #27 had intact cognition and no behaviors or rejection of care. Further review of the MDS revealed Resident #27 had impaired range of motion (ROM) on one side of her upper and lower extremities and suffered from hemiparesis or hemiplegia. Review of the physician orders revealed orders dated 07/06/23 for Resident #27 to wear a left hand split throughout the day as tolerated and a PRAFO boot (a custom fit ankle foot orthosis) on the left foot when in bed. Further review of the orders revealed staff were to monitor for skin breakdown or adverse reactions to the splint. Review of the care plan dated 01/07/23 to 01/13/25 revealed Resident #27 had an activities of daily living (ADL) self-care deficit weakness and poor left-sided mobility and required the assistance of one to two staff for all ADLs. Further review of the care plan interventions revealed Resident #27 was to wear a left hand splint throughout the day as tolerated and a PRAFO boot to the left foot when in bed. The interventions further directed staff to monitor for skin breakdown related to left hand splint and left foot brace use. Review of the occupational therapy discharge summary signed 06/18/24 for dates span 02/28/24 to 06/18/24 revealed a recommendation Resident #27 continue to wear the left resting hand splint throughout the day as tolerated and for staff to monitor for skin breakdown or any adverse reactions. Review of the medical record point-of-care task documentation list revealed there were no required tasks related to staff ensuring a left hand splint or left PRAFO boot was applied to Resident #27. Review of the medication administration record (MAR) and the treatment administration record (TAR) from the past three months revealed no nursing documentation indicating application of splints or braces for Resident #27. Interview on 10/28/24 at 10:05 A.M. with Resident #27 revealed she felt she needed therapy as she stated her foot was stuck downward and her hand was too tight and closed all the time. During the interview, Resident #27 confirmed she had a hand splint, but did not know where it went, hadn't worn it in what she described as possibly a few months, and staff did not provide any exercises to prevent her hand from getting worse. Observation of Resident #27 and her surroundings at the time of the interview revealed a contracture of the left hand, no left hand splint in place and two signs on Resident #27's bulletin board, one with a picture of the hand splint and the other with instructions on how to properly apply the hand splint. Follow-up observations on 10/29/24 at 4:05 P.M., 10/30/24 at 9:48 A.M., and 10/31/24 at 9:55 A.M. revealed Resident #27 was not wearing a left hand splint. Interviews with Resident #27 at the time of each observation confirmed that staff had not inquired about the hand splint or attempt to apply one. Interview on 10/31/24 at 10:51 A.M. with Licensed Practical Nurse (LPN) #715 confirmed she had observed a blue splint on Resident # 27's left hand in the past, but did not know when she was supposed to wear it. At the time of the interview, LPN #715 confirmed Resident #27 was not wearing a hand splint and that she confirmed with Resident #27 she did not know where the splint was. Interview on 11/04/24 at 12:38 P.M. with LPN #844 confirmed she had nothing on her report sheet stating Resident # 27 was to wear a hand splint and had no other information pertaining to the hand splint to offer. Interview on 11/04/24 at 9:27 A.M. with Director of Therapy #658 confirmed Resident #27 was last admitted to Occupation Therapy (OT) services on 02/28/24 for evaluation of splinting of the left hand. Director of Therapy #658 further confirmed Resident #27 was discharged on 06/18/24 and was able to tolerate the resting left hand splint up to four hours daily. During the interview, Director of Therapy #658 confirmed therapy discharge recommendations were for Resident #27 to wear the left hand splint daily as tolerated, and staff were to monitor for skin breakdown or adverse reactions. Observation on 11/04/24 at 12:23 P.M. revealed Resident #27 was in bed with no hand split. An Interview conducted at the time of the observation with Resident #27 confirmed no staff had offered to help find her left hand splint or apply it. Resident #27 further stated it was very difficult to put the splint on herself without staff assistance but could sometimes do it herself if she had it available. Resident #27 further stated she felt like her left hand was closed tighter than when she was previously wearing her brace consistently. Interview on 11/04/24 at 2:50 P.M. CNA #843 confirmed she received no report that Resident #27 had a hand splint or a PRAFO boot. She further confirmed Resident #27 was wearing neither and searched the drawers in one of Resident #27's dressers, with permission of Resident #27, and did not find the hand splint. She further confirmed the foot brace was on Resident #27's bedroom floor but she did not know when it was to be applied. Interview on 11/04/24 at 2:53 P.M. with CNA #749 confirmed she had not provided care for Resident #27 in a long time and she was unaware of an order for any splints or braces. Interview on 11/04/24 with Resident #27 at 3:05 P.M. confirmed she had a brace for her left foot that was lying on the floor, but she had not worn it in a while. She did not confirm or deny that she wanted to wear the PRAFO boot while she was in bed or whether staff had offered to place it on her left foot. Resident #27 then reiterated she was more concerned with wearing her hand splint. Interview on 11/04/24 with LPN Unit Manager #787 at 3:10 P.M. confirmed the facility did not provide restorative nursing services and further confirmed Resident #27 had orders placed in 2023 for a left resting hand splint and Left foot PRAFO boot. He further confirmed both were listed on Resident #27's care plan but were not on the [NAME] (a document describing resident care needs) for nursing staff due to them being entered on the care plan incorrectly. This deficiency represents non-compliance investigated under Complaint Number OH00158529.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure appropriate care and services were in place for Resident #111's enteral feeding tube. This affected one resident (Resident #111) of one reviewed for tube feeding concerns. The facility identified eleven residents ( #46, #63, #66, #79, #97, #98, #110, #111, #128, #137, and #148) who received enteral tube feedings. The facility census was 166. Findings include: Review of the medical record for Resident #111 revealed an initial admission date of 12/20/23 and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #111 had intact cognition and exhibited no behaviors or rejection of care. Further review of the MDS revealed Resident #111 received his primary nutrition and hydration through a feeding tube. Review of the care plan dated 09/18/24 revealed Resident #111 required a PEG (percutaneous endoscopic gastrostomy) tube (a feeding tube inserted into the stomach which may be used for nutrition, hydration, and medication administration) secondary to dysphagia. Interventions included providing local PEG tube site care per orders and monitoring for signs and symptoms of infection. Review of all active physician orders revealed no orders related to care of Resident #111's PEG tube insertion site. Observation on 10/28/24 at 2:22 P.M. revealed the tube pump beeping hold error (a water flush had been infusing) and a PEG tube PEG dressing with several yellowish to yellow-brown stains which was dated 10/25/24. An interview with Resident #111 at the time of the observation confirmed the feeding pump had been beeping for 10 minutes, it beeps all the time, and staff take a long time to check to see why it is beeping. During the interview, Resident #111 stated he was uncertain how often his PEG tube dressing got changed because it tends to vary, but thought this one had been on since last week. Continued observation from the hallway revealed no staff entered the room of Resident #111 to check on the beeping feeding pump until 2:50 P.M., though one staff member was observed walking past the room twice. Interview on 10/28/24 at 2:50 P.M. with Certified Nursing Assistant (CNA) #841 confirmed the PEG tube dressing was dated 10/25/24 and confirmed she was on the way to let the nurse know the feeding pump had been beeping. Interview on 10/30/24 at 2:18 P.M. with Resident #111 revealed something around his abdomen was bothering him after his shower and he thought there might still be a dressing on his PEG tube insertion site. At the time of the interview, he began pulling at his gown and grabbing around the PEG tube stating he wanted it off. Interview on 10/30/24 at 2:24 P.M. with Licensed Practical Nurse (LPN) #795 confirmed her knowledge of Resident #111's PEG tube care was that if it is dirty, change it. LPN #795 further revealed nurses were to follow orders, adding if they have them. Observation on 10/30/24 at 2:36 P.M. of Resident #111 receiving PEG tube site care from LPN #795 revealed there was no dressing (he had just been showered within the hour), and the site appeared clean, dry, and intact. LPN #795 was observed cleaning the PEG site with moistened gauze, drying with a clean gauze pad, and applying a clean split gauze which was dated and initialed. An interview with LPN #795 after the PEG tube care was completed confirmed the gauze used to clean around the PEG tube insertion site was moistened with Dakin's solution (a strong topical antiseptic solution used to treat or prevent wound infections), but she was uncertain the strength of the solution she used and was unable to verbalize what the orders were for the PEG tube site care she just performed for Resident #111. Interview on 10/31/24 at 10:48 A.M. with LPN #715 confirmed Resident #111 had no orders regarding PEG site care. Interview on 10/31/24 at 11:20 A.M. with LPN Unit Manager #787 confirmed PEG tube site care should be done daily and as needed by cleaning and applying a clean split gauze. During the interview, LPN #787 confirmed Resident #111 had no orders related to PEG site care, just checking placement and residuals every eight hours. Review of the policy titled Peg Tube Care and Maintenance revised October 2017 revealed no creams, powders, or dressings were to be applied underneath the external anchor device unless ordered by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews, and review of facility policy, the facility failed to provide appropriate assessments and monitoring to ensure residents were free from complications before and after dialysis treatments. This affected three residents (Resident #50, Resident #126, and Resident #314) of three residents reviewed for dialysis. The facility identified three residents (#50, #126 and #314) as receiving dialysis. The facility census was 166. Findings include: 1. Review of the medical record for Resident #126 revealed an admission date of 08/15/24. Diagnoses included end stage renal disease, diabetes mellitus type one, and dependence on renal dialysis. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on 10/08/24 revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders revealed an order dated 08/17/24 for Resident #126 to be transported to Centers for Dialysis Care (CDC) every Monday, Wednesday, and Friday to receive dialysis related to end stage renal disease. Review of the care plan dated 08/15/24 revealed Resident #126 required dialysis every Monday, Wednesday, and Friday at CDC related to renal failure. Interventions included monitoring and reporting complications related to dialysis. Further review of the care plan revealed Resident #126 had renal failure secondary to end stage renal disease. Interventions included monitoring for signs and symptoms of hyper or hypovolemia, dyspnea, increased heart rate, blood pressure changes, changes in peripheral pulses or skin temperature, and daily weight changes of two pounds. Review of the clinical assessment history in the electronic medical record (EMR) on 10/31/24 at 1:47 P.M. revealed only two assessments titled Monte-Dialysis - Pre and Post Communication Tool were present, one dated 08/16/24 with status listed as Errors and one dated 08/26/24 with status listed as In Progress. On 11/04/24, the EMR clinical assessment history revealed 15 pre and post dialysis assessments listed as Complete and two (dated 08/16/24 and 08/26/24) listed as In Progress. Of the additional 15 pre and post dialysis assessments, they were signed and locked on the following dates by the following staff: • The pre dialysis assessments dated 09/04/24, 09/25/24, 09/27/24, and 10/25/24 were signed and locked by Registered Nurse (RN) #814 on 11/02/24 between 11:33 P.M. and 11:58 P.M. • The pre dialysis assessment dated [DATE] was signed by Licensed Practical Nurse (LPN) #719 and the dialysis center and post dialysis evaluations were signed by RN #814 on 11/03/24. • The pre and post dialysis evaluation information for dialysis dated 10/02/24 (7:36 P.M.) and 10/04/24 (7:48 P.M.) were signed and locked on 11/03/24 by LPN #719. • The pre and post dialysis evaluation information for dialysis dated 10/07/24 (10:58 P.M.), 10/09/24 (11:04 P.M.) , 10/16/24 (10:52 P.M.), and 10/21/24 (12:06 A.M.) were signed and locked on 11/03/24 by RN #814. • The pre and post dialysis evaluation information for dialysis dated 10/11/24, 10/14/24, 10/18/24, and 10/23/24 were all signed and locked on 11/03/24 at 10:47 P.M. by LPN #719. Review of all the dialysis assessments in the medical record revealed Resident #126 did not have a pre-dialysis or post-dialysis assessment completed on 08/19/24, 08/21/24, 08/23/24, 08/28/24, or 08/30/24. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis weight, dated 04/12/24 at 11:06 A.M., was 122.6 pounds and there was no indication of a post-dialysis weight. The first post-dialysis evaluation and the second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) each used the same vital signs, which were taken between 4:34 P.M. and 4:35 P.M.; however, the original copy of the pre and post dialysis assessment, obtained on 10/31/24, contained no record of a second post-dialysis assessment and had been incomplete in the In Progress status prior to receiving the completed copy on 11/04/24. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same blood pressure, which was taken on 08/26/24 at 8:48 A.M The first post-dialysis assessment and the second post-dialysis assessment used the same temperature, pulse, and respirations, which were taken on 08/23/24 at 9:04 P.M. and the same pain assessment, which was assessed on 08/24/24 at 10:11 P.M. The pre-dialysis weight, dated 04/12/24 at 11:06 A.M., was 122.6 pounds and there was no indication of a post-dialysis weight. The original copy of the pre and post dialysis assessment from this date, obtained on 10/31/24, was an open document with missing assessment data, listed in the status of Errors. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same blood pressure, which was taken on 09/04/24 at 8:52 A.M., and the same temperature, pulse, and oxygen saturations, which were taken on 08/26/24 between 10:42 A.M. and 10:43 A.M. The pre-dialysis assessment and the first post-dialysis assessment used the same respiratory rate assessment, which was taken on 08/26/24 at 10:43 A.M.; however, the second post-dialysis assessment had respirations recorded on 09/13/24 at 6:36 P.M., nine days after the dialysis was received on 09/04/24. The pre-dialysis weight, dated 08/28/24 at 11:06 A.M., was 128.3 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/13/24 at 6:36 P.M. and the same pain assessment, which was taken on 09/18/24 at 8:59 A.M. The pre-dialysis weight, dated 09/04/24 at 6:47 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/24/24 at 5:23 P.M. and the same pain assessment, which was taken on 09/25/24 at 8:47 A.M. The pre-dialysis weight, dated 09/24/24 at 5:22 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 09/24/24 at 5:23 P.M. and the same pain assessment, which was taken on 09/27/24 at 8:34 A.M. The pre-dialysis weight, dated 09/24/24 at 5:22 P.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, pre-dialysis evaluation had an oxygen saturation of 98% that was taken on 10/02/24 at 7:24 P.M. (Resident #126 was sent to dialysis at 10:11 A.M.), a first post-dialysis oxygen saturation of 99% that was documented on 10/02/24 at 5:16 P.M., and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) oxygen saturation of 99% that was documented on 10/02/24 at 4:34 P.M. The second post-dialysis pain assessment revealed the pain level taken on 09/30/24 at 9:19 A.M. The pre-dialysis weight, dated 10/02/24 at 9:22 A.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/04/24 between 5:40 P.M. and 5:42 P.M. and a pre-dialysis and second post-dialysis pain level both taken on 10/07/24 at 11:33 A.M. The pre-dialysis weight, dated 10/04/24 at 9:36 A.M., was 110 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/09/24 between 10:00 A.M. and 10:59 A.M. and the same pain assessment, taken on 10/09/24 at 8:47 A.M. The pre-dialysis weight, dated 10/09/24 at 10:33 A.M., was 129.2 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/11/24 between 9:25 A.M. and 9:39 A.M. and a second post-dialysis pain assessment taken on 08/26/24 at 10:43 A.M. The pre-dialysis weight, dated 10/09/24 at 10:33 A.M., was 129.2 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/14/24 and timed between 8:17 A.M. and 10:26 A.M. and a second post-dialysis pain assessment taken on 08/26/24 at 10:43 A.M. The pre-dialysis weight, dated 10/14/24 at 10:26 A.M., was 128.9 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, except for pain level, which were dated 10/14/24 and timed between 8:17 A.M. and 9:17 A.M. The pain level documented on the pre-dialysis and both post-dialysis evaluations were taken on 10/16/24 at 8:49 A.M. The pre-dialysis weight, dated 10/16/24 at 11:03 A.M., was 128.9 pounds and there was no indication of a post-dialysis weight. The last recorded weight in the electronic medical record, aside from this pre-dialysis evaluation, revealed a weight of 128.9 pounds on 10/14/23 at 10:26 A.M. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/18/24 timed between 8:12 A.M. and 8:56 A.M. This assessment also had a pre-dialysis and first post-dialysis oxygen saturation recorded from 10/04/24 at 5:42 P.M. and second post-dialysis oxygen saturation recorded from 08/26/24 at 10:43 A.M. The pre-dialysis weight, dated 10/14/24 at 10:26 A.M., was 128.9 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, which were dated 10/21/24 and timed between 12:00 A.M. and 10:59 A.M. The pre-dialysis weight, dated 10/14/24 at 10:26 A.M., was 128.9 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same pulse rate, which were dated 10/23/24 and timed 10:32 A.M. The first and the second post-dialysis evaluations both used the same blood pressure, temperature, and oxygen saturations, which were dated 10/23/24 and timed between 5:23 P.M. and 5:26 P.M. The second post-dialysis respirations were dated 09/24/24 and time 5:23 P.M. and the pain level was dated 10/23/24 but timed for 10:38 A.M. The pre-dialysis weight, dated 10/23/24 at 10:51 A.M., was 106 pounds and there was no indication of a post-dialysis weight. Review of Resident #126's dialysis assessment dated [DATE] revealed the first post-dialysis blood pressure, temperature, pulse, respiration, and oxygen saturation were taken on 09/24/24 at 5:23 P.M. and a second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) had blood pressure taken on 10/25/24 at 7:51 A.M. and a pulse, respirations, and oxygen saturation taken on 10/25/24 at 7:56 A.M. The pre-dialysis weight, dated 10/14/24 at 10:26 A.M., was 128.9 pounds and there was no indication of a post-dialysis weight. Review of the medication administration record (MAR) and the treatment administration record (TAR) from August 2024 revealed documentation that Resident # 126 went to dialysis three times per week/week from admission through the end of the month. There were no pre or post dialysis assessments available documented on the MAR or the TAR. Review of the MAR/TAR for September 2024 revealed Resident #126 went to outpatient dialysis three times a week, except for 09/06/24, 09/09/24, 09/11/24 when she was in the hospital and 09/23/24 when she attended an outside appointment. There were no pre or post dialysis assessments documented on the MAR or the TAR. Review of the MAR/TAR for October 2024 revealed documentation that Resident #126 went to dialysis three times per week, except for 10/30/24 where the TAR notes she was at an outside appointment (she was in the hospital at that time). The TAR also contained documentation Resident #126 went to dialysis on 10/28/24, despite the lack of transportation and Resident #126 missed her dialysis appointment on 10/28/24. There were no pre or post dialysis assessments documented on the MAR or the TAR. Interview on 11/04/24 at 10:45 A.M. with RN #814 confirmed that either the assigned nurse or the unit manager was responsible for obtaining vital signs before and after dialysis, but that the weights are taken at the dialysis center and the facility only obtains weights of all residents monthly, unless ordered otherwise. She further revealed that, to her knowledge, the facility was not responsible for obtaining pre-dialysis and post-dialysis weights. During this interview, RN #814 confirmed the pre-dialysis and post-dialysis dates and times recorded on the Monte-Dialysis - Pre and Post Communication Tool did not reflect actual pre-dialysis and post-dialysis assessments but pulled the most recent assessment data that was entered into the medical record into the pre-dialysis and post-dialysis evaluations. She further confirmed that if dates and times on the pre-dialysis and post-dialysis evaluations were not reflective of the actual pre-dialysis and post-dialysis times, then the assessments were not completed at the desired pre-dialysis and post-dialysis assessment times. Interview on 11/04/24 at 12:05 P.M. with Centers for Dialysis Care (CDC) Representative #840 confirmed Resident #126 received dialysis on the following dates in August 2024 after her admission to the facility: 08/16/24, 08/19/24, 08/21/24, 8/23/24, 8/26/24, and 08/30/24. Further interview with CDC Representative #840 confirmed Resident #126 did not show-up for her scheduled appointment for dialysis on 10/28/24. Interview on 11/04/24 at 4:23 P.M. with RN #814 confirmed there were no pre or post dialysis assessments completed on 08/19/24, 08/21/24, 08/23/24, or 8/30/24. Review of the policy titled End-Stage Renal Disease, Care of Resident with revised September 2010 revealed the facility would assess the resident pre and post dialysis and communicate concerns with staff, medical providers, and dietitian. 2. Review of the medical record for Resident #50 revealed an admission date of 08/25/22 with diagnoses including end stage renal disease, dementia, congestive heart failure, and dependence on renal dialysis. Review of the physician's orders for October 2024 identified orders for dialysis three times weekly on Tuesday, Thursday, and Saturday (ordered 02/21/24), perform pre-dialysis assessment once daily on dialysis days (ordered 12/02/23), and perform post-dialysis assessment every evening shift on dialysis days (ordered 12/03/23). Review of the quarterly MDS 3.0 assessment, dated 10/25/24, revealed Resident #50 had severe cognitive impairment and received dialysis treatments. Review of the medication administration records (MARs) for August 2024 through October 2024 revealed there were no pre-dialysis vital signs on 09/07/24 and 10/19/24, and there were no post-dialysis vital signs on 08/30/24, 09/05/24, 09/26/24, 10/08/24, 10/15/24, and 10/22/24. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/03/24 at 4:00 P.M. and returned from dialysis at 12:00 A.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs, including a temperature, pulse, and oxygen saturation all dated 08/03/24 at 1:36 P.M., and a blood pressure dated 08/03/24 at 3:24 P.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pain level dated 07/30/24 at 6:38 P.M. and a respiration rate dated 08/01/24 at 11:16 P.M. The pre-dialysis weight, dated 07/26/24 at 1:44 A.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/08/24 at 4:30 P.M. and returned from dialysis on 08/08/24 at 11:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/06/24 at 10:49 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/03/24 at 7:12 P.M., and a respiration rate and oxygen saturation both dated 08/06/24 at 10:49 P.M. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/13/24 at 9:00 A.M. and returned from dialysis on 08/13/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/09/24 at 2:16 A.M. and a blood pressure dated 08/13/24 at 9:26 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/15/24 at 9:45 A.M. and returned from dialysis on 08/15/24 at 4:30 P.M. The pre-dialysis evaluation included a pulse and oxygen saturation both dated 08/14/24 at 1:36 A.M. The first post-dialysis evaluation and the second post-dialysis evaluation both included a respiration rate and pain level both dated 08/13/24 at 6:03 P.M., a temperature, pulse, and oxygen saturation all dated 08/14/24 at 1:36 A.M., and a blood pressure dated 08/15/24 at 9:17 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/17/24 at 9:00 A.M. and returned from dialysis on 08/17/24 at 4:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/14/24 at 1:36 A.M., a blood glucose dated 08/17/24 at 5:19 P.M., and a temperature, pulse, respiration rate, and pain level all dated 08/17/24 at 6:55 P.M. The first post-dialysis evaluation included a temperature dated 08/15/24 at 9:56 A.M., and a pain level dated 08/15/24 at 9:57 A.M. The second post-dialysis evaluation (four hours post-dialysis) included a temperature and respiration rate both dated 08/15/24 at 9:56 A.M., a pain level dated 08/15/24 at 9:57 A.M., and a blood pressure dated 08/17/24 at 9:56 A.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/20/24 at 9:45 A.M. and returned from dialysis on 08/20/24 at 5:00 P.M. The pre-dialysis evaluation included a pain level dated 08/17/24 at 6:55 P.M., and a respiration rate dated 08/17/24 at 10:39 P.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pain level dated 08/17/24 at 6:55 P.M., a respiration rate dated 08/17/24 at 10:39 P.M., and a temperature, pulse, and oxygen saturation all dated 08/20/24 at 3:56 P.M., which was the same temperature and oxygen saturation that was included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/22/24 at 8:30 A.M. and returned from dialysis on 08/22/24 at 4:00 P.M. The pre-dialysis evaluation included an oxygen saturation dated 08/22/24 at 7:34 P.M. The first post-dialysis evaluation included a pulse dated 08/20/24 at 11:42 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 08/17/24 at 6:55 P.M., a respiration rate dated 08/17/24 at 10:39 P.M., an oxygen saturation dated 08/20/24 at 3:56 P.M., and a temperature and pulse both dated 08/20/24 at 11:42 P.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/27/24 at 8:00 A.M. and returned from dialysis on 08/27/24 at 3:55 P.M. The pre-dialysis evaluation included a respiration rate dated 08/24/24 at 10:29 P.M. The second post-dialysis evaluation (four hours post dialysis) included a pain level dated 08/22/24 at 4:37 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 08/24/24 at 10:29 P.M., and a blood pressure dated 08/27/24 at 9:29 A.M., which was the same blood pressure that was included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/29/24 at 9:30 A.M. and returned from dialysis at 12:00 A.M. The first post-dialysis evaluation and second post-dialysis evaluation both included a pulse dated 08/27/24 at 3:56 P.M., a respiration rate and pain level both dated 08/27/24 at 3:57 P.M., a temperature and oxygen saturation both dated 08/28/24 at 1:13 A.M., and a blood pressure dated 08/29/24 at 9:34 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 08/31/24 at 9:00 A.M. and returned from dialysis on 08/31/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post dialysis) included a pain level dated 08/29/24 at 9:36 A.M., a pulse, respiration rate, and oxygen saturation all dated 08/29/24 at 11:30 P.M., a temperature dated 08/31/24 at 8:59 A.M., and a blood pressure dated 08/31/24 at 9:55 A.M., which were the same temperature and blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/05/24 at 9:00 A.M. and returned from dialysis on 09/05/24 at 4:00 P.M. The pre-dialysis evaluation included a respiration rate dated 09/04/24 at 1:27 A.M. The second post-dialysis evaluation included a pain level dated 08/31/24 at 7:14 P.M., an oxygen saturation dated 09/01/24 at 4:08 A.M., a temperature, pulse, and respiration rate all dated 09/04/24 at 1:27 A.M., and a blood pressure dated 09/05/24 at 9:44 A.M., which were the same respiration rate and blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/10/24 at 9:00 A.M. and returned from dialysis on 09/10/24 at 4:00 P.M. The pre-dialysis evaluation included a blood glucose dated 09/09/24 at 5:04 P.M. The second post-dialysis evaluation included a pain level dated 09/05/24 at 6:44 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/08/24 at 12:19 A.M., and a blood pressure dated 09/10/24 at 5:07 A.M. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/14/24 at 9:30 A.M. and returned from dialysis on 09/14/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/10/24 at 6:17 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/12/24 at 10:44 P.M., and a blood pressure dated 09/14/24 at 9:35 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The pre-dialysis weight, dated 08/08/24 at 3:29 P.M., was 142 pounds. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/19/24 at 9:00 A.M. and returned from dialysis on 09/19/24 at 4:00 P.M. The pre-dialysis evaluation included a temperature, pulse, and oxygen saturation all dated 09/19/24 at 1:07 P.M. The first post-dialysis evaluation included an oxygen saturation all dated 09/19/24 at 1:07 P.M., which was the same oxygen saturation included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/24/24 at 8:45 A.M. and returned from dialysis on 09/24/24 at 4:30 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/20/24 at 12:36 A.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/21/24 at 11:13 P.M., and a blood pressure dated 09/24/24 at 8:55 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 09/28/24 at 9:00 A.M. and returned from dialysis on 09/28/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 09/24/24 at 4:32 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 09/26/24 at 3:51 P.M., and a blood pressure dated 09/28/24 at 9:30 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/03/24 at 9:00 A.M. and returned from dialysis on 10/03/24 at 4:00 P.M. The pre-dialysis evaluation included a temperature, pulse, and blood glucose all dated 10/03/24 at 1:20 P.M., and a pain level dated 10/03/24 at 1:23 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a respiration rate, oxygen saturation, and pain level all dated 09/28/24 at 4:00 P.M., a blood pressure dated 10/03/24 at 8:37 A.M., and a temperature and pulse both dated 10/03/24 at 1:20 P.M., which were the same blood pressure, temperature, and pulse included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/08/24 at 9:00 A.M. and returned from dialysis on 10/08/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 10/03/24 at 4:00 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 10/05/24 at 11:48 P.M., and a blood pressure dated 10/08/24 at 8:37 A.M., which was the same blood pressure included in the pre-dialysis evaluation. The post-dialysis weight, dated 09/14/24 at 6:12 P.M., was 146.4 pounds and there was no indication of a pre-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/12/24 at 9:00 A.M. and returned from dialysis on 10/12/24 at 4:00 P.M. The second post-dialysis evaluation (four hours post-dialysis) included a pain level dated 10/08/24 at 4:14 P.M., a temperature, pulse, respiration rate, and oxygen saturation all dated 10/10/24 at 9:58 P.M., and a blood pressure dated 10/12/24 at 8:26 A.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/15/24 at 10:00 A.M. and returned from dialysis on 10/15/24 at 4:00 P.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all used the same vital signs were dated 10/15/24 at 5:18 P.M., and the same pain level dated 10/12/24 at 4:07 P.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/17/24 at 12:00 A.M. and returned from dialysis on 10/17/24 at 4:00 A.M. The pre-dialysis evaluation and second post-dialysis evaluation (four hours post-dialysis) included the same pain level dated 10/12/24 at 4:07 P.M., and the same vital signs dated 10/17/24 at 11:57 A.M. The pre-dialysis weight, dated 10/10/24 at 8:00 A.M., was 143.5 pounds and there was no indication of a post-dialysis weight. Review of Resident #50's dialysis assessment dated [DATE] revealed Resident #50 went to dialysis on 10/19/24 at 9:00 A.M. and returned from dialysis on 10/19/24 at 4:18 P.M. The pre-dialysis evaluation, first post-dialysis evaluation, and second post-dialysis evaluation (which the assessment indicated was four hours post-dialysis) all included the same temperature, pulse, and respiration rate all dated 10/17/24 at 6:31 P.M., an oxygen saturation and pain level dated 10/17/24 at 6:32 P.M., a blood glucose dated 10/18/24 at 3:39 P.M., and a blood pressure da[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure staff administered Resident #107's insulin as ordered by the physician. This affected one resident (#107) out of four residents observed for medication administration. The facility census was 166. Findings include: Review of the medical record revealed Resident #107 was re-admitted on [DATE] with diagnoses including diabetes mellitus, and long term use of insulin. Resident #107's physician order dated 09/23/24 indicated to administer 21 units of Insulin Glargine Solution 100 units per milliliter (u/ml) subcutaneously (SQ) one time a day for diabetes mellitus. There were no parameters for holding the insulin medication in the order. An observation on 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to Resident #107 revealed a failure to administer the Insulin Glargine Solution medication as ordered by the physician. The following medications were administered during the observation: Aspirin 81 milligrams (mg) orally, floranex (lactobacillus) one tablet orally, polysaccharide iron 150 mg orally, metformin 500 mg orally, metoprolol 25 mg orally, vitamin D3 2000 international units (IU) (50 mcg) orally and tagrisso 80 mg tab orally A review of Resident #107's Medication Administration Record (MAR) dated 10/01/24 to 10/31/24 indicated on 10/29/24 the Insulin Glargine Solution medication as ordered above was scheduled to be administered at 9:00 A.M. The documentation on the MAR indicated LPN #763 documented the Insulin Glargine Solution medication was not administered due to not available or not administered because was outside the parameters for pulse, blood pressure or blood sugar. An interview with LPN #763 on 10/29/24 at 10:13 A.M. verified the above findings and stated she thought the insulin should have been held due to the blood sugar measured 98 mg/dL (milligrams per diluent). LPN #763 agreed there were no blood sugar parameters written in the physician order to hold the Insulin Glargine Solution. LPN #763 said the insulin was a long acting insulin and was scheduled to be given once a day at 9:00 A.M. and should not have been held. The facility policy titled Administering Medications revised 12/2012 indicated the policy stated medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00159071.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's fall investigations, and interview, the facility failed to ensure documentation was complete and accurate for Resident #15, #19 and #50. This affected three residents (#15, #19, and #50) of 43 records reviewed. The facility census was 166. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/29/18 with diagnoses including age-related osteoporosis, presence of left artificial shoulder joint, major depressive disorder, presence of right artificial hip joint, hypothyroidism, and a history of falling. Review of the facility's fall investigation dated 10/03/24 at 11:40 P.M. revealed Resident #19 had an unwitnessed fall while self-ambulating, complained of six out of ten pain to the right side, was administered acetaminophen and an ice pack, and was sent to the hospital around 1:40 A.M. on 10/04/24, two hours after the fall occurred. There was no witness statement for Licensed Practical Nurse (LPN) #791, who wrote a progress note for the incident. Review of the progress note, created 10/04/24 at 2:51 A.M. with an effective date of 10/03/24 at 11:40 A.M., and authored by LPN #791 indicated Resident #19 had an unwitnessed fall, the nurse heard Resident #19 yelling from her room, Resident #19 was observed sitting against the wall on the bathroom floor with pants halfway down and the floor was wet, Resident #19 was assisted back to bed by three staff members, a head to toe assessment was completed, Resident #19 complained of right side pain six out of 10 with tenderness to touch, an ice pack was applied, Tylenol was given, and no other injuries were noted. The note indicated Resident #19 was sent to the hospital at approximately 1:40 A.M. Review of the progress note, created 10/05/24 at 12:54 P.M. with an effective date of 10/03/24 at 11:57 P.M., revealed Resident #19 was screaming for help from her room and observed on the floor of the bathroom claiming she had hit her back. Resident #19 was assisted back to bed by three staff. Resident #19 complained of right side pain and cried when her side was touched. Ice was applied and Tylenol was given. Resident #19 was sent to the hospital at 1:40 A.M. due to intense pain and crying. The note indicated Resident #19 was admitted to the intensive care unit (ICU) for rib fractures. Review of the physician's orders for October 2024 revealed there were no physician's orders to send Resident #19 to the hospital on [DATE] or 10/04/24. On 11/04/24 at 12:23 P.M., an interview with Unit Manager/LPN #789 stated the progress note with an effective date of 10/03/24 at 11:40 A.M. was inaccurately documented because the incident documented in the note occurred on night shift not day shift. Unit Manager #789 also stated he did not have a witness statement for LPN #791, who wrote the progress note documenting the incident. On 11/04/24 at 2:41 P.M., an interview with LPN #791 stated she did not complete a witness statement for the incident, she just wrote a progress note in the chart. On 11/05/24 at 9:55 A.M., an interview with Unit Manager #789 confirmed the progress note, authored by him, was created on 10/05/24 after the interdisciplinary team (IDT) had completed their investigation of the fall and he back-dated the note to the time of the incident on 10/03/24. Unit Manager #789 stated again that LPN #791's progress note, dated 10/03/24 at 11:40 A.M., was inaccurately documented because it should have reflected a time of 11:40 P.M. On 11/05/24 at 1:15 P.M., an interview with Nurse Practitioner (NP) #839 verified there were no physician's orders in the medical record to send Resident #19 to the hospital on [DATE] or 10/04/24. 2. Review of the medical record for Resident #50 revealed an admission date of 08/25/22 with diagnoses including end stage renal disease, dementia, congestive heart failure, and dependence on renal dialysis. Review of the physician's orders for October 2024 identified orders for dialysis three times weekly on Tuesday, Thursday, and Saturday (ordered 02/21/24), perform pre-dialysis assessment once daily on dialysis days (ordered 12/02/23), and perform post-dialysis assessment every evening shift on dialysis days (ordered 12/03/23). Review of the medication administration records (MARs) for August 2024 through October 2024 revealed there were no pre-dialysis vital signs on 09/07/24 and 10/19/24, and there were no post-dialysis vital signs on 08/30/24, 09/05/24, 09/26/24, 10/08/24, 10/15/24, and 10/22/24. Review of Resident #50's dialysis assessments for August 2024 through October 2024 revealed pre- and post-dialysis assessments were not always completed on all dialysis days and the time stamps for some of the vital signs were while the resident was out of the facility at dialysis. On 10/30/24 at 9:28 A.M., an interview with the Director of Nursing (DON) confirmed the dialysis assessments on the MAR were not completed every dialysis day. The DON further stated staff were not required to complete the dialysis assessment information on the MAR because they completed the pre- and post-assessments in the resident evaluations. On 10/31/24 at 1:08 P.M., an interview with Registered Nurse (RN) Supervisor #654 verified the information on pre- and post-dialysis assessments for Resident #50. RN Supervisor #654 also confirmed weights were not documented for all dialysis days. On 10/31/24 at 1:55 P.M., an interview with Unit Manager/Licensed Practical Nurse (LPN) #789 stated just because things were time stamped a certain time did not mean that was when it was completed, and that time stamp was just when it was documented in the chart. 3. Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including chronic kidney disease, dementia, diabetes mellitus, malnutrition, high blood pressure, dysphagia (trouble swallowing), prosthetic heart valve, aortic valve stenosis, hypothyroidism, and gastroesophageal reflux disease. A review of Resident #15's clinical record revealed an assessment dated from 05/2024 to 10/2024 which indicated Resident #15 had a high risk for falls. Resident #15's plan of care indicated Resident #15 was at risk for falls. A review of Resident #15's fall investigations dated 03/2024 to 11/2024 revealed Resident #15 had sustained nine falls during the review period. Five of the investigations referred to nursing progress notes that were not entered at the time of the fall. There was no indication the progress note was written at a different time than when the fall actually occurred. There was no late entry to indicate the fall occurred at a different time than what was indicated in the nursing progress note. The fall investigation indicated the fall occurred on 09/15/24 at 7:25 P.M. The nursing progress note documented the fall on 09/16/24 at 7:15 A.M. The fall investigation indicated a fall occurred on 07/20/24 at 9:10 P.M. The nursing progress note documented the fall on 07/20/24 at 4:20 A.M. The fall investigation indicated a fall occurred on 05/23/24 at 7:50 A.M. The nursing progress note documented the fall on 05/23/24 at 4:18 P.M. The fall investigation documented the fall occurred on -5/09/24 at 2:40 A.M. The nursing progress note documented the fall on 05/09/24 at 4:59 P.M. The fall investigation indicated a fall occurred on 03/04/24 at 9:30 P.M. The nursing progress note indicated the fall occurred on 03/05/24 at 12:31 A.M. An interview with Licensed Practical Nurse (LPN) #767 on 11/05/24 at 10:38 A.M. verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00159071 and OH00158882.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #111 revealed an initial admission date of 12/20/23 and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #111 had intact cognition. Further review of the MDS revealed Resident #111 had an indwelling urinary catheter and received nutrition and hydration through a feeding tube. Review of the physician orders revealed an order dated 04/16/24 for enhanced barrier precautions. Review of the care plan dated 09/18/24 revealed Resident #111 required a PEG tube (percutaneous endoscopic gastrostomy, a feeding tube inserted into the stomach which may be used for nutrition, hydration, and medication administration) secondary to dysphagia. Interventions included maintaining enhanced barrier precautions (EBP) while performing high-contact resident care activities. Observation on 10/30/24 at 2:30 P.M. revealed Licensed Practical Nurse (LPN) #795 performed PEG tube site care for Resident #111. During the observation, LPN #795 donned gloves to perform the procedure, but not a gown. There were also no gowns noted near the outside or inside of Resident #111's room. Interview on 10/30/24 at 2:46 P.M. with LPN #795 confirmed Resident #111 was in enhanced barrier precautions because of the PEG tube and urinary catheter and when providing the PEG site care, a gown should have been worn. Further interview with LPN #795 confirmed she did not wear a gown to perform PEG care for Resident #111 and did not see any available in his room. Interview on 10/31/24 at 11:20 A.M. with LPN Unit Manager #787 confirmed staff were supposed to wear a gown and gloves to perform PEG tube care. Review of the policy titled Enhanced Barrier Precautions revised August 2022 revealed gloves and a gown were to be worn while performing high contact resident care activities which included care of a feeding tube. This deficiency represents non-compliance investigated under Complaint Number OH00158550. Based on observation, record review, review of facility policy and interview the facility failed to maintain infection control standards during care for Resident #107 during medication administration and Resident #111 during gastronomy tube site care. This affected one resident (#107) out of four residents reviewed for medications administration and one resident (#111) out of one resident reviewed for tube feeding. The facility census was 166. Findings include: 1. Resident #107 was re-admitted on [DATE] with diagnoses including heart failure, iron deficiency anemia, diabetes mellitus, high white blood cell count, lung cancer, Alzheimer's dementia, aortic valve stenosis, fractured right femur, high blood pressure, leiomyoma of uterus (uterine fibroids), vascular dementia, cerebral vascular disease with transient ischemic attack (TIA) and stroke, high cholesterol, lymphoma, and long term use of insulin. An observation 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to Resident #107 revealed a failure to maintain infection control standards to prevent possible cross contamination of germs. LPN #763 assisted Resident #107 to a seated position and did not sanitize or wash her hands prior to obtaining medications from medication cart containing other residents medications. LPN #763 proceeded to dispense the medications in a medication cup. While dispensing the medications from the bubble card packaging LPN #763 touched the tagrisso 80 mg tablet with her bare thumb and placed the table in the medication cup. LPN #763 removed the polysaccharide iron 150 mg capsule and pulled apart the capsule to dispense the medication in the cup of other crushed medications with her bare hands. LPN #763 entered Resident #107's room and when leaning over to administer the medications her long braided hair fell from her shoulder/back to her front hanging down and touching Resident #107's chest. LPN #763 pushed/tossed her hair braids to remove it from her face seven times during the task. When handing the cup of water to Resident #107 she placed forefinger inside of cup of water. An interview with LPN #763 on 10/29/24 at 10:13 A.M. verified the above findings and confirmed she failed to follow infection control standards. The facility policy titled Handwashing/Hand Hygiene revised August 2019 indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff should use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty, direct contact with residents, preparing or handling medications, any non-surgical invasive procedures, handling an invasive device (e.g., urinary catheters, IV access sites), before donning sterile gloves, handling clean or soiled dressings, gauze pads, etc., moving from a contaminated body site to a clean body site during resident care, contact with a resident's intact skin, contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc., after removing gloves, after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, before and after entering isolation precaution settings. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a dignified dining experience for Resident #62, Resident #13, Resident #52 and Resident #24. This affected four residents (#62, #13, #52 and #24) out of 12 residents observed eating their meals in the secured unit dining room. The facility census was 166. Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), and osteoarthritis. Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. A review of Resident #62's plan of care revised 12/19/22 indicated an activity of living deficit related to cognition and ability. Interventions on the plan of care indicated she required one person to feed her meals and required two-person assistance for toileting, transfers, and assistance with bathing, showering, bed mobility, dressing, personal hygiene and oral care. An observation of the meal service on 10/30/24 from 12:30 P.M. to 2:00 P.M. revealed Resident #62 was assisted to the dining room in her wheelchair at 12:40 P.M. Loud rock-n-roll music was playing on the radio in the dining room. At 1:15 P.M. Resident #62 was served her lunch by Certified Nursing Assistant (CNA) #900. CNA #900 set the meal tray in front of Resident #62 and repositioned Resident #62 in an upright position, uncovered her meal plate and set-up the tray for Resident #62 and then walked away to continue to serve the meal trays to the other residents in the dining room. At 1:19 P.M. Licensed Practical Nurse (LPN) #763 walked over and fed Resident #62 a few bites of her meal while standing next to her. LPN #763 walked away from Resident #62 and left the dining room. Resident #62 sat in front of her meal tray and tried to eat a few bites of her meal. At 1:48 P.M. Resident #62's meal tray was removed from the table and CNA #900 assisted Resident #62 back to the common area in the nursing unit. Resident #62 ate approximately 10% of her meal. Residents who were seated together were not served at the same time. Some residents were eating their meal before other residents received their meal who were seated together at the same table. Interviews with Resident #13, Resident #24, Resident #52 on 10/30/24 at 1:00 P.M. revealed they did not like the music playing on the radio and were not given a choice of their preference for the type of music they wanted to play during their meals. On 10/30/24 at 1:33 P.M. LPN #734 verified the music was not appreciated by several of the residents and turned the music off and did not change the radio station. LPN #734 agreed the residents probably did not like the music and was unable to say who chose the music. An interview with Activity Director #824 on 10/30/24 at 1:33 P.M. indicated the staff had chosen the type of music played during meals and the music could be changed to a different radio station according to resident preference. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not served their meal at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNA assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses including anemia, adult failure to thrive, diabetes mellitus, cognitive communication deficit, heart arrhythmia, Alzheimer's dementia, anxiety, intestinal disease, osteoarthritis, spinal stenosis, morbid obesity, asthma, severe malnutrition, dysphagia and gastroesophageal reflux disease. Resident #13's plan of care revised on 10/10/24 indicated she had an activity of daily living performance deficit. Interventions on the plan of care revealed she needed assistance with setting up her meals with food cut in to small bites and close supervision for safety. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including dementia, high blood pressure, embolism (object or bodily substance obstructing blood flow) and thrombus (blood clot) of the superficial and deep veins of the left lower extremity, end-stage glaucoma, peripheral vascular disease, pulmonary embolism, neurocognitive disorder, dysphagia, high cholesterol, diabetes mellitus, and osteoarthritis. Resident #24's plan of care revised on 01/22/24 indicated she had an activity of daily living self-care performance deficit. Intervention on the care plan included assisting Resident 324 with setting up her meal and provide supervision of one staff member. Resident #13 and Resident #24 were seated in the dining room on 10/30/24 at 12:30 P.M. waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the residents were not served their meal at the same time who were seated together. This deficieny represents non-compliance investigated under Complaint Number OH00158389 and OH00159168.

Based on observation, interview, and recipe review, the facility failed to ensure appropriate puree preparation techniques were followed. This had the potential to affect 17 Residents (#17, #37, #42, #53, #62, #63, #74, #79, #80, #86, #88, #98, #105, #106, #113, #132, and #326) the facility identified as requiring a puree textured diet. The facility census was 166. Findings include: Observation on 10/30/24 from 10:19 A.M. to 10:55 A.M. of puree preparation by [NAME] #684 revealed preparation of puree cake, Brussels sprouts, sweet potatoes, and tomato soup. Dietary Director (DD) #813 and Dietary Manager (DM) #836 were also present for observation. [NAME] #684 did not refer to any recipes or diet manual during the preparation. [NAME] #684 indicated he was looking for a pudding like consistency. [NAME] #684 was noted to add large amounts of water and thickener (a powdered substance used to alter the texture of foods and beverages to allow for safe swallowing) to the Brussels sprouts, sweet potatoes, and tomato soup. After completing the puree preparation [NAME] #684 was observed to add a seasoning to the Brussels sprouts and tomato soup. The seasoning was not powdered and had large chunks of what appeared to be dried garlic, onion, and other spices. There was no additional check to ensure appropriate consistency. Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and DM #836 confirmed findings of excessive use of water to thin, excessive use of powdered thickener, and use of chunky seasoning. [NAME] #684 confirmed he had not referred to the puree recipes or diet manual during puree preparation. [NAME] #684 indicated he had been working at the facility for some time and knew the texture he was looking for. Review of recipe Mashed Sweet Potatoes undated revealed the sweet potatoes were prepared with milk, margarine, ground cinnamon, and ground nutmeg. None of which was added to the mixture. Review of recipe Sweet Potatoes, Puree undated revealed the sweet potatoes were prepared with apple juice and food thickener as needed. Review of recipe Garlic Brussels Sprouts, Puree undated revealed the Brussels sprouts were prepared with broth or gravy. It was noted food thickener should be added as needed and gradually only until desired consistency is reached. Review of recipe Tomato Soup undated revealed tomato soup was appropriate as prepared for puree texture and did not require thickening or seasoning.

2. Review of the facility menu for breakfast on 10/30/24 revealed the meal was to consist of farina (hot cereal), vegetable and potato egg skillet, Danish and canned fruit. At the bottom of the menu was a section titled also available and for breakfast listed fresh fruit, assorted cold cereal, hard boiled eggs and yogurt as alternative options for the meal. Review of the menu substitution log for 10/30/24 breakfast revealed cereal, yogurt and banana would be served secondary to no cook scheduled. The original menu that was being substituted was not indicated on the substitution log and there were no additional substitutes listed for the yogurt or banana. Observation on 10/28/24 at 9:38 A.M. of resident breakfast meal service revealed Resident #81 was complaining about her meal and described the facility food as horrible all the time. Interview on 10/30/24 at 9:34 A.M. to 9:40 A.M. with Resident #81 revealed she had not yet received her breakfast tray and she was expecting to be served eggs because that was what was on the menu. During the interview, Resident #81 received her breakfast, which did not include the eggs she expected. Further observation of the breakfast tray revealed Resident #81 received a Danish, applesauce, and farina instead of the eggs she expected. Review of the meal ticket revealed the meal Resident #81 was to receive that morning included a Danish, farina, yogurt, and a banana. There was no yogurt or banana served to Resident #81. Interview on 10/30/24 at 9:44 AM with Certified Nursing Assistant (CNA) #845 confirmed Resident #81's meal ticket and food served on her meal tray did not match the meal ticket. CNA #845 verified Resident #81 should have received the yogurt and banana. CNA #845 also verified there were several residents who received applesauce instead of yogurt and a banana and she had only seen three resident trays with bananas on them during this meal tray pass. During this interview, CNA #845 stated several residents had asked her why they did not get eggs this morning because that was what they were expecting according to the original menu. CNA #845 was not sure if there were hard boiled eggs or any eggs available in the kitchen if a resident wished to have an egg for breakfast. A group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 revealed food served often did not match the menu and the food on their trays often did not match the meal tickets on their trays. All confirmed not being informed when there would be a substitution from what they expected to receive. Review of the policy Menu Substitutions last revised January 2023 revealed menus may be revised to accommodate unforeseen circumstances and should be recorded in the binder, indicating the food that was supposed to be served, the substituted food, and the reason for the substitution, and the residents should be notified as soon as possible. Based on record review, observation and interview, the facility failed to ensure all menu items were prepared in advance and menus and/or substitutions were followed for resident meal service. This had the potential to affect all 159 residents receiving meals from the kitchen excluding the seven residents (#44, #46, #97, #110, #111, #137, and #315) the facility identified as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Review of the facility menu for 10/30/24 lunch revealed the meal was to consist of tomato soup, grilled cheese on Texas toast, potato chips, oven roasted vegetables and banana cake. Review of the resident's menu extension sheets for 10/30/24 revealed residents on a regular and mechanical soft texture diet were to receive four ounces of an oven roasted vegetable, and residents on a puree texture diet should receive the equivalent of one pureed grilled cheese sandwich. Review of the recipe Grilled Swiss Cheese Sandwich, Puree undated, revealed the grilled cheese sandwich would be served with a four-ounce scoop. Observation on 10/30/24 at 11:58 A.M. of lunch meal service revealed tray line had begun and there was no evidence of oven roasted vegetables being served to the residents on regular and mechanical soft textured diets. There was also no evidence of pureed grilled cheese being served to the residents on puree textured diets. It was not until approximately halfway through tray line that [NAME] #684 brought out a cart with pans of Brussels sprouts and carrots. The facility had not identified pureed grilled cheese was not prepared for the tray line lunch meal until questioned by the surveyor. Interview on 10/30/24 12:36 P.M. with Dietary Director #813 and Dietary Manager #836 confirmed the vegetables were not served to the residents on regular and mechanical soft textured diets and pureed grilled cheese was not served to the residents on puree textured diets. It was not until 12:46 P.M. that pureed grilled cheese was available to serve. There was no evidence portions of vegetable or grilled cheese were sent for trays that were already served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Interview on 10/29/24 at 11:22 A.M. with Resident #68 revealed she thought the food served by the facility was absolutely horrible and gave the following examples/descriptions: a cabbage roll burnt to (expletive), a baked potato that was so undercooked it was too hard to eat, chicken breast small, dry, and so hard it could not be cut. During the interview, Resident #68 revealed her son brought in food three times a week so she could get enough to eat. Observation and interview conducted on 10/30/24 at 9:18 A.M. revealed Resident #68 lifted the lid off of the plate to expose one piece of hard dry toast which she picked up and dropped back down onto the plate to demonstrate how hard the toast was, as it made a noise when it hit the plate. Resident #68 stated there was no butter or jelly to even put on the toast. Further observation of the meal tray revealed Resident #68 also received a container of non-fat yogurt, one banana, and farina (hot cereal). There were zero condiments on the tray. Resident #68 stated she did not like or eat hot cereal, would not eat anything on her tray, and would only drink her hot tea. Resident #81 stated the items she received were not what was listed on the menu for this date and residents were supposed to have access to an alternate menu, but she had never been given an alternate menu to review. Group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 confirmed they each had the following concerns related to dietary services and food palatability: • Any food item that is breaded, such as chicken nuggets or patty's, all get overcooked, which made it too hard to eat. Resident #20 stated he would rather eat nothing at all than try to eat those overcooked breaded items. • Breakfast was always boring and not filling. Interview on 10/31/24 with Resident #18 at 3:00 P.M. revealed food was sometimes plated in a manner that allowed all the food to run together, which gave the appearance of dog food' on his lunch and dinner plates. This deficiency represents non-compliance investigated under Complaint Number OH00158389. Based on observation, interview, and food committee meeting minutes review, the facility failed to ensure palatable and appealing meals were served. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. Observation on 10/30/24 at 1:37 P.M. of a test tray with DD #813 and Dietary Manager (DM) #836 revealed the tray was served to the last unit identified as [NAME] Two. All resident trays were passed prior to taking temperatures. The temperatures were taken using the facility's digital thermometer by DM #836. Final temperatures were 124 degrees Fahrenheit (F) for grilled cheese, 127 degrees F for carrots, and 120 degrees F for tomato soup. Taste test with DD #813 revealed the grilled cheese was soggy and not palatable. The sandwich consisted of two slices of bread and one piece of cheese. DD #813 confirmed there was not enough cheese on the sandwich and it would taste better with more cheese. Taste test of the carrots revealed no concerns. Taste test of the tomato soup revealed the soup was lukewarm and not palatable. DD #813 verified the soup was not palatable. Interview on 10/30/24 at 1:42 P.M. with DD #813 and DM #836 confirmed the food temperatures and palability were not acceptable for the grilled cheese and tomato soup. Review of Food Committee Meeting Minutes dated 08/16/24 revealed proper food temperatures and meal delivery was a focus of the meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Review of the facility meal times revised on 04/10/24 revealed breakfast was served from 7:45 A.M. to 8:55 A.M., lunch was served from 11:45 A.M. to 12:50 P.M., and dinner was served from 5:00 P.M. to 6:00 P.M. The identified order of serving was first [NAME] One Unit, [NAME] Unit, [NAME] Three Unit, [NAME] Two Unit, and last [NAME] Two Unit. It was noted meal times were based on census and may deviate 15 minutes from scheduled time. Review of Food Committee Meeting Minutes dated 07/16/24 revealed meal times were reviewed and the committee discussed reasons for delays in meal delivery. Review of Food Committee Meeting Minutes dated 08/16/24 revealed residents reviewed the focus on meal times and proper food temperatures. Review of Food Committee Meeting Minutes dated 10/22/24 revealed concerns remained with meal times and the times were reviewed. Residents were notified deviation can occur by 15-20 minutes as the census was growing. The meal times were planned to be revised if the census consistently stayed above 150 and the attending residents agreed. Residents also requested the Administrator attend next meeting as there was a motion to consider resuming dining room steam table meal service. Interview on 10/28/24 at 10:01 A.M. with Resident #40 stated the meals were always served late and she had not even had breakfast yet. Observation on 10/28/24 at 10:08 A.M. revealed Resident #40's breakfast tray was delivered. Interview on 10/28/24 at 10:14 A.M. with Licensed Practical Nurse (LPN) #787 confirmed the breakfast trays were being delivered at that time. LPN #787 further stated they were at the mercy of the kitchen and delivered meal trays whenever the kitchen brought them to the unit. Observation during an interview with Resident #147 on 10/28/24 at 10:20 A.M. revealed her breakfast tray was passed at this time. Observation on 10/28/24 at 10:24 A.M. revealed two staff passing general breakfast trays on Resident #147's unit. Interview with Certified Nursing Assistant (CNA) #740 at this time revealed this was the usual time for breakfast trays to be passed on the unit. Observation on 10/28/24 at 10:28 A.M. revealed the breakfast meal service was in progress. Staff were delivering the meal trays to the residents in their room. Interview with LPN #768 on 10/28/24 at 10:30 A.M. revealed the breakfast trays were routinely delivered late on the secured dementia unit. LPN #768 stated the lunch meal was usually served at approximately 1:00 P.M. which was later than the time scheduled to be delivered for both breakfast and lunch. Interview on 10/30/24 at 11:42 A.M. with Dietary Supervisor #676 revealed with the increased census the meal times needed revised. Observation on 10/30/24 at 12:30 P.M. revealed Resident #13 and Resident #24 were seated in the dining room waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. DD #813 indicated he has noted an improvement since he started in September 2024 however was still not able to always serve meals on time. Observation on 10/30/24 at 1:37 P.M. revealed the last meal tray had been served on [NAME] Two unit which was identified as the last unit served. Observation on 10/31/24 at 8:15 A.M. revealed a breakfast tray cart arrived on [NAME] Three unit and a second cart was delivered at 8:20 A.M. Observations revealed CNAs did not completed tray pass until 9:37 A.M. Interview on 10/31/24 at 9:49 A.M. with CNA #607 confirmed tray pass took over an hour to complete. CNA #607 indicated the other two aides on shift were agency and were stopping in the middle of tray pass to provide morning care. Interview on 10/31/24 at 11:07 A.M. with Registered Nurse (RN) #661 stated there was no consistency with meal times. Interview on 11/04/24 at 8:55 A.M. with Registered Dietitian (RD) #711 revealed there had been three dietary managers since June 2024. RD #711 reported concerns with meal times had been identified. RD #711 indicated the issue was both from the kitchen and with staff passing trays. RD #711 indicated the meal times were based on census of 150 and they had a 15-20 minute leeway however indicated they were considering revising. RD #711 indicated the residents have been requesting to go back to dining room service and noted we had good customer satisfaction with serving from the pantry. RD #711 indicated she had mentioned this multiple times from June 2024 to October 2024 and the concern had been mentioned formally in food committee. RD #711 indicated the Administrator was aware of the concerns.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff followed appropriate food safety and handling techniques including equipment cleaning and sanitation, glove use, handwashing, hairnet use. This had the potential to affect all 159 residents receiving meals from the kitchen. The facility identified seven residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Observation on 10/30/24 at 8:51 A.M. revealed Mashgiach #837 (a person in the Judaism religion who supervises the kosher status of a food establishment) in the kitchen area. Mashgiach #837 was not wearing a hair net. Dietary Director (DD) #813 asked Mashgiach #837 to wear a hair net and Mashgiach refused and stated she was wearing a wig, so she does not need to. Observation on 10/30/24 at 10:19 A.M. to 10:55 A.M. of [NAME] #684 preparing pureed cake revealed [NAME] #684 adjusted his beard net with gloved hands and did not change gloves or wash hands. [NAME] #684 used the food processor and a rubber spatula during pureed cake preparation. [NAME] #684 used gloved hands to scoop pureed cake from food processor into a pan. [NAME] #684 transferred the pureed cake back into processor from the pan and continued to puree. [NAME] #684 scooped cake with gloved hand back into pan. [NAME] #684 removed gloves and tossed soiled gloves at a trash can across the kitchen, missed, and picked up gloves off the floor and put into trash. [NAME] #684 did not wash his hands and donned another pair of gloves. [NAME] #684 rinsed the food processor parts and a rubber spatula used to demonstrate texture in a preparation sink under running water. The water from the sink was observed to splash into the pan with pureed cake. [NAME] #684 used the rinsed spatula in the pureed cake then set aside the pureed cake. [NAME] #684 did not allow the food processor time to dry before next use. There was visible residue on the food processor from pureed cake. [NAME] #684 then moved on to preparing pureed Brussels sprouts. [NAME] #684 used the food processor, a whisk, a rubber spatula, and a scoop during preparation. [NAME] #684 transferred pureed Brussels sprouts from food processor to a pan. [NAME] #684 used gloved hand to sift through puree and pull-out large chunks of brussels sprouts. [NAME] #684 rinsed his gloved hands in sink and continued wearing wet gloves. [NAME] #684 whisked in food thickener and checked texture using a scoop then removed gloves. [NAME] #684 walked over to hand wash sink and wiped the sweat from his face with paper towel then donned new gloves without washing hands. [NAME] #684 again rinsed food processor parts, spatula, scoop, and whisk in sink. [NAME] #684 was wearing gloves throughout rinsing and did not change when wet. [NAME] #684 left food processor parts in sink at this time. The spatula, scoop, and whisk were not allowed time to dry before next use. [NAME] #684 then moved on to preparing pureed sweet potatoes. [NAME] #684 drained two large cans of sweet potatoes in the sink. The liquid from the cans was drained over the food processor parts in the sink. [NAME] #684 then re-rinsed food processor and did not allow time to dry then added sweet potatoes and water from sink to food processor. While sweet potatoes were pureeing in the food processor [NAME] #684 walked over to the dairy pot washing area and grabbed a pitcher off of a cart of what appeared to be dirty dishes. [NAME] #684 then rinsed pitcher in the sink with water then used to scoop tomato soup into a pan. [NAME] #684 added water from the sink to the soup then whisked thickener into the soup. The mixture was not run through food processor. [NAME] #684 rinsed whisk, spatula and scoop in sink. [NAME] #684 had not yet changed gloves. [NAME] #684 used gloved hands to scoop sweet potatoes into pan and whisked in food thickener. [NAME] #684 then rinsed scoop and demonstrated final texture. Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and Dietary Manager (DM) #836 confirmed above findings during puree preparation. [NAME] #684 confirmed he had not properly cleaned and sanitized equipment in dish machine or three compartment sink. [NAME] #684 confirmed he had not allowed the equipment time to dry between uses. Observation on 10/30/24 at 11:04 A.M. revealed Mashgiach #837 in the area of the dairy dish machine washing dishes. Mashgiach #837 continued to not wear a hair net. Interview on 10/30/24 at 11:45 A.M. with DM #836 confirmed observations of Mashgiach #837 not wearing a hair net in the kitchen area. DM #836 indicated he worked at a sister facility and had no issues with his Mashgiach wearing a hair net in the kitchen area. Review of facility policy, Hair and [NAME] Restraints, revised January 2023 revealed hair restraints must be worn at all times in the kitchen. Review of facility policy, Hand Washing, revised January 2023 revealed staff would wash hands frequently to ensure safe food handling. Hands should be washed after using a handkerchief or disposable tissue, after handling soiled equipment or utensils, during food preparation to remove soil and contaminants, when changing tasks, and after engaging in any activity that may soil or contaminate hands. Review of facility policy, General Safe Food Handling, revised February 2024 revealed kitchen equipment was to be cleaned after each use. Review of facility policy, Disposable Gloves, revised May 2024 revealed single-use disposable gloves shall be used for only one task and discarded when damaged or soiled and when interruptions occur in task completion. Hands were to be washed before and after wearing disposable gloves.

Based on record review, observations, and interview the facility failed to maintain standard infection control protocol when administrating medications. This affected one (Resident #137) of one resident reviewed for medication administration. Findings include: Review of medical record for Resident #137 revealed an admission date of 07/17/24. Diagnoses included acute kidney failure, spastic quadriplegic cerebral palsy, and neuromuscular dysfunction of the bladder. The resident had impaired cognition. A random observation on 09/09/24 at 9:31 A.M. revealed Licensed Practical Nurse (LPN) # 515 administering medications for Resident #137. LPN #515 placed three of 13 medications from medication cards into her bare hand. Interview during observations LPN#515 stated medications should be placed into the medication cup, not a bare hand. Review of the facility policy titled Administering Oral Medications, dated 2010 revealed staff were directed not to touch medications with their hands and to place all medications into a medication cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were stored in a secure location at all times. This had the potential to affect 40 residents (#1, #6, #7, #10, #12, #13, #15, #16, #19, #22, #24, #27, #30, #36, #37, #46, #51, #60, #62, #65, #67, #69, #77, #79, #85, #88, #91, #99, #103, #105, #106, #107, #110, #118, #119, #123, #130, #132, #147, and #148) residing on [NAME] three unit. The facility census was 150. Findings include: On 09/09/24 at 10:05 A.M., an observation of the [NAME] three unit revealed a medication cart was unattended and unlocked in the hallway between Resident #7's room and Resident #107's room. At the time of observation, there was one resident ambulating in the hallway with a walker and one family member present in the hallway. On 09/09/24 at 10:10 A.M., upon returning to the medication cart, Licensed Practical Nurse (LPN) #700 confirmed the medication cart was left unattended and unlocked in the hallway. LPN #700 further stated the medication cart should have been locked. Review of the facility census revealed 40 residents (#1, #6, #7, #10, #12, #13, #15, #16, #19, #22, #24, #27, #30, #36, #37, #46, #51, #60, #62, #65, #67, #69, #77, #79, #85, #88, #91, #99, #103, #105, #106, #107, #110, #118, #119, #123, #130, #132, #147, and #148) resided on [NAME] three unit. Review of the facility's policy titled Medication Administration/Treatment, dated 10/18, indicated the nurse would cover all patient information to protect privacy and lock the medication cart before leaving the cart to pass the medication.

Based on observation, interview, and medical record review, the facility failed to provide wound treatment according to physician orders. This affected one (#67) of three residents reviewed for wound care. The facility census was 161. Findings Include: Review of Resident #67's medical record revealed an admission date of 06/01/22. Diagnoses included hemiplegia, right heart failure, and unspecified malnutrition. Review of a wound physician assessment, dated 01/03/24, revealed Resident #67 had moisture associated skin damage (MASD) to the buttocks, which had improved since its development on 12/27/23, and measured 3 centimeters (cm) by 1.5 cm with a depth of 0.2 cm. The assessment called for a treatment of honey alginate (a mesh dressing mixed with honey gel) covered by a foam dressing to be changed daily. Review of a physician order dated 12/27/23 confirmed there was an active order in place for this treatment. Observation of wound care for Resident #67 by Licensed Practical Nurse (LPN) #501 on 01/09/24 at 10:45 A.M. revealed she performed the dressing care by washing the wound with normal saline, drying it with gauze, applying Medihoney gel, then a foam dressing. The wound itself appeared consisted of a small pink area with a very small open red area within with no obvious drainage or sign of infection. Observation of the Medihoney gel container revealed no evidence it contained alginate. Interview with LPN #501 on 01/09/24 at 11:01 A.M. confirmed she did not use honey alginate on the wound as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00149356.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview and review of a fall investigation, the facility failed to provide appropriate monitoring during personal care to prevent a fall. This affected one (#114) of three residents reviewed for falls. The facility census was 161. Findings Include: Review of Resident #114's medical record revealed an admission date of [DATE]. Diagnoses included encephalopathy, chronic kidney disease, and unspecified dementia. Resident #114 was admitted to hospice on [DATE] and expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #114 was severely cognitively impaired, was dependent on staff for toileting assistance, and needed substantial assistance with turning in bed. Review of a plan of care focus area, revised [DATE], revealed Resident #114 had an activities of daily living (ADLs) self-performance deficit related to impaired mobility. Interventions included extensive one to two person staff assistance with bed mobility. Review of a fall risk assessment, dated [DATE], revealed Resident #114 was at high risk for falls. Review of a progress note, dated [DATE], revealed Resident #114 fell during personal care when a nurse aide left to get a towel and came back to see the resident sliding off the bed. Resident #114 was noted to have hit his head and had a small abrasion above the eye with slight swelling and no bleeding. Hospice was notified. Follow-up vital signs and neurological assessments revealed no further injury. Review of the fall investigation revealed a written statement, dated [DATE], by State Tested Nursing Aide (STNA) #601. The statement indicated STNA #601 was changing Resident #114, left to get more towels, returned and began to wet the towels, then heard a noise and saw Resident #114 was falling. STNA #114 tried to catch the resident but he was too heavy and slid to the floor. Further review of the investigation revealed the intervention noted was to educate staff to bring all supplies before entering rooms and to lay residents flat before leaving their side. Interview on [DATE] at 11:03 A.M. with Licensed Practical Nurse (LPN) #502 revealed she was involved with the investigation and follow-up to Resident #114's fall. LPN #502 stated STNA #601 begun providing incontinence care and left Resident #114 on his side to retrieve more supplies, and when she returned he was seen sliding from the bed. She confirmed staff was not to leave residents alone on their side when giving care and the aide should have rung for assistance or returned him to a supine position before leaving. LPN #502 stated STNA #601 was reeducated following the event. Interview on [DATE] at 2:05 P.M. with STNA #601 confirmed she was the aide giving care when Resident #114 fell. STNA #601 stated she lowered the bed during care and left the room to get more towels. While wetting a towel in the sink, STNA #601 stated she hear Resident #114 shout and found him hanging on to the railing with his legs out of the bed. STNA #601 stated she tried to catch the resident's lets legs but he was too heavy and she assisted him to slide out of the bed. STNA #601 denied leaving Resident #114 on his side, but acknowledged he was close to the edge of the bed. This deficiency represents non-compliance investigated under Master Complaint Number OH00149666.

Based on record review and interview the facility failed to obtain signed authorization with a witness not connected to the facility to open resident accounts. This affected two residents (#36 and #121) of five residents reviewed for personal resident fund accounts. The facility census was 142. Findings include: On 10/23/23 at 1:30 PM a review of personal resident funds was conducted with Resident Banker (RB) #763 and the Administrator. Review of the personal resident fund account for Resident #36 revealed a balance of $1737.34. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review. Review of the personal resident fund account for Resident #121 revealed a balance of negative $46.00. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a complete and accurate care plans had been established for Resident #11. This affected one resident (#11) of 29 residents reviewed for care plans. The facility census was 142. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included multiple sclerosis, Alzheimer's Disease with late onset dementia, anemia, neuromuscular dysfunction of bladder, age-related osteoporosis, depression, hypothyroidism, osteogenesis, presence of urogenital implants, history of COVID-19, and retention of urine. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had intact cognition and had a foley catheter for bladder elimination. Review of Resident #11's care plan dated 09/12/23 did not include foley catheter care. Review of physician orders for October 2023 revealed no orders for foley catheter care. Interview on 10/24/23 at 10:26 A.M. with the Director of Nursing (DON) verified Resident #11 did not have a care plan for foley catheter care. Review of the facility policy, Catheter Care, Urinary, revised September 2014, revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections and to review the resident's care plan to assess for any special needs of the resident. Review of the facility policy, Care Plan, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview the facility failed to administer insulin per physician order and complete blood sugar testing related to the administration of insulin for Resident #66. This affected one resident (#66) of five residents reviewed for medication administration. In addition, based on observation, interview and record review, the facility failed to ensure adequate care and treatment of a burn-related wound for Resident #90. This affected one resident (#90) of five residents reviewed for wound care. The facility census was 142. Findings include: 1. Review of the medical record revealed Resident #66 was admitted on [DATE] with a diagnosis including type two diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 10/02/23 revealed Resident #66 had intact cognition. Review of the physician orders dated October 2023 revealed an order for glargine subcutaneous (SQ) solution pen-injector 100 unit/Milliliter (U/ml) (Insulin Glargine) inject 12 units SQ at bedtime related to type two DM and insulin Lispro injection solution 100 U/ml (Insulin Lispro) inject four units SQ with meals related to type two DM. Review of the Medication Administration Record (MAR) for October 2023 revealed the blood sugar to be checked at 9:00 P.M. and administer the insulin glargine 12 units SQ at that time. The glargine insulin was given without first checking Resident #66's blood sugar on 10/01/23, 10/05/23, 10/06/23 and 10/11/23 which was indicated on the MAR by the letters NA. The letters NA were not listed on the MAR as a code to be used for documentation. Review of the MAR for October 2023 revealed insulin Lispro injection solution 100 U/ml to inject four units SQ with meals (and check blood sugars at meals) was not administered per physician orders and/or blood sugars (BS) not checked prior to administration on the following dates/times: 10/02/23 at 8:00 A.M., 12:00 P.M. and 5:00 P.M. the BS slot had a letter X (no blood sugar level recorded) in the slot and a code #5 indicating the insulin was not given due to vitals/labs outside parameters. On 10/04/23 at 8:00 A.M. and 12:00 P.M. no BS was taken (blank slot) and no signature signed off for insulin administered. On 10/05/23 8:00 A.M, 12:00 P.M. and 5:00 P.M. the BS slot had an X and signature for code #5 indicating medication not administered. On 10/06/23 the BS at 8:00 A.M. was recorded as 117 with a code #5 with signature indicating the medication not administered. On 10/07/23 at 12:00 P.M. a BS of 152 was recorded and signature with code #5 indicating medication not administered, and at 5:00 P.M. a BS was recorded at 134 and signature with code #5 indicating medication not given. On 10/08/23 at 8:00 A.M. a BS was not recorded, and insulin was not given. On 10/08/23 at 5:00 P.M. a BS of 130 was recorded and signature with code #5 indicating medication not administered. On 10/10/23 at 8:00 A.M. and 12:00 P.M. a BS was not recorded, and the insulin was not given and at 5:00 P.M. a BS of 130 was recorded and signature with code #5 indicating medication not administered. On 10/11/23 at 8:00 A.M, 12:00 P.M., and 5:00 P.M. a BS of 106, 124, and 119 respectfully and signature with a code #5 indicating medication not administered. On 10/12/23 for 5:00 P.M. the BS was not taken, and medication not administered. On 10/13/23 at 8:00 A.M. a BS had an X and signature with code #5 indicating medication not administered. On 10/14/23 at 8:00 A.M. a BS of 103 was recorded and a signature with code #5 indicating medication not administered and 12:00 P.M. a BS of 128 and signature with code #5 indicating medication not administered. On 10/15/23 at 8:00 A.M. a BS with an X recorded and 12:00 P.M. BS of 135 and both the 8:00 A.M. and 12:00 P.M. signature with code #5 indicating medication not administered. During an interview on 10/16/23 at 10:15 A.M. with Resident #66 revealed concerns she was diabetic, and her blood sugar wasn't taken, and medications were not provided as ordered. Interview on 10/19/23 at 12:00 P.M. with Director of Nursing (DON) regarding Resident #66's MAR documentation pertaining to the X, NA and blank spots for BS and insulin administration revealed she did not know what it meant, and she would have to check. Interview on 10/19/23 at 1:57 P.M. with LPN #853 revealed she didn't know what the X or NA in the BS slot meant. LPN #853 verified the X or NA was not one of the documentation codes listed on the MAR. LPN #853 verified the blood sugars were not taken per physician orders and insulin not administered per physician orders. LPN #853 kept saying we need to do a lot of education. LPN #853 verified for glargine insulin on 10/01/23, 10/5/23, 10/06/23, 10/11/23, and for Lispro insulin any blank slot, NA, and X indicated the blood sugar was not taken and verified #5 with signature meant no insulin medication was administered. Interview on 10/19/23 at 2:15 P.M. with RN #848 revealed she didn't know what the X or NA in the BS slot meant. RN #848 verified the X or NA was not one of the codes listed on the MAR. RN #848 verified the blood sugars were not taken per physician orders or insulin not administered per physician orders. RN #848 reported education would need to be done. RN #848 verified for glargine insulin for 10/01/23, 10/5/23, 10/06/23, 10/11/23, and for Lispro insulin any blank slot, NA, and X indicated no blood sugar was not taken and verified #5 with signature meant no insulin medication was administered. Review of facility policy, Medication Administration, effective date 09/14/20 revealed the individual administering the medications will check the label three (3) times and verify the right patient/resident right medication, right dose, right time, right route, right documentation and ensure patient/resident is in proper positioning. Review of facility policy, Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the purpose of the procedure is to obtain a blood sample to determine the resident's blood glucose level and the following documentation guidelines to include the date and time procedure performed, name and title of individual who performed the procedure, if resident refused, reason why, and intervention taken, the blood sugar results and to follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication doses, etc , the signature and title of the person recording the date, report results promptly, notify supervisor if resident refuses, and report other information in accordance with facility policy and professional standards of practice). 2. Review of Resident #90's medical record revealed an admission date of 01/07/22. Diagnoses included stroke with left sided weakness. Review of care plan dated 07/25/23 revealed Resident #90 had self care performance deficits. Interventions included assist resident with care as needed. Review of MDS dated [DATE] revealed Resident #90 had intact cognition. Resident #90 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of a progress note dated 10/11/23 revealed Resident #90 had spilled hot coffee on herself resulting in a second degree burn to her right thigh. Review of physician orders dated 10/12/23 revealed cleanse Resident #90's right thigh burn with normal saline, apply silvadene (burn ointment) cream, apply xeroform (lubricated wound dressing) and cover with absorbent dressing twice a day and as needed. Interview on 10/16/23 at 12:25 P.M. with Resident #90 revealed approximately a week ago she had burned her leg after spilling a cup of hot coffee. Observation of Resident #90 at time of interview revealed she was in bed and her right leg was exposed. Resident #90's right leg had a gauze dressing wrapped around her leg that was not intact and was not covering the entire burned area. Observation further revealed Resident #90 had a large burn from the top portion of her right outer thigh that extended down to close proximity of the resident knee area. Resident #90 stated wound care was performed almost every day. Observation of wound care on 10/19/23 beginning at 11:10 A.M. for Resident #90 with LPN #807 revealed she was unable to locate the resident ordered wound cream or normal saline to perform the wound care. LPN #807 stated she would inform the unit manager to attempt to locate the needed supplies. At 11:44 A.M. unit manager, LPN #853, had returned to the unit and had informed LPN #807 she was unable to locate Resident #90's ordered wound cream. LPN #853 stated she had contacted the nurse practitioner and had obtained new orders for Resident #90's wound care until the ordered wound cream was delivered to the facility. At 12:26 P.M. LPN #807 had entered Resident #90's room to begin wound care. Observation of wound care with LPN #807 revealed Resident #90 had a foam dressing dated 10/19/23 to the top portion of the resident's right thigh. LPN #807 stated the physician orders for the wound care did not include a foam dressing and she was not able to state why a foam dressing had been placed on Resident #90's burned area. Further observation revealed no other dressings to Resident #90's large, burned area. LPN #807 stated the orders stated to cover the entire burned area with xeroform (lubricated wound dressing) and cover with an absorbent dressing. Further observation revealed Resident #90 had a thin piece of an unidentified material (appeared to be a piece of wound tape) that was stuck to a section of Resident #90's burned area. LPN #807 was unable to state what the material was. This violation represents non-compliance investigated under Master Complaint Number OH00147069.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview the facility failed to provide adequate care and services to identify, assess and/or provide treatments to promote healing of a pressure ulcer for Resident #19 and Resident #99. This affected two residents (#19 and #99) of five residents reviewed for wound care and/or pressure ulcers. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included stage four pressure ulcer ( full thickness loss of tissue exposing bone, muscle or tendon) of the sacrum (tailbone), muscle weakness, and difficulty walking. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with bed mobility, toileting and personal hygiene and total dependence for transfers. Review of progress notes dated 08/26/23 to 08/27/23 revealed Resident #19 was identified as having an open area to the coccyx, the area was assessed and measured and the physician and family had been notified. Further review of the medical record for any wound assessment dated [DATE] revealed no evidence of the wound identified on 08/26/23 being measured and assessed for care and treatments prior to the resident being sent to the hospital. On 08/27/23 Resident #19 was sent to the hospital for evaluation and treatment following a fall. Review of hospital records from 08/27/23 to 09/05/23 revealed Resident #19's care included treatments to a wound on her sacrum. Review of a progress note dated 09/05/23 revealed Resident #19 was readmitted to the facility. Review of physician orders dated 09/27/23 through 10/20/23 revealed to cleanse sacral wound with normal saline, pack wound with Dakins (antiseptic solution) soaked gauze and cover completely twice daily and as needed. Review of the care plan dated 09/28/23 revealed Resident #19 was admitted with a pressure ulcer upon admission from the hospital. Interventions included administer treatment as ordered and monitor for effectiveness. Observation of wound care on 10/18/23 at 12:22 P.M. with Licensed Practical Nurse (LPN) #942 for Resident #19 revealed the resident had a foam dressing dated 10/18/23, the dressing was not intact and was not fully covering the sacral wound. LPN #942 confirmed the dressing was not covering the wound and had proceeded to remove the dressing. When LPN #942 removed the dressing two small balled up dry pieces of gauze fell out of Resident #19's sacral wound. LPN #942 verified the observation and explained Resident #19's wound orders were to pack the sacral wound with Dakins soaked gauze. LPN #942 stated the gauze should have been in one piece and should have been moistened. An interview conducted on 10/24/23 at 1:33 P.M. with the Director of Nursing (DON) revealed the nursing supervisor had been aware Resident #19 had an open area to her sacrum on 08/26/23 which was the day prior to Resident #19's hospital admission. The DON confirmed there was no evidence of a wound assessment measuring the wound or putting any treatments or interventions in place prior to the resident being sent to the hospital on [DATE]. 2. Review of the medical record for Resident #99 revealed an admission date of 02/15/20. Diagnoses included anemia, difficulty in walking, muscle weakness, lung cancer, and stroke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was not assessed, the resident required extensive assistance of one staff for bed mobility, transfers, and toilet use. The assessment also indicated the resident had one stage three pressure ulcer (full thickness tissue loss where fat may be exposed) and one deep tissue injury. Review of wound notes dated 09/06/23 through 10/16/23 revealed Resident #99 had impaired skin including a right heel wound. Recommendations included monitor site for signs and symptoms of infection, bogginess, drainage, erythema; air mattress to bed and check for function every shift and as needed; elevate heels off mattress while in bed with pillows or heel offloading boots; and left heel to pad and protect with foam daily and prn. The resident was noted to be noncompliant with elevating heels or heel offloading boots. Review of the October 2023 physician orders included orders for low air loss mattress, check for bottoming out every shift for skin precautions with a start date of 06/19/23. Review of the census list revealed the resident moved from the first floor to the third floor on 10/11/23. Interview and observation on 10/17/23 at 3:47 P.M. of Resident #99 in bed laying on her back on a regular mattress with her right foot wrapped, offloading boot in use and legs propped on a pillow. Interview at this time with Resident #99 revealed her air mattress was still in her old room and she had been in the current room since last Monday. Resident #99 stated she was told someone was supposed to bring her the air mattress. Observation on 10/17/23 at 3:55 P.M. with LPN #991 of Resident #99's mattress revealed LPN #991 verified the mattress Resident #99 was laying on was a regular mattress and not the low air loss mattress. LPN #991 stated the resident told her earlier today she was waiting on her air mattress to be brought up. Interview on 10/18/23 at 9:17 A.M. with Resident #99 revealed still no update on her air mattress and observed she was still laying in the regular mattress. Interview on 10/19/23 at 10:22 A.M. with Resident #99 revealed she had not heard anything regarding her air mattress and observed she still had the regular mattress. Interview on 10/19/23 at 1:54 P.M. with Housekeeping Supervisor (HKS) #958 revealed he just brought up the air mattress for Resident #99 about 10 minutes ago. Observation at this time of Resident #99 was up and dressed sitting in a wheelchair in her room. The air mattress was on the bed and in the process of inflating on the bed. HSK #958 stated it should take about 20 minutes to inflate it and that it was brand new out of the box. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018 revealed under treatment/management the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Under monitoring, revealed current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. This deficiency represents non-compliance investigated under Master Complaint Number OH00147069.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to utilize proper transfer technique for Resident #258 and Resident #19, and failed to ensure fall interventions were implemented to mitigate fall risks for Resident #126. This affected three residents (#258, #19 and #126) of four residents reviewed for accidents/hazards. The facility census was 142. Findings include: 1. Review of the medical record for Resident #258 revealed she was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, and difficulty in walking. Review of the Five day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating she was alert ad oriented to person, place, and time. Resident #258 was maximal assist for Activities of Daily Living (ADLs). Review of the care plan dated 10/05/23 revealed Resident #258 had an ADL self-care performance deficit and was at risk for falls due to a history of falls. Interventions included staff assistance of one-person for transfers and to be free from injury. Review of the physician orders dated 10/06/23 revealed an order for physical therapy evaluation and treatment five to six times per week for 45 days. Review of the physical and occupational therapy evaluations dated 10/06/23 revealed Resident #258 was a maximal assist of two-people for transfers, moderate to maximal assist for sit-to-stand and basic functional transfers, and required moderate to maximal assist for standing balance and safe ambulation. Observation on 10/17/23 at 10:14 A.M. revealed Resident #258 was sitting in a chair scale adjacent to her bed. State Tested Nurse Assistant (STNA) #871 was standing next to Resident #258 on her right side while STNA #762 was standing near the window on the opposite side of the bed. Observation revealed STNA #871 lifted Resident #258 out of the chair scale and into her arms. Resident #258's body was positioned on STNA #871's forearms and then STNA #258 moved her onto the side of the bed and positioned Resident #258's legs into the bed. STNA #258 used no assistive devices or medical equipment such as a wheelchair or wheeled walker at the time of the transfer. STNA #762 did not assist with the transfer. Interview on 10/17/23 at 10:16 A.M. with STNA #871 revealed Resident #258 was alert and oriented but could not ambulate on her own. STNA #871 revealed she was obtaining Resident #258 weight, but she did not require a mechanical lift. STNA #871 revealed she was trained in appropriate techniques and devices to lift and move residents. STNA #871 verified at the time of the interview the above observation of the manual transfer by lifting Resident #258 into her arms and placing her in the bed. Interview on 10/17/23 at 10:18 A.M. with Resident #258 confirmed STNA #871 weighed her in the chair scale and picked her up and placed her in the bed by herself. Resident #258 revealed STNA #762 assisted once she was in bed. Interview on 10/24/23 at 2:22 P.M. with Rehab Director (RD) #868 revealed Resident #258 was a sit-to-stand for all transfers and required contact guard to minimal assist of one-person utilizing a wheelchair to walker. RD #868 revealed she should not have been manually lifted from the chair scale into her bed by staff. 2. Review of Resident #19's medical record revealed an admission date of 03/11/22 with diagnoses including muscle weakness and difficulty walking. Review of the care plan dated 09/28/23 revealed Resident #19 had self care deficits related to impaired mobility. Interventions included one person staff assist with use of a gait belt for transfers. Review of MDS 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with bed mobility, toileting and personal hygiene. Resident #19 was totally dependent for transfers. Review of current physician orders for October 2023 revealed no orders related to transfers. Observation of transfer assistance on 10/18/23 at 9:52 A.M. with STNA #828 and #964 for Resident #19 revealed the resident was in a wheelchair and was requesting to be placed in bed. STNA #828 and #964 had assisted Resident #19 to stand and pivot into bed. STNA #828 and #964 had not used any assistive devices to assist with the transfer. Interview with STNA #828 and #964 revealed they were not aware of any assistive devices required to transfer Resident #19 and stated that was how they always transferred her. Interview on 10/24/23 at 2:16 P.M. with RD #868 revealed Resident #19 was no longer receiving physical therapy services due she had not been making progress. RD #868 stated Resident #19 had been discharged from services on 10/12/23 and at the time of the discharge a recommendation had been made for the use of mechanical lift for transfers. RD #868 stated the nursing staff should have informed the physician of the recommendations and orders should have been in place. RD #868 confirmed there were no physician orders to address the transfer status requiring use of a mechanical lift for Resident #19. RD #868 reviewed the care plan dated 09/28/23 and verified the care plan indicated Resident #19 required the use of a gait belt during transfers and did not specify a mechanical lift was needed to transfer Resident #19. Review of the facility document titled Safe Lifting and Movement of Residents revised July 2017, revealed the facility had a policy in place to protect the safety and well-being of staff and residents, and to promote quality care by using appropriate techniques and devices to lift and move residents. Review of the policy revealed manual lifting of residents would be eliminated when feasible. 3. Review of the medical record for Resident #126 revealed an admission date of 06/25/23. Diagnosis included congestive heart failure, type two diabetes mellitus, difficulty walking, muscle weakness, age related osteoporosis, and unsteadiness on feet. Review of the morse fall scale dated 06/25/23 revealed the resident was high risk for falls. Review of the incident audit report dated 07/03/23 revealed Resident #126 had an unwitnessed fall in her room. The audit report stated the following: the resident was observed sitting on the floor, in front of wheelchair, blood on the floor in front of dresser, bedside table moved to side, telephone on the floor off the hook in blood. Call light attached to rail and within reach, not sounding, resident was wearing pants, sweater, skid free socks, and oxygen was in place. Resident was bleeding from left side of head, with hematoma present. Resident stated, I fell out of the chair. Action taken included vital signs were obtained, on oxygen via nasal cannula, 911 was called, range of motion (ROM) performed and were within normal limits (WNL) of resident. Cold pack placed on left side of head. Staff attempted to lay resident down, resident complained of nausea, and sat back up. Resident still unable to tell staff what happened. Rescue squad in and assessed resident, stood, and pivoted patient to cot and left facility. Resident's son and nurse practitioner were called and informed of fall and being sent to hospital. New intervention included Dycem (prevents sliding) to wheelchair cushion. Review of the incident audit report dated 08/04/23 revealed Resident #126 had an unwitnessed fall in her room. The audit report stated the following: staff heard a loud crash and therapy staff were first to enter the resident's room. The resident was observed laying on the floor against the wall beside the closet bleeding from the head. Resident was responsive and alert. Vital signs were obtained. Resident was seen by the nurse practitioner and ordered to send to the hospital via 911. Ice applied to head until 911 arrived. Resident stated she slipped trying to go to the bathroom. Resident's son was informed. Under notes section, the new invention included call before fall sign placed in the resident room to remind her to use her call light for assistance. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, used a walker and/or wheelchair, and had two or more falls with injury since admission. Review of the plan of care revised 08/15/23 revealed Resident #126 was at risk for falls related to history. Fall with injury on 07/03/23 and 08/14/23 fall with injury. Intervention included call before you fall sign placed in the resident room to remind her to use her call light for assistance. Observation 10/18/23 at 4:10 P.M. of Resident #126 in her room sitting in her wheelchair, shoes on her feet but no call before you fall signs observed in the resident's room. Interview on 10/18/23 at 4:17 P.M. with STNA #708 revealed Resident #126 had not had any recent falls. Review of Resident #126's care plan with STNA #708 verified one of her fall interventions included a call before fall sign placed in the resident's room. Observation and interview on 10/18/23 at 4:30 P.M. with STNA #708 verified there was no call before you fall sign placed in the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00147069.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnosis included multiple sclerosis, Alzheimer's disease with late onset, dementia, anemia, neuromuscular dysfunction of bladder, age-related osteoporosis, depression, hypothyroidism, osteogenesis, presence of urogenital implants, history of COVID-19, and retention of urine. Review of the physician orders dated October 2023 revealed no orders for foley catheter care. No previous orders were in place regarding Resident #11's foley catheter care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 10/03/23 revealed Resident #11 had intact cognition. Resident #11 had a foley catheter for bladder elimination. Review of Resident #11's care plan dated 07/11/23 did not include foley catheter care. Interview on 10/24/23 at 10:26 A.M. with Director of Nursing (DON) confirmed Resident #11's physician orders did not contain foley catheter care. Review of the facility policy, Catheter Care, Urinary, revised September 2014, revealed the purpose of the procedure is to prevent catheter-associated urinary tract infections and to review the resident's care plan to assess for any special needs of the resident. This deficiency represents non-compliance investigated under Master Complaint Number OH00147069. Based on observation, record review, policy review and interview the facility failed to timely collect a urine specimen for suspicion of a urinary tract infection for Resident #19 and failed to ensure physician's orders were in place for Foley catheter care for Resident #11. This affected two residents (#11 and #19) of three residents reviewed for Foley catheter care. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included neuromuscular bladder, difficulty walking and muscle weakness. Review of the care plan dated 09/28/23 revealed Resident #19 was on antibiotic therapy related to frequent urinary tract infections. Interventions included administer antibiotics as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with toileting and personal hygiene. Resident #19 was incontinent of bowel and bladder. Review of physician orders dated 10/11/23 revealed to straight cath (non indwelling urinary catheter used to collect urine specimen) to obtain a urinalysis and a culture and sensitivity. Review of a progress note dated 10/13/23 revealed unable to collect urine via straight cath. Review of a progress note dated 10/14/23 revealed urine was not collected. Review of progress note dated 10/18/23 revealed urine was not collected. Review of a progress note dated 10/23/23 at 8:15 P.M. authored by a nurse practitioner revealed Resident #19's family requested resident be sent to the hospital for evaluation and treatment related to abdominal pain. Progress note stated Resident #19's family had multiple complaints regarding the ordered urine collection. Observation on 10/24/23 at 7:42 A.M. revealed Resident #19 was present at the facility and was sleeping in bed. Interview on 10/24/23 at 7:55 A.M. with Licensed Practical Nurse (LPN) #959 revealed she had been informed in morning report Resident #19 was to be taken to the hospital last night, however, she had been informed transportation had not shown up to transport the resident. Interview on 10/24/23 at 9:10 A.M. with LPN #853 revealed she had not been aware Resident #19 had not been transported to the hospital last night. LPN #853 stated she had called the transportation company who stated they would at the facility within approximately 30 minutes. Observation on 10/24/23 at 10:03 A.M. revealed Resident #19 was being transported out of the facility. Interview on 10/24/23 at 2:38 P.M. with LPN #853 confirmed the urine sample had been unable to collected and sent prior to the resident being sent to the hospital.

Based on observation and interview the facility failed to ensure medications were not left unattended at the residents bedside. This affected three residents (#69, #84 and #129) of 142 residents observed for medication storage. The facility census was 142. Findings include: 1. Observation on 10/17/23 at 8:38 A.M. revealed Resident #129 was in bed in her room with a medication cup containing one white pill and one brownish colored pill, a medication cup with an orange colored liquid medication, a medication cup with a red colored liquid medication and a medication cup with a clear liquid medication. Resident #129 was not interviewable. 2. Observation on 10/17/23 at 8:40 A.M. revealed Resident #84 was in his room standing next to his bedside table and Resident #84 had a medication cup with several medications inside. Upon entering Resident #84's room Licensed Practical Nurse (LPN) #959 entered and stated Resident #84 knows to take his meds, I was just coming back to check if he did. 3. Observation on 10/17/23 at 8:43 A.M. revealed Resident #69 was sleeping in bed, he had a medication cup with several medications inside on his bedside table. Upon exiting Resident #69's room LPN #959 was observed in Resident #129's room administering the medications previously observed as left unattended on the residents bedside table. LPN #959 stated Resident #129 didn't like to take his medications so she came back to try again. LPN #959 remained in Resident #129's room to observe resident taking her medications. LPN #959 stated residents medication should not be left unattended however she would come back to check to see if they took them. LPN #959 had returned to Resident #69's room to ensure medications had been consumed and medication cup was observed to have been empty. Resident #69 refused an interview at the time of the observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adaptive equipment was provided with meals. This affected one resident (#40) of five residents reviewed for nutrition. The facility census was 142. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/30/21. Diagnoses included dysphagia, muscle weakness, and hemiplegia and hemiparesis following a stroke affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician orders for October 2023 revealed the resident had a diet order for regular diet, pureed texture, and regular (thin) consistency diet. Review of the plan of care revised on 09/12/23 for nutrition revealed the resident received a mechanical altered diet due to dysphagia and received built-up utensils. Observation on 10/16/23 at 1:11 P.M. of Resident #40 in bed eating lunch revealed the resident's tray ticket read built-up utensils but observed regular utensils on the tray. Interview at this time with Resident #40 stated she was supposed to have different silverware. Observation and interview on 10/16/23 at 1:17 P.M. with Stated Tested Nurse Aide (STNA) #823 verified the observation and stated she had never seen Resident #40 with built-up utensils at meals. Interview on 10/18/23 at 4:17 P.M. with STNA #708 stated Resident #40 required tray set up but was able to feed herself. STNA #708 stated she had never seen her with built -up utensils but had seen it written on her meal ticket for built -up utensils. Interview on 10/23/23 at 11:04 A.M. with Registered Dietitian (RD) #923 stated she spoke with the Resident #40's daughter on Thursday 10/19/23 and got a history on the built-up utensils. RD #923 stated it was discussed at the 09/12/23 care conference and RD #923 recalled the resident's daughter had requested the use of the built-up utensils so RD #923 had added it to the meal ticket and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, observation and interview, the facility failed to ensure all residents were treated with dignity and respect. This affected four residents (#49, #52, #255 and #268) of 142 residents observed for right to dignity and respect. The facility census was 142. Findings include: 1. Review of the medical record for Resident #255 revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, paroxysmal atrial fibrillation, and urinary tract infection. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #255 had a Brief Interview for Mental Status (BIMS) score of 9 indicating short-term and long-term cognition impairment. Resident #255 was dependent to maximal assistance by staff for activities of daily living (ADL). Review of the care plan dated 10/18/23 revealed Resident #255 had an ADL self-care performance deficit and had incontinence of bowel and bladder. Interventions included to maintain and/or improve current level of functioning, and to remain clean and dry. Review of the physician orders dated 10/02/23 revealed an order for physical therapy evaluation and treatment five to six times per week for 45 days. Observation on 10/17/23 at 10:20 A.M. revealed Resident #255 was laying in his bed with a gown on, legs open, with his brief exposed. Resident #255's room door was open, and he was visible from the hallway by passersby. Physical Therapist (PT) #883 was assisting Resident #255 in bed and Housekeeper (HKP) #815 was cleaning Resident #255's bathroom. Interview on 10/17/23 at 10:20 A.M. in the entryway of Resident #255 room, with PT #883 revealed she was from the therapy department and HKP #815 was cleaning Resident #255's room and verified the door remained open with clear view of the resident in bed. Interview on 10/17/23 at 10:25 A.M. with HKP #815 revealed she cleaned resident rooms daily and left the door open. HKP #815 verified Resident #255 was participating in therapy, was in a gown with brief exposed, while the door remained open. 2. Review of the medical record for Resident #268 revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, wedge compression fracture of fifth lumbar vertebra, and adult failure to thrive. Review of the Baseline Care Plan (BCP) assessment dated [DATE] revealed Resident #268 was substantial to maximal assist for ADLs and was occasionally incontinent of bowel and bladder. Review of the care plan dated 10/16/23 revealed Resident #268 had an ADL self-care performance deficit. Interventions included staff assistance of one person for toileting. Review of the progress note dated 10/16/23 at 5:06 P.M. revealed Resident #268 admitted to the facility incontinent of bowel and bladder. Observation and interview on 10/17/23 at 10:26 A.M. revealed Resident #268 was yelling out from her bed for help and her call light was not activated. Upon entering the room, Resident #268 revealed she was placed on the bedpan 30 minutes ago and her buttocks were numb and hurting. Resident #268 revealed she could not identify the staff member who placed her on the bedpan. Interview and observation on 10/17/23 at 10:28 A.M. during the time of incontinence care for Resident #268 with Registered Nurse (RN) #848 and #909 revealed she was sitting on a bedpan with an incontinence brief in place. Resident #268 brief was intact and fully secured in place. Upon removal of brief, Resident #268 had a large amount of stool in place. RN #848 and #909 revealed they did not know how long Resident #268 was left on the bedpan and did not know why she would be placed on a bedpan with a brief fully intact. RN #848 and #909 verified the findings at the time of the observation. 3. Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes, depression, and anxiety disorder. Review of the annual MDS 3.0 assessment dated [DATE] revealed she had a BIMS score of 15 that indicated she was alert and oriented to person place and time. Resident #52 was moderate assist to independent for ADLs. Observation during the annual screening process with Resident #52 on 10/16/23 at 11:17 A.M. revealed Registered Nurse (RN) #968 entered Resident #52's room without knocking and proceeded to question Resident #52 on who she was talking to. Interview on 10/16/23 at 11:17 A.M. with RN #968 revealed she heard Resident #52 talking as if she was on a conference call on the phone and entered to see who she was talking to. RN #968 revealed she knew the protocol for entering residents rooms and was supposed to knock prior to entering. Interview with RN #968 verified she entered Resident #52's room without knocking first. Interview on 10/16/23 at 11:18 A.M. with Resident #52 revealed sometime staff entered her room without knocking. 4. Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses of chronic kidney disease, dementia, aphasia, dysphagia, hypertension, anemia, pressure ulcer of sacral region, gastrostomy status, history of COVID-19, hypertensive heart disease, and chronic atrial fibrillation. The annual MDS 3.0 assessment dated [DATE] revealed Resident #49 had severely impaired cognition and was rarely understood. Observation on 10/18/23 at 2:35 P.M. revealed RN #977 entered Resident #49's room without knocking. Observation on 10/18/23 at 2:39 P.M. revealed RN #977 entered Resident #49's room again without knocking. Interview on 10/18/23 at 2:49 P.M. with RN #977 confirmed she did not knock before entering Resident #49's room because She is not going to be able to hear me anyways! RN #977 verified she was suppose to knock before entering resident rooms. Review of the facility document titled Offering/Removing Bedpan/Urinal dated February 2018, revealed the facility had a policy in place to not allow a resident to sit on a bedpan for extended periods. Further review of the policy revealed it would cause discomfort and cause skin breakdown for the resident. Review of the Rights and Responsibilities Code of Conduct and Ohio Revised Code sections 3721.10 to 3721.17 located in the admission Agreement revealed residents had the right to have room doors closed and to not have them opened without knocking, except in a case of an emergency and to respect their privacy and personal belongings. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00147069 and Complaint Number OH00146916.

Based on observation and interview the failed to ensure meals were served at a palatable temperature. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Findings include: Observation of a test tray on 10/18/23 at 6:12 P.M. of the dinner meal with Dietary Manager (DM) #969 revealed the temperature of the salisbury steak was 116.2 degrees Fahrenheit (F), mashed potatoes was 112.6 degrees F, mixed vegetables was 107.3 degrees F, and the chicken barley soup was 145.4 degrees F. The Salisbury steak, mashed potatoes, and mixed veggies tasted very good but was cold to taste. During the observation DM #969 declined to taste the meal but verified the temperatures. Interviews on 10/18/23 between 6:23 P.M. and 6:27 P.M. with Residents #39 and #82 stated the meal was cold when they received it. Resident #82 stated it's always cold.

Based on observation, record review, and interview the facility failed to ensure meals were served in a timely manner according to the designated meal times for the facility. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Findings include: Review of the mealtimes revealed breakfast was at 8:30 A.M., lunch 12:30 P.M., and dinner 5:30 P.M. Observation on 10/16/23 at 1:06 P.M. revealed lunch trays were still being plated in a common kitchen for delivery to the resident rooms on the second floor MY2 unit. Observation on 10/17/23 at 9:47 A.M. of breakfast trays for the second floor MY2 unit resident rooms revealed trays were still being delivered and Resident #35, who was not interviewable, did not get her tray until 9:47 A.M. Interview on 10/18/23 at 10:46 A.M. with Dietary Manager (DM) #944 and Registered Dietitian (RD) #923 verified the mealtimes were breakfast at 8:30 A.M., lunch at 12:30 P.M., and dinner at 5:30 P.M. and all floors were to start meals service at those times. Observation on 10/18/23 at 1:24 P.M. with State Tested Nurse Aide (STNA) #809 still passing lunch trays on the second floor MY2 unit. Interview at this time with STNA #809 stated this was common for meals to be delivered this late. This deficiency represents non-compliance investigated under Complaint Number OH00147069.

Based on observation, record review, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, and interview the facility failed to maintain proper infection control practices/procedures to prevent the spread of infection including COVID-19. This had the potential to affect eight residents (#17, #64, #80, #136, #259, #262, #263 and #265) who resided on the same unit as Resident #261 who was in isolation for COVID-19. The facility census was 142. Findings include: Review of Resident #261's medical record revealed an admission date of 10/13/23. Diagnoses included COVID-19 and lung cancer. Review of the current physician orders for October 2023 revealed Resident #261 was on isolation precautions for all care and services related to being positive for COVID-19. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed the assessment was in progress. Review of the care plan dated 10/15/23 revealed no interventions related to COVID-19. Observation on 10/17/23 at 7:01 A.M. revealed State Tested Nursing Assistant (STNA) #755 had exited Resident #261's room. Further observation revealed signs posted outside of Resident #261's room indicated the resident was in isolation precautions, and isolation supplies hanging in a bin outside of Resident #261's room included, gowns, gloves, and masks. STNA #755 was observed to remove her gown and gloves outside of Resident #261's room and placed them inside a linen cart. The STNA was observed to have been wearing two surgical masks underneath of an N95 mask. STNA #755 failed to complete hand hygiene after removing her gown and gloves and she continued to wear the same N95 mask and a face shield. Interview with STNA #755 at the time of the observation confirmed Resident #261 was positive for COVID-19. The STNA revealed she was not aware of where to place the used gown and gloves. STNA #755 stated she had only used red biohazard bags for C-diff residents. STNA #755 had continued to wear the face shield and N95 that had been worn inside of Resident #261's room. STNA #755 was asked about wearing two surgical masks underneath of the N95 and stated she was not aware if that was an appropriate technique. STNA #755 then removed the N95 mask and discarded it in the linen cart and stated she would discard her face shield before she went outside to her car. STNA #755 stated she was not aware if she was to disinfect the face shield and stated she would just throw it away. STNA #755 stated she should have used hand hygiene after she had removed the PPE. Interview on 10/17/23 at 9:55 A.M. with Infection Preventionist (IP) #860 revealed staff were required to wear personal protective equipment (PPE) including an N95 mask, eye protection, gown and gloves prior to entering a room of a COVID positive resident. IP #860 revealed staff were required to remove PPE prior to exiting an isolation room and place the PPE into a red biohazard bag. Review of facility policy titled Covid-19 Personal Protective Equipment (PPE) Use During Pandemic revised 08/2022 revealed staff were to wear an N95 mask, eye protection, gown and gloves during care of residents on isolation precautions. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes revealed older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for SARSCoV- 2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalizations, and death. In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g.,use of Transmission-Based Precautions for those that have had close contact to someone with SARS-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This deficiency represents non-compliance investigated under Complaint Number OH00146916.

Based on observation, record review, facility policy review and interview the facility failed to ensure all food items were properly stored and served in a manner to prevent contamination, spoilage and/or food borne illness. This had the potential to affect 141 of 141 residents who received meal trays from the kitchen. The facility identified one resident (#108) who received nothing by mouth (NPO status). The facility census was 142. Findings include: 1. On 10/16/23 at 9:30 A.M. an initial tour of kitchen was conducted with Dietary General Manager (DGM) #944. There were seven half-gallon containers of whole milk noted in the dairy refrigerator that had a sell by date of 10/09/23. There were four large dry storage bins containing potato flakes, sugar, flour and breadcrumbs. Each bin had a scoop inside of it. On 10/16/23 at 9:50 A.M. DGM #944 verified the sell by date on the seven half gallons of whole milk was 10/09/23. DGM #944 also verified the scoops inside of the storage bins containing potato flakes, sugar, flour and breadcrumbs. Review of the policy titled Food Storage dated October 2019 revealed scoops would be provided for bulk items and stored outside of the container and sell by date items are to be discarded within five to seven days of the date. 2. Observation on 10/16/23 at 12:33 P.M. of the lunch meal service to the resident rooms on the third floor revealed the cake portions on the meal trays were not covered and were on an open cart that had been pushed throughout the facility to get to the third floor. Observation on 10/16/23 at 12:43 P.M. of a second cart of room lunch trays revealed an open cart with uncovered cake on the lunch trays was traveling through the facility. Interview at this time with State Tested Nurse Aide (STNA) #823 verified the observation and stated the dessert was supposed to be covered but they did not have any saran wrap to cover the cake. Observation on 10/16/23 at 1:04 P.M. of the lunch tray cart arrived to the second floor and the cake remained uncovered on meal trays. Interview on 10/16/23 at 1:06 P.M. with STNA #701 verified the observation and stated she did not know why they were not covered. Observation on 10/16/23 at 1:11 P.M. of the second lunch cart arriving on the second floor with the desserts uncovered on the trays. Interview on 10/16/23 at 1:12 P.M. STNA #265 verified the observation and stated she did not why they were not covered. 3. Observation on 10/18/23 at 5:23 P.M. of tray line food temperatures for dinner on unit MY2 with Dietary Staff (DS) #829 revealed chicken barley soup 164.3 degrees Fahrenheit (F), mixed vegetables 172.8 degrees F, Salisbury steak 147.2 degrees F, mashed potatoes 131 degrees F, pureed meat 136.4 degrees F, pureed vegetables 129.9 degrees F, mechanical meat 159 degrees F, and pureed soup 143.8 degrees F. Interview at this time with DS #829 stated the minimum standard was 140 to 165 degrees Fahrenheit and she would normally take the item and heat up to temperature. DS #829 verified the mashed potatoes and pureed veggies did not meet temperature and then stated she turned up the temperature of the steam table and then touched the side of the pan with pureed veggies and stated it felt warmer. DS #829 did not get a second temperature for these items. Observation on 10/18/23 at 5:35 P.M. of 12 small plates each with a chocolate chip cookie all uncovered on a silver tray sitting on a table located against the wall across from the steamtable, also observed two meal carts each with two meal trays sitting on top of each cart. There were also chocolate chips cookies on each tray that were uncovered. Interview on 10/18/23 at 5:44 P.M. with Dietary Manager (DM) #969 verified the observation and covered the silver tray of cookies with a sheet of parchment paper. DM #969 stated they usually wrap them. Review of the food temperature log dated 10/18/23 at 5:22 P.M. completed by DS #829 revealed at the bottom of the form in a different handwriting there were written a second set of temperatures for the pureed Salisbury steak at 157 degrees F and the mashed potatoes at 160 degrees F. The form indicated the minimum holding standard for hot food items was greater than or equal to 140 degrees F (optimal 165 degrees). A follow-up interview on 10/23/23 at 12:25 P.M. with DS #829 stated she did not take a second set of temperatures on the 10/18/23 dinner meal. Review of the facility policy titled Food Temperature, revised January 2023 revealed food temperatures will be obtained and recorded by each dining server prior to meal service from the steam tables. Any food item that fails to meet minimum acceptable temperature will be removed from service and re-thermalized to the minimum acceptable temperature. Each food temperature log contains guidance for minimum holding temperature standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure Resident #92's call light was within reach. This affected one of 36 sampled residents. The facility census was 222. Findings include: Review of the record revealed Resident #92 was admitted on [DATE] with diagnoses including dementia, anxiety disorder, and depressive disorder. The care plan for falls dated 03/09/17 indicated the resident had interventions including non-skid socks when up out of bed, restorative referral, lay resident down after meals, and be sure the resident's call light is within reach and encourage her to use it for assistance. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #92 had severe cognitive deficits with short and long-term memory impairments. The resident had no behaviors, no refusal of care, and required extensive assistance for bed mobility, transfers, toilet use, and locomotion on the unit. On 03/02/20 at 11:00 A.M., an observation revealed Resident #92 was lying in bed. She had the bed control to raise and lower her bed in her hand. The call light cord and call button were on the floor next to her bed. On 03/02/20 at 2:35 P.M., Resident #92 was lying in bed. The call light cord and call button were on the floor next to her bed. On 03/02/20 at 3:22 P.M., Resident #92 was in her room. She was calling out, Mama, mama. An observation revealed the resident was lying in bed with the call light cord and call button on the floor next to her bed. The surveyor informed the state tested nursing assistant the resident needed assistance. On 03/03/20 at 9:19 A.M., an observation revealed Resident #92 was seated in a recliner in her room. Her call light cord and call button were across the room attached to the grab bar about six feet away from the resident. On 03/03/20 at 10:03 A.M., Resident #92 remained seated in the recliner. Her call light cord and call button were across the room on the grab bar. On 03/03/20 at 11:31 A.M., an observation revealed Resident #92 remained seated in the recliner. Her call light cord and call button remained on the grab bar. On 03/03/20 at 4:29 P.M., Resident #92 was lying in bed. Her call light cord and call button were on the floor next to the resident's bed. On 03/04/20 at 7:01 A.M., an observation revealed Resident #92 was seated in a recliner in her room. Her call light cord was attached to her grab bar about six feet away from the resident. On 03/04/20 at 2:48 P.M., the surveyor and Nurse Manager #203 were standing in the hallway when State Tested Nursing Assistant (STNA) #179 was observed coming out of Resident #92's room carrying a trash bag. At 2:49 P.M., an observation of Resident #92 revealed she was lying in bed with her call light cord and call button on the floor next to the bed. During an observation and interview at 2:50 P.M., Nurse Manager #203 confirmed Resident #92's call light cord and call button were on the floor next to the resident's bed. The nurse manager repositioned the call light so it was within reach of Resident #93.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions were in place for Resident #219's pressure ulcers as ordered. This affected one of seven residents reviewed for pressure ulcers (Residents #35, #41, #78, #170, #190, #200, and #219). The facility identified 16 residents as having pressure ulcers. Finding include: Review of the record revealed Resident #219 was admitted on [DATE] with diagnoses including dementia, chronic peripheral venous insufficiency, and rheumatoid arthritis. The quarterly Minimum Data Set 3.0 assessment dated [DATE] indicated she had severe cognitive deficits and required extensive assistance with bed mobility, transfers, and walking. Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/03/19 indicated she was at high risk for the development of pressure sores. Review of a progress note dated 11/15/19 indicated the nurse observed Resident #219 to have purplish-black colored area to both heels. The resident reported the areas were slightly painful. On 11/15/19, the nurse practitioner ordered a wound consult, a treatment order to pad and protect bilateral heels daily, and Prevalon boots every shift while in bed. (Prevalon boots help to minimize pressure to the heel area.) Review of the wound care consultant's assessment dated [DATE] indicated Resident #219's heels were suspected deep tissue injuries. The left heel was 100% fibrotic tissue with yellow slough, moist, and with scant clear drainage. The area measured 1.4 centimeters (cm) long by 1.7 cm wide by 0.2 cm deep. The right heel was black (necrotic tissue) hard, and without drainage. The area measured 3.0 cm long by 4.8 cm wide by 0.1 cm deep. During an observation on 03/04/20 at 7:20 A.M., Licensed Practical Nurse (LPN) #36 changed Resident #219's dressings to both heels. Upon entering the room, Resident #219 was in bed and not wearing the Prevalon boots to bilateral feet. LPN #36 described the left heel as having yellowish-white slough covering 50% of wound bed. She described the right heel as being covered by black, soft eschar (nonviable tissue). LPN #36 completed the dressing changes at 7:49 A.M. She did not apply the Prevalon boots to Resident #219's feet before leaving the room. During an interview on 03/04/20 at 7:50 A.M., LPN #36 indicated the state tested nursing assistant removed the Prevalon boots when she provided care to Resident #219 this morning. On 03/04/20 at 7:55 A.M., an observation accompanied by Nurse Manager #203 revealed the Prevalon boots were on the floor next to the recliner in Resident #219's room. The resident was lying in bed. The nurse manager confirmed the observation. On 03/04/20 at 10:22 A.M., an observation accompanied by Nurse Manager #203 indicated the Prevalon boots remained on the floor next to the recliner in Resident #219's room. The resident was still lying in bed. Nurse Manager #203 confirmed the observation. She then apologized saying she had been busy and had not had time to put the Prevalon boots on Resident #219.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy on hand hygiene the facility failed to ensure staff washed or cleansed their hands between the dirty and clean phases of dressing changes to prevent potential cross-contamination. This affected three (Residents #34, #170, and #219) of four residents observed for dressing changes (Residents #34, #42, #170, and #219). The facility census was 222. Findings include: 1. Review of the record revealed Resident #219 was admitted on [DATE] with diagnoses including dementia, chronic peripheral venous insufficiency, and rheumatoid arthritis. Review of a progress note dated 11/15/19 indicated the nurse observed Resident #219 to have purplish-black colored area to both heels. The resident reported the areas were slightly painful. On 11/15/19, the nurse practitioner ordered to cleanse bilateral heels with normal saline, apply ABD pad, and wrap with Kerlix daily and prn (as needed). On 02/19/20, the wound care consultant changed the treatment order to the left heel to cleanse with normal saline, dry, apply Xeroform to fit. Cover with ABD pad and Kerlix daily. Review of the wound care consultant's assessment dated [DATE] indicated Resident #219's heels were suspected deep tissue injuries. The left heel was 100% fibrotic tissue with yellow slough (nonviable tissue) moist, and with scant clear drainage. The area measured 1.4 centimeters (cm) long by 1.7 cm wide by 0.2 cm deep. The right heel was black (necrotic tissue), hard, and without drainage. The area measured 3.0 cm long by 4.8 cm wide by 0.1 cm deep. During an observation on 03/04/20 at 7:20 A.M., Licensed Practical Nurse (LPN) #36 changed Resident #219's dressings to both heels. The LPN washed her hands and donned gloves. She removed the old dressing. She washed her hands and left the room to obtain additional supplies. LPN #36 returned to the room and washed her hands and donned gloves. She cleaned the wound bed with normal saline then described the wound to the left heel as having yellowish-white colored slough covering 50% of the wound bed. Using scissors, the nurse cut a piece of the Xeroform gauze and placed in onto the wound bed, covered it with an ABD pad, then wrapped the area with Kerlix. She secured it with tape. LPN #36 did not wash or cleanse her hands after cleaning the pressure ulcer to Resident #219's left heel and prior to cutting the Xeroform gauze then placing it directly on the open wound bed. During an interview on 03/04/20 at 7:50 A.M., LPN #36 verified she did not wash or cleanse her hands and don new gloves between cleaning the left heel and cutting the Xeroform gauze and placing it on the open wound bed. 2. Review of the record revealed Resident #34 was admitted on [DATE] with diagnoses including dementia, anemia, and hypertension. Review of a physician order dated 01/29/20 indicated to wash wound with wound wash, pack wound lightly with 1/2 inch Iodoform and cover with Mepilex (border dressing). Change every 24 hours and prn for pilonidal cyst. (A pilonidal cyst is an abnormal pocket of skin and hair that is almost always located near the tailbone and can become easily infected.) The wound care consultant changed the treatment orders on 02/09/20 and 02/25/20. Review of a wound care consultant assessment dated [DATE] indicated the sacral wound was in an old pilonidal cyst cavity and measured 6.0 cm long by 2.0 cm wide by 3.0 cm deep. He described the wound bed as 10% slough and 90% exposed tissue. The wound care consultant changed the treatment order on 02/26/20 to pack wound with Kerlix moistened with 1/4 strength Dakins solution and cover with ABD pad two times a day. During an observation on 03/04/20 at 10:40 A.M., Wound Care Consultant #425 changed the dressing to Resident #34's wound. The wound care consult washed his hands prior to beginning the dressing change. Nurse Manager #203 removed the old dressing. Wound Care Consultant #425 removed the packing from the wound. With the gloved hand, he used a four by four gauze pad soaked in wound wash solution to clean the wound bed by rubbing the wound area. The nurse practitioner left the room to obtain additional supplies, leaving State Tested Nursing Assistant (STNA) #149 in the room with the wound care consultant. Wound Care Consultant #425 measured the wound from the pilonidal cyst as being 4.5 cm long by 2.5 cm wide by 4.3 cm deep. He indicated there was yellow slough in the wound bed. The consultant took a four by four pad soaked in Dakins solution and packed the wound with his gloved hand. He then covered the wound with a Mepilex border dressing. After completing the dressing change, Wound Care Consultant #425 washed his hands. The wound care consultant did not wash or cleanse his hands between the dirty and clean phases of the dressing change. During an interview on 03/04/20 at 10:46 A.M., STNA #149 confirmed Wound Care Consultant #425 never left Resident #34's bedside and did not cleanse or wash his hands until finishing the dressing change. 3. Review of the record revealed Resident #170 was admitted on [DATE] with diagnoses including diabetes, dysphagia, anemia, and hypertension. Review of the Nursing admission Screen dated 10/04/19 indicated the resident returned from a hospitalization with a pressure ulcer to the coccyx/sacral area. The ulcer measured 5.0 cm long by 3.25 cm wide. The Skin Tool Wound Nurse assessment dated [DATE] described the wound as a Stage II pressure ulcer (superficial skin break into the skin layer only) measuring 6.0 cm long by 3.5 cm wide by 0.1 cm deep. The nurse practitioner ordered a wound consult. Review of the most recent treatment order dated 01/22/20 indicated to wash sacral wound with wound wash, cover base of wound with Silver Alginate (a healing agent) and place a four by four gauze pad over the Silver Alginate. Cover with Mepilex border dressing every day shift and as needed for wound care. Review of the wound care consultant assessment dated [DATE] indicated the sacral wound was a Stage IV pressure ulcer (extending below the subcutaneous fat into the deep tissues). The pressure ulcer measured 4.0 cm long by 3.8 cm wide by 1.2 cm deep. The wound bed was 90% granulation and 10% exposed structures. During an observation on 03/04/20 at 11:01 A.M., Wound Care Consultant #425 changed the dressing to Resident #170's sacral wound. The wound care consult washed his hands and donned gloves prior to beginning the dressing change. With gloved hands, the wound care consultant and Nurse Manager #207 moved a full size mattress located on the floor next to the resident's bed. Nurse Manager #207 washed her hands and donned gloves and removed the old dressing to Resident #170 sacrum. Wound Care Consultant #425 removed the packing from the wound then measured the wound. He indicated the pressure ulcer measured 2.4 cm long by 2.5 cm wide by 2.4 cm deep. With the gloved hand, he used a four by four gauze pad soaked in wound wash solution to clean the wound bed by rubbing the wound bed. Nurse Manager #207 folded the Calcium Alginate Silver and handed it to the consultant who placed it in the wound bed. He then covered it with a four by four gauze pad and Mepilex border dressing. The consultant washed his hands after completing the dressing. The wound care consultant did not wash or cleanse his hands after moving the mattress or between the dirty and clean phases of the dressing change. During an interview on 03/04/20 at 11:08 A.M., Nurse Manager #207 confirmed Wound Care Consultant #425 did not wash his hands until after he completed the dressing change. She agreed he moved the mattress which had been on the floor and did not wash or cleanse his hands. Review of the facility's Hand Hygiene Policy and Procedure (reviewed September 2017) indicated hand hygiene should be performed including after contact with a resident's mucous membranes, body fluids, or excretions, after handling soiled or used linens, dressings, bedpans, catheters, and urinals, and before and after performing an invasive procedures.

Based on observation and interview the facility failed to ensure food was served in a sanitary manner. This affected three residents (#39, #49, and #276) in the small dining room on the 100 unit and had the potential to affect 52 residents (Residents #1, #39, #40, #49, #50, #80, #81, #82, #114, #135, #136, #144, #145, #151, #164, #166, #178, #180, #182, #185, #190, #194,#195, #212, #214, #215, #216, #220, #274, #275, #276, #277, #278, #279, #280, #281, #282, #283, #284, #285, #286, #287, #288, #289, #290, #291, #292, #293, #294, #296, #297, and #298) currently residing on the first floor. The facility census was 244. Findings include: 1. Observation on 03/02/20 at 12:35 P.M. of the noon meal in the small dining room on the 100 unit revealed the tray line server, Dietary Aide (DA) #250, dropped an empty package from a sanitizer wipe he'd used to clean the thermometer onto the floor. With his gloved hands, he picked it up and put it the trash can. His hand made contact with the swinging trash lid. DA #250 then went back to the steam table and grabbed a dessert bowl. He was instructed by the surveyor to cease serving and wash his hands and re-glove. Three residents (#39, #49, and #276) were currently in the dining room for the lunch meal. DA #250 verified he had picked up the packaging off the floor and placed it in the trash without changing gloves and washing his hands. He verified he would have served the three residents wearing contaminated gloves. 2. Observation in the resident servery on the first floor on 03/02/20 at 1:09 P.M. revealed State Tested Nurse Aide (STNA) #401 dropped the cap from a two liter ginger ale bottle onto the floor. STNA #401 picked it up and placed it back on the bottle, then placed the bottle of ginger ale in the reach in cooler in the servery. STNA #110 who was present at the time, verified the observation and identified STNA #401 as agency staff. STNA #110 then educated STNA #401 that if he dropped anything on the floor again, he was to just throw it away. STNA #110 verified all the residents on the first floor received foods and beverages from the servery. The facility identified 54 residents currently residing on the first floor, who could potentially be affected by lack of proper handling and storage of foods and beverages by staff.