Based on interview and record review, the facility failed to ensure discharge Minimum Data Set (MDS) 3.0 assessments were completed accurately and a correction was submitted timely to reflect Resident #90's disposition. This affected one resident (#90) out of four residents reviewed for MDS assessments. The facility census was 94.Findings include:Review of the medical record for Resident #90 revealed an admission date of 06/17/19, with diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder.Review of a progress note dated 03/02/25 revealed Resident #90 was enroute to a local hospital by critical transport, and the power of attorney was notified of the intended location.Review of the Discharge Minimum Data Set (MDS) 3.0 assessment, completed on 03/02/25, revealed the discharge status was coded as discharge - return anticipated and marked as an unplanned discharge.Review of an appointment form dated 03/03/25 revealed the resident was discharged to the hospital with the intention of going home on hospice services.Interview conducted on 08/05/25 at 11:36 A.M. with Registered Nurse (RN) MDS Coordinator #260 revealed a correction to the MDS assessment was not completed to reflect the discharge disposition of discharge - return not anticipated. RN MDS Coordinator #260 revealed a correction assessment would be submitted to ensure MDS data reflected an accurate record.

Based on observation, interview and record review the facility failed to ensure pressure reducing devices were free from soil. This affected one (Resident #33) out of three residents reviewed for pressure reducing measures. The facility census was 94. Findings include:Review of the medical record for Resident #33 revealed an admission date of 05/06/25 with diagnoses of acute respiratory failure with hypoxia, type two diabetes mellitus, severe protein-calorie malnutrition, severe sepsis with septic shock, metabolic encephalopathy and a stage 2 pressure ulcer on the left heel.Review of the care plan dated 05/07/25 revealed Resident #33 has an actual area of skin impairment with interventions including use of an air mattress, encouragement to wear boots on both feet, evaluation for pain, completion of wound treatments, nursing observation of the wound dressing to ensure it remains intact, monitoring for clinical changes in the wound and completion of skin observations on shower days and as ordered.Review of physician orders dated 05/08/25 revealed the resident is to wear boots on both feet while in bed as tolerated for prevention.Review of the admission Minimum Data Set (MDS) 3.0 assessment completed 05/13/25 revealed Resident #33 is moderately cognitively impaired, dependent on staff assistance for bathing and hygiene and has one stage three pressure ulcer present upon admission.Review of the skin grid pressure assessment completed 07/30/25 revealed Resident #33 has a skin impairment on the left heel, present upon admission. The wound is classified as unstable measuring 5.5 centimeters (cm) by 2.3 cm with 30% granulation and 70% slough, moderate serosanguinous and yellow/green drainage with slight odor. The wound showed noted improvement.Observation on 08/04/25 at 3:30 P.M. during wound care with the Assistant Director of Nursing (ADON) #276, Licensed Practical Nurse (LPN) #274 and Certified Nursing Assistant #273 revealed Resident #33 had a pressure ulcer located on the left heel. Prior to beginning wound care, both boots were noted to have staining on the exterior bottom portion of the heel-elevating boots. The staining appeared scattered with ring-like formations indicative of dried fluid and light pink discoloration. Additionally, the interior portion of the right boot, specifically in the toe area, showed shadowing or discoloration, slightly darkened but without definitive staining or wetness. LPN #274 began the dressing change by removing the resident's left boot, noting the dressing was saturated with pale yellow drainage. LPN #274 confirmed a large amount of drainage but denied dressing seepage through to the boot. The boot was placed at the bedside. No concerns were noted during wound care and once completed, the boot was replaced with the staining present.Observations on 08/05/25 at 6:34 A.M. and 11:03 A.M. of Resident #33's boots revealed both remained soiled with the same staining present.Interview on 08/05/25 at 11:30 A.M. with LPN #238 confirmed the staining on the exterior bottom portion of Resident #33's heel-elevating boots. LPN #238 denied performing Resident #33's wound dressing change but stated new heel boots are needed and the old boots will be laundered.Interview on 08/05/25 at 12:40 P.M. with the Director of Nursing (DON) confirmed Resident #33's pressure-reducing boots were soiled on the exterior portion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean, safe, and comfortable living environment for residents. This had the potential to affect all residents in the facility. The facility census was 94. Findings include: An observation on 08/04/25 from 8:57 A.M. to 9:12 A.M. was conducted throughout multiple hallways and common areas. Upon entrance to the building, a large stain was noted on the ceiling tile above the second door on the right. In Hallway G, light fixtures two, six and seven contained debris and light shades on fixtures six and seven were cracked. Peeling ceiling drywall was observed after light fixture three. Outside Resident #74's room, the ceiling showed damaged paint and unfinished ceiling texture. Outside Resident #72's room, peeling ceiling was identified around the fire sprinkler and a ceiling stain was visible above the beauty shop door.Continued observation revealed in Hallway H, damaged drywall shaped like a removed hand sanitizer dispenser was observed before the emergency doors. Light fixture one had a cracked shade. Light fixtures two, three, four and five contained bugs and debris. Ceiling cracks and staining were identified outside the clean linen room. In Hallway F, ceiling vents near light fixtures one, two, four, six and seven had visible dust accumulation clinging to the ceiling surface. Light fixtures three and eight had cracked shades. Outside Resident #42's room, damaged drywall shaped like a removed hand sanitizer dispenser was observed. Light fixtures six, seven and eight had light shades containing significant amounts of debris. In Hallway E, located in the resident lounge, the ceiling was unfinished and had a ceiling curtain track along the side of the wall. In Hallway E, light fixtures one, two, three, four, six and eight contained debris. Light fixture seven was missing its light shade. Ceiling vents located outside rooms two, three and eight had heavy dust accumulation.Observation conducted on 08/04/25 from 2:42 P.M. to 2:55 P.M. revealed all concerns identified remained unaddressed.Interview conducted on 08/04/25 at 2:24 P.M. with the Administrator confirmed environmental and maintenance concerns are present. The Administrator reported the Director of Maintenance was out on leave, and a new assistant was just hired and currently in orientation. The Administrator stated the new maintenance assistant had minimal resources to provide or follow up on maintenance concerns or complaints at the current time. Interview and observation on 08/05/25 at 10:55 A.M. of all previously observed locations was conducted with the Director of Housekeeping (DOH) #257 and the Assistant Director of Housekeeping (ADOH) #600. During this walkthrough, both DOH #257 and ADOH #600 confirmed the presence of all identified issues. They acknowledged debris inside light fixtures G two, G six, G seven, H two, H three, H four, H five, F six, F seven, F eight and E one, E two, E three, E four, E six and E eight, cracked shades on G six, G seven, H one, F three and F eight and the missing shade on E seven. They confirmed the presence of peeling and stained ceilings at G three, above the beauty shop door, outside room [ROOM NUMBER] and outside the clean linen room, damaged drywall in hallway G outside Resident #74 room, before the emergency doors and in F hallway outside Resident #42 room and visible dust buildup on ceiling vents at F one, F two, F four, F six, F seven and E outside rooms two, three and eight. DOH #257 and ADOH #600 stated cleaning of light fixtures and vents falls under housekeeping's responsibilities while issues involving drywall and ceiling damage are referred to maintenance for resolution. Review of the policy Safe and Homelike Environment dated 06/01/24 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on interviews, observation and policy review, the facility failed to ensure scheduled activities were completed as well as ensuring evening activities were scheduled. This affected 92 residents (except for Resident #233) who attend/participate in activities. The facility census was 93. Findings include: Interview on 06/30/25 at 10:31 A.M. with Resident #301 in the activities room revealed the facility rarely does the activities that are posted on the board and stated They just sit out stuff on the table for us to do on our own. No activities in the evening so he gets bored a lot. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed there are really never any activities occurring. There are items on the tables, but when it comes to the scheduled events, they rarely happen. There are no evening activities to do as well. She goes into the activities room a lot and can never find anyone with activities in there. Observation on 06/30/25 at 11:30 A.M. of the activities room revealed no move and groove activity being conducted as per schedule with a total of 9 residents throughout the area sitting at tables. No activity workers in the room. Observation on 06/30/25 at 11:47 A.M. of the activities room revealed no move and groove activity being conducted as per schedule with a total of 12 residents throughout the area sitting at tables. No activity workers in the room. Interview on 06/30/25 at 11:48 A.M. with Resident #333 revealed her to be waiting for the move and groove activity in the activity room and had been waiting for at least 10 minutes. Interview on 06/30/25 at 11:52 A.M. with the Activities Recreation Director revealed she was not sure why the move and groove activity was not occurring as scheduled and went to check with her Activity Aide. Interview on 06/30/25 at 12:47 P.M. with the Activities Recreation Director revealed that for evening activities, they always leave activities out on the tables, but no scheduled evening activities as the activities department goes home and no other staff conduct activities when the activities department are not there. Verified for July 2025 no scheduled activities after 2:00 P.M. every Saturday and Sunday and no weekday scheduled events after 4:00 P.M. Interview on 06/30/25 at 2:19 P.M. with the Activities Recreation Director said her assistant only asked two residents when they came in from smoking if they wanted to do the 11:30 A.M. activity which was the move and groove and they denied. She did not ask any other residents throughout the time period of the activity as residents came and gone for activities. Verified the move and groove activity was not completed as scheduled and the Activities Aide should have been in the room asking residents if they wanted to participate throughout the time frame of the activity. Review of the Activities Calendar for June 2025 revealed no activities scheduled after 2:00 P.M. every Saturday and Sunday and no activities scheduled after 4:00 P.M. every weekday. Review of facility policy titled Activities, revised 06/01/24, revealed activities will encourage both independence and interaction within the community. Residents are encouraged to participate in scheduled activities. This deficiency represents non-compliance investigated under Complaint Number OH00167006.

Based on observations, interviews, and policy review, the facility failed to ensure name badges were worn at all times by facility staff. This affected all 93 residents at the facility. Facility census was 93. Findings include: Observation on 06/30/25 at 9:48 A.M. of Certified Nurse Assistant #1111 revealed no name badge present. Concurrent interview verified no name badge was present and has not had a permanent one since being hired. The temporary badges that are being used fall off a lot as they are just a sticker. Observation on 06/30/25 at 10:29 A.M. of Activities Aide #1000 revealed no name badge present. Concurrent interview verified that no name badge was present and had not had a permanent one since she lost it. Will obtain a temporary sticker one now. Interview on 06/30/25 at 10:31 A.M. with Resident #301 revealed the staff at the facility rarely have name badges on. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed the staff at the facility rarely have name badges on and she can't keep them straight because of that. Interview on 06/30/25 at 10:47 A.M. with Resident #200 revealed the staff continue to not wear name badges so she is not sure who cares for her. Interview on 06/30/25 at 11:31 A.M. with Administrator #2222 verified it is the Administrators duty to make sure all staff are wearing their name badges as part of the facility uniform policy. Interview on 06/30/25 at 11:38 A.M. with the Human Resource Manager #4444 verified she has not been printing off permanent name badges for several months or longer as she should have been. Review of facility policy titled Uniform Policy, no date, revealed name badges are to be worn at all times as part of the uniform. This deficiency represents non-compliance investigated under Master Complaint Number OH00167052.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, staff interview, and facility policy review, the facility failed to provide the opportunity to view or receive resident medical records in a timely manner. This affected one (Resident #65) of one resident reviewed for medical record release. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. Review of facility Minimum Data Set (MDS) assessment, dated 09/05/24, revealed he was cognitively intact. Review of facility Authorization for Release of Health Information form revealed Resident #65 signed the front page of the form on 09/20/24 to release specific medical records. Then, there was a second page of the form that stated he wanted the records released to himself. He signed that page of the document on 09/25/24. There was no evidence the facility started the process of collecting medical records to give to the resident or provide the option for the resident to review his documents online, when the initial request was made on 09/20/24. Review of facility Invoice for Resident Records, dated 09/27/24, revealed an invoice was given to Resident #65 on 09/27/24 for $321.00, based on the rate set forth for copies of medical records. Interview with Administrator on 12/05/24 at 1:50 P.M. confirmed the opportunity of allowing Resident #65 or his representatives to see his medical records was never discussed as an option. Also, he confirmed the initial request for the medical records was made on 09/20/24, but the invoice for the medical records was not given to Resident #65 until 09/27/24, which was seven days after the initial request. Review of facility Release of Medical Records policy, dated 06/01/24, revealed upon request to access or obtain copies of the medical record, the facility should review the authorization to ascertain access rights of that person. A valid request for medical information concerning a resident, by a party other than the resident, includes the name of the resident, name and address of the facility, name and address of individuals or organizations requesting information, specific information and reports requested, period of stay for which information is to be released, date of the request, and signature of the resident or legally appointed representative authorizing release of information. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available two days after receipt of payment for the copies. This deficiency represents non-compliance investigated under Complaint Number OH00159181.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to notify the physician after a significant weight change occurred for Resident #66. This affected one (Resident #66) of five residents reviewed for nutrition. The facility census was 88. Findings include: Review of the medical record for Resident #66 revealed an admission date of 03/16/23 with diagnoses including type 2 diabetes, metabolic encephalopathy, and unspecified dementia. Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely/never understood, and Section K triggered weight loss concerns without a prescribed weight-loss regimen. A brief interview for mental status (BIMS) assessment revealed a score of 8 out of 15, indicating moderate cognitive impairment. Review of Resident #66's care plan included maintaining adequate nutritional status and addressing weight changes, with interventions including fortified foods twice daily and boost glucose control supplementation. Review of the physician orders for Resident #66 revealed orders for weekly weights on Tuesdays, one time a day, starting 05/14/24, with a discontinue date of 06/06/24. Review of the weight history for Resident #66 revealed a weight of 174.0 pounds (lbs) on 12/26/23 and a weight of 153.4 lbs on 06/03/24, for a weight loss of 11.84% in 180 days. Additionally, Resident #66 had a weight of 153.4 lbs on 06/03/24 and a weight of 143.6 lbs on 09/04/24, with a weight loss of 6.39% in 90 days. Additionally, Resident #66 had a weight of 160.8 lbs on 03/05/24 and a weight of 143.6 lbs on 09/04/24, for a weight loss of 10.68% in 180 days. Review of the dietary progress notes revealed that on 12/22/23, the physician was notified of a significant weight loss with a recommendation for weekly weights. There was no evidence that any further physician notifications were made regarding the additional weight losses. Interview on 12/05/24 at 10:19 with Dietician #168 revealed that if there is an indication of weight loss, she will request a re-weight, and if the weight is verified as a loss, she will notify the physician of the weight change. Dietician #168 stated she does not report weight loss every time; if there is a continuous trend of weight loss, she will only notify the physician of the initial weight loss. Dietician #168 also stated that if there are any changes, she will send a weight log to the nurse practitioner. Dietician #168 reported she would send over the weight log if she had any, but did not send any information. Review of the notification of changes policy revealed the facility must contact the resident's physician regarding any significant changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and policy review, the facility failed to complete a timely and thorough grievance investigation and resolution for resident #9's grievances. This affected one (Resident #9) of two residents reviewed for grievance handling. The facility census was 88. Findings include: Review of the medical record for Resident #9 revealed an admission date of 02/15/23 and readmitted on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity with alveolar hypoventilation, asthma, chronic obstructive pulmonary disease, dependence on respirator/ventilator status, obstructive sleep apnea, essential hypertension, chronic venous insufficiency, unspecified depression, anxiety disorder, gastro-esophageal reflux disease, anemia, paroxysmal atrial fibrillation, generalized muscle weakness, and stenosis of a coronary artery stent. Review of the Minimum Data Set (MDS) 3.0 assessment revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Resident #9 had impaired mobility and required moderate assistance with showers but was independent with all other activities of daily living. Review of the care plan for Resident #9 revealed a focus on managing chronic conditions, including respiratory support, pain management, and addressing anxiety. There was no documented care plan addressing missing personal items or grievances. Review of the grievance logs for Resident #9 from September 2024 to December 2024 revealed three incidents on 09/24/24 with no investigation conducted for the missing items and no signature present on the investigation form. Additionally, on 09/26/24 there is another missing item on the log, but Social Worker #112 could not find the investigation report for this item and could not recall what the item missing was. On 11/21/24 there was an occurrence of a cracked phone with an investigation started via housekeeping. Social Worker #112 and the administrator reported via the investigation the phone was not on the initial items log, so the phone was not replaced or repaired with no signatures on the investigation report. On 11/26/24 there were three additional items on the log. The investigation logs had no completed investigations for all three items and the investigation logs were not signed. Interview on 12/04/24 at 3:38 P.M. with Social Worker #112 reported once an incident occurs the staff will complete a grievance log. She stated depending on the situation she will delegate the investigation to the appropriate department and once the investigation is complete the concern report logs are filled out, signed, and placed in the log. Interview on 12/04/24 at 4:09 P.M. with Social Worker #112 confirmed that the investigations for Resident #9 were not completed. Social Worker #112 and the Administrator stated they were going to make copies of all grievance logs and concern reports. Interview on 12/04/24 at 4:40 P.M. the Administrator reported that he misplaced all the copies of the concern logs and could not find the originals so he could not provide me a copy of the logs. Interview on 12/05/24 at 7:52 A.M. with the Administrator he again confirmed that he misplaced all the logs and could not provide me a copy. Review of the Grievance Policy revealed social services will instruct facility staff to submit the social services director that all concerns received will be investigated within seventy-two hours following receipt of the concern. Within seven days following the receipt of the concern, the facility will inform the complainant with the results of the investigation. Additionally, it stated, when the concern is related to missing item(s), complete the missing items form. The timeframe for resolutions will remain the same as above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to develop a comprehensive plan of care for residents. This affected three (#10,#18, and #69) of 24 sampled residents. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, diabetes mellitus, congestive heart failure (CHF), depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 01/12/23 revealed the resident utilized a non-invasive ventilator dependent related to respiratory failure with hypercapnia and COPD. Interventions included keep call bell within reach at all times, keep head of bed elevated above 30 degrees unless providing care or resident request, maintain spare tracheostomy supplies and suction at the bedside, maintain ventilator settings as ordered, observe for changes in respiratory rate or depth, observe for indications of airway obstruction and suction as needed, obtain oxygen saturation while resident is on mechanical ventilator support and/or during weaning process per facility policy, provide nutrition as ordered, provide oral care per facility policy, reposition resident every 2 hours, review all lab work and report abnormal findings to the physician and/or nurse practitioner (NP) and observe for signs/symptoms of hypoxia. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident received oxygen therapy and utilized a non-invasive ventilator. Review of the resident's monthly physician orders for December 2024 identified orders dated 10/17/24 one to five liters of oxygen via nasal cannula as needed for oxygen saturation lower than 90% and 12/03/24 ventilation support settings: AVAPS. AE, AVAPS Rate 3, TV 500, max pressure 12, PS 6/8, EPAP 4/6, RR14, nursing to assist resident with placement of therapy and once daily and as needed wash interface and tubing in warm soapy water, rinse and dry every night shift for respiratory assistance. On 12/02/24 at 2:33 P.M., observation of the resident's nasal cannula oxygen delivery tubing revealed no date indicating when the nasal cannula was last changed. On 12/05/24 at 9:23 A.M., interview with the Director of Nursing (DON) verified the resident's plan of care lacked a care plan addressing the resident's oxygen use. 2. Review of the medical record for Resident #69 revealed an initial admission date of 04/19/23 with the diagnoses including but not limited to cerebral infraction due to occlusion or stenosis of right middle cerebral artery, diabetes mellitus, sever protein calorie malnutrition, hyperlipidemia, metabolic encephalopathy, occlusion and stenosis of right carotid artery, personal history of malignant neoplasm of larynx, hypothyroidism, tracheostomy, hypertension, aphasia, chronic kidney disease, retention of urine, gastro-esophageal reflux disease and gastrostomy. Review of the resident's plan of care dated 05/14/24 revealed the resident had an alteration in respiratory status/difficulty breathing related to tracheostomy and history of malignant neoplasm of larynx. Interventions included administer medication/puffers as ordered, monitor for effectiveness and side effects, observe/document changes in orientation, increased restlessness, anxiety, and air hunger, observe for signs/symptoms of respiratory distress and report to physician and/or NP as needed, observe/document/report abnormal breathing patterns to physician and/or NP, position resident with proper body alignment for optimal breathing pattern and provide oxygen as ordered. Review of the plan of care dated 04/19/23 revealed the resident had a tracheostomy and was at risk for complications including respiratory distress, increased secretions, weight loss and infection. Interventions included keep call light within easy reach, observe skin at tracheostomy site to prevent breakdown, provide alternative forms of communication (pad/pencil, slate, etc), provide mouth care every shift and as needed and suction as necessary. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident received oxygen therapy, suctioning and tracheostomy care. Review of the resident's monthly physician orders for December 2023 identified orders dated 04/19/23 change aerosol bottle/humidifier canister every Monday, Wednesday, Friday and as needed, tracheostomy care every shift and as needed, clean non-disposable inner cannula daily and as needed, pulmonary consult as needed, Respiratory Therapy (RT) to evaluate and treat, use sterile water for aerosol bottle, tracheostomy suction every shift and as needed for excessive secretions, change tracheostomy ties weekly on Sunday on night shift and as needed, 05/15/23 cool air mist via tracheostomy every shift, 07/03/23 #6 Boniva laryngectomy tube, 08/20/23 titrate oxygen to maintain oxygen saturation rate greater or equal to 92%, notify physician if less than 92%, 12/04/23 change corrugate tubing weekly on Mondays, respiratory to change, nursing staff to change as needed, 01/08/24 change suction tubing and canister and change oxygen tubing weekly on Monday by RT and as needed. On 12/02/24 at 2:39 P.M., observation of Resident #18 revealed a tracheostomy present with humidified oxygen being provided via tracheostomy mask. On 12/05/24 at 9:23 A.M., interview with the DON verified the lack of a comprehensive plan of care for the resident's tracheostomy. 3. Review of the medical record for Resident #18 revealed an initial admission date of 08/07/24 with the most recent admission of 10/11/24 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, fibromyalgia, arthritis, major depressive disorder with psychotic features, obstructive sleep apnea, gastro-esophageal reflux disease, paraplegia, pain, constipation, osteoarthritis, dysphagia and urinary tract infection (UTI). Review of the plan of care dated 09/05/24 revealed the resident required assistance for activities of daily living (ADL) related to fibromyalgia and paraplegia. Interventions included apply house moisture barrier cream after each incontinence episode, assist in choosing appropriate clothing as needed, encourage and allow resident to complete self care as able, inspect skin condition daily during personal care and report any impaired areas to charge nurse, observe for changes in ADL ability and adjust assistance as needed, resident requires weight-bearing assistance with transfers, dressing, bathing, toilet hygiene, putting on and taking off footwear, personal hygiene, lying to sitting and sit to stand and staff will assist as needed with daily hygiene and will assist with showering residents as per facility policy weekly. Review of the resident's 360 ancillary consent form dated 08/24/24 revealed the resident consented to receive all ancillary services including dental. Review of the resident's admission assessment with baseline care plan revealed the resident had his own teeth in good/fair repair. Review of the resident's readmission assessment dated [DATE] revealed the resident had broken/chipped or carious teeth. Review of the resident's readmission assessment dated [DATE] revealed the resident had broken/chipped or carious teeth. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no mouth or facial pain/discomfort or difficulty with chewing. Review of the resident's oral assessment dated [DATE] revealed the resident had no issues with his natural teeth and his oral status does not effect his eating. On 12/02/24 at 11:32 A.M., observation of the resident's natural teeth revealed the resident's teeth were in poor repair with obvious carried teeth. On 12/04/24 at 12:14 P.M., interview with the DON verified the admission assessment was not accurate and the resident had no plan of care addressing the resident's poor dental status.

2. Review of the medical record for Resident #70 revealed an admission date of 04/08/24 with diagnoses including anterior displaced Type II dens fracture, hypertension, glaucoma, blindness in both eyes, other health conditions such as dementia, dysphagia, vitamin deficiencies, and alcohol abuse. Review of the Minimum Data Set (MDS) assessment created on 10/31/24 revealed that Resident #70 had a BIMS score of 12 (indicating mild cognitive impairment) out of 15, and the resident is blind. The MDS did not indicate any specific documentation related to the interdisciplinary team's involvement in care planning or coordination of services. Review of the Multidisciplinary Care Conference assessments revealed care conferences were held on 04/26/24 and 09/18/24. There was no record of who was invited or attended the care conference. Additionally, the care conference assessments were unlocked and relocked on 12/4/24. Additionally, Social Worker #112 provided a scratch piece of paper she took notes on that confirmed there is no evidence of who attended the care conference. Interview on 12/04/24 at 9:05 AM with Social Worker #112 confirmed that the care conferences were unlocked to review information, but no changes were made. Social Worker #112 also confirmed that the only documentation of the care conferences was in the PointClickCare system. Interview on 12/04/24 at 11:26 A.M. with Social Worker #112 reported that the information in PointClickCare is the only information regarding the care conferences. Review of facility policy titled Care Planning-Resident Participation, dated 6/1/24 , revealed the facility will notify the resident and / or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care .The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of day for the resident/resident's representative. Based on observations, interviews and policy and procedure review the facility failed to invite residents' family and or resident representative to a residents' Care Conference. This had the potential to affect two residents (#50 and #70) . The census was 88 . Findings include: 1. Review of the medical record for the Resident #50 revealed an admission date of 07/21/21 with sever cognitive deficits. Diagnoses included Alzheimer's disease, chronic kidney disease, depression and anxiety. Resident #50 requires one person assist with activities of daily living. Review of Resident #50 Care Conference Summary on 07/11/24 revealed Resident #50's Health Care Power of Attorney was not invited to the care conference. Interview on 12/02/24 at 2:05 P.M. with Resident #50's family representative revealed she has not been invited to Resident #50's Care conferences. She confirmed she is the Health Care and Financial Power of Attorney. Interview on 12/04/24 with the Social Services Designee # 112 confirmed she has no documentation indicating Resident #50's representative had been invited to participate in care conference on 07/11/24 and or his last conference 10/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident (#10), who was dependent on staff received routine nail care. This affected one resident (#10) of four resident reviewed for activities of daily living (ADL). The facility census was 88. Findings include: Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 11/03/22 revealed the resident required assistance with activities of daily living (ADL) related to new admission, weakness, depression, cognition. Interventions included inspect skin condition daily during personal care and report any impairment to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed and president is totally dependent and does not participate in any aspect of the following tasks, toileting, bathing, transfers, bed mobility, dressing, hygiene, putting on/taking off footwear and locomotion. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. On 12/02/24 at 2:25 P.M., observation of Resident #10 revealed his nails were long, jagged and dirty with a brown substance. On 12/03/24 at 1:35 P.M., observation of the resident's nails revealed they remained long, jagged and dirty with a brown substance. On 12/04/24 at 9:15 A.M., observation of the resident's nails remain long, jagged and dirty with a brown substance. On 12/04/24 at 9:35 A.M., interview with Licensed Practical Nurse (LPN) #127 verified the resident's nails were long, jagged and dirty with a brown substance. Review of the facility policy titled, Resident Care, dated 06/18 revealed facility staff will provide general care as necessary for each resident per their preferences when able and per physician orders. Typical personal hygiene for a resident will include but not limited to care of the skin to include routine and as needed bathing, foot care, shampooing and grooming of the hair per resident preferences, oral hygiene, shaving and trimming per resident preferences, removal of women's facial hair when requested and cleaning and cutting of fingernails and toenails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #70 revealed an admission date of 04/08/24 with diagnoses including anterior displaced Type II dens fracture, hypertension, glaucoma, blindness in both eyes, other health conditions such as dementia, dysphagia, vitamin deficiencies, and alcohol abuse. Review of the Minimum Data Set (MDS) assessment created on 10/31/24 revealed that Resident #70 had a BIMS score of 12 out of 15 (indicating mild cognitive impairment), and the resident is blind. The MDS did not indicate any specific documentation related to the interdisciplinary team's involvement in care planning or coordination of services. Review of the progress note on 12/02/24 at 4:37 P.M., a progress note documented that Resident #70 returned from Ohio State University Main Hospital at 4:00 P.M. The resident was alert, oriented, and able to verbalize needs. Dry necrotic tissue was noted on the right foot's great and second toes, but no wound care orders were placed at that time. Interview on 12/04/24 at 10:57 A.M. with the director of nursing (DON) verified when a resident returns from the hospital a complete head to toe assessment is conducted and any findings are reported to the physician. The staff will review the hospital records and address any orders noted on the discharge summary within 24 hours. DON confirmed that the wound on Resident #70's foot was not addressed upon return from the hospital and there were no new orders in place for wound care. The DON confirmed that the orders should be in the chart at that time, and she is unsure why the wound care orders have not been put into place. Review of the progress note on 12/04/24 at 11:31 A.M. revealed the wound nurse assessed Resident #70's foot/toe wound. Upon assessment Resident #70's right food second toenail was loose, dried blood noted around the toenail. The right foot's second toenail was still intact. The skin in between the toes was clean, dry, and intact. Podiatry services were set up for 12/18/24 and the resident was aware of the new orders. Review of the physician orders for Resident #70 revealed new orders for wound care were put into place including, monitor right foot second toenail every shift. Notify medical director of any changes every shift with a start date of 12/04/24. Additionally, right foot second toenail: paint with betadine daily until resolved every night shift for 30 days with a start date of 12/4/2024 7:00 P.M. and an end date of 01/03/2025. This deficiency represents non-compliance investigated under Complaint Number OH00159181. Based on medical record review, staff interview, and facility policy review, the facility failed to follow physician orders for as needed pain medication administration. This affected one (Resident #65) of three residents reviewed for opioid use. Also, the facility failed to follow wound care orders. This affected one (Resident #70) of three residents reviewed for wound care. The census was 88. Findings Include: 1. Resident #65 was admitted to the facility on [DATE]. Her diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. Review of facility Minimum Data Set (MDS) assessment, dated 09/05/24, revealed he was cognitively intact. Review of Resident #65 physician orders revealed an order for Oxycodone five milligrams (mg) as needed three time daily. Within the same order, it states that the facility will administer a half tablet (2.5 mg) for pain levels one to five, and two half tablets (five mg) for pain levels six to ten. This physician order was from 09/28/24 to 11/06/24. Review of Resident #65 Medication Administration Records (MAR) and Controlled Drug Receipt/Records/Disposition form, dated 09/28/24 to 11/06/24, revealed the following administrations that did not follow the physician order: on 09/28/24, 10/01/24, 10/02/24, 10/03/24, 10/05/24, 10/06/24, and 10/13/24, Resident #65 had pain levels that were between six to ten, and the facility administered one half tablet (2.5 mg) of Oxycodone when they should have administered two half tablets (5 mg). On 10/09/24, 10/16/24, 10/22/24, and 11/05/24, Resident #65 had pain levels between one to five, and the facility administered two half tablets (five mg) of Oxycodone when they should have administered one half tablet (2.5 mg). Interview with Licensed Practical Nurse (LPN) #602 on 12/05/24 at 2:11 P.M. confirmed as needed pain medications would be counted on the narcotics sheet to verify the dose that was given. She confirmed the number of tablets/dose should be accurate from the physician orders to the number of tablets documented as being administered from the narcotic sheet. Interview with Director of Nursing (DON) on 12/05/24 at 2:39 P.M. confirmed pain medications were given outside the parameters for Resident #65; the dose did not match the order for the pain level the resident had.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure off-loading skin interventions were in place as physician ordered for one resident. This affected one resident (#10) of two residents reviewed for pressure ulcers. The facility census was 88. Findings Include: Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 11/03/22 revealed the resident required assistance with activities of daily living (ADL) related to new admission, weakness, depression, cognition. Interventions included inspect skin condition daily during personal care and report any impairment to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed and president is totally dependent and does not participate in any aspect of the following tasks, toileting, bathing, transfers, bed mobility, dressing, hygiene, putting on/taking off footwear and locomotion. Review of the resident's plan of care dated 11/25/22 revealed the resident had the potential for alteration in skin integrity related to decreased mobility, incontinence diabetes mellitus and history of pressure ulcers. Interventions included assist to trim fingernails, educate resident/family on skin breakdown risk factors and preventative measures, education provided to be aware of surroundings when in wheelchair, encourage res to be mindful of his surroundings while turning in wheelchair, encourage res to not wear briefs inserts,encourage to float heels while in bed, encourage to turn and position as tolerated, evaluate resident's specific risk factors, pressure reducing boots to bilateral feet as tolerated, pressure reducing cushion to chair, provide assistance with hygiene, including peri-care as needed, record meal intake percentages per facility policy and use barrier cream with showers and with incontinent episode. Review of the resident's Braden scale dated 07/24/24 revealed a score of 15 indicating the resident was at low risk for skin breakdown. Review of the plan of care dated 10/24/24 revealed the resident had an actual area of skin impairment related to pressure ulcer to the right outer ankle and the right and left ischium. Interventions included bariatric pressure reducing mattress to bed, educate resident to be aware of surroundings while in wheelchair, education and demonstration provided to resident to release hand from wheelchair when propelling to reduce friction for skin integrity, encourage resident to lay down in between smoke breaks as tolerated, encourage resident to limit time in wheelchair to 60 minutes at a time, encourage resident to turn and reposition, encourage resident to wear prevalon boots as much as tolerated, gel cushion to wheelchair as tolerated, initiate wound treatment, continue treatment as ordered by physician, observe and document character of wound weekly, observe for clinical changes, skin observation and document on bath/shower days, administer diet as ordered and record percentage of intake every meal, administer supplements as ordered and record percentage taken, weekly skin assessments, when transferring, turning and repositioning, use proper techniques to avoid friction and shear, assist with transfers as needed, dietician to review nutritional status quarterly and inspect for any reddened areas during daily care. Review of the weekly pressure skin grid dated 10/24/24 revealed the resident was found to have a deep tissue injury (DTI) to the right outer heel measuring 4.0 centimeters (cm) by 2.0 cm. The wound was described as dark purple. Review of the resident's Braden scale dated 10/24/24 revealed a score of 11 indicating the resident was at high risk for skin breakdown. Review of the weekly pressure skin grid dated 10/30/24 revealed the deep tissue injury (DTI) to the right outer heel measured 2.3 centimeters (cm) by 3.3 cm. The wound was described as dark purple. The facility determined the wound had improved. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident was frequently incontinent of bladder and always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one stage III and one unstageable pressure ulcer not present on admission. The assessment indicated the resident had no other skin issues. The facility implemented pressure reducing device to bed/chair, pressure ulcer/injury care and application of ointments/medications other than to feet. The assessment indicated the resident had no functional limitation in range of motion. Review of the weekly pressure skin grid dated 11/06/24 revealed the deep tissue injury (DTI) to the right outer heel measured 2.2 centimeters (cm) by 3.0 cm. The wound was described as dark purple. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 11/13/24 revealed the deep tissue injury (DTI) to the right outer heel measured 2.0 centimeters (cm) by 3.0 cm. The wound was described as dark purple. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 11/20/24 revealed the deep tissue injury (DTI) to the right outer heel measured 2.0 centimeters (cm) by 3.0 cm. The wound was described as dark purple. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 11/27/24 revealed the deep tissue injury (DTI) to the right outer heel measured 2.0 centimeters (cm) by 2.5 cm. The wound was described as dark purple. The facility determined the wound had improved. Review of the resident's monthly physician orders for December 2024 identified orders dated 02/25/23 foam cushion to wheelchair as tolerated, 01/15/24 house barrier cream every shift and as needed for incontinence/moisture for skin integrity prevention, 02/02/24 wear prevalon boots as tolerated while in bed every shift for skin integrity, 02/25/24 apply anti-fungal cream after each incontinent episode and as needed, 10/24/24 encourage resident to wear prevalon boots as much as tolerated every shift, encourage resident to turn and reposition every two hours as tolerated every shift, 11/22/24 pressure reducing mattress to bed, encourage resident to lay down in between smoke breaks as tolerated. chart effectiveness and compliance every shift, limit time sitting up in wheelchair for 60 minutes per Wound Physician, document compliance and non-compliance with wound care every shift and 11/27/24 paint right outer heel with betadine daily until resolved. On 12/02/24 at 2:30 P.M., observation of the resident revealed the physician ordered Prevalon boots were not in place. On 12/03/24 at 10:35 A.M., observation of the resident revealed the physician ordered Prevalon boots were not in place. On 12/04/24 at 9:35 A.M., interview with Licensed Practical Nurse (LPN) #127 verified the Prevalon boots were not in place as physician ordered.

Based on observation, record review, and staff interview, the facility failed to ensure appropriate enteral feeding services were provided Resident #189. This affected one (Resident #189) of one resident reviewed for tube feeding services. The facility census was 88. Findings include: Review of the medical record for Resident #189 revealed an admission date of 11/18/24 with diagnoses including unspecified fracture of the fourth lumbar vertebra, Type 2 diabetes mellitus with hyperglycemia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), dysphagia, and other complex conditions. Review of Resident #189's Minimum Data Set (MDS) 3.0 assessment indicated severe cognitive impairment and the need for maximum assistance with activities of daily living (ADLs), including dressing, toileting, and mobility. Review of the physician orders for Resident #189 revealed orders to clean the peg tube site with normal saline and apply split gauze daily starting 11/19/24. Additionally, Enteral feeding was ordered once daily via PEG tube, with a specified rate of 50 milliliters (ml) an hour of Glucerna 1.5 for a total of 1000 ml a day, via Kangaroo pump, starting 11/19/24 at 2:00 PM. Additionally, flushes were ordered at 50 ml an hour for 20 hours daily to provide a total of 1000 ml of free water per day. Tube placement was to be checked every shift using a 10 cc air bolus before medication administration, feedings, and flushes. The feeding should be delivered via a Kangaroo pump, with the order specifying that the feeding bag should be replaced daily at 6:00 P.M. Observation on 12/05/24 at 9:38 A.M. revealed the Glucerna bag was not replaced until 12/05/24 at 1:00 A.M. Interview on 12/05/24 at 9:43 A.M. with Licensed Practical Nurse (LPN) #128 confirmed the Glucerna bag was not replaced until 12/05/24 at 1:00 A.M. and should have been replaced on 12/04/24 at 6:00 P.M. to start Resident #189's enteral feeding services. This resulted in Resident #189 going for 7 hours (from 6:00 P.M. on 12/04/24 to 1:00 A.M. on 12/05/24) without any nutrition. Interview on 12/05/24 at 9:57 A.M. with LPN#128 verified she did not have a proper hand off from night shift nursing and there were no notes in the chart for Resident #70 justifying why the Glucerna bag was not replaced until 12/05/24 at 1:00 A.M. LPN #128 confirmed Resident #189 will typically go from 2:00 P.M. to 6:00 P.M. without the feeding services and new feed will start at 6:00 P.M. Review of the Care and Treatment of Feeding Tubes policy revealed feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided. Direction for staff regarding how to manage and monitor the rate of flow will be provided. The facility will notify and involve the physician or designated practitioner of any complications, and in evaluating and managing care to address the complications and risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #9 revealed an admission date of 02/15/23 and readmitted on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity with alveolar hypoventilation, asthma, chronic obstructive pulmonary disease, dependence on respirator/ventilator status, obstructive sleep apnea, essential hypertension, chronic venous insufficiency, unspecified depression, anxiety disorder, gastro-esophageal reflux disease, anemia, paroxysmal atrial fibrillation, generalized muscle weakness, and stenosis of a coronary artery stent. Review of the Minimum Data Set (MDS) 3.0 assessment revealed no cognitive impairment. Resident #9 had impaired mobility and required moderate assistance with showers but was independent with all other activities of daily living. Review of the care plan for Resident #9 revealed a focus on managing chronic conditions, including respiratory support, pain management, and addressing anxiety. Review of the physician orders for Resident #9 revealed orders indicating the need for weekly change of corrugated tubing and canisters for trach care every Thursday, and as needed, starting 11/26/24. The orders also specified weekly changes of trach ties and trach collar/mask every Tuesday on the 7 PM to 7 AM shift, and as needed, starting 09/12/24. Additionally, the resident was prescribed suctioning of the trach as needed for increased secretions. Observation on 12/05/24 at 9:30 AM revealed that the resident's room was missing an Ambu bag, a necessary emergency trach supply. Interview on 12/05/24 at 9:31 A.M. with the resident confirmed the facility had previously used the Ambu bag, but it had not been replaced at the time of the observation. Interview with the Director of Nursing (DON) on 12/05/24 at 9:57 AM confirmed that the supplemental supplies, including the Ambu bag, should have been readily available in the resident's room for emergencies. The DON acknowledged that it was a lapse in the system that led to the missing equipment. Interview on 12/05/24 at 11:19 A.M. with Regional Registered Nurse (RRN) #250 confirmed that the Ambu bag needed to be replaced and was not in the room at that time. RRN #250 verified that the Ambu bag was replaced. Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure provision of appropriate equipment was at the bedside for immediate access for two residents (#9 and #69) and failed to ensure one resident's (#10) nasal cannula oxygen delivery equipment was dated. This affected three residents ( Resident #9,#10 and #69) of three residents reviewed for respiratory care. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, diabetes mellitus, congestive heart failure (CHF), depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 01/12/23 revealed the resident utilized a non-invasive ventilator dependent related to respiratory failure with hypercapnia and COPD. Interventions included keep call bell within reach at all times, keep head of bed elevated above 30 degrees unless providing care or resident request, maintain spare tracheostomy supplies and suction at the bedside, maintain ventilator settings as ordered, observe for changes in respiratory rate or depth, observe for indications of airway obstruction and suction as needed, obtain oxygen saturation while resident is on mechanical ventilator support and/or during weaning process per facility policy, provide nutrition as ordered, provide oral care per facility policy, reposition resident every 2 hours, review all lab work and report abnormal findings to the physician and/or nurse practitioner (NP) and observe for signs/symptoms of hypoxia, Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident received oxygen therapy and utilized a non-invasive ventilator. Review of the resident's monthly physician orders for December 2024 identified orders dated 10/17/24 one to five liters of oxygen via nasal cannula as needed for oxygen saturation lower than 90% and 12/03/24 ventilation support settings: AVAPS. AE, AVAPS Rate 3, TV 500, max pressure 12, PS 6/8, EPAP 4/6, RR14, nursing to assist resident with placement of therapy and once daily and as needed wash interface and tubing in warm soapy water, rinse and dry every night shift for respiratory assistance. On 12/02/24 at 2:33 P.M., observation of the resident's nasal cannula oxygen delivery tubing revealed no date indicating when the nasal cannula was last changed. On 12/03/24 at 1:35 P.M., observation of the resident's nasal cannula oxygen tubing revealed the oxygen delivery tubing remained undated. On 12/04/24 at 9:15 A.M., observation of the resident's nasal cannula oxygen tubing revealed the oxygen delivery tubing remained undated. 12/04/24 at 9:35 A.M., interview with Licensed Practical Nurse (LPN) verified the facility scheduled nasal cannula oxygen delivery tubing changes on the night shift and are to be dated at the time of the change. On 12/05/24 at 9:23 A.M., interview with the Director of Nursing (DON) verified the resident's plan of care lacked a care plan addressing the resident's oxygen use. 2. Review of the medical record for Resident #69 revealed an initial admission date of 04/19/23 with the diagnoses including but not limited to cerebral infraction due to occlusion or stenosis of right middle cerebral artery, diabetes mellitus, sever protein calorie malnutrition, hyperlipidemia, metabolic encephalopathy, occlusion and stenosis of right carotid artery, personal history of malignant neoplasm of larynx, hypothyroidism, tracheostomy, hypertension, aphasia, chronic kidney disease, retention of urine, gastro-esophageal reflux disease and gastrostomy. Review of the resident's plan of care dated 05/14/24 revealed the resident had an alteration in respiratory status/difficulty breathing related to tracheostomy and history of malignant neoplasm of larynx. Interventions included administer medication/puffers as ordered, monitor for effectiveness and side effects, observe/document changes in orientation, increased restlessness, anxiety, and air hunger, observe for signs/symptoms of respiratory distress and report to physician and/or NP as needed, observe/document/report abnormal breathing patterns to physician and/or NP, position resident with proper body alignment for optimal breathing pattern and provide oxygen as ordered. Review of the plan of care dated 04/19/23 revealed the resident had a tracheostomy and was at risk for complications including respiratory distress, increased secretions, weight loss and infection. Interventions included keep call light within easy reach, observe skin at tracheostomy site to prevent breakdown, provide alternative forms of communication (pad/pencil, slate, etc), provide mouth care every shift and as needed and suction as necessary. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident received oxygen therapy, suctioning and tracheostomy care. Review of the resident's monthly physician orders for December 2023 identified orders dated 04/19/23 change aerosol bottle/humidifier canister every Monday, Wednesday, Friday and as needed, tracheostomy care every shift and as needed, clean non-disposable inner cannula daily and as needed, pulmonary consult as needed, Respiratory Therapy (RT) to evaluate and treat, use sterile water for aerosol bottle, tracheostomy suction every shift and as needed for excessive secretions, change tracheostomy ties weekly on Sunday on night shift and as needed, 05/15/23 cool air mist via tracheostomy every shift, 07/03/23 #6 Boniva laryngectomy tube, 08/20/23 titrate oxygen to maintain oxygen saturation rate greater or equal to 92%, notify physician if less than 92%, 12/04/23 change corrugate tubing weekly on Mondays, respiratory to change, nursing staff to change as needed, 01/08/24 change suction tubing and canister and change oxygen tubing weekly on Monday by RT and as needed. On 12/05/24 at 7:54 A.M., observation of Licensed Practical Nurse (LPN) provide the physician ordered tracheostomy care revealed he washed his hands, donned PPE (gloves, gowns, mask and goggles). The LPN placed a barrier on the resident's bedside table and set-up the required supplies. The LPN applied a pulse oximetry to the resident's right index finger to monitor the resident oxygen saturation rate during the procedure. The LPN removed the soiled split drain sponge from the resident's tracheostomy stoma. The LPN sanitized his hands and donned a pair of sterile gloves, the LPN then removed the tracheostomy using his left hand. The LPN then poured hydrogen peroxide and normal saline (NS) in the sterile tray. The LPN then cleansed the tracheostomy using the sterile brush from the kit. The LPN then used NS and a 4X4 and cleansed the tracheostomy stoma. The LPN then placed the tracheostomy cannula in the resident's tracheostomy stoma and changed the tracheostomy ties. The LPN then placed a split drain sponge around the tracheostomy stoma. The surveyor and the LPN was not able to locate a spare tracheostomy cannula and found the ambu bag in the resident's second drawer of his night stand. On 12/05/24 at 8:23 A.M., interview with LPN #142 verified the resident did not have a spare tracheostomy cannula at bedside for emergency use and the ambu bag was not easily accessible for emergency use. Review of the facility policy titled, Tracheostomy Care, dated 06/02/23 revealed tracheostomy care will be provided according to eh physician's orders, comprehensive and individual care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include provide tracheostomy care at least twice weekly and maintain a suction machine, supply of suction catheters, correctly sized cannulas and an ambu bag easily accessible for immediate emergency care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to have all dialysis communication and records were in the facility to ensure full care could be provided. This affected one (Resident #65) of one resident reviewed for dialysis. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. Review of facility Minimum Data Set (MDS) assessment, dated 09/05/24, revealed he was cognitively intact. Review of Resident #65 physician orders found he was scheduled to have dialysis on Tuesday, Thursdays, and Saturdays. Review of Resident #65 dialysis notes within the facility found the following notes without the needed weight information: 11/30/24 (no pre weight), 11/27/24 (no pre and post weight), 11/07/24 (no pre weight), 10/24/24 (no pre weight), 10/19/24 (no pre weight), 09/26/24 (no pre weight), 09/19/24 (no pre weight), and 09/05/24 (no pre weight). After review of the facility dialysis records for Resident #65 on 12/04/24 and informing the facility there were multiple weights not documented, the facility provided communication documentation from the dialysis center with the needed weights on 12/05/24. Interview with Regional Nurse #250 on 12/05/24 at 10:35 A.M. stated they had a separate medical records area that had these dialysis records; she stated they did not get them from the dialysis center recently. Interview with Dialysis Center Representative #601 on 12/05/24 at 10:42 A.M. confirmed they sent specific dialysis records for Resident #65 that were requested by the facility, in the afternoon of 12/04/24. She confirmed the facility stated they didn't have the needed records and needed the dialysis center to send them over. She confirmed it was communication dialysis logs that had both pre and post weights for Resident #65.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly monitor residents psychotropic medications to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88. Findings include: Resident #7 was admitted to the facility on [DATE]. Her diagnoses were schizoaffective disorder, asthma, type II diabetes, anxiety disorder, major depressive disorder, hypertension, dementia, lack of coordination, schizoaffective disorder, shortness of breath, osteoporosis, aphasia, dysphagia, hypertensive heart disease, moderate intellectual disabilities, hypothyroidism, hyperlipidemia, and diffuse traumatic brain injury. Review of her minimum data set (MDS) assessment, dated 10/02/24, revealed she had a severe cognitive impairment. Review of Resident #7 physician orders found she was prescribed the following psychotropic medications: Olanzapine 15 milligrams (mg), Depakote 250 mg twice daily, Fluphenazine five mg twice daily, and Fluphenazine Decanoate Solution intramuscularly 25 mg every 21 days for schizoaffective disorder, and venlafaxine 75 mg for depression. Review of Resident #7 pharmacy recommendations, dated November 2023 to November 2024, revealed one pharmacy recommendation for a gradual dose reduction (GDR) for Fluphenazine in January 2024. The physician reviewed it and determined a GDR would not be beneficial to her mental health to reduce the dosage. Other than this recommendation, no other psychotropic medication had a recommendation for a GDR as required. Interview with Regional Nurse #250 on 12/05/24 at 9:20 A.M. and 9:45 A.M. stated the pharmacy will review each resident's psychiatric notes (including Resident #7) and then determine if they will complete any type of recommendation for irregularity, including GDR. She confirmed the pharmacy did not complete a GDR recommendation for Resident #7 psychotropic medications in the last 12 months, other than Fluphenazine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered for Resident #9. This affected one (Resident #9) of six residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of the medical record for Resident #9 revealed an admission date of 2/15/23 and readmitted on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity with alveolar hypoventilation, asthma, chronic obstructive pulmonary disease, dependence on respirator/ventilator status, obstructive sleep apnea, essential hypertension, chronic venous insufficiency, unspecified depression, anxiety disorder, gastro-esophageal reflux disease, anemia, paroxysmal atrial fibrillation, generalized muscle weakness, and stenosis of a coronary artery stent. Review of the Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Resident #9 had impaired mobility and required moderate assistance with showers but was independent with all other activities of daily living. Review of the care plan for Resident #9 revealed a focus on managing chronic conditions, including respiratory support, pain management, and addressing anxiety. Review of the physician orders for Resident #9 revealed orders for Entresto were initiated on 10/08/24 with a dosage of 24-26 milligrams (mg) twice daily for hypertension. The orders specified that Entresto should be held if the resident's systolic blood pressure (SBP) was below 110 millimeters of mercury (mmHg) or if the heart rate (HR) was below 60 beats per minute (bpm). Review of the Medication Administration Records (MAR) confirmed that Entresto was administered outside the prescribed parameters on multiple occasions: 11/12/24: 106/81 (12:44 A.M.) and 129/81 (10:00 A.M.), both outside the specified SBP parameter. On 11/10/24: 109/73 (8:34 A.M.) and 8:35 A.M. On 10/31/24: 106/79 at 9:30 A.M. On 10/28/24: 109/70 at 8:37 P.M. On 10/15/24: 109/77 at 9:31 A.M. and 9:32 A.M. These values indicate that Entresto was administered even when the resident's blood pressure was below the ordered threshold of 110 mmHg. Interview on 12/04/24 at 2:33 P.M. with the Director of Nursing (DON), revealed that the facility's practice was to administer Entresto if the readings were only one digit outside of the parameters, stating it was a known rule for nursing discretion. The DON confirmed that the Entresto was administered outside the prescribed parameters and acknowledged the need to verify the facility's practices with the physician. The DON could find no documented evidence related to the nursing discretion rule. The DON could also find no evidence of the staff notifying the physician prior to administering the medication while outside of the ordered parameters. Additionally, the rule regarding nursing discretion was confirmed in a written statement from the physician on 12/05/24, but this was the first documented evidence of such a rule. No prior written documentation or confirmation of the nurse discretion practice could be found in the resident's medical record or facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly monitor resident behaviors to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88. Findings include: Resident #7 was admitted to the facility on [DATE]. Her diagnoses were schizoaffective disorder, asthma, type II diabetes, anxiety disorder, major depressive disorder, hypertension, dementia, lack of coordination, schizoaffective disorder, shortness of breath, osteoporosis, aphasia, dysphagia, hypertensive heart disease, moderate intellectual disabilities, hypothyroidism, hyperlipidemia, and diffuse traumatic brain injury. Review of her minimum data set (MDS) assessment, dated 10/02/24, revealed she had a severe cognitive impairment. Review of Resident #7 physician orders found a new order for Olanzapine 15 milligrams (mg) for schizoaffective disorder was started on 11/18/24. Prior to this order, she was on Olanzapine/Zyprexa 10 mg for schizoaffective disorder. In addition to Olanzapine for schizoaffective disorder, she was also prescribed Depakote 250 mg twice daily, Fluphenazine five me twice daily, and Fluphenazine Decanoate Solution intramuscularly 25 mg every 21 days for schizoaffective disorder, and venlafaxine 75 mg for depression. Review of Resident #7 psychiatry progress notes, dated 11/18/24, revealed an office visit which indicated that Resident #7 stated she was having trouble sleeping the last few nights. When asked other questions, it was documented that she was answering non-sensically when asked about her mania/hypomania. According to staff information provided to the psychiatrist, she was telling staff that she will be giving birth. There were no reports of aggression, agitation, or irritability. Review of Resident #7 behavior monitoring documentation, dated September 2024 to December 2024, found the behaviors the facility was monitoring for her use of antidepressants and antipsychotics were as follows: hallucinations, delusions, paranoia, sadness, withdrawn, and appetite changes. Review of those behavior logs found no behaviors were documented as being exhibited. There was no justification leading up to the increase of Resident #7 Olanzapine from 10 mg to 15 mg. Interviews with Regional Nurse #250 on 12/05/24 at 9:20 A.M. and 9:45 A.M. confirmed there were no behaviors documented in the Resident #7 records to support an increase in her Olanzapine. She confirmed there was an increase in Olanzapine on 11/18/24 for Resident #7 thinking she was pregnant and not sleeping for a few nights. She confirmed there should have been documentation to support these behaviors.

Based on record review, staff interview, resident interview, and policy review, the facility failed to ensure timely collection of a urine sample for a urinary tract infection (UTI) as ordered for Resident #81. This affected one (Resident #81) out of one resident reviewed for labs. The facility census was 88. Findings include: Review of the medical record for Resident #81 revealed an admission date of 5/28/24 with diagnoses including acute respiratory failure with hypoxia, type II diabetes, obesity, dependence on respirator, lack of coordination, obstructive sleep apnea, bladder-neck obstruction, obstructive and reflux uropathy, difficulty walking, edema, combined systolic heart failure, spinal stenosis, and several other chronic conditions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (Additionally, a BIMS assessment on 12/02/24 with a score of 15), indicating no cognitive impairment. Resident #81 was dependent on a wheelchair and required assistance with toileting, bathing, and personal hygiene. The resident had an indwelling catheter and was frequently incontinent with bowel movements. Review of the progress notes for Resident #81 revealed on 10/20/24 at 11:21 A.M., the nursing note indicated a small amount of mucus was noted in the urine, and new orders were received for a urine culture and sensitivity, with the responsible party notified. Review of the physician orders for Resident #81 revealed a physician's order was placed on 10/21/24 for a urine culture and sensitivity, which was not collected promptly. The sample was collected on 10/24/24, resulting in a delay of three days before the lab results were available. This delay impacted the timely initiation of appropriate treatment for the UTI. Review of the progress notes for Resident #81 revealed on 10/26/24 at 6:31 P.M., a nursing note indicated that lab results were reviewed with the resident and Med One was notified for new orders to start Bactrim DS (Sulfamethoxazole-Trimethoprim) for the UTI. The resident and responsible party (RP) were informed. Interview on 12/04/24 at 2:55 P.M. with the Director of Nursing (DON) confirmed the collection sample was delayed and there was no justification as to why the sample was delayed by three days. Review of the Diagnostic Testing Services Policy revealed the facility will provide appropriate diagnostic services required to maintain the overall health of its residents and in accordance with state and federal guidelines. Additionally, the policy stated the facility will maintain a schedule of diagnostic tests in accordance with the physicians' orders. No diagnostic tests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with state law to include scope of practice laws. Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and require immediate attention at which time the physician will be notified upon receipt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#18) oral assessments were accurate and dental services were arranged to address the resident's poor dental status. This affected one resident (Resident #18) of one resident reviewed for dental. The facility census was 88. Findings Include: Review of the medical record for Resident #18 revealed an initial admission date of 08/07/24 with the most recent admission of 10/11/24 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, fibromyalgia, arthritis, major depressive disorder with psychotic features, obstructive sleep apnea, gastro-esophageal reflux disease, paraplegia, pain, constipation, osteoarthritis, dysphagia and urinary tract infection (UTI). Review of the plan of care dated 09/05/24 revealed the resident required assistance for activities of daily living (ADL) related to fibromyalgia and paraplegia. Interventions included apply house moisture barrier cream after each incontinence episode, assist in choosing appropriate clothing as needed, encourage and allow resident to complete self care as able, inspect skin condition daily during personal care and report any impaired areas to charge nurse, observe for changes in ADL ability and adjust assistance as needed, resident requires weight-bearing assistance with transfers, dressing, bathing, toilet hygiene, putting on and taking off footwear, personal hygiene, lying to sitting and sit to stand and staff will assist as needed with daily hygiene and will assist with showering residents as per facility policy weekly. Review of the resident's 360 ancillary consent form dated 08/24/24 revealed the resident consented to receive all ancillary services including dental. Review of the resident's admission assessment with baseline care plan dated 08/07/24 revealed the resident had his own teeth in good/fair repair. Review of the resident's readmission assessment dated [DATE] revealed the resident had broken/chipped or carious teeth. Review of the resident's readmission assessment dated [DATE] revealed the resident had broken/chipped or carious teeth. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no mouth or facial pain/discomfort or difficulty with chewing. Review of the resident's oral assessment dated [DATE] revealed the resident had no issues with his natural teeth and his oral status does not effect his eating. On 12/02/24 at 11:32 A.M., interview/observation of the resident's natural teeth revealed the resident's teeth were in poor repair with obvious carried teeth. Resident #18 stated he had requested several times to seen the facility dentist and was told, you are on the list. Resident #18 revealed he wanted to make an appointment with a community dentist but the facility would not transport him to the appointment as he would have to make his own transportation arrangements. On 12/05/24 at 10:46 A.M., interview with Social Worker (SW) #112 verified the resident had not seen the facility contracted dentist and was present in the facility during the dentist's last visit. On 12/04/24 at 12:14 P.M., interview with the Director of Nursing verified the admission assessment was not accurate to reflect the resident's poor dental status of carried teeth. Review of the facility policy titled, Dental Services, dated 2022 revealed it was the policy of the facility to assist residents in obtaining routine and emergency dental care. The dental needs of each resident are identified through the physical assessment and MDS assessment process and addressed in each resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review,staff interview, and facility policy review, the facility failed to follow their antibiotic stewardship processes for Residents #81 and #43. This affected two (Resident's #81 and #43) out of three residents reviewed for antibiotic use. The facility census was 88. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 5/28/24 with diagnoses including acute respiratory failure with hypoxia, type II diabetes, obesity, dependence on respirator, lack of coordination, obstructive sleep apnea, bladder-neck obstruction, obstructive and reflux uropathy, difficulty walking, edema, combined systolic heart failure, spinal stenosis, and several other chronic conditions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (Additionally, a BIMS assessment on 12/02/24 with a score of 15), indicating no cognitive impairment. Resident #9 was dependent on a wheelchair and required assistance with toileting, bathing, and personal hygiene. The resident had an indwelling catheter and was frequently incontinent with bowel movements. Review of the progress notes for Resident #81 revealed on 10/26/24 at 6:31 P.M. lab results indicated a urinary tract infection (UTI), and Bactrim was prescribed on 10/27/24. Review of the physician orders for Resident #81 revealed an order for Bactrim Tablet 800-160 milligram's (MG) (Sulfamethoxazole-Trimethoprim) give 1 tablet by mouth two times a day for UTI for seven days with a start date of 10/27/24 and an end date of 11/03/2024. Review of the Medication Administration Records (MAR) confirmed Bactrim was prescribed from 10/27/24 to 11/03/24. Review of the urine analysis labs revealed the organism present was proteus mirabilis with a growth of >100,000 Colony-Forming Units per Milliliter (CFU/mL). Under the antibiotic sensitivity section it indicated bacterial resistance to Bactrim (denoted as R [>2/38], confirming resistance per minimum inhibitory concentration standards). Interview on 12/05/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed that Bactrim was prescribed despite the culture showing resistance. The DON stated that they had no justification for the antibiotic order and confirmed that there was no documentation explaining the reason for the choice of Bactrim. Review of the Antibiotic Stewardship Policy revealed that Antibiotics must be selected based on culture and susceptibility data whenever available to ensure effectiveness against the identified pathogen. Clinical staff must document the rationale for the selection of an antibiotic, particularly when culture data indicates resistance to the prescribed medication. Timely review of laboratory results, including culture and sensitivity reports, is required to guide adjustments in treatment. Inappropriate antibiotic use, such as prescribing resistant antibiotics, must be avoided to minimize the risk of treatment failure and antimicrobial resistance. 2. Review of the medical record for Resident #43 revealed an initial admission date on 10/04/24 and a readmission date on 10/14/24. Medical diagnoses included anxiety disorder, transient cerebral ischemic attack, other nontraumatic intracerebral hemorrhage, cerebral infarction, opioid abuse, and hemiplegia affecting left nondominant side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had intact cognition and scored 15 out of 15 on the Brief Interview Mental Status (BIMS) assessment. Resident #43 required varied assistance with Activities of Daily Living (ADLs) ranging from independence to substantial assistance from staff. Review of the infection control log revealed Resident #43 was admitted from the hospital on [DATE] with a urinary tract infection (UTI). There was no organism listed. The urinalysis with sensitivity was listed as unable to obtain (uto). Resident #43 did not meet McGreer's criteria for an infection. Resident #43 received Amoxicillin from 11/12/24 to 11/17/24 (five days). Review of the Medication Administration Record (MAR) dated November 2024 revealed Resident #43 had a physician order for Amoxicillin-Potassium Clavulanate (an antibiotic) 875-125 milligrams (mg) with instructions to take one tablet two times daily for a UTI for five days. The order was dated 11/12/24. Resident #43 received one dose on 11/12/24, two doses on 11/13/24, 11/14/24, 11/15/24, and 11/26/24, and one dose on 11/17/24. The resident received a total of ten doses of the antibiotic. Review of the progress notes revealed there was no evidence Resident #43 was evaluated by a physician or Certified Nurse Practitioner (CNP) after returning from the hospital to ensure the antibiotic order was appropriate. There was no evidence of Resident #43's lab results in the resident's medical record to verify the resident had a UTI. Interview on 12/05/24 at 2:01 P.M. with Regional Nurse (RGN) #250 confirmed Resident #43 returned from the hospital with an ordered antibiotic for a UTI. The facility was not able to obtain labs from the hospital to verify an organism or the positive UTI results. RGN #250 confirmed Resident #43 did not meet McGreer's criteria for a UTI and the resident was not seen by a physician or CNP to verify the appropriateness of the antibiotic order. Review of the facility policy, Antibiotic Stewardship, undated, revealed the policy stated, Providers will utilize the McGreer's Criteria when considering initiation of antibiotics. When infection is suspected review with physician the criteria that was met for use of antibiotic. At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, selection, and de-escalation potential. Completion of an antibiotic time-out must be recorded in the resident record.

Based on medical record review, review of immunization records, staff interview, and facility policy review, the facility failed to administer the influenza vaccine to one resident (Resident #20) and the facility failed to administer the pneumococcal vaccine to one resident (Resident #6) after the residents consented to receive the vaccinations. The deficient practice affected two residents (Residents #6 and #20) of five reviewed for immunizations. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date on 01/18/24 and a readmission date on 03/08/24. Medical diagnoses included Type II Diabetes Mellitus without complications, metabolic encephalopathy, vascular dementia, essential hypertension, and cognitive communication deficit. Review of the Vaccine Administration Record Informed Consent for Vaccination dated 10/25/24 revealed Resident #20's representative consented for the resident to receive an influenza vaccine. There was no evidence in the medical record Resident #20 received the influenza vaccination after the resident's representative consented. 2. Review of the medical record for Resident #6 revealed an admission date on 03/09/17. Medical diagnoses included secondary parkinsonism, aphasia, hemiplegia affecting left nondominant side, dementia, and psychotic disturbance, mood disturbance and anxiety. Review of the Vaccine Administration Record Informed Consent for Vaccination dated 10/24/24 revealed Resident #6 verbally consented to receive the pneumococcal vaccination. There was no evidence Resident #6 received the pneumococcal vaccination after consenting to receive the vaccine. Interviews on 12/05/24 at 2:17 P.M. and 2:18 P.M. with Regional Nurse (RGN) #250 confirmed Resident #20 did not receive the influenza vaccine after his representative consented for the resident to receive the vaccine. RGN #250 confirmed Resident #6 did not receive the pneumococcal vaccination after verbally consenting to receive the vaccine. Review of the facility policy, Infection Prevention and Control Program, revised 06/01/24, revealed the policy stated, Residents will be offered the influenza vaccine each year between October 1 and March 31 unless contraindicated or received the vaccine elsewhere during that time. Residents will be offered the pneumococcal vaccines recommended by the Centers for Disease Control (CDC) upon admission, unless contraindicated or received the vaccines elsewhere. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. Residents will have opportunity to refuse the vaccines. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations.

Based on interviews, and resident council meeting notes the facility failed to document in writing its responses and rationale to resident council grievances and recommendations. This had the potential to affect eight (#1, #9, #24, #14, #42, #51, #58 and # 66) residents who attend the meetings monthly. The census was 88. Findings include: Review of the Resident Council monthly meeting minutes from 12/26/23 to 11/24/24 revealed old business issues are discussed with no details documented. The meetings do discuss any concerns the residents have and are listed in the meeting minutes, however, there is no documentation from administration of addressing the residents' questions and concerns. Interview on 12/4/24 at 3:29 PM with Resident Council President #42 reported she is not aware of any written responses to the questions and concerns voiced at Resident Council . It is her understanding Activity Director #182 takes care of all the details. Interview on 12/04/24 at 3:45 P.M. with the Activity Director #182 revealed they report concerns from Resident Council in stand up administrative meetings each day . She does not receive resolutions to the reported problems in writing from the Resident Council Meetings. Interview on 12/04/24 at 4:10 PM interview with the Social Service Designee # 112 and the Administrator confirmed they do not have a resolution form for the concerns brought up at resident council meetings, they discuss the councils concerns during stand up meeting the following day. If an individual problem is reported, they record the concern on a grievance form and address it with the identified resident. The facility does not have a policy titled Resident Council Meetings.

Based on personnel record review and staff interview, the facility failed to complete staff performance evaluations as required. This had the potential to affect 88 of 88 residents. Findings Include: Review of Certified Nursing Assistant (CNA) #165 and CNA #179 personnel records found they did not have a completed 90 day performance evaluation completed. Interview with Visiting Administrator #600 on 12/04/24 at 10:30 A.M. confirmed they have no evidence to support the above staff had performance evaluations completed as required.

Based on observations , and staff interviews the facility failed to ensure the steam warmer and two compartment sink was maintained in a safe and operating condition . This had the potential to affect 85 residents. The census was 88. Findings include: Observation on 12/04/24 at 10:24 A.M. of the kitchen's two compartment sink omitted a strong odor of sewage. The sink was empty. Verified by dietary Aide #105. Observation on 12/4/24 at 10:28 A.M. behind the serving line the steam oven was dripping water from the bottom left side of the door. The water dripped approximately 2 feet down to a 11 x 11 serving metal bin. [NAME] # 217 revealed when she uses the steamer the water drips out . The staff must empty the water filled bin every one to two hours. Dietician #168 verified the water and confirmed she reported the issue to corporate in November 2024. Interview on 12/04/24 03:16 P.M. with the Administrator regarding the steam oven, he confirmed it had been replaced once in the past. The maintenance man must change the seals to prevent the water from dripping. Interview on 12/05/24 01:08 P.M. to 1:30 P.M. with Maintenance Director #177 confirmed the steamer was not new when they got it from a sister facility. He was aware of the drip ; the seals have not been replaced. He is aware of the odor in the kitchen. He explained, Three weeks ago, he tried to snake the drains under the two compartment sink , but the odor still exists. After surveyor intervention he has called a Plumber to service the drains on 12/05/24. Review of the e-mail from the administrator on 12/05/24 at 3:40 P.M. confirmed after surveyor intervention corporate approved the facility to purchase a new steamer. They received a quote, and it has been approved and purchased. Arrival date is to be determined. Review of the work receipt by the plumber dated 12/05/24 revealed he cleaned the kitchen sink drain to remove clog. Determined the odor was coming from floor drains from grease interceptor not being properly cleaned. The drains all need to be cleaned and the pumps need to be pumped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #189 revealed an admission date of 11/18/24 with diagnoses including unspecified fracture of the fourth lumbar vertebra, Type 2 diabetes mellitus with hyperglycemia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), dysphagia, and other complex conditions. Review of Resident #70's Minimum Data Set (MDS) 3.0 assessment indicated severe cognitive impairment and the need for maximum assistance with activities of daily living (ADLs), including dressing, toileting, and mobility. Review of the care plan for Resident #189 revealed a focus on managing the resident's complex health conditions, including tube feeding via a PEG tube and the need for assistance with personal care. Review of the physician orders for Resident #189 revealed the following orders: Clean PEG tube site with normal saline (NS), pat dry, and apply split gauze to the site every shift starting 11/19/24. Additionally, Enteral feeding orders via the PEG tube, including a rate of 50 milliliters (mL) an hour of Glucerna 1.5 for 20 hours daily, starting 11/19/24. However, there were no physician orders for enhanced barrier precautions for Resident #189. Observation on 12/02/24 at 1:24 P.M. revealed there were no enhanced barrier precautions set up for Resident #189. Observation on 12/03/24 at 3:54 P.M. and 12/04/24 at 8:46 AM, no enhanced barrier precautions were in place for the resident's PEG tube feeding. Interview on 12/04/24 at 8:50 A.M. with Registered Nurse (RN) #126 confirmed that enhanced barrier precautions are used for open wounds, catheters, feeding tubes, and similar situations. Observation on 12/04/24 at 3:03 P.M. revealed barrier precautions were still not in place. Observation on 12/05/24 at 9:29 A.M., revealed no enhanced barrier precautions were observed despite discussions with nursing staff. Interview on 12/05/24 at 9:43 A.M., LPN# 128, confirmed that enhanced barrier precautions should have been in place for the PEG tube but were not implemented. Review of the care plan for Resident #189 revealed that the care plan was updated to include enhanced barrier precautions on 12/05/24, but these precautions were not implemented prior to this date. Review of the Infection Prevention and Control Program revealed the policy requires adherence to standard precautions for infection control, which include proper hygiene, use of personal protective equipment (PPE), and following appropriate isolation procedures for residents with high infection risks. This directly applies to the resident with a PEG tube, who should be receiving enhanced barrier precautions to prevent contamination and infection. Enhanced Barrier Precautions are required for residents with open wounds or invasive devices, like a feeding tube, to minimize the risk of infection. The absence of these precautions violates the facility's infection control procedures. Based on observations, staff interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one resident (Resident #189) who had a feeding tube in place. The facility also failed to follow infection control procedures during wound care for two residents (Residents #81 and #300) and did not follow infection control procedures during catheter care for one resident (Resident #10). The deficient practices affected four residents (#10, #81, #189, #300) of four reviewed for infection control. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #81 revealed an initial admission date of 05/28/24 with the diagnoses including but not limited to acute respiratory failure with hypoxia, diabetes mellitus, dependence on respirator, obstructive sleep apnea, bladder neck obstruction, obstructive and reflux uropathy, congestive heart failure, spinal stenosis lumbar region, hypertension and depression. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the resident's monthly physician orders for December 2024 identified orders dated 07/24/24 catheter care every shift, 10/18/24 catheter size 16 FR 10 milliliter (ml) balloon and 11/14/24 acetic acid irrigation solution 0.25% with the special instructions to use 50 ml via irrigation every 12 hours as needed for mucous accumulation in indwelling urinary catheter. On 12/04/24 at 3:20 P.M., observation of Certified Nursing Assistant (CNA) #106 provide the physician ordered catheter care revealed the CNA entered the resident's room and donned a pair of disposable gloves. The CNA obtained a clear plastic graduate container and emptied the resident's indwelling urinary catheter collection bag. The CNA set the clear plastic graduate container on the floor and wiped the end of the plastic drainage tube with an alcohol wipe, clamped the tube shut and emptied the urine into the toilet. The CNA rinsed the plastic graduate container and placed in a clear plastic bag. The CNA then changed her gloves without washing or sanitizing her hands. She obtained one soapy washcloth and one wet wash cloth and cleansed the resident's groins. The CNA then rinsed the resident's groins and pat dry with a towel. The CNA then cleansed the indwelling urinary catheter with a disposable alcohol swab moving up and down the indwelling urinary catheter. The CNA then covered the resident with a sheet. The CNA washed her hands and exited the room with the dirty linen and trash. On 12/04/24 at 3:26 P.M., interview with CNA #106 verified the lack of personal protective equipment (PPE) while providing the physician ordered catheter care. The CNA verified a disposable gown should have been worn while providing the physician ordered catheter care. The CNA also verified the movement of the alcohol swab up and down the indwelling urinary catheter instead of going from insertion site down in a circular motion. Review of the facility policy titled, Catheter Care, dated 06/01/24 revealed it was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are used. When providing catheter care to a male gently draw foreskin back if applicable, using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap), with a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft, with a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter and dry area with towel. 2. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 11/03/22 revealed the resident required assistance with activities of daily living (ADL) related to new admission, weakness, depression, cognition. Interventions included inspect skin condition daily during personal care and report any impairment to charge nurse, keep call light in reach while in bed, observe for changes in ADL ability and adjust assistance as needed and president is totally dependent and does not participate in any aspect of the following tasks, toileting, bathing, transfers, bed mobility, dressing, hygiene, putting on/taking off footwear and locomotion. Review of the plan of care dated 10/24/24 revealed the resident had an actual area of skin impairment related to pressure ulcer to the right outer ankle and the right and left ischium. Interventions included bariatric pressure reducing mattress to bed, educate resident to be aware of surroundings while in wheelchair, education and demonstration provided to resident to release hand from wheelchair when propelling to reduce friction for skin integrity, encourage resident to lay down in between smoke breaks as tolerated, encourage resident to limit time in wheelchair to 60 minutes at a time, encourage resident to turn and reposition, encourage resident to wear prevalon boots as much as tolerated, gel cushion to wheelchair as tolerated, initiate wound treatment, continue treatment as ordered by physician, observe and document character of wound weekly, observe for clinical changes, skin observation and document on bath/shower days, administer diet as ordered and record percentage of intake every meal, administer supplements as ordered and record percentage taken, weekly skin assessments, when transferring, turning and repositioning, use proper techniques to avoid friction and shear, assist with transfers as needed, dietician to review nutritional status quarterly and inspect for any reddened areas during daily care. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident was frequently incontinent of bladder and always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one stage III and one unstageable pressure ulcer not present on admission. The assessment indicated the resident had no other skin issues. The facility implemented pressure reducing device to bed/chair, pressure ulcer/injury care and application of ointments/medications other than to feet. The assessment indicated the resident had no functional limitation in range of motion. Review of the weekly pressure skin grid dated 11/13/24 revealed the stage III pressure ulcer to the sacrum wound was resolved. Review of the progress note dated 11/22/24 at 7:15 A.M. revealed the nurse was checking the resident's buttocks when receiving care and found bilateral buttocks having pressure sore measuring 13.0 cm by 8.0 cm by 0.5 cm on the right side and 12.0 cm by 8.0 cm by 0.5 cm on the left side. A small amount of blood was noted. The wounds were cleansed with NS, pat dry, Xerofoam applied and covered with a dry clean dressing. The intervention to turn and reposition every two hours was implemented. Review of the resident's primary care physician progress note dated 11/22/24 revealed the resident was being seen for regulatory visit to address chronic condition and skin breakdown. The resident was found to have excoriation to groin and the resident's bottom, superimposed candidiasis with Diflucan two doses, zinc and nystatin cream was initiated. The wound team was to follow and offloading recommended. Review of the resident's monthly physician orders for December 2024 identified orders dated 02/15/23 regular no added salt diet, 10/31/24 ProHeal 30 milliliters (ml) by mouth twice daily, 02/25/23 foam cushion to wheelchair as tolerated, 01/15/24 house barrier cream every shift and as needed for incontinence/moisture for skin integrity prevention, 02/02/24 wear prevalon boots as tolerated while in bed every shift for skin integrity, 02/25/24 apply anti-fungal cream after each incontinent episode and as needed, 10/24/24 encourage resident to wear prevalon boots as much as tolerated every shift, encourage resident to turn and reposition every two hours as tolerated every shift, 11/22/24 pressure reducing mattress to bed, encourage resident to lay down in between smoke breaks as tolerated. chart effectiveness and compliance every shift, limit time sitting up in wheelchair for 60 minutes per Wound Physician, document compliance and non-compliance with wound care every shift and 11/27/24 paint right outer heel with betadine daily until resolved, cleanse left and right ischium with normal saline, pat dry, apply Mesalt to wound bed, cover with dry clean dressing daily and as needed, 12/02/24 gel cushion to wheelchair as tolerated. On 12/05/24 at 8:31 A.M., observation of Licensed Practical Nurse (LPN) #142 provide the physician ordered treatment to the resident's left and right buttocks revealed supplies were set-up on a barrier on the resident's bedside table upon entry to the room. The LPN washed her hands and donned gloves. The resident had the prevalon boots on and was positioned with pillows. No offloading was observed with the positioning. The resident was assisted onto his right side. The left and right buttocks wounds had no dressing in place. The LPN cleansed the left buttocks wound with normal saline (NS) and a 4X4. She then washed her hands and donned a pair of gloves and cleansed the right buttocks with NS and a 4X4. The LPN then changed her gloves without washing or sanitizing her hands. She then placed Mesalt pad onto the left buttocks wound and covered the wound with bordered dressing. The LPN then placed a Mesalt pad on the right buttocks wound and covered with a bordered dressing using the same gloves she dressed the left buttocks wound with. The resident was positioned on his left side but offloading was not achieved. On 12/05/24 at 8:42 A.M., interview with LPN #152 verified she completed the two wounds as one instead of separating the wounds and completing separately. 3. Review of the medical record for Resident #300 revealed an initial admission date of 01/23/24 with the latest readmission of 11/21/24 with diagnoses including but not limited to cirrhosis of liver, morbid obesity, asthma, diabetes mellitus, protein calorie malnutrition, chronic obstructive pulmonary disease, anemia, acute and chronic respiratory failure, insomnia, allergic rhinitis, retention of urine, dysphagia, pressure ulcer of unspecified site, depression, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, obstructive sleep apnea, cerebral infarct and chronic kidney disease. Review of the plan of care dated 01/24/24 revealed the resident has an actual area of skin impairment related to pressure area to sacrum, skin tear to right iliac crest and abrasion to right buttocks and right back. Interventions included air mattress as ordered, ask resident about pain level prior to dressing change procedure, medicate if needed, enhanced barrier precautions, evaluate for pain and provide pain relieving interventions as ordered, initiate wound treatment, continue treatment as ordered by the physician, limit time out of bed, nursing to observe the wound dressing daily to ensure that the dressing remains in tact and that there are no signs/symptoms of infection or increased drainage, observe and document character of wound weekly, observe for clinical changes, pressure reducing cushion to chair, refer to dietician to determine need/no need for dietary intervention and skin observation an document on bath/shower days. Review of the plan of care dated 02/05/24 revealed the resident had potential for alteration in skin integrity, requires protective/preventative skin care maintenance related to bowel/bladder incontinence, decreased mobility and history of previous skin breakdown. Interventions included air mattress to bed, apply house barrier as ordered, assist with transfers as needed, dietician to review nutritional status quarterly, encourage to float heels as tolerated, inspect for any reddened areas daily during care, pressure reducing cushion to chair to promote comfort and prevent skin breakdown as tolerated, provide peri-care with each incontinence episode, review for change in continence, weekly skin assessments, when transferring, turning and repositioning, use proper techniques to avoid friction and shear, diet as ordered and dietary supplements as tolerated to aid in wound healing, administer treatment to skin tear as ordered, keep skin clean and dry, apply lotion to dry skin and notify physician of signs/symptoms of infection or ineffective treatment. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident was at risk for skin breakdown and had one stage IV pressure ulcer on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition/hydration intervention to manage skin problems, pressure ulcer/injury care and application of ointments/medications other than to feet. Review of the resident's monthly physician orders for December 2024 identified orders dated 11/21/24 identified orders dated 11/27/24 cleanse upper sacral wound with normal saline (NS), place gentamicin to gauze packing strips, pack into small area wound and cover with dry clean dressing daily and as needed, 12/02/24 cleanse lower sacral wound with NS, pack wound with Dakins 1/2 Strength solution Kerlix, cover with dry clean dressing daily and as needed. On 12/03/24 at 3:26 P.M., observation of Licensed Practical Nurse (LPN) #145 and LPN #142 provide the physician ordered treatment to the stage IV pressure ulcer to the sacrum revealed the LPN donned PPE (gown/gloves). LPN #142 applied a disposable barrier on the resident's bedside table. assembled the required supplies and set-up the supplies on the barrier. LPN #145 washed her hands and donned a pair of gloves. LPN #145 then removed the soiled dressing to the wound to the left upper buttocks and the sacral wound. The wound bed was noted to be pink in color with a small amount of bleeding around the edges. LPN #145 changed her gloves without washing/sanitizing her hands. LPN #145 then cleansed the wound to the left upper buttocks with normal saline (NS) and a 4X4. She then obtained a clean NS soaked 4X4 and cleansed the sacral wound. The LPN then pat both areas dry using a 4X4 for each area. LPN #145 then changed her gloves without washing/sanitizing her hands. The LPN then packed the left upper buttocks with gentamicin soaked iodafoam. The LPN then packed the sacral wound with half strength Dakin's soaked Kerlix. The LPN then covered the sacral wound with a foam dressing and the left upper buttocks with an ABD pad. The LPN then positioned the resident to comfort with a wedge under her left side, a pillow under her right side and her heels floating with pillows. On 12/03/24 at 3:49 P.M., interview with LPN #145 verified the treatments to the left upper buttocks and the sacrum was administered together instead of separate to prevent the potential spread of infection and the lack of handwashing during glove changes. Review of the facility policy titled, Hand Washing Guidelines, last revised 01/19 revealed it was the policy of this facility that staff washes their hands on a regular basis, including before and after providing care for a resident, when visibly soiling is present, before and after the use of gloves, and as needed to assure clean hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy review, the facility did not keep an accurate record of skin wound assessments in the medical record for one (Resident #101) out of three residents with skin wounds. The facility census was 87. Findings include: Review of the medical record for Resident #101, revealed an admission date of 01/18/24. Diagnoses included metabolic encephalopathy, bacteremia, vascular dementia, and type 2 diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4 out of 15 which indicates severe cognitive impairment. The resident was determined to not have a pressure ulcer but at risk for developing them. Review of the nursing admission assessment dated [DATE] for Resident #101 revealed no skin alterations for his left and right buttock and his groin area. Review of the skin observation dated 01/21/24 for Resident #101 revealed skin was intact with no new areas opened. Review of Resident #101's assessment for skin grid pressure dated 01/22/24 revealed a reddened area to the right buttock with scant amount of blood measuring 8 centimeters (cm) by 11 cm by .01 cm. Review of twice a day skilled nurse notes for day shift for Resident #101 dated 01/22/24 revealed skin assessment as: other open lesion. Review of the progress note for Resident #101 dated 01/23/24 revealed a clarification was added by the Director of Nursing (DON) stating the area was moisture associated skin damage (MASD) noted to the middle right inner buttocks to anus measuring 3 cm by 3 cm by 0.1 cm. Review of twice a day skilled nurse notes for day shift for Resident #101 dated 01/23/24 revealed skin assessment as other open lesion. Review of Resident #101's assessment of skin grid non-pressure dated 01/23/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 3 cm by 3 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches, and had scar tissue visible and wound status as improved. Review of the weekly skin observation dated 01/23/24 for Resident #101 revealed skin was not intact, previous area identified, dressing dry and intact and no new areas noted with MASD to right buttock and groin with no measurements. Review of twice a day skilled nurse notes for night shift for Resident #101 dated 01/23/24 and 01/26/24 revealed skin was within normal limits. Review of twice a day skilled nurse notes for Resident #101 revealed the dates for: 01/27/24 day and night shift and 01/28/24 day shift skin assessment as other: open lesions. Review of twice a day skilled nurse notes for Resident #101 revealed the date of 01/30/24 as the skin assessment being within normal limits. Review of Resident #101's assessment of weekly skin grid non-pressure dated 01/30/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 2 cm by 1 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches and also has scar tissue visible and wound status as improved. Review of Resident #101's assessment of weekly skin grid non-pressure dated 01/31/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 2 cm by 1 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches and also has scar tissue visible and wound status as improved. Review of twice a day skilled nurse notes for Resident #101 dated 01/31/23 day shift, 02/01/24 day shift, 02/05/24 night shift, and 02/06/24 day shift documented skin assessment as other: open lesion. Review of twice a day skilled nurse notes for Residents #101 dated 02/02/24 and 02/03/24 for day shifts revealed skin assessment with: other concerns, see narrative note below with no notes. Review of Resident #101's assessment of weekly skin grid non-pressure dated 02/07/24 revealed the MASD are noted to be found on 01/22/24 and was the left buttock measuring 6.5 cm x 2.5 cm x 0.1 cm and was described as MASD to the left buttock, surrounding area blanches and also has scare tissue visible. Moisture around surrounding skin and wound status has improved. Review of weekly skin observation dated 02/07/24 for Resident #101 revealed skin was not intact and the left buttock was a sore wound. Review of the twice a day skilled nurses notes for Resident #101 dated 02/07/24 day shift revealed skin assessment was within normal limits. Interview on 02/13/24 at 11:43 A.M. with the Regional Nurse revealed when nurses are charting on skilled documentation's it should reflect their current skin status and verified since admission, Resident #101's twice a day skilled nurses notes have not reflected his actual skin assessments during his stay. Verified the resident also has never had a pressure ulcer to the right buttock, but a left MASD skin issue, despite the documentation on the weekly skin-grids documenting buttocks and groin. Interview on 02/14/23 at 1:00 P.M. with the Regional Nurse revealed for Resident #101's skin documentation's throughout his entire stay are not consistent and accurate and immediate education with be started for the issues and are not following facility policy. Observation on 02/14/24 at 10:23 A.M. for Resident #101 revealed the residents skin issue is to the left buttock only with clean dressing applied per Assistant Director of Nursing (ADON) #888. Review of the facility policy titled Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective (not opinionated, or speculative), complete, and accurate. This deficiency represents non-compliance investigated under Master Complaint Number OH00150749.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and facility policy review, the facility failed to appropriately confirm one resident's (Resident #71's) code status. This affected one resident (Resident #71) of one resident reviewed for advanced directives. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on [DATE]. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated [DATE] revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. Review of Resident #71's facesheet revealed the resident was his own responsible party and guarantor. Resident #71's wife was listed as an emergency contact only. Review of the admission Assessment with Baseline Care Plan dated [DATE] revealed the code status section of the assessment was not completed. Resident #71 was alert to person with unclear verbal communication. Resident #71 had impaired cognition or decision making skills noted. Review of the care plan dated [DATE] revealed Resident #71/family chose a Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) status. Cardiopulmonary Resuscitation (CPR) measures will not be attempted during a cardiac arrest. Interventions included if code status changes, code status will be posted in resident's chart and physician's orders. Review of the physician orders dated [DATE] revealed Resident #71 had an order for Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) dated [DATE]. Review of DNR Order Form dated [DATE] revealed the Patient or Authorized Representative Signature section stated Resident #71's wife's name, verbal signature and had DNRCC-A marked as the code status. Review of the care conference summary dated [DATE] revealed Resident #71 had a code status of Full Resuscitation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #71 required total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Resident #71 required extensive assistance to total dependence from one to two staff to complete ADLs. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated [DATE] and completed by Physician #208 revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. Interview on [DATE] at 1:39 P.M. with Social Services (SS) #179 revealed Resident #71 did not have a POA for healthcare in place and did not have a guardian appointed. SS #179 stated Physician #208 completed three expert evaluations on Resident #71 on [DATE], [DATE], and [DATE]. The physician's opinion was that Resident #71 was able to make decisions on [DATE] and [DATE]. The physician's opinion on [DATE] was that Resident #71 was not able to make decisions and agreed a guardian should be appointed. SS #179 confirmed prior to [DATE], the facility used Resident #71's wife as the resident's responsible party for healthcare decisions even though the resident's wife did not have POA for healthcare decisions in place. SS #179 confirmed there were not any legal documents in place that indicated Resident #71 could not make his own decisions. Resident #71 had a guardianship hearing scheduled in [DATE] (a year and six months after admission). Interview on [DATE] at 4:36 P.M. with Resident #71 revealed the resident used an iPad to answer yes and no. When asked if Resident #71 knew what Full Code and DNR meant, Resident #71 pressed the yes button on his iPad. However, Resident #71 was not able to elaborate or describe what either code status meant to demonstrate understanding. When asked if Resident #71 wanted to be a Full Code or DNR, Resident #71 did not respond. Interview on [DATE] at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since [DATE] and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, Residents' Rights Regarding Treatment and Advanced Directives, dated [DATE], revealed the policy stated, the facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to accurately assess one resident's (Resident #71) cognition. This affected one resident (Resident #71) of one reviewed for appropriate cognitive status. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored three out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored ten out of 15 on the BIMS assessment. Review of the Statement of Expert Evaluation dated 09/06/23 and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated 09/27/23 and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated 10/11/23 and completed by Physician #208 revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. At the time of the survey (over a year after Resident #71's admission), the facility had not determined whether or not Resident #71 needed assistance with healthcare decision making and had not identified a legal representative for the resident, if needed. Interview on 11/14/23 at 12:26 P.M. with Speech Therapist (ST) #207 revealed she had worked with Resident #71 on communication and swallowing. Resident #71 was last discharged from her caseload on 09/13/23 due to the resident reached the highest practical level. ST #207 stated Resident #71's communication abilities remained the same during each episode of therapy. ST #207 stated Resident #71 had severe expressive and receptive aphasia that would not improve. ST #207 stated she did not feel the BIMS assessment was a reliable or an accurate tool in assessing Resident #71's cognitive status due to the resident's severe aphasia. ST #207 stated she was not sure how Resident #71 received scores on the assessments because the resident was not able to complete the assessment. ST #207 stated she noted Resident #71 to have a BIMS of zero out of 15 upon initial evaluation and the score had not changed. ST #207 stated she felt Resident #71's use of the iPad was misleading because the resident was only 60% accurate when he used the iPad to communicate but a lot of people assume the resident was 100% accurate. ST #207 confirmed Resident #71's cognition had not been assessed accurately across various departments within the facility. Interview on 11/14/23 at 1:39 P.M. with Social Services (SS) #179 revealed she had completed the BIMS assessment with Resident #71 in the most recent MDS assessment. SS #179 stated Resident #71 used his iPad to respond to yes or no to questions. SS #179 confirmed she did not feel the BIMS assessment was an accurate depiction of Resident #71's cognitive status due to the resident's expressive and receptive aphasia. Interview on 11/15/23 at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since March 2023 and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, CMS's RAI Version 3.0 Manual, Section C: Cognitive Patterns, dated October 2023, revealed the policy stated, the items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. This deficiency represents noncompliance investigated under Complaint Number OH00147681.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective) disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had an order for Seroquel (an antipsychotic medication) 50 milligrams (mg) at bedtime for mood disorder related to dementia. The order was dated 08/28/23. Review of the Medication Administration Records dated September 2023, October 2023, and November 2023 revealed Resident #33 received Seroquel daily as ordered. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily antipsychotic medication. Review of the care plan revised 09/21/23 revealed the care plan did not address Resident #33's antipsychotic medication use. Interview on 11/15/23 at 4:50 P.M. with Regional Nurse (RGN) #203 confirmed Resident #33's care plan did not address the use of antipsychotic medication. Review of the facility policy, Comprehensive Care Plans, dated 08/22/22, revealed the policy stated, the facility would develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Based on observation, record review, interview and facility policy review, the facility failed to develop and implement a comprehensive plan of care for three residents (#33, #53, #61) in the area of contractures and antipsychotic medication use. This affected one (Resident #61) of one resident reviewed for contractures and two (Resident #33 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The assessment indicated the resident had displayed no behaviors and received antipsychotic medication on a routine basis. Review of the medical record revealed the resident had no care plan addressing the use of the antipsychotic medication, Seroquel or the target behaviors for the use of the antipsychotic medications. Review of the monthly physician orders for November 2023 identified orders dated 05/05/23 Seroquel 25 milligrams (mg) with the special instructions to administer two tablets by mouth daily at bedtime for schizophrenia. On 11/16/23 at 9:20 A.M., interview Director of Nursing (DON) #140 verified the facility had not developed and implemented a plan of care addressing the use of the antipsychotic medication, Seroquel or had not identified target behaviors for the use of the antipsychotic medications. 2. Review of the medical record for Resident #61 revealed an initial admission date of 09/13/23 with the diagnoses including encephalopathy, anxiety disorder, depression, urinary tract infection, hypotension, bradycardia and cerebrovascular accident with left sided hemiplegia. Review of the admission assessment with baseline plan of care dated 09/13/23 revealed the resident was admitted to the facility with a left hand/palm contracture. Review of the plan of care revealed the resident had no care plan addressing the care of the contracture to the resident's left hand/wrist. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, toileting, dressing, personal hygiene and was dependent on one staff for bathing. The assessment indicated the resident had no functional impairment to the upper or lower extremities. On 11/16/23 at 11:22 A.M., interview with Registered Nurse (RN) #107 verified the comprehensive MDS dated [DATE] failed to capture the resident's contractures to the left hand/wrist and the facility had not developed and implemented a comprehensive plan of care related to the resident's left hand/wrist contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and facility policy review, the facility failed to revise a comprehensive care plan to specifically address one resident's (Resident #71) cognitive status changes and whether or not a legal resident representative was needed for healthcare decision making. This affected one resident (Resident #71) of 20 residents reviewed for care plans. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated 01/24/22 revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. Review of Resident #71's facesheet revealed the resident was his own responsible partly and guarantor. Resident #71's wife was listed as an emergency contact only. Review of the admission Assessment with Baseline Care Plan dated 06/03/22 revealed the code status section of the assessment was not completed. Resident #71 was alert to person with unclear verbal communication. Resident #71 had impaired cognition or decision making skills noted. Review of the care plan dated 06/03/22 revealed Resident #71 had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included communicate with staff, family, physician/Certified Nurse Practitioner (CNP) regarding resident's needs. The care plan did not identify a specific resident representative and did not indicate specifically whether or not Resident #71 was able to make healthcare decisions for himself. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored six out of 15 on the BIMS assessment. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored three out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored eight out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired cognition and scored ten out of 15 on the BIMS assessment. Review of the Statement of Expert Evaluation dated 09/06/23 and completed by Physician #208 revealed Resident #71 was aphasic but oriented. Resident #71 was reportedly married and had a living mother. The situation was complicated due to family dynamics regarding a legal next of kin. Resident #71 was not able to functionally care for himself but was able to participate in medical decisions with assistive devices due to aphasia. Physician #208's opinion was for guardianship to be denied. Review of the Statement of Expert Evaluation dated 09/27/23 and completed by Physician #208 revealed Resident #71 was not mentally impaired. Resident #71 appeared mentally intact upon assessment. Resident #71 had profound dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) that limited his ability to communicate. Resident #71 used an iPad with a yes and no button. Physician #208's opinion was Resident #71 required assistance with Activities of Daily Living (ADLs), but was able to participate in medical decisions and guardianship should be denied. Review of the Statement of Expert Evaluation dated 10/11/23 and completed by Physician #208 revealed Resident #71 had aphasia (the loss of ability to understand or express speech, caused by brain damage) and an altered mental state. Resident #71 had impairments with orientation, speech, motor behavior, memory and judgement. Resident #71 exhibited inconsistencies with responses during the assessment. Resident #71 would not be capable of managing finances or personal property. Physician #208's opinion was that guardianship should be established. Interview on 11/14/23 at 12:26 P.M. with Speech Therapist (ST) #207 revealed she had worked with Resident #71 on communication and swallowing. Resident #71 was last discharged from her caseload on 09/13/23 due to the resident reached the highest practical level. ST #207 stated Resident #71's communication abilities remained the same during each episode of therapy. ST #207 stated Resident #71 had severe expressive and receptive aphasia that would not improve. ST #207 stated she did not feel the BIMS assessment was a reliable or an accurate tool in assessing Resident #71's cognitive status due to the resident's severe aphasia. ST #207 stated she was not sure how Resident #71 received scores on the assessments because the resident was not able to complete the assessment. ST #207 stated she noted Resident #71 to have a BIMS of zero out of 15 upon initial evaluation and the score had not changed. ST #207 stated she felt Resident #71's use of the iPad was misleading because the resident was only 60% accurate when he used the iPad to communicate but a lot of people assume the resident was 100% accurate. ST #207 confirmed Resident #71's cognition had not been assessed accurately across various departments within the facility. Interview on 11/14/23 at 1:39 P.M. with Social Services (SS) #179 revealed Resident #71 did not have a POA for healthcare in place and did not have a guardian appointed. SS #179 stated Physician #208 completed three expert evaluations on Resident #71 on 09/06/23, 09/27/23, and 10/11/23. The physician's opinion was that Resident #71 was able to make decisions on 09/06/23 and 09/27/23. The physician's opinion on 10/11/23 was that Resident #71 was not able to make decisions and agreed a guardian should be appointed. SS #179 confirmed prior to September 2023, the facility used Resident #71's wife as the resident's responsible party for healthcare decisions even though the resident's wife did not have POA for healthcare decisions in place. SS #179 confirmed there were not any legal documents in place that indicated Resident #71 could not make his own decisions. Interview on 11/15/23 at 9:08 A.M. with Physician #208 revealed she had been the facility's physician since March 2023 and had visited Resident #71 on multiple occasions. Physician #208 confirmed she completed three expert evaluations for court appointed guardianship on Resident #71. Two of her evaluations determined guardianship should be denied and the most recent evaluation, Physician #208 found that guardianship should be established for Resident #71. Physician #208 stated Resident #71 had severe aphasia and used an iPad to communicate mostly. During her first two evaluations, she allowed Resident #71 to use the iPad to answer questions and during her third evaluation, she presented other tools, such as a calendar, for Resident #71 to use to help answer questions. Physician #208 stated when Resident #71 was presented with the more unfamiliar objects, inconsistencies with responses arose. Physician #208 stated in her opinion, Resident #71 would be able to make some simple healthcare decisions but would not be able to fully understand more complex healthcare decisions and therefore, in her opinion, Resident #71 should have a court appointed guardian put into place for him. Review of the facility policy, Comprehensive Care Plans, dated 08/22/22, revealed the policy stated, the comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, resident specific interventions that reflect the resident's needs and preferences, and identify tools used for communication. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Alternative interventions will be documented, as needed. This deficiency represents noncompliance investigated under Complaint Number OH00147681.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident's (Resident #239) vital signs were checked upon returning from dialysis treatments. This affected one resident (Resident #239) of one reviewed for dialysis. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed and initial admission date on 10/24/23 and a readmission date on 11/03/23. Medical diagnoses included cognitive deficit deficit, end stage renal disease, and acute kidney failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #239 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #239's function level varied from supervision with eating to total dependence with personal hygiene. Resident #239 required maximal assistance with lower dressing, bathing, and toileting. Resident #239 did not require dialysis at the time of the assessment. Additional MDS assessments had not been processed at the time of the survey. Review of the physician orders dated November 2023 revealed an order for dialysis on Monday, Wednesday, and Friday to an outside dialysis center dated 11/07/23. Review of the Medication Administration Record (MAR) dated November 2023 revealed Resident #239 attended dialysis treatments as ordered. Review of the care plan revised 11/11/23 revealed Resident #239 was at risk for potential complications related to renal failure requiring dialysis treatment. Interventions included obtain vital signs and weight per protocol and report significant changes in pulse, respirations, and blood pressure immediately. Review of the Dialysis Communications Forms dated 11/06/23, 11/08/23, 11/10/23, and 11/13/23 revealed Resident #239's vital signs were not monitored upon returning to the facility from dialysis treatments. Interview on 11/14/23 at 5:40 P.M. with Resident #239 revealed she had not been sent with Dialysis Communication Forms to all dialysis treatments. Resident #239 stated the dialysis center checked her vital signs but the facility did not check her vital signs upon returning to the facility after dialysis treatments. Interview on 11/15/23 at 11:00 A.M. with Regional Nurse (RGN) #203 confirmed Resident #239's vital signs were not being monitored upon returning to the facility from the dialysis center. Review of the facility policy, Monitoring/Communication Re: Dialysis Residents, revised 07/2018, revealed the policy stated, staff observe for significant change in status prior to going to dialysis, and upon return. The physician/Certified Nurse Practitioner (CNP) will be notified of a significant change in status or other concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of pharmacy recommendations, and facility policy review, the facility failed to timely address a pharmacy recommendation for one resident (Resident #33) and failed to provide a rationale for declining a Gradual Dose Reduction (GDR) for two residents (Residents #28 and #33). This affected two residents (Residents #28 and #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the pharmacy recommendation dated 04/10/23 revealed Resident #33 received a current dose of Seroquel (Quetiapine) 75 milligrams once daily without an attempted Gradual Dose Reduction (GDR). The recommendation was to consider a GDR while monitoring for re-emergence of behavioral and/or withdrawal symptoms. There was no rationale documented related to why the GDR was contraindicated. The pharmacy recommendation was reviewed and declined by the physician or Certified Nurse Practitioner (CNP) on 05/05/23 (nearly one month later). Interview on 11/15/23 at 4:50 P.M. with Regional Nurse (RGN) #203 confirmed the pharmacy recommendation dated 04/10/23 was not addressed until 05/05/23 (nearly one month later). RGN #203 did not know why there was a delay in addressing the recommendation and confirmed there was not a documented rationale provided for why the GDR recommended was contraindicated. 2. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury (TBI), schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the plan of care dated 05/01/20 revealed the resident had potential for adverse side effects of psychotropic drug use, antidepressant, TBI and major depressive disorder, 03/01/21 voices wants to kill himself at times, receiving antidepressant and antipsychotic medications. Interventions included continue to offer counseling despite previous refusals, document side effects of medication, notify physician of any mental status changes that occur, observe and document any abnormal behavior or moods and obtain vital signs as ordered and report abnormalities to physician. Review of the pharmacy recommendation dated 02/10/23 revealed the pharmacist recommended a gradual dose reduction (GDR) for the medication Seroquel 25 mg by mouth twice daily. The physician addressed the recommendation on 02/13/23 and declined the recommendation checking the box GDR contraindicated as continued use in accordance with current relevant standards of practice and the following rationale. Further review revealed no documented rationale to decline the GDR. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. The assessment indicated the resident had hallucinations and delusions. The assessment indicated the resident received antipsychotic, antidepressant on a routine basis. The facility had not attempted a gradual dose reduction (GDR) and the physician had no documented a GDR as clinically contraindicated. Review of the monthly physician orders for November 2023 identified orders 08/29/23 Seroquel 25 mg by mouth twice daily for behaviors and 08/29/23 Seroquel 50 mg by mouth twice daily for schizoaffective disorder bipolar type. On 11/14/23 at 4:33 P.M., interview with Director of Nursing (DON) #140 verified the pharmacy recommendation dated 02/10/23 had no documented justification to decline the recommended GDR for the antipsychotic medication Seroquel. Review of the facility policy, Medication Regimen Review, undated, revealed the policy stated, timelines and responsibilities for Medication Regimen Review (MRR) included: facility staff shall act upon all recommendation according to procedures for addressing medication regimen review irregularities. Furthermore, the pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure parameters for when the physician should be notified were provided for one resident's (Resident #33) insulin orders. This affected one resident (Resident #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with neuropathy and chronic kidney disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had the following insulin orders: Humalog Infection Solution inject five units subcutaneously at bedtime dated 06/22/23, Insulin Glargine Solution inject 20 units subcutaneously one time a day upon rise dated 07/29/23, Insulin Glargine Solution inject 30 units subcutaneously at bedtime dated 07/28/23, and Trulicity Subcutaneous Solution inject 4.5 milligrams (mg) subcutaneously every Tuesday upon rise dated 06/27/23. None of the insulin orders included parameters to notify the physician for staff to follow. Resident #33 also had an order for accuchecks to be completed twice daily dated 06/22/23. Review of blood glucose levels dated from 07/28/23 through 11/10/23 revealed Resident #33's blood glucose levels ranged from 51 to 390. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily insulin injections. Review of the care plan revised 09/21/23 revealed Resident #33 was at risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included be alert for signs and symptoms of hypoglycemia including blood sugars less than 50 mg/dl and be alert for signs and symptoms of hyperglycemia including blood sugars greater than 200 mg/dl. Interview on 11/16/23 at 1:24 P.M. with Regional Nurse (RGN) #203 confirmed Resident #33's insulin orders did not include any parameters to notify the physician. RGN #203 stated the orders should include parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had an order for Seroquel (an antipsychotic medication) 50 milligrams (mg) at bedtime for mood disorder related to dementia. The order was dated 08/28/23. There were no orders to monitor for specific target behaviors or side effects of the antipsychotic medication. Review of the Medication Administration Records dated September 2023, October 2023, and November 2023 revealed Resident #33 received Seroquel daily as ordered. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #33 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #33 received daily antipsychotic medication. Review of the behavior monitoring task dated from 10/16/23 through 11/16/23 revealed Resident #33 was noted to yell or scream on three days out of 30. There were no other behaviors noted for Resident #33. Review of the care plan revised 09/21/23 revealed the care plan did not address Resident #33's antipsychotic medication use or monitoring for target behaviors and side effects of the medication. Interview on 11/16/23 at 1:24 P.M. with Regional Nurse (RGN) #203 confirmed there were not any target behaviors indicated for Resident #33. Also, RGN #203 confirmed there was not any orders or care plan to monitor for side effects of the antipsychotic medication, Seroquel. A facility policy was requested related to antipsychotic medications. The policy, Medication Regimen Review, undated, was provided. However, upon review of the policy, the policy does not address antipsychotic medications specifically. Based on record review and interview, the facility failed to identify target behaviors for the use of antipsychotic medications for three residents (#28, #33, #53) and failed to monitor for side effects of antipsychotic medication use for one resident (#33). This affected three of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the plan of care dated 05/01/20 revealed the resident had potential for adverse side effects of psychotropic drug use, antidepressant, TBI and major depressive disorder, 03/01/21 voices wants to kill himself at times, receiving antidepressant and antipsychotic medications. Interventions included continue to offer counseling despite previous refusals, document side effects of medication, notify physician of any mental status changes that occur, observe and document any abnormal behavior or moods and obtain vital signs as ordered and report abnormalities to physician. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. The assessment indicated the resident had hallucinations and delusions. The assessment indicated the resident received antipsychotic on a routine basis. Review of the monthly physician orders for November 2023 identified orders dated 08/29/23 Seroquel 25 mg by mouth twice daily for behaviors and Seroquel 50 mg by mouth twice daily for schizoaffective disorder bipolar type. The facility increased the resident's Seroquel on 08/29/23 from 50 mg by mouth to twice daily to 75 mg by mouth twice daily following a failed GDR. Review of the resident's treatment administration record revealed the resident is monitored for sadness, irritability, and withdrawn for the use of the medication Seroquel. On 11/14/23 at 4:33 P.M., interview with Director of Nursing (DON) #140 verified the identified target behaviors were not appropriate for the use of the antipsychotic medication Seroquel. 2. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The assessment indicated the resident had displayed no behaviors, received antipsychotic medications on a routine basis. The assessment indicated the diagnoses depression, bipolar disorder and schizophrenia were active diagnoses. Review of the medical record revealed the resident had no care plan addressing the use of the antipsychotic medication or the target behaviors for the use of the antipsychotic medications. Review of the monthly physician orders for November 2023 identified orders dated 05/05/23 Seroquel 25 mg with the special instructions to administer two tablets by mouth daily at bedtime for schizophrenia. Review of the treatment administration record (TAR) revealed the facility monitored the resident for increased behaviors, increased agitation, and lethargy of the use of Seroquel. On 11/16/23 at 9:20 A.M., interview with DON #140 verified the identified target behaviors were not appropriate for the use of the antipsychotic medication Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain laboratory tests for residents as physician ordered. This affected two (Resident #28 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the monthly physician orders for November 2023 identified orders dated 02/10/22 Depakote level and liver function test (LFT), every three months, 02/16/22 complete metabolic [NAME] (CMP), complete blood count (CBC) every six months and Fasting Lipid Panel annually. Review of the resident's laboratory results revealed no LFT results for June 2023 and no CMP/CBC results for September 2023. Review of the resident's discontinued physician orders revealed no order for the CMP/CBC to be drawn in June 2023 On 11/15/23 at 10:48 A.M., interview with Registered Nurse (RN) #107 verified the LFT, CBC and CMP were not obtained as physician ordered. 2. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added. Review of the pharmacy recommendation dated 09/05/23 revealed the pharmacist recommended a Hemoglobin A1c (HgbA1c) next lab day and yearly thereafter due to the use of the antipsychotic medication Seroquel use. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident has a moderate cognitive deficit. Review of the monthly physician orders for November 2023 identified orders dated 09/08/23 for HgbA1c today and yearly. Review of the resident's medical record revealed no HgbA1c results for the physician order dated 09/08/23. On 11/16/23 at 9:20 A.M., interview Director of Nursing (DON) #140 verified HgbA1c was not obtained on 09/08/23 as physician ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to maintain one resident's (Resident #239) wheelchair in proper working order. This affected one of 22 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed an initial admission date of 10/24/23 with the latest readmission of 11/03/23 with diagnoses including cognitive communication deficit, retention of urine, end stage renal disease, dependence on hemodialysis and acute kidney failure. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. On 11/13/23 at 4:22 P.M., interview with Resident #239 revealed she had two different foot pedals to her wheelchair and the left foot pedal would not latch causing her legs spread when moved. Resident #239 revealed this caused her pain to her hips and legs. The resident revealed her transport driver who transports her to dialysis three times a week, as well as herself had asked the facility more than one to be repaired. On 11/14/23 at 2:45 P.M., observation of the resident's wheelchair sitting outside the resident's door revealed two foot pedals were sitting on the seat of the wheelchair. One right foot pedal was black and latched when attached to the wheelchair. The left foot pedal was blue and would not latch when put on the wheelchair. Interview with State Tested Nursing Assistant (STNA) #190 at the time of the observation revealed the ambulance driver had asked for the wheelchair to be repaired but the facility had not repaired the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to export resident assessments in a timely manner. This affected 16 (Residents #5, #16, #25, #35, #38, #39, #40, #44, #48, #50, #51, #52, #56, #67, #74, and #83) of 19 resident assessments reviewed. The census was 88. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Her diagnoses were dementia, anemia, type II diabetes, depression, COPD, schizoaffective disorder, hyperlipidemia, hypothyroidism, dysphagia, schizophrenia, hypokalemia, aphasia, osteoarthritis, hypertension, cognitive communication deficit, altered mental status, and psychosis. Review of her Minimum Data Set (MDS) assessment, dated 07/06/23, revealed she had a severe cognitive impairment. Review of Resident #5 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/06/23. The facility had started/completed the her most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 2. Resident #16 was admitted to the facility on [DATE]. His diagnoses were hydrocephalus, hypertensive retinopathy, major depressive disorder, cognitive communication deficit, hyperlipidemia, hypercalcemia, spastic hemiplegia, type II diabetes, hypokalemia, anxiety disorder, hypertension, and depression. Review of his Minimum Data Set (MDS) assessment, dated 07/04/23, revealed he was cognitively intact. Review of Resident #16 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the his most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 3. Resident #25 was admitted to the facility on [DATE]. Her diagnoses were bipolar disorder, dementia, major depressive disorder, anxiety disorder, psychosis, type II diabetes, insomnia, and dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #25 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the her most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 4. Resident #35 was admitted to the facility on [DATE]. Her diagnoses were COPD, emphysema, chronic kidney disease, hypertensive heart disease, congestive heart failure, lymphedema, dermatitis, cognitive communication deficit, atherosclerotic heart disease, hypothyroidism, type II diabetes, hyperlipidemia, peripheral vascular disease, hypotension, opioid dependence, edema, chronic gout, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 07/04/23, revealed she was cognitively intact. Review of Resident #35 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the her most recent MDS on 10/04/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/04/23 had not been submitted; it was documented as being ready to export. 5. Resident #38 was admitted to the facility on [DATE]. His diagnoses were type II diabetes, insomnia, hypertension, anxiety disorder, dementia, chronic pain syndrome, schizoaffective disorder, hypo-osmolality and hyponatremia, hypothyroidism, cognitive communication deficit, and metabolic encephalopathy. Review of his Minimum Data Set (MDS) assessment, dated 07/04/23, revealed he had a mild cognitive impairment. Review of Resident #38 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/04/23. The facility had started/completed the his most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 6. Resident #39 was admitted to the facility on [DATE]. His diagnoses were frontotemporal neurocognitive disorder, hypertension, cognitive communication deficit, hyperlipidemia, hypertension, paranoid personality disorder, delusional disorder, dementia, and convulsions. Review of his Minimum Data Set (MDS) assessment, dated 07/07/23, revealed he had a severe cognitive impairment. Review of Resident #39 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the his most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 7. Resident #40 was admitted to the facility on [DATE]. Her diagnoses were peripheral vascular disease, hypertension, COPD, hearing loss, muscle weakness, dementia, hyperlipidemia, and anemia. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #40 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the her most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 8. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure, metabolic encephalopathy, schizophrenia, COPD, congestive heart failure, shortness of breath, muscle weakness, cognitive communication deficit, insomnia, and altered mental status. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she had a mild cognitive impairment. Review of Resident #44 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most recent MDS on 10/07/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/07/23 had not been submitted; it was documented as being ready to export. 9. Resident #48 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, anemia, type II diabetes, hypertension, major depressive disorder, chronic kidney disease (stage III), atherosclerotic heart disease, insomnia, vitamin B deficiency, vitamin D deficiency, anxiety disorder, osteoarthritis, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/08/23, revealed she was cognitively intact. Review of Resident #48 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/08/23. The facility had started/completed the her most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 10. Resident #50 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, insomnia, hypertension, dysphagia, cognitive communication deficit, cerebral infarction, hyperlipidemia, altered mental status, delirium, hypotension, and COPD. Review of his Minimum Data Set (MDS) assessment, dated 07/03/23, revealed he was cognitively intact. Review of Resident #50 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the his most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 11. Resident #51 was admitted to the facility on [DATE]. Her diagnoses were schizophrenia, encephalopathy, anemia, cognitive communication deficit, dysphagia, major depressive disorder, aphasia, and dementia. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she had a severe cognitive impairment. Review of Resident #51 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most recent MDS on 10/07/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/07/23 had not been submitted; it was documented as being ready to export. 12. Resident #52 was admitted to the facility on [DATE]. His diagnoses were schizophrenia, hypertension, type II diabetes, hyperlipidemia, delusional disorder, dysphagia, major depressive disorder, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 07/08/23, revealed he was cognitively intact. Review of Resident #52 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/08/23. The facility had started/completed the his most recent MDS on 10/08/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/08/23 had not been submitted; it was documented as being ready to export. 13. Resident #56 was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure, psychosis, traumatic subdural hemorrhage, depression, hyperlipidemia, polyneuropathy, anemia, encephalopathy, anxiety disorder, dysphagia, hypertension, cognitive communication deficit, and type II diabetes. Review of his Minimum Data Set (MDS) assessment, dated 07/03/23, revealed he had a mild cognitive impairment. Review of Resident #56 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/03/23. The facility had started/completed the his most recent MDS on 10/03/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/03/23 had not been submitted; it was documented as being ready to export. 14. Resident #67 was admitted to the facility on [DATE]. Her diagnoses were acute transverse myelitis, paraplegia, bipolar disorder, neuromuscular dysfunction, mood disorder, and depression. Review of her Minimum Data Set (MDS) assessment, dated 07/02/23, revealed she had a mild cognitive impairment. Review of Resident #67 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/02/23. The facility had started/completed the her most recent MDS on 10/02/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/02/23 had not been submitted; it was documented as being ready to export. 15. Resident #74 was admitted to the facility on [DATE]. His diagnoses were hemiplegia and hemiparesis, hypertension, congestive heart failure, cognitive communication deficit, hyperlipidemia, cerebral infarction, depression, aphasia, dysphagia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 07/06/23, revealed he had a mild cognitive impairment. Review of Resident #74 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/06/23. The facility had started/completed the his most recent MDS on 10/06/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/06/23 had not been submitted; it was documented as being ready to export. 16. Resident #83 was admitted to the facility on [DATE]. Her diagnoses were acute transverse myelitis, paraplegia, bipolar disorder, neuromuscular dysfunction, mood disorder, and depression. Review of her Minimum Data Set (MDS) assessment, dated 07/07/23, revealed she cognitively intact. Review of Resident #83 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/07/23. The facility had started/completed the her most recent MDS on 10/05/23, but due to the electronic medical records company having an error with their program, they could not submit the assessment until 11/01/23. As of 11/14/23, the assessment from 10/05/23 had not been submitted; it was documented as being ready to export. Interview with Regional MDS Director #205 on 11/15/23 at 10:02 A.M. revealed they had the MDS assessments completed by the required timeframe. She also confirmed they could not submit the MDS assessments from 10/01/23 to 11/01/23 due to an error within the electronic medical record system. She confirmed the error was fixed with the records system on 11/01/23 and the assessments should have been sent in after that. She confirmed as of 11/14/23, the assessments had not been sent int, which was not completed in a timely manner. Review of facility Maintaining MDS Assessment policy, dated 10/01/23, revealed MDS information will be readily and easily accessible for review by the state survey agency and CMS.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving to residents on a pureed diet and required surveyor intervention for safety. This had the potential to affect nine residents (Residents #7, #49, #39, #5, #75, #4, #81, #64, and #52) who were on a prescribed pureed diet. The facility census was 88. Findings Include: 1. Observation on 11/15/23 at 10:48 A.M. with [NAME] #117 revealed the cook was preparing pureed Italian blend vegetables. [NAME] #117 confirmed the menu for lunch was Italian blend mixed vegetables and barbeque chicken. The recipes were observed to the left of [NAME] #117 during preparation. Vegetables in the Italian vegetable mix include carrots, green beans, cauliflower, and broccoli. Dietary Manager (DM) #178 was present for observation. Observation and interview on 11/15/23 at 10:54 A.M. revealed [NAME] #117 stopped puree machine and stated the vegetable mix was the proper texture for serving to residents. The surveyor present tasted the vegetable mix for proper texture. The pureed vegetable mix required some chewing and did not have a smooth texture. Interview on 11/15/23 at 10:55 A.M., [NAME] #117 and DM #178 were asked to taste the puree and they both said it was okay to serve. [NAME] #117 transferred the pureed vegetable mix from the blender into a metal container, covered it, and placed the container in the steamer to keep warm until it was time to place it on the tray line. Another Healthcare Facility Surveyor was asked to taste the food. Observation on 11/15/23 at 11:25 A.M., the second surveyor tasted the mixed vegetable puree and said it didn't have a smooth texture. The surveyor opened her mouth to show there was a chunk of cauliflower on her tongue. Interview on 11/15/23 at 11:25 A.M. with DM #178 confirmed they would puree the vegetable mix more. Review of the Vegetable Italian Blend recipe notes, 1. Remove portions to be pureed from the regular prepared vegetable. 2. Place in food processor and process until fine in consistency. 2. Observation on 11/15/23 at 10:57 A.M. with [NAME] #117 revealed the cook was preparing barbeque chicken to puree. The recipes were observed to the left of [NAME] #117 during preparation. Dietary Manager (DM) #178 was present for observation. Observation and interview on 11/15/23 at 11:01 A.M. revealed [NAME] #117 stopped puree machine and stated the barbeque chicken was the proper texture for serving to residents. The surveyor present tasted the barbeque chicken for proper texture. The barbeque chicken required chewing, was stringy, and did not have a smooth texture. Interview on 11/15/23 at 11:01 A.M. [NAME] #117 and DM #178 were asked to taste the puree and they both said it was okay to serve. [NAME] #117 transferred the barbeque chicken from the blender into a metal container, covered it, and placed the container in the steamer to keep warm until it was time to place it on the tray line. Another Healthcare Facility Surveyor was asked to taste the food. Observation on 11/15/23 at 11:18 A.M., the second surveyor tasted the barbeque chicken and said it didn't have a smooth texture. The surveyor opened her mouth to show there was a chunk of chicken on her tongue. Interview on 11/15/23 at 11:18 A.M. with DM #178 confirmed they would puree the barbeque chicken more. Review of the barbeque chicken recipe notes, 1. Place prepared BBQ chicken in food processor. 2. Add hot broth (base and water) and process until smooth in texture. Review of the facility policy, Dysphagia Puree (Level 1) Diet, dated 2008 revealed the policy stated, All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. The policy also states All foods must be the consistency of moist mashed potatoes or pudding.

Based on observation, interview, and facility policy review, the facility failed to keep clean drying dishware in a clean dry location and not exposed to dust or other contamination. This had the potential to affect 87 out of 88 residents who receive beverages from the facility. The facility census was 88. Findings include: Observation on 11/13/23 at 11:27 A.M. revealed a recently cleaned rack of mugs and cups air drying on the end of the dishwasher line. Observed a ceiling tile with light pink insulation and dust hanging down from both ends of the ceiling tile and a ceiling vent next to the ceiling tile that was covered in dust. The tiles were above the clean rack of mugs and cups. Interview on 11/13/23 at 11:27 A.M. with Corporate Food Service Director #208 confirmed the ceiling area could be cleaner and there is pink dust at the end of the ceiling vents. Review of the undated Dish Machine Cleaning policy and the weekly Cleaning chart both do not indicate the area above where air drying is taking place.

Based on medical record review, resident and staff interview, observation, policy review, and review of a Centers for Medicare and Medicaid Services (CMS) memo, the facility failed to ensure activities were provided to meet the needs of the residents. This affected three (#38, #40, and #86) of three residents reviewed for activities. The census was 87. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 07/15/21. Resident #40's medical diagnoses included bipolar disorder, diabetes, non-Alzheimer's dementia, and psychotic disorder. Review of Resident #40's annual Minimum Data Set (MDS) assessment, dated 07/03/23, revealed Resident #40 was cognitively intact. Review of the activities care plan, dated 08/02/23, revealed Resident #40 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #40 to participate in activities. Review of Resident #40's Record of One on One Activities, dated September 2023, revealed Resident #40 was documented as having a active reaction/response to a one on one activity of social chat on 09/01/23, a active reaction/response to a one on one activity of talking on 09/08/23 and 09/12/23. On 09/06/23, social was documented as Resident #38's one on one activity however Resident #38's reaction/response was documented as not in the room. Resident #38 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #40's Activity Participation for 09/01/23 through 09/14/23 revealed Resident #40 was documented as participating in book reading everyday between 09/01/23 and 09/14/23, TV in room everyday between 09/01/23 and 09/14/23, socializing with peers everyday between 09/01/23 and 09/14/23, outside everyday between 09/01/23 and 09/14/23, crossword/word search everyday between 09/01/23 and 09/14/23. Resident #40 was documented as participating in food related groups on 09/03/23, 09/04/23, and 09/06/23. Resident #40 was documented as participating in arts and crafts on 09/06/23, 09/07/23, 09/11/23, 09/13/23, and 09/14/23. Interview with Resident #40 on 09/13/23 at 10:04 A.M. revealed there had not been any structured activities in the past one to two weeks due to COVID-19. 2. Review of the medical record for Resident #38 revealed an admission date of 03/04/23. Resident #38's medical diagnosis included congested heart failure. Review of the quarterly MDS assessment, dated 07/21/23, revealed Resident #38 was cognitively intact. Review of Resident #38's activities care plan, dated 02/17/23, revealed Resident #38 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #38 to participate in activities. Review of Resident #38's Record of One on One Activities, dated September 2023, revealed Resident #38 was documented as having a active reaction/response to a one on one activity of current events chat on 09/01/23, a active reaction/response to a one on one activity of talking on 09/08/23, 09/12/23, and 09/15/23. On 09/06/23, social/talk was documented as Resident #38's one on one activity however Resident #38's reaction/response was documented as not in the room. Resident #38 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #38's Activity Participation for 09/01/23 through 09/14/23 revealed Resident #38 was documented as participating in puzzles/cards everyday between 09/01/23 and 09/14/23, TV in room everyday between 09/01/23 and 09/14/23, socializing with peers everyday between 09/01/23 and 09/14/23, outside smoking everyday between 09/01/23 and 09/14/23, crossword/word search everyday between 09/01/23 and 09/07/23, trivia/reminiscing everyday between 09/01/23 and 09/14/23. Resident #38 was documented as participating in food related groups on 09/03/23, 09/04/23, and 09/06/23. Resident #38 was documented as participating in arts and crafts on 09/01/23, 09/04/23, 09/06/23, 09/07/23, 09/11/23, 09/13/23, and 09/14/23. Interview with Resident #38 on 09/19/23 at 10:38 A.M. revealed she was told there wasn't going to be any communal activities due to the COVID-19 virus. 3. Review of the medical record for Resident #86 revealed an admission date of 09/07/23. Resident #86's medical diagnosis included unspecified fracture of the left femur. Review of the progress note dated 09/07/23 revealed Resident #86 was alert and oriented times four. Review of the care plan dated 09/11/23 revealed Resident #86 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #86 to participate in group activities. Review of Resident #86's Record of One on One Activities, dated September 2023, revealed Resident #86 was documented as having a active reaction/response to a one on one activity of talk/nails on 09/12/23. Resident #86 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #86's Activity Participation for 09/08/23 through 09/14/23 revealed Resident #86 was documented as participating in trivia/reminiscing everyday between 09/08/23 and 09/14/23, TV in room everyday between 09/08/23 and 09/14/23, outside smoking everyday between 09/08/23 and 09/14/23, and arts and crafts everyday between 09/10/23 and 09/14/23. Interview with Resident #86 on 09/13/23 at 3:01 P.M. revealed there had not been any structured activities due to the facilities COVID-19 outbreak. Review of the facility timeline for the COVID-19 outbreak revealed the first resident was found to be positive for COVID-19 on 08/23/23 and no new residents had tested positive for COVID-19 after 09/03/23. As of 09/13/23, all COVID-19 positive residents were removed from isolation. Review of the activity calendar for 09/13/23 revealed fall crafts was scheduled for 10:30 A.M., Optum shopping and a hydration cart/music was scheduled for 12:00 P.M., and national chocolate day was scheduled for 2:00 P.M. Observation on 09/13/23 from 10:25 A.M. to 10:34 A.M. revealed no evidence of the fall crafts activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Observation on 09/13/23 at 12:00 P.M., revealed no evidence of the Optum shopping activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Observation on 09/13/23 at 2:00 P.M. revealed no evidence of a National Chocolate Day activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Interview with State Tested Nursing Aide (STNA) #121 on 09/13/23 at 9:30 A.M. revealed there weren't any communal activities for the residents since the most recent COVID-19 outbreak began. Interview with STNA #109 on 09/13/23 at 9:45 A.M. revealed there had not been any communal activities for the residents since the most recent COVID-19 outbreak started. Interview with Activity Director (AD) #180 on 09/13/23 at 2:25 P.M. revealed she revised the schedule for the activities due to COVID-19 and was not conducting communal activities for the residents. Interview with Receptionist #192 on 09/19/23 at 10:33 A.M. revealed there had not been any communal activities since the most recent COVID-19 outbreak began. Review of the policy titled Activity Program, undated, revealed the facility would provide activity programs that are designed to meet the needs of residents and are available on a daily basis. Various activities are provided to meet the needs of residents with a range of cognitive and physical levels of functioning. The policy further revealed social distancing and isolating/sheltering in place does not mean that the fun must stop! In fact, the energy level of activity staff must increase. Review of the CMS memo QSO-20-39-NH, revised 05/08/23, revealed while adhering to the core principles of COVID-19 infection prevention, communal activities may occur. This deficiency represents non-compliance investigated under Master Complaint Number OH00146252.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and policy review the facility failed to ensure personal hygiene was completed for one resident (#52) who was dependent on staff. This affected one resident (#52) of three residents reviewed for activities of daily living (ADL). The facility census was 86. Findings include: Review of the medical record for Resident #52 revealed an admission date of 06/22/23 with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, vascular dementia, dysphagia, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had severe cognitive impairment. Additionally, the resident required the extensive assistance of one person for personal hygiene. Review of the care plan dated 07/18/23 revealed Resident #52 required assistance for ADL related to cognitive impairment and immobility. Interventions included inspecting skin during personal care, staff assist with daily hygiene, and showering as per facility policy, therapy as ordered, and keeping the call light within reach while in bed. Observation on 08/01/23 at 8:50 A.M. and 4:00 P.M. of Resident #52 revealed she had long curled facial hair under her nose and on her chin. Resident #52's teeth were observed to have a thick buildup of plaque. Interview on 08/01/23 at 4:05 P.M. with State Tested Nursing Aide (STNA) #111 verified Resident #52 had facial hair that should have been removed previously. She additionally verified Resident #52's teeth needed brushed. Interview on 08/03/23 at 9:00 A.M. with the Director of Nursing (DON) revealed they had a beauty shop that came in every Monday that took care of both hair and facial hair. She reported the beauty shop was not open this week; however, she verified the aides should be addressing facial hair as needed. Review of the undated policy titled Resident Grooming revealed staff were to assist with shaving, combing, or brushing hair according to resident preference. This deficiency represents non-compliance investigated under Complaint Number OH00144808.

Based on medical record review, observation, staff interview, policy review, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore personel protective equipment (PPE) appropriately and failed to ensure isolation carts were stocked with the appropriate supplies/PPE. This had the potential to affect all 91 residents residing in the facility. The census was 91. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 06/26/19 with diagnoses including cognitive communication deficit, hyperlipidemia, paranoid personality disorder, and delusional disorders. Review of the progress note, dated 01/02/23, revealed Resident #16 tested positive for COVID-19, and Resident #16's guardian and the nurse practitioner were notified. Review of the physician order dated 01/02/23 to 01/13/23 revealed Resident #16 required isolation and observation due to positive COVID-19 status. Observation on 01/09/23 at 12:10 P.M. of Resident #16 revealed Resident #16 was under airborne isolation precautions. The isolation cart outside of Resident #16's room with PPE in it did not contain gloves, hand sanitizer, eye protection, or disinfectant/alcohol pads. Observation on 01/09/23 at 12:25 P.M. revealed STNA #239 entered Resident #16's room, who was under airborne isolation precautions due to testing positive for COVID-19, without donning an isolation gown or gloves to deliver a meal tray. STNA #239 was wearing an N95 respirator and goggles. STNA #239 placed the meal tray on Resident #16's bedside table, adjusted the height of the table, and set up Resident #16's meal tray. STNA #239 washed her hands at the sink before exiting Resident #16's room. STNA #239 did not sanitize her goggles upon exiting Resident #16's room. STNA #239 changed her N95 respirator and continued to deliver meal trays to other unidentified residents, and started feeding an unidentified resident who was not under any isolation precautions. Interview on 01/09/23 at 12:27 P.M. with STNA #239 confirmed Resident #16 was positive for COVID-19 and she had entered the room without donning an isolation gown or gloves. STNA #239 stated she forgot Resident #16 was positive for COVID-19. Interview on 01/09/23 at 12:48 P.M. with STNA #239 confirmed she had not sanitized her goggles after delivering meal trays to Resident #16's room, who tested positive for COVID-19, and before delivering meal trays and feeding an unidentified resident who was negative for COVID-19. Interview and observation on 01/09/23 at 1:15 P.M. with the Director of Nursing (DON) confirmed the PPE cart outside Resident #16's room was not fully stocked with all needed supplies including hand sanitizer, clean gloves, and disinfectant/alcohol pads. The DON stated gloves were kept inside resident rooms, including resident rooms who were under airborne precautions due to testing positive for COVID-19 or having been exposed to COVID-19. 2. Review of the medical record for Resident #26 revealed an admission date of 11/13/22 with diagnoses including dementia, chronic obstructive pulmonary disease, hypertension, type two diabetes, and COVID-19 (01/02/23). Review of the physician order, dated 01/02/23 to 01/12/23, revealed Resident #26 required isolation and observation due to positive COVID-19 status. Review of the medical record for Resident #91 revealed an admission date of 07/06/22 with diagnoses including traumatic subarachnoid hemorrhage, hypertension, anxiety disorder, alcohol abuse, gastro-esophageal reflux disease, and COVID-19 (01/02/23). Review of the physician order, dated 01/02/23 to 01/12/23, revealed Resident #91 required isolation and observation due to COVID-19 status. Observation on 01/09/23 at 12:12 P.M. of Resident #26 and Resident #91 revealed both residents were under airborne isolation precautions. The door was shut. The observation revealed State Tested Nurse Aide (STNA) #323 donned a gown and gloves prior to entering the room to deliver meal trays. STNA #239 brought the second meal tray to the room and handed it to STNA #323 without entering the room. Further observation on 01/09/23 at 12:14 P.M. revealed STNA #323 exited the room and used hand sanitizer and donned a new N95 respirator from the PPE cart outside of the room. The N95 respirator was not donned appropriately and both straps were placed under her ears and around her neck. STNA #323 did not sanitize her goggles and continued to pass meal trays to additional unidentified residents who were not under any isolation precautions. Interview on 01/09/23 at 12:33 P.M. with STNA #323 confirmed she had not sanitized her goggles after delivering meal trays to Resident #26 and Resident #91, who were both positive for COVID-19, and continued to pass meal trays to additional residents who had tested negative for COVID-19. STNA #323 also confirmed her N95 respirator was not donned appropriately. Observation and interview with STNA #323 at this time confirmed the cart with PPE near Resident #26 and Resident #91's room was not stocked with hand sanitizer, gloves, or disinfectant wipes/alcohol pads. Interview and observation on 01/09/23 at 1:15 P.M. with the DON confirmed the PPE carts were not fully stocked with all of the needed supplies including hand sanitizer, clean gloves, or disinfectant/alcohol pads. The DON stated gloves were kept inside resident rooms, including resident rooms who were under airborne precautions due to testing positive for COVID-19 or having been exposed to COVID-19. 3. Review of the medical record for Resident #25 revealed an admission date of 12/06/22 with diagnoses including acute respiratory failure, encephalopathy, anemia, hypertension, cognitive communication deficit, and adult failure to thrive. Review of the physician order, dated 01/02/23, revealed Resident #25 had an order for isolation and observation due to exposure to COVID-19. Review of the Evaluation for COVID 19, dated 01/05/23, revealed Resident #25 was on isolation due to COVID-19 exposure. Observation on 01/09/23 at 12:55 P.M. of STNA #273 revealed STNA #273 was in Resident #25's room, who was under airborne isolation precautions due to exposure to COVID-19, without an isolation gown or gloves on. The aide gathered two bags of trash and placed a towel under Resident #25's bare feet. STNA #273 tied up the bags of trash, exited the room, and took the trash to the soiled utility room down the hallway to dispose of the trash. Interview on 01/09/23 at 12:59 P.M. with STNA #273 revealed she had removed her isolation gown and gloves inside the room and then stayed in the room to talk with Resident #25. STNA #273 confirmed Resident #25 was under airborne isolation precautions and she should have an isolation gown and gloves on while in the room with Resident #25. Observation on 01/09/23 at 1:00 P.M. of STNA #273 revealed STNA #273 re-entered Resident #25's room without an isolation gown or gloves on. Interview on 01/09/23 at 1:03 P.M. with STNA #273 confirmed she had not donned an isolation gown or gloves prior to entering Resident #25's room. STNA #273 stated, I messed up. Review of facility policy titled Infection Prevention and Control Program, dated 04/01/22, revealed the policy stated, Isolation Protocol (Transmission-Based Precautions): residents with an infection or communicable disease shall be placed on TBP (Transmission-Based Precautions) as recommended by current Centers for Disease Control (CDC) guidelines. Review of the facility policy titled Transmission Based Precautions, dated 10/01/22, revealed the policy stated, facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on TBP. Furthermore, Airborne Precautions: the facility will follow CDC guidance as to cohorting, private room accommodation and/or designated units and staff will wear a fit-tested N95 or higher-level respirator and other appropriate PPE while delivering care to the resident. Review of the facility policy titled Care for the Patient with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19), dated 08/01/22, revealed the policy stated, eye protection: reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Review of the Centers for Disease Control (CDC) guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 09/23/22, revealed the guidance stated, Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Furthermore, dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-Co-V-2 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. This deficiency represents non-compliance investigated under Complaint Number OH00138462.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #5's blood pressure was adequately monitored to ensure the as needed (PRN) anti-hypertensive medication (Hydralazine) was administered if needed and failed to ensure the resident was provided the medication as ordered when the resident's blood pressure was elevated and within the physician ordered parameters to give. This affected one resident (#5) of three residents reviewed for medication administration. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including encephalopathy, hypertension, hyperlipidemia, gout, history of transient ischemic attack, delirium, visual hallucinations, insomnia, central pain syndrome, hemiplegia of left side, anemia, osteoarthritis and tendinitis of right knee and congestive heart failure. Review of physician's orders revealed an order, dated 10/05/22 for Hydralazine HCL (vasodilator to treat high blood pressure) 25 milligrams (mg) every eight hours as needed (PRN) for systolic blood pressure greater than 180 or diastolic blood pressure greater than 100. A physician's order, dated 10/07/22 revealed to check the resident's blood pressure once a shift. The facility staff worked 12 hours shifts, resulting in two shifts each day. The resident's blood pressure was documented as being checked twice per day/once each facility shift. However, this monitoring was inconsistent with the resident's PRN order for Hydralazine which was ordered to be given every eight hours as needed for blood pressure parameters set by the physician. Review of the plan of care, dated 10/17/22 revealed Resident #5 had alteration in tissue perfusion related to hypertension. Interventions included to administer medications as ordered and obtain vital signs as ordered and as needed, especially blood pressure. Review of the Medication Administration Record (MAR) revealed Resident #5's blood pressure was 159/103 millimeter of mercury (mmHg) the evening of 10/20/22. Review of the MAR revealed the resident was not administered the Hydralazine HCL as ordered at that time. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/10/22 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of nine indicating the resident had moderately impaired cognition. The assessment revealed Resident #5 required extensive assistance from two staff for bed mobility and transfers. On 11/18/22 at 2:54 P.M. interview with the Director of Nursing (DON) verified facility staff were checking the resident's blood pressure twice a day (once on each 12 hour shift). However, the resident had a medication order for the Hydralazine to be administered once every eight hours as needed. During the interview, the DON also verified Resident #5 did not receive the Hydralazine HCL as ordered the evening of 10/20/22 when the resident's blood pressure was 159/103 mmHg. This deficiency represents non-compliance investigated under Complaint Number OH00137185.

2. Review of the medical record for Resident #93 revealed an admission date of 04/16/21. Resident #93's diagnoses included schizoaffective disorder, coronary artery disease, muscle weakness, hypertension and repeated falls. Review of the plan of care, dated 04/16/21 revealed Resident #93 was at risk for falls related to cognitive communication deficits, not recognizing limitations, presence of psychotropic medications, balance problems and incontinence of bowel and bladder. Interventions for Resident #93 included to ensure call light was within reach at all times, assist with transfers and monitor for side effects of psychotropic medications. Review of the Fall Risk Evaluations, dated 04/16/21 and 07/16/21 revealed Resident #93 was at high risk for falls. Review of the quarterly MDS 3.0 assessment, dated 07/15/21 revealed Resident #93 required extensive assistance from one staff for bed mobility, transfers and toileting. On 10/25/21 at 10:20 A.M. Resident #93 was observed sitting in a chair near his bed. Resident #93 was observed to ask for help getting in bed. The call light was observed to be on the other side of the bed, resting on the floor and not in reach of Resident #93. On 10/25/21 at 11:35 A.M. Resident #93 was observed laying in bed and the call light was laying on the floor and not within reach of the resident. On 10/25/21 at 11:36 A.M. interview with Agency STNA #539 confirmed Resident #93's call light was on the floor and not within reach of the resident. Additional observations on 10/26/21 at 9:06 AM and 10:21 A.M. revealed Resident #93 was laying in bed and his call light was laying on the floor. On 10/26/21 at 10:21 A.M. interview with STNA #485 confirmed Resident #93's call light was on the floor and there was not clip on the call light to keep it near the resident. On 10/28/21 at 2:30 P.M. and on 11/01/21 at 10:30 A.M. Resident #93 was observed in bed with the call light on the floor. The resident had no access to the call light which was a fall risk intervention. On 11/01/21 at 10:30 A.M. interview with STNA #485 confirmed Resident #93's call light was on the floor and there was not a clip to enable to call light to attach the resident or the blanket. STNA #485 revealed she did know how to put in maintenance order and request a clip. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #87 and Resident #93's call lights were within reach to accommodate the residents' need to obtain staff assistance by ringing the call light. This affected two residents (#87 and #93) of 51 sampled residents. Findings include: 1. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the plan of care, dated 02/05/21 revealed the resident required assistance for activities related to cognitive/communication deficits, no awareness of needs or limitations and incontinence of bowel and bladder. Interventions included to keep call light in reach while in bed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made self understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. Review of the mood and behavior revealed the resident had delusions, displayed verbal behaviors directed towards others and behaviors not directed towards others. The resident required extensive assistance from one staff for bed mobility and transfers and was dependent on one staff for toilet use. On 10/25/21 at 1:17 P.M. observation of Resident #87 revealed her call light was wrapped around and tied to the privacy curtain at the bottom of the bed. Licensed Practical Nurse (LPN) #304 verified the call light was not within the resident's reach at that time. On 10/28/21 at 11:37 A.M. Resident #87 was observed lying in a supine position in bed with her call light at the bottom of the bed. LPN #304 verified the resident's call light was not within reach at that time. Review of the facility policy titled Call Lights, dated 11/2018 revealed it was the policy of the facility to provide an operational call light system for residents. The call light system would be available to facilitate resident use and safety in the resident's rooms, bathroom and bathing areas.

Based on record review and interview the facility failed to provide quarterly statements for residents they managed personal fund accounts for. This affected two residents (#15 and #71) of seven residents reviewed for accounting of funds. The facility identified 84 residents for whom they managed personal fund accounts. Findings include: On 10/25/21 at 10:35 A.M. interview with Resident #15 revealed the facility had never provided him with an account statement for his personal funds account and he didn't know how much money he had. On 10/25/21 at 11:06 A.M. interview with Resident #71 revealed the facility managed personal funds for him and he had never received a balance statement. Review of the personal fund account documentation for Resident #121, #11, #112, #48, #39, #15 and #71 revealed no evidence quarterly statements were provided to the residents and/or their representatives each quarter. On 10/26/21 at 1:29 P.M. interview with Business Office Manager #550 verified there was no documentation/ evidence quarterly statements were issued to Resident #121, #11, #112, #48, #39, #15 or #71 who were reviewed for personal fund accounts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #21 and Resident #87's advance directives were accurate and based on the residents' current wishes. This affected two residents (#21 and #87) of five residents reviewed for advance directives. Findings include: 1. Review of Resident #87's medical record revealed an original admission date [DATE] with the latest readmission of [DATE]. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. Review of the plan of care, dated [DATE] revealed the resident was a full code indicating the resident/family had chosen that CPR would be attempted during a cardiac arrest. Interventions included if code status changed, code status would be posted in resident's chart and physician's orders; if resident was choking, perform Heimlich maneuver and proceed with CPR if needed, inform new caregivers of code status, notify family of change in condition, nursing staff would provide chest compressions when the resident was in cardiac arrest and call ambulance for transport to the hospital, offer reassurance and support to resident and family and staff would honor resident with privacy during CPR. Review of the resident's monthly physician's orders for [DATE] revealed an order, dated [DATE] for a Do Not Resuscitate Comfort Care (DNRCC). Review of the resident's signed DNRCC form, dated [DATE] revealed the resident was a DNRCC. On [DATE] at 11:05 A.M. interview with Registered Nurse (RN) #406 revealed the resident was in fact a DNRCC and the plan of care inaccurately reflected a Full Code status. 2. Review of Resident #21's medical record revealed the resident had diagnoses including encephalopathy, aphasia, chronic obstructive pulmonary disease and chronic kidney disease. Review of the plan of care, dated [DATE] revealed the resident was a Full Code: Resident/ Family had chosen that CPR would be attempted during a cardiac arrest. Further review revealed a Do Not Resuscitate (DNR) identification form, dated [DATE] which indicated Resident #21 was a DNRCC Arrest. Review of the quarterly MDS 3.0 assessment, dated [DATE] revealed the resident's cognition was moderately impaired. The assessment revealed the resident was independent with bed mobility, dressing, eating and toilet use and required staff supervision and set up help only for transfers. Review of the physician's orders for 10/2021 revealed the resident was a Full Code. On [DATE] at 10:55 A.M. interview with Registered Nurse (RN) #406 verified there were two different code status in the medical record for Resident #21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/28/21 at 11:20 A.M. Licensed Practical Nurse (LPN) #303 with the assistance of State Tested Nursing Assistant (STNA) #372 was observed completing the physician ordered wound treatment to a deep tissue injury to Resident #27's heel. During the observation, neither the LPN or STNA attempted to provide any type of privacy for Resident #27 during the wound treatment. No privacy curtain was observed to be in the resident's room. On 10/28/21 at 11:30 A.M. interview with STNA #372 and LPN #303 confirmed they failed to provide privacy to Resident #27 during the wound care. Both staff members also verified there was no privacy curtain available for use in the resident's room. STNA #372 further revealed Resident #19 was moved to the room with Resident #27 on 10/22/21 (eight days earlier) and the room had been without a privacy curtain since that time. Review of the medical record for Resident #19 confirmed she was moved to Resident #27's room on 10/22/21. Review of the facility policy titled Resident Privacy, revised 05/2014 revealed staff would provide care and treatment in such a way as to maintain resident dignity and privacy. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure privacy was provided during wound care for Resident #27 and during urinary catheter care for Resident #58. This affected one resident (#58) four residents reviewed urinary catheter use and one resident (#27) of three residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, obstructive and reflux uropathy (urine regurgitates from the bladder back into the ureter) chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident was cognitively impaired, he required supervision with set up assistance and supervision from one staff for bed mobility, transfers and dressing with one person physical assist. Review of the current physician's orders revealed an order, initiated 02/05/21 for urinary catheter (tube into the bladder for drainage of urine) care every shift. On 10/28/21 at 1:01 P.M. observation of catheter care revealed Nurse Aide (NA) #486 closed the room door, but left the blinds open to the outside. The resident's room was noted to be facing the parking lot. The NA also failed to close the privacy curtain around the resident's bed. NA #486 then completed urinary catheter care. Interview with NA #486 at the time of the observation verified he had not pulled the privacy curtain or closed the window blinds during catheter care. Review of the facility policy titled Resident Privacy, revised 05/2014 revealed staff would provide care and treatment in such a way as to maintain resident dignity and privacy.

Based on record review and interview the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level I screen was completed accurately for Resident #126 upon admission. This affected one resident (#126) of eight residents reviewed for PASARR. Findings include: Review of the medical record for Resident #126 revealed an admission date of 05/20/21 with diagnoses including personal history of malignant neoplasm of unspecified digestive organ, encephalopathy, altered mental status, hyperlipidemia, unspecified dementia without behavioral disturbance, cognitive communication deficit and aphasia. The diagnosis of delusional disorders was dated 05/20/21. Review of the review results, dated 05/21/21 revealed the Pre-admission Screening (PAS) determination had no indications of serious mental illness nor a developmental disability. Review of the PASARR for Resident #126 dated 05/21/21 revealed no mental illness was noted. On 10/26/21 from 4:36 P.M. to 4:48 P.M. interview with Social Worker (SW) #481 revealed she was responsible for completing the PASARR forms for residents. SW #481 reported she completed them upon admission and if she noticed any that had been missed upon admission. SW #481 was unaware PASARR's needed to be completed when a resident had a new mental illness and confirmed she had not been doing this. She reported the previous admissions director had been telling her when to complete resident PASARR reviews and she knew she missed some while she was learning to do it on her own. SW #481 confirmed Resident #126's PASARR did not include the delusional disorder present on the resident's diagnosis list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominants side, muscle weakness, hypertension, atrial fibrillation and need for assistance with personal care. Review of the physician's orders dated 04/29/21 revealed an order to apply DermaSarra Anti-Itch Lotion 0.5-0.5 % (Camphor-Menthol) every shift for itching for Resident #46. Review of the plan of care, dated 06/04/21 revealed Resident #46 had the potential for alteration in skin integrity related to cognitive communication deficit, hand contracture, weakness and reduce mobility. Interventions included to inspect skin condition daily during care, report any impaired areas to charge nurse and educate family and staff of risks for skin breakdown risk factor and preventative measures. Record review revealed no plan of care had been developed for Resident #46 related to itching or skin conditions associated to itching. On 10/25/21 at 2:34 P.M. Resident #46 was observed to pull his left pant leg up and revealed multiple small round scabbed areas, (ranging from approximately two by two centimeters (cm) to four by five cm). Some of the scabs were open and bleeding and there was an area of dried blood on Resident 46's outer ankle and sock, measuring approximately four cm by five cm. Resident #46 was then observed to scratch the area with his hand. When asked if the area itched, Resident #46 nodded his head yes. When asked if the nurses put cream on the area, Resident #46 made a side to side motion with his hand. Review of the shower sheets for Resident #46 dated 10/25/21, 10/23/21 and 10/18/21 revealed no mention of skin concerns to the resident's legs. Review of the skin assessments, dated 10/20/21 and 10/24/21 documented Resident #46's skin was intact. Review of the Treatment Administration Record (TAR) for the month of October 2021 revealed the anti-itch cream was signed off as administered twice per day, including on 10/25/21 A.M. On 10/25/21 at 4:00 P.M. interview with Licensed Practical Nurse (LPN) #347 revealed she frequently cared for Resident #46 and administered his treatments and medications. When asked about Resident #46's legs and treatment, LPN #347 was unable to recall any concerns or treatments. LPN #347 further revealed she had not completed any treatments to Resident #46's legs on this date. LPN #347 further confirmed she did mark her initials in the TAR without administering the treatment that was ordered. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive care plans including individualized interventions were developed for all residents and/or failed to implement care plans as written. This affected three residents (#87, #117 and #46) of 51 sampled residents whose care plans were reviewed. Findings include: 1. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. The resident was identified as being always incontinent of both bowel and bladder. Review of the admission assessment with baseline care plan dated 10/19/21 revealed the resident was readmitted to the facility from an acute care hospital with an indwelling urinary catheter. Review of the plan of care dated 10/19/21 revealed the resident had potential for complications related to indwelling urinary catheter use. Interventions included to assist with Foley catheter care as needed, educate resident to report signs/symptoms of urinary tract infection (UTI), encourage proper nutrition and adequate fluid intake, evaluate need for catheter and supporting diagnoses and observe for signs/symptoms of UTI. On 10/25/21 at 1:14 P.M. observation of the resident revealed an indwelling urinary catheter did not have a privacy bag and was under the bed on the floor. On 11/01/21 at 8:56 A.M. interview with the Director of Nursing (DON) verified the resident's comprehensive plan of care failed to address the resident's indwelling urinary catheter interventions for care. 2. Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, high blood pressure and anemia. Review of the admission MDS 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired, he required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The assessment revealed the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the physician's orders for 10/2021 revealed an order for Foley catheter care every shift and as needed, empty urinary catheter bag every shift and as needed (prn) and record output and total every 24 hours. Review of the plan of care, dated 10/16/21 revealed to obtain urine output each shift and total for 24 hour period. Further review of the medical record revealed the urine output and total was not completed every shift following the plan of care. On 11/01/21 at 2:20 P.M. interview with Licensed Practical Nurse (LPN) #453 verified the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to accurately assess and monitor areas of non-pressure related skin impairment for Resident #46 and failed to ensure physician ordered skin treatments were documented only when completed. This affected one resident (#46) of three residents reviewed for skin treatments. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominants side, muscle weakness, hypertension, atrial fibrillation and need for assistance with personal care. Review of the physician's orders dated 04/29/21 revealed an order to apply DermaSarra Anti-Itch Lotion 0.5-0.5 % (Camphor-Menthol) every shift for itching for Resident #46. Review of the plan of care, dated 06/04/21 revealed Resident #46 had the potential for alteration in skin integrity related to cognitive communication deficit, hand contracture, weakness and reduce mobility. Interventions included to inspect skin condition daily during care, report any impaired areas to charge nurse and educate family and staff of risks for skin breakdown risk factor and preventative measures. Record review revealed no plan of care had been developed for Resident #46 related to itching or skin conditions associated to itching. On 10/25/21 at 2:34 P.M. Resident #46 was observed to pull his left pant leg up and revealed multiple small round scabbed areas, (ranging from approximately two by two centimeters (cm) to four by five cm). Some of the scabs were open and bleeding and there was an area of dried blood on Resident 46's outer ankle and sock, measuring approximately four cm by five cm. Resident #46 was then observed to scratch the area with his hand. When asked if the area itched, Resident #46 nodded his head yes. When asked if the nurses put cream on the area, Resident #46 made a side to side motion with his hand. Review of the shower sheets for Resident #46 dated 10/25/21, 10/23/21 and 10/18/21 revealed no mention of skin concerns to the resident's legs. Review of the skin assessments, dated 10/20/21 and 10/24/21 documented Resident #46's skin was intact. Review of the Treatment Administration Record (TAR) for the month of October 2021 revealed the anti-itch cream was signed off as administered twice per day, including on 10/25/21 A.M. On 10/25/21 at 4:00 P.M. interview with Licensed Practical Nurse (LPN) #347 revealed she frequently cared for Resident #46 and administered his treatments and medications. When asked about Resident #46's legs and treatment, LPN #347 was unable to recall any concerns or treatments. LPN #347 further revealed she had not completed any treatments to Resident #46's legs on this date. LPN #347 further confirmed she did mark her initials in the TAR without administering the treatment that was ordered. Review of the undated facility policy titled Medication Administration revealed medications must be administered in accordance with the orders, including the required time frame and the individual administering the medication must initial on the resident's medication administration record (MAR), on the appropriate line after giving the medication and before administering the next medications.

Based on record review and interview the facility failed to ensure Resident #123 received a vision follow up for complaints of double vision. This affected one resident (#123) of two residents reviewed for vision services. Findings include: Record review for Resident #123 revealed an admission date of 02/12/21 with diagnoses including heart failure, anxiety, diabetes type two, depression, weakness and chronic pain syndrome. Review of the care plan, dated 02/15/21 revealed the resident was at risk for visual decline/undetected eye diseases, or currently exhibited deficits as evidenced by diabetes type two. Interventions included to arrange eye appointments if increased visual deficits were noted Review of an eye exam, dated 08/23/21 revealed the resident's right and left eyes were in stable condition, the resident denied changes in vision and eye pain. There was no active diabetic retinopathy in either eye. Hypertensive retinopathy noted with mild retinal changes consistent with high blood pressure and minimal occlusive risk. New orders to return in six to nine months for a follow up. Review of the physician note, dated 09/07/21 revealed the physician documented the eye doctor saw the resident recently without new orders. The resident complained of interim double vision. The assessment plan revealed to follow up on the most recent eye appointment. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/25/21 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The assessment revealed the resident required supervision with one (staff) assist for activities of daily living. The MDS further revealed the resident utilized corrective lenses. On 11/01/21 at 1:56 P.M. interview with Resident #123 revealed he complained of double vision to the physician but no one had done anything about it. On 11/02/21 at 3:19 P.M. interview with Regional Director of Clinical Services #406 confirmed the facility didn't follow up with any eye doctor after the 09/07/21 physician note.

Based on observation, record review, facility policy and procedure review and interview the facility failed to assess and implement weight loss interventions for Resident #87, a resident identified with a a significant weight loss following a hospitalization. This affected one resident (#87) of six residents reviewed for nutrition. Findings include: Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the plan of care, dated 02/05/21 revealed Resident #87 was at risk for alteration in nutrition and/or hydration related to behavioral problems, edentulous, need for feeding assistance and mechanically altered diet. Interventions included to address any chewing/swallowing problems that occur, address any sings of aspiration, assist with feeding needs as needed, administer medications as ordered, monitor for signs/symptoms of dehydration, monitor weight every month and as needed, observe skin condition and request dietary interventions as needed, offer finger foods, offer meal substitutes for dislikes, provide diet counseling as needed, provide diet as ordered, record consumption of meals including fluid intake and review labs as ordered. Review of the resident's medical nutrition therapy progress/quarterly note, dated 08/17/21 revealed the resident was on a regular mechanical soft diet with med pass (supplement) twice daily. The resident required assistance with eating. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. The resident had no known weight loss and received a mechanically altered diet. Review of the admission assessment with baseline care plan, dated 10/19/21 revealed the resident was readmitted to the facility from an acute care hospital and weighed 141.0 pounds upon readmission to facility. Review of the plan of care, dated 10/19/21 revealed the resident had dietary risks for weight loss/gain related to swallowing and chewing problems. Interventions included to follow physician ordered diet. Review of the resident's monthly physician's orders for October 2021 revealed an order (dated 10/19/21) for a regular diet, puree texture, nectar thick liquids and Med pass 2.0 (supplement) four ounces two times a day. This was the same supplement order as prior to the resident's hospitalization. Review of the resident's weights revealed on 09/22/21 she weighed 156.3 pounds. On 10/19/21 (readmission) the resident's weight was 141 pounds which indicated a significant weight loss of 10.85% in 30 days. On 10/26/21 a weight of 141.7 pounds was obtained. Review of the medical record failed to provide evidence of a comprehensive and individualized nutritional assessment or newly implemented interventions addressing the resident's significant weight loss following re-admission. Review of the resident's meal percentages from 10/06/21 through 11/03/21 revealed the facility failed to document the resident's meal percentage intakes except one meal on 10/06/21, 10/17/21 and 10/29/21. On 10/25/21 at 2:30 P.M. observation of the resident's lunch meal revealed the staff placed a disposable container on a tray in her room and left. The resident was in bed. The meal tray had no drinks or utensils on the tray. On 10/28/21 at 2:58 P.M. interview with Registered Dietician (RD) #488 revealed she knew the resident had a weight loss on admission so added fortified foods and a magic cup at lunch and dinner. She said she also placed the resident on weekly weights. RD #488 revealed she had been assisting in the kitchen and knew there were several new admissions but had not had time to document on the resident as of this time. Review of the facility policy titled Weight Policy, dated 11/18 revealed it was the policy of the facility to attain/maintain a resident's weight within the recommended range as appropriate in relation to their medical and physical status. The Dietitian would be notified of significant changes in weights, insidious weight loss and other concerns related to diet and intake. Acute and chronic weight changes would be documented and recommendations would be provided by the dietitian as appropriate. The dietician would work with the facility staff during the routine weight meeting to review resident weight trends and determine any additional interventions for the resident's weight change.

Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #92's oxygen equipment was maintained in a clean and sanitary manner and failed to ensure oxygen tubing was changed per physician order. This affected one resident (#92) of three residents reviewed for respiratory care. Findings include: Review of Resident #92's medical record revealed an admission date of 09/02/21 and diagnoses of acute respiratory failure and oxygen dependence. Review of the physician's orders, dated 09/03/21 revealed staff were to change the resident's oxygen tubing and set up every Friday. On 09/02/21 the resident was ordered oxygen on one liter via nasal cannula. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/09/21 revealed the resident had a Brief Interview of Mental Status (BIMS) of 02, indicating impaired cognition. The assessment revealed the resident required limited assistance from one staff for bed mobility, transfers, locomotion via walker and personal hygiene and the resident utilized oxygen therapy. Review of the care plan, dated 09/16/21 revealed the resident was at risk for respiratory insufficiency as evidenced by acute respiratory failure and oxygen dependence with interventions to auscultate lung sounds upon admission, observe the resident for difficulty breathing and elevate the head of the bed. On 10/25/21 at 11:10 A.M. observation revealed Resident #92's oxygen tubing was dated 10/09/21. On 10/27/21 at 9:56 A.M. observation and interview with Regional Director of Clinical Services #406 confirmed the date on the resident's oxygen tubing was 10/09/21. There was no evidence the oxygen tubing and set up were being changed every Friday as ordered. Review of the facility policy and procedure titled, Oxygen Administration, dated 2021 revealed staff should change oxygen tubing and delivery devices every 72 hours or per facility policy and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure ongoing communication with the hemodialysis center regarding care and services for Resident #109. This affected one resident (#109) of one resident reviewed for hemodialysis. Findings include: Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis and schizoaffective disorder. Review of the plan of care, dated 06/15/21 revealed communicate with dialysis center staff regarding plan of care, lab values and diet/fluid restriction recommendations. Nurse to utilize dialysis communication form for pre-dialysis assessment including obtaining vital signs. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/16/21 revealed the resident's cognition was moderately impaired. The assessment revealed the resident required supervision from staff with set up assistance for dressing and personal hygiene. The resident was independent with set up assistance from staff for bed mobility, transfers and toilet use. Review of the current physician's orders revealed an order to monitor right chest port for signs and symptoms of infection, edema and bleeding and hemodialysis days (Monday, Wednesday and Friday). Review of the communication forms between the facility and the hemodialysis center revealed the facility failed to have completed documentation of communication with the dialysis center on all the days the resident received treatment. On 08/06/21, 08/11/21, 08/13/21, 08/30/21, 09/03/21, 09/17/21, 09/22/21, 09/24/21, 09/27/21, 09/29/21, 10/01/21, 10/08/21, 10/15/21 and 10/29/21 there was no documented communication with the hemodialysis available to review in the resident's medical record information. On 11/01/21 at 3:00 P.M. interview with Registered Nurse #350 verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure medications were available for administration as ordered. This affected three residents (#31, #91 and #282) of 51 sampled residents. Findings include: 1. Review of the medical record for Resident #91 revealed an admission date of 08/26/21 with diagnoses including intellectual disabilities, psychosis, mood disorder, weakness, insomnia, difficulty walking, need for assistance with personal care and paranoid schizophrenia. Review of the care plan, dated 08/26/21 revealed Resident #91 had impaired cognitive process for daily decision making and she was at risk for further decline in cognitive function. Interventions included to encourage the resident to make routine daily decisions and administer medications as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/08/21 revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition. The assessment revealed the resident was independent for activities of daily living. Review of a nurse's note, dated 10/13/21 at 11:38 A.M. revealed the nurse spoke with resident about her allergy pill. The resident was requesting to take Claritin-D instead of just Claritin. Resident stated the Claritin wasn't working and she used to take Claritin-D and it worked better. The physician was notified. Review of the physician's orders revealed the resident was ordered Claritin 10 mg daily for allergies until 10/13/21 when it was discontinued and the resident started on Claritin-D Extended Release 24 Hour 10-240 milligram (mg) as needed for congestion. Review of the Medication Administration Record (MAR) revealed the medication was administered on 10/30/21 and 11/01/21. On 10/25/21 at 10:16 A.M. interview with Resident #91 revealed her eyes were hurting and watering because she needed her allergy medications. She stated she was started on Claritin but she said it didn't work. On 10/25/21 at 2:00 P.M. interview with Regional Director of Clinical Services (RDCS) #406 revealed staff had ordered The Claritin-D but they had to wait on pharmacy. On 11/02/21 at 12:33 P.M. during a follow up interview, RDCS #406 revealed staff had not ordered the medication until 10/25/21. On 11/02/21 at 1:35 P.M. interview with RDCS #406 revealed the Claritin D medication was in the cart the whole time with a date of 09/30/21 and staff just didn't see it in the cart in order for it to be administered to the resident as ordered. Review of the facility undated policy and procedure titled, Administering Medications revealed medications shall be administered in a safe and timely manner as prescribed. 2. Medical record review for Resident #282 revealed an admission date of 09/28/21 with diagnoses including pancreatitis, depression, Sjogren syndrome, anxiety, migraines, bipolar disorder, diabetes type two, cognitive communication deficit, other signs and symptoms involving cognitive functions and awareness and panic disorder. Review of the care plan, dated 10/06/21 revealed the resident had the potential for mood swings and behavioral issues related to depression, anxiety, bipolar, attention deficit hyperactivity disorder (ADHD) and panic disorder with interventions to administer medications as ordered. Review of the MDS 3.0 assessment, dated 10/07/21 revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. The assessment revealed the resident was independent for activities of daily living and had behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Review of the residents physician orders revealed an order for Clonazepam 1 mg with instructions to give three times daily (6:00 A.M., 2:00 P.M., and 10:00 P.M.) for anxiety. Review of the Medication Administration Record (MAR) revealed the medication was not administered on 10/09/21 at 2:00 P.M. or 10:00 P.M. Review of the nurse's notes from 10/09/21 at 11:58 P.M. revealed the resident's Clonazepam 1 milligram (mg) for anxiety was not received. Pharmacy contacted and confirmed delivery of the medication for tonight but the medication had not arrived. Pharmacy contacted again stating the medication would be in the morning tote. The physician was notified. On 11/03/21 from 12:36 P.M. through 12:54 P.M. interview with RDCS #406 confirmed Resident #282 did not receive both doses of Clonazepam on 10/09/21 in the afternoon. RDCS #406 revealed the medication was available in the facility emergency medication kit (EBox), but it was 0.5 mg. RDCS #406 further revealed there were four of the Clonazepam 0.5 mg doses in the EBox which could have been used to administer to Resident #282. Review of the facility policy and procedure titled Controlled Substances, dated 06/21/17 revealed it was the facility and prescriber responsibility to obtain the required prescription needed to meet the needs of the resident. 3. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, atrial fibrillation, osteoporosis and encephalopathy. Review of the quarterly MDS 3.0 assessment, dated 07/17/21 revealed the resident required extensive assistance from two plus staff members for bed mobility, dressing and personal hygiene and total dependence from two plus staff members for transfers and toilet use. Review of the physician's orders revealed Resident #31 had an order (status post hospitalization on 10/31/21) for Afrin Nasal Spray two sprays into each nostril twice a day until 11/03/21 at 2:31 P.M. On 11/02/21 at 2:31 P.M. interview with Licensed Practical Nurse (LPN) #327 revealed the nasal spray was not available to administer to Resident #31, had not been administered and she would need to call pharmacy about it. Review of the Medication Administration Record (MAR) revealed nursing staff were incorrectly documenting the Afrin nasal spray had been given on 11/01/21 and 11/02/21 even though it was unavailable from pharmacy on these dates.

Based on record review and interview the facility failed to timely clarify conflicting physician recommendations from a pharmacy medication regimen review dated 06/23/21 to ensure Resident #79 received appropriate care and treatment related to the use of an anti-anxiety medication. This affected one resident (#79) of six residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #79 revealed an admission date of 08/06/16 with diagnoses of anxiety, depression, psychosis, dementia with behavior disturbances, encephalopathy and insomnia. Review of the care plan, dated 06/10/20 revealed the resident had the potential for mood swings and behavioral issues related to depression, psychosis and anxiety. Interventions included to administer as needed medications as ordered when the resident exhibited any increased agitation, anxiety, pacing, hallucinations, mood changes, restlessness, wandering or abusive behaviors, etc. Review of the resident's physician orders revealed from 06/19/21 through 07/07/21 the resident had an order for Ativan 0.5 milligrams (mg) as needed every four hours for shortness of breath. Review of the medication regimen reviews (MRR) revealed on 06/23/21 the resident was receiving Ativan 0.5 mg every four hours as needed and the pharmacist recommended the facility document the rationale for the medication if it was to continue past 14 days in duration. On 07/06/21 a nurse practitioner ordered the medication to be discontinued, and it was discontinued on 07/07/21. On 07/29/21 a different physician reviewed the same MRR (dated 06/23/21) and ordered the Ativan medication to continue, documenting the resident had anxiety related to the dying process and to continue the medication for 14 days. However, no order for the medication was written on this date. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/17/21 revealed a Brief Interview of Mental Status (BIMS) of 10 indicating impaired cognition. The assessment revealed the resident required supervision one staff assist for bed mobility and locomotion. The assessment revealed the resident had no behaviors. On 11/02/21 at 9:58 A.M. interview with the Director of Nursing (DON) confirmed the physician recommendation on 07/29/21 was not clarified and no order for Ativan was written at that time.

Based on record review, facility policy and procedure review and interview the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days without a rationale extending the medication for Resident #79 and failed to ensure non-pharmacological interventions were attempted prior to the use of an as needed psychotropic medication for Resident #87. This affected two residents (#79 and #87) of six residents reviewed for unnecessary medications use. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of 08/06/16 with diagnoses including anxiety, depression, psychosis, dementia with behavior disturbances, encephalopathy and insomnia. Review of the care plan, dated 06/10/20 revealed the resident had the potential for mood swings and behavioral issues related to depression, psychosis and anxiety. Interventions included to administer as needed medications as ordered when the resident exhibited any increased agitation, anxiety, pacing, hallucinations, mood changes, restlessness, wandering or abusive behaviors, etc. Review of the resident's physician orders revealed an order from 06/19/21 through 09/09/21 for the antipsychotic medication, Haldol 0.5 milligrams (mg) as needed every four hours for agitation and restlessness. Review of the medication regimen reviews (MRR) revealed on 08/16/21 the resident was receiving Haldol 0.5 mg every four hours as needed and the pharmacist recommendation noted the use of as needed antipsychotics was not generally recommended to manage behaviors and required regular re-evaluation to support continuation. The review indicated PRN antipsychotics may be appropriate if documentation showed acute potential harm to the resident or others. Additionally, there were federal regulations limiting the use of PRN antipsychotics and PRN orders were now limited to 14 days initially and if continuation was intended, the resident must be reevaluated every 14 days for each subsequent renewal. Record review revealed the medication was discontinued, but not until 09/09/21. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/17/21 revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating impaired cognition. The assessment revealed the resident required supervision one assist from staff for bed mobility and locomotion. The assessment revealed the resident had no behaviors. On 11/02/21 at 9:58 A.M. interview with the Director of Nursing (DON) confirmed there was no indication for use of the Haldol for Resident #79 for longer than 14 days after originally ordered on 06/19/21. The DON verified the medication was not discontinued until 09/09/21. Review of the facility policy and procedure titled Consulting Pharmacist Monthly Drug Review, dated 2016 revealed an unnecessary drug was any drug used in excessive duration or without adequate indications for use. 2. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21 and diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the plan of care, dated 02/05/21 revealed the resident had an alteration in behaviors related to yelling out disturbing other residents, throwing things into the hallway and tearing down privacy curtain. Interventions included to administer medications as physician ordered and document behaviors as to type, duration and precipitating factors. Review of the MDS 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. Review of the mood and behavior section of the MDS revealed the resident had delusions, displayed verbal behaviors directed towards others and behaviors not directed towards others. The resident received antipsychotic, antianxiety, antidepressant and hypnotic medications. Review of the resident's monthly physician's orders for October 2021 revealed an order, (dated 10/19/21) for the antipsychotic medication, Haloperidol (Haldol) two milligrams (mg) with the special instructions to give 2 mg by mouth every 12 hours as needed for agitation, an order (dated 10/21/21) for Haloperidol Lactate Concentrate 2 mg/milliliter (ml) with the special instructions to give 0.25 ml by mouth every four hours as needed for anxiety, agitation or restlessness for 14 days and an order (dated 10/28/21) for the antianxiety medication, Lorazepam Intensol Concentrate 2 mg/ml with the special instructions to give 0.5 mg by mouth every four hours as needed for anxiety, agitation or restlessness for six months. Review of the resident's October 2021 Medication Administration Record (MAR) revealed she was medicated with Haldol 2 mg by mouth on 10/24/21 at 10:53 A.M. and Haldol Lactate Concentrate 0.25 ml by mouth on 10/26/21 at 1:49 A.M. and 11:46 P.M. with no evidence of any non-pharmacological interventions being attempted prior to the administration of the as needed medication. On 11/01/21 at 8:56 A.M. interview with the Director of Nursing (DON) verified the resident had been given as needed antipsychotic medication without non-pharmacological interventions attempts prior to the administration of the medication. Review of the facility policy titled, Unnecessary Drug Information,dated 07/2018 revealed when administering an as needed medication for pain or behavior you must evaluate and assess the resident's signs and symptoms and identify the specific behaviors that warrant and intervention for behavior, attempt to determine if there was a cause of the behavior or pain and meet that need if possible. Attempt to use non-medication interventions to redirect, stop or reduce the identified behavior. If the non-medication interventions were not successful the as needed medication may be administered as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #98's medical record revealed an original admission date of 06/13/19 with the latest readmission of 08/05/19 with admitting diagnoses of diffuse traumatic brain injury with loss of consciousness, nicotine dependence, right hip pain, schizoaffective disorder, diabetes mellitus, hyperlipidemia, bipolar disorder, mood disorder, dementia with behavioral disturbances, PTSD, hypertension, asthma, epilepsy, hypothyroidism, insomnia, alcoholic cirrhosis of liver without ascites, and severe morbid obesity. The resident was discharged to another skilled nursing facility on 11/01/21. Resident #98 had a physician's order, dated 09/12/19 indicating may see in house dentist. Review of the plan of care, dated 09/07/20 revealed the resident was at risk for dental or chewing problems related to obvious, likely cavity. Interventions included to apply lip balm/moisturizer to lips as needed, arrange periodic dental consult, assist as needed with oral hygiene, including denture care if applicable, diet as ordered, dietary to review nutritional status at least quarterly and as needed, encourage resident to report any oral discomfort, note % of intake at each meal and document and review for weight changes. Review of the resident's dental summary report revealed the resident was seen on 02/08/21 by the facility contracted dentist. Further review revealed the dentist referred the resident for a crown for tooth number three. The resident's medical record contained no evidence the resident was sent for the crown placement. Review of an oral assessment, dated 08/11/21 revealed the resident had natural teeth with no issues. The resident had no complaints of pain or chewing problems per the assessment completed at that time. Review of the resident's quarterly MDS 3.0 assessment, dated 08/13/21 revealed the resident had clear speech, understand others, makes self understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 11. The assessment indicated the resident had no dental issues. On 11/02/21 at 2:39 P.M. interview with Registered Nurse (RN) #406 verified the resident had not had any dental follow up for the crown. Based on record review and interview the facility failed to obtain dental services in a timely manner for Resident #11, Resident #18 and Resident #98. This affected three residents (#11, #18 and #98) of three residents reviewed for dental services. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident was cognitively impaired. The assessment revealed the resident required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff member for toilet use, dressing and personal hygiene. Review of the dental record revealed on 05/20/21 an emergency exam was completed and the resident was to be seen for further dental care. Record review revealed no further dental care had been provided for the resident as recommended following the 05/20/21 emergency exam. On 10/28/21 at 12:37 P.M. interview with Social Worker (SW) #481 verified the above findings. Following the interview, a dental appointment was made for the resident on 11/16/21 at 1:00 P.M. 2. Review of Resident #18's medical record revealed an admission date of 12/12/18 with diagnoses including Alzheimer's dementia, chronic kidney disease, diabetes and anemia. Record review revealed the most recent dental visit for the resident was completed on 02/12/20. There was no evidence the resident had been seen for a routine dental visit since this time. Review of the admission MDS 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired. The resident required extensive assistance from two or more staff members for bed mobility, transfers, dressing and toilet use. On 10/28/21 at 12:37 P.M. interview with SW #481 verified the above findings. The SW was unable to provide any additional information as to why the resident had not been seen for routine dental care since 02/12/20.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #117's medical record was maintained in a complete and accurate manner related to monitoring the resident's output. This affected one resident (#117) of 51 sampled residents whose medical records were reviewed. Findings include: Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, high blood pressure and anemia. On 09/19/21 a physician's orders was received to record output every shift (qshift). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired, he required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The assessment revealed the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the treatment records for 09/2021 and 10/2021 revealed incomplete output documentation on 09/26/21, 10/04/21, 10/12/21, 10/14/21, 10/19/21, 10/20/21, and 10/26/21. On 11/01/21 at 10:43 A.M. interview with the Director of Nursing (DON) verified the incomplete output monitoring and documentation for Resident #117 as noted above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension. bipolar disorder, atrial fibrillation and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. The resident required extensive assistance of one staff for bed mobility, transfers and was dependent on one staff for toilet use. The resident was identified as being always incontinent of both bowel and bladder. Review of the admission assessment with baseline care plan, dated 10/19/21 revealed the resident was readmitted to the facility from an acute care hospital with an indwelling urinary catheter. Review of the plan of care, dated 10/19/21 revealed the resident had potential for complications related to indwelling urinary catheter use. Interventions included to assist with Foley catheter care as needed, educate resident to report signs/symptoms of urinary tract infection (UTI), encourage proper nutrition and adequate fluid intake, evaluate need for catheter and supporting diagnoses and observe for signs/symptoms of UTI. Review of the resident's monthly physician's orders for October 2021 identified orders, dated 10/19/21 for Foley catheter care every shift, change catheter collection bag as needed, change Foley catheter when blocked or unable to flow freely as needed, secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction, Foley catheter size 16 FR with 30 milliliter (ml) balloon, Foley catheter to remain covered for privacy. On 10/25/21 at 1:17 P.M. observation of the resident revealed she had no linen on her bed and was lying on an exposed mattress. Further observation revealed her hospital gown was pulled up around her waist resulting in her disposable brief being exposed and in view from the hallway. Licensed Practical Nurse (LPN) #304 verified the resident had no linens on her bed and her disposable brief was exposed and viewable from the hallway. On 10/26/21 at 10:59 A.M. observation of the resident revealed her indwelling urinary catheter collection bag was not covered and dark yellow urine was visible from the hallway. On 10/26/21 at 11:01 A.M. interview with LPN #482 verified the indwelling urinary catheter collection bag was not covered and dark yellow urine was visible from the hallway. On 10/28/21 at 11:37 A.M. Resident #87 was observed lying in a supine position in bed with a hospital gown pulled up exposing her disposable brief from the hallway. LPN #304 verified the resident's disposable brief was visible from the hallway at the time of the observation. Based on observation, record review and interview the facility failed to ensure residents were treated with respect and dignity. This affected six residents (#11, #35, #45, #53, #87 and #117) of 134 residing in the facility. Findings include: 1. On 10/25/21 at 12:50 P.M. observation of the lunch meal revealed State Tested Nursing Assistant (STNA) #445 was observed passing meal trays on Hall A. At 12:50 P.M. Resident #117, who was observed in the dining room was served a meal tray. There were four other residents, Resident #11, #35, #45 and #53 at the table who were not served at that time. STNA #445 then passed more trays on Hall A leaving the dining room to do so. At 1:04 P.M. STNA #445 had Resident #48 come to the dining area and served him his tray and Resident #35 was also served at this time. STNA #445 again left the dining room and passed more trays on the hall A. Resident #11, #45 and #53 watched the other residents eat until 1:06 P.M. when they were finally served their tray. Interview with STNA #445 verified she had not delivered the meal trays to the residents in the dining room and some residents watched other residents eat while they were waiting for their meal as noted above. 2. Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, high blood pressure and anemia. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired. Resident #117 was assessed to require extensive assistance from two staff members for bed mobility, transfers, dressing and toilet use and required extensive assistance from one staff member for personal hygiene. The assessment revealed the resident had an indwelling urinary catheter and was frequently incontinent of bowel. On 10/28/21 at 8:23 A.M., 10:15 A.M. and 11:30 A.M. Resident #117 was observed sitting in a wheelchair in the dining area. The resident was observed to have a urinary catheter and the urinary catheter drainage collection bag was uncovered and visible with urine in it. On 10/28/21 at 11:30 A.M. interview with Licensed Practical Nurse (LPN) #327 verified the resident's urinary catheter collection bag was uncovered and hanging on the wheelchair in the dining/lounge area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain a safe, clean and comfortable environment for all residents. This affected six residents (#34, #24, #71, #385, #46 and #11) of 14 residents reviewed for physical environment. Findings include: 1. On 10/25/21 at 10:46 A.M. Resident #34 was observed sitting on a bedside commode as if it were a chair. The bed side commode was next to the head of Resident #34's bed. Resident #34 was fully dressed and gazing out the window. There was not a personal (sitting) chair located in Resident #34's room. Additional observations on 10/27/21 at 8:38 A.M. and on 11/03/21 at 8:50 A.M. revealed the bedside commode remained beside Resident #34's bed and no other chair was observed to be in the resident's room. On 10/27/21 at 10:47 A.M. interview with State Tested Nursing Assistant (STNA) #485 confirmed there was no chair available for Resident #34 or any visitors in the resident's room. STNA #485 revealed she thought the resident was OK sitting on a bedside commode. STNA #485 revealed Resident #34 was independent with toileting and did not use the bed side commode for toileting purposes. Additional observations throughout the survey from 10/25/21 through 11/03/21 revealed there were no chairs or any other furniture for sitting, in the rooms of Resident #24, #71 or #385, who all resided on the C Hall. On 10/25/21 at 11:06 A.M. interview with Resident #71 revealed he would like a chair in his room, to sit and read and he was not sure why the room did not have one. On 10/25/21 at 11:26 A.M. interview with Resident #24 revealed he would like a chair in his room. Review of the medical records for Resident #24, #34, #71, and #385 revealed the records contained no documentation of behaviors or interventions indicating safety concerns or other reasons the residents would not have chair in their room to sit on. On 10/27/21 at 9:36 A.M. interview with Regional Director of Clinical Services (RN) #406 revealed there was no facility policy preventing residents from having chairs in their rooms. RN #406 further confirmed if a resident did not have a chair in their room due to behaviors or safety, it would have to be in the individual plan of care. On 10/27/21 at 10:47 A.M. interview with STNA #485 confirmed there were no chairs available in the rooms of Resident #24, #71 or #385. 2. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominants side, muscle weakness, hypertension, atrial fibrillation and need for assistance with personal care. Review of the plan of care, dated 04/30/21 revealed Resident #46 needed assistance with activities of daily living (ADLs) due to cognitive impairment, hemiparesis, pain and limited mobility. Interventions listed for Resident #46 included one person physical assist for dressing, and staff to assist with daily hygiene. Review of the Minimum Date Set (MDS) 3.0 assessment, dated 07/23/21 revealed Resident #46 was severely cognitively impaired. The resident was noted to require assistance of one staff for dressing, hygiene and bathing. Resident #46 was noted to use his wheelchair independently for locomotion on the unit. On 10/25/21 at 10:52 A.M. Resident #46 was observed in his wheelchair, wheeling himself down the hallway using his feet. Resident #46's right hand was noted to be in a splint and the resident appeared to have limited range of motion to the hand. Observation of the splint revealed it had several darkened and discolored areas that appeared to be stains. The seat of Resident #46's wheelchair was observed to have pressure reducing cushion on it. Several multicolored stains and what appeared to be crumbs of food were dried to the seat of the wheelchair, the pressure reducing cushion and in between the two. On 10/27/21 at 8:39 A.M. Resident #46 was observed in his wheelchair, wheeling himself down the hallway using his feet. Resident #46 was again wearing his splint, which was observed to have a red spot approximately three by four centimeters that appeared to be dried red sauce, in addition to the darkened and discolored areas that appears to be stains. The seat of Resident #46's wheelchair was again observed to have several multicolored stains and what appeared to be crumbs of food dried to the seat of the wheelchair, the pressure reducing cushion and in between the two. On 10/27/21 at 8:40 A.M. interview with STNA #410 confirmed the presence of what appeared to be dried food and stains of Resident #46's wheelchair seat and splint. STNA #410 revealed night shift staff should clean resident wheelchairs and that it does not appear to have been done. STNA#410 revealed she did not know the policy for cleaning resident splints. On 10/27/21 at 9:36 A.M. interview with Regional Director of Clinical Services (RN) #406 confirmed the presence of what appeared to be food and dirt on Resident #46's wheelchair and splint. RN #406 revealed there was a cleaning schedule and third shift staff should clean wheelchairs, but the facility does not keep a sign off sheet or other documentation that it was completed. Review of the undated facility policy titled Night Shift Cleaning Schedule revealed wheelchairs should be cleaned on Mondays and Wednesdays. 3. During a tour of the facility on 10/27/21 between 10:15 A.M. and 10:32 A.M. with Maintenance Man (MM) #346 observation of Resident #11's wheelchair revealed the right arm of the chair was taped and appeared dirty. The wheelchair seat was observed to be torn and had dried food debris and dirt on it. Interview with MM #346 at the time of the observation verified the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed for residents diagnosed with a new mental diagnosis at the time of or after their admission to the facility. This affected five residents (#11, #63, #64, #98, and #109) of eight residents reviewed for PASRR. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of [DATE] with diagnoses including aphasia, anxiety disorder, dementia, chronic obstructive pulmonary disease, major depression disorder. A new diagnosis (dated [DATE]) for unspecified psychosis not due to a substance or known physiological condition was also included on the resident's diagnoses list. Review of the Preadmission Screening/Resident Review Identification Screen, dated [DATE] revealed Resident #63 had a mood disorder and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had impaired cognition. On [DATE] from 4:36 P.M. to 4:48 P.M. interview with Social Worker (SW) #481 revealed she was responsible for completing the PASARR forms. SW #481 reported she completed them upon admission and if she noticed any that had been missed upon admission. SW #481 was unaware PASARR forms needed to be completed when a resident had a new mental illness and confirmed she had not been doing this. She reported the previous admissions director had been telling her when to complete the PASARR's for residents and she knew she missed some while she was learning to do it on her own. She confirmed the facility did not complete a new PASARR for Resident #63 following the [DATE] diagnosis of unspecified psychosis. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, encephalopathy, unspecified dementia with behavioral disturbance, delusional disorders, hyperlipidemia and dysphagia. On [DATE] a new diagnosis of schizoaffective disorder was added. Review of the review results dated [DATE] revealed the pre-admission screening determination for Resident #64 was not applicable. On [DATE] from 4:36 P.M. to 4:48 P.M. interview with SW #481 revealed she was responsible for completing the PASARR forms. SW #481 reported she completed them upon admission and if she noticed any that had been missed upon admission. SW #481 was unaware PASARR forms needed to be completed when a resident had a new mental illness and confirmed she had not been doing this. She reported the previous admissions director had been telling her when to complete the PASARR's for residents and she knew she missed some while she was learning to do it on her own. SW #481 revealed the review results were all she was able to locate for Resident #64 and confirmed a new PASARR had not been completed when the resident received a new mental illness diagnosis. 3. Review of Resident #98's medical record revealed an original admission date of [DATE] with the latest readmission of [DATE] with admitting diagnoses of diffuse traumatic brain injury with loss of consciousness, nicotine dependence, right hip pain, diabetes mellitus, hyperlipidemia, bipolar disorder, mood disorder, dementia with behavioral disturbances, post traumatic stress disorder (PTSD), hypertension, asthma, epilepsy, hypothyroidism, insomnia, alcoholic cirrhosis of liver without ascites, and severe morbid obesity. The resident's diagnoses list was updated on [DATE] to reflect the addition of a diagnosis of schizoaffective disorder. Review of the hospital exemption from preadmission screening notification, dated [DATE] revealed the resident had a mood disorder with a description of mood disorder, depressive disorder. Record review revealed no evidence a new PASARR was completed on or after [DATE], when Resident #98 was given the diagnoses of schizoaffective disorder. Review of the resident's quarterly MDS 3.0 assessment, dated [DATE] revealed the resident had clear speech, understands others, makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 11. On [DATE] at 12:33 P.M. interview with Registered Nurse (RN) #406 verified a PASARR was not completed for the added schizoaffective disorder on [DATE]. 4. Review of Resident #11's medical record revealed the resident had diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the annual MDS 3.0 assessment, dated [DATE] revealed the resident was cognitively impaired, required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff member for toilet use, dressing and personal hygiene. Record review revealed the resident had a new diagnosis of schizophrenia on [DATE]. However, no updated PASARR was completed at that time or since hat time. On [DATE] from 4:36 P.M. to 4:48 P.M. interview with SW #481 revealed she was responsible for completing the PASARR forms. SW #481 reported she completed them upon admission and if she noticed any that had been missed upon admission. SW #481 was unaware PASARR forms needed to be completed when a resident had a new mental illness and confirmed she had not been doing this. She reported the previous admissions director had been telling her when to complete the PASARR's for residents and she knew she missed some while she was learning to do it on her own. During the interview SW #481 confirmed Resident #11 had new mental illness diagnoses since the last PASARR completed which was from 1993. 5. Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis and schizoaffective disorder. Review of the quarterly MDS 3.0 assessment, dated [DATE] revealed the resident had moderately impaired cognition, required supervision with set up help for dressing and personal hygiene and was independent with set up help for bed mobility, transfers and toilet use. Review of the PASARR, dated [DATE] revealed no evidence the form accurately reflected the resident's diagnosis of schizophrenia. Resident #109 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. On [DATE] from 4:36 P.M. to 4:48 P.M. interview with SW #481 revealed she was responsible for completing the PASARR forms. SW #481 reported she completed them upon admission and if she noticed any that had been missed upon admission. SW #481 was unaware PASARR forms needed to be completed when a resident had a new mental illness and confirmed she had not been doing this. She reported the previous admissions director had been telling her when to complete the PASARR's for residents and she knew she missed some while she was learning to do it on her own. During the interview, SW #481 confirmed Resident #109 did not have an up to date PASARR, she revealed the hospital exemption had expired and nobody had completed a new one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE] with the most recent re-admission on [DATE]. Resident #65's diagnoses included encephalopathy, atrial fibrillation, hypertension, end stage renal failure, non-Alzheimer's dementia and need for assistance with personal care. Review of the plan of care, dated 02/25/21 revealed Resident #65 needed assistance with ADL care related to immobility. Interventions include to assist with dressing, toileting, oral care and grooming. Review of most current MDS 3.0 assessment revealed the resident was moderately cognitively impaired, required extensive assistance from one staff for bed mobility, transfers, locomotion, dressing, personal hygiene and toileting and was dependent on staff for bathing. On 10/25/21 at 2:19 P.M. Resident #65's fingernails were observed to be long, with a brown substance under them, that appeared to be dirt or food. At the time of the observation, Resident #65 revealed he would like to have his fingernails trimmed. On 10/25/21 at 2:22 P.M. observation and interview with STNA #485 confirmed Resident #65's fingernails were too long and needed cleaned. Review of the shower sheets, dated 10/25/21 and 10/18/21 revealed they were both marked that fingernail care was completed. The record was observed to silent for documented showers or baths between 10/18/21 and 10/25/21. Further review of the record revealed personal hygiene and/or nail care/hand hygiene was provided once, on 10/20/21. On 11/01/21 at 3:45 P.M. interview with the Director of Nursing (DON) confirmed the medical record was silent for any showers from 10/18/21 through 10/25/21 for Resident #65, and that personal hygiene was documented as being provided once, in an eight day period. Review of the facility policy titled Resident Care revised 06/2018 revealed facility staff would provide general care as necessary for each resident per their preferences when able and per physician's orders. The policy clarified, typical personal hygiene for a resident included but was not limited to cleaning and cutting of fingernails and toenails. 5. Review of Resident #85's medical record revealed an admission date of 12/09/20 with diagnoses including need for assistance with personal care, abnormality of gait and mobility, muscle weakness and adult failure to thrive. Review of the care plan, dated 12/28/20 revealed the resident experienced bowel and/or bladder incontinence with interventions to provide incontinence care every two hours and as needed. Review of the MDS 3.0 assessment, dated 08/27/21 revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating impaired cognition. The assessment revealed the resident required limited assistance from one staff for bed mobility, extensive assistance of one staff for dressing and personal hygiene and extensive assistance of two staff for transfers and toilet use. The MDS also revealed the resident was always incontinent of bowel and bladder. On 10/25/21 at 10:57 A.M. interview with Resident #85 revealed she was dependent on staff for all care. During the interview, the resident did exhibit cognitive impairment but voiced a concern that staff were supposed to change her (bed) sheets but stated they didn't. At the time of the interview, Resident #85 was observed sitting on her bed with an incontinence (pull up) brief in place. There was a feces odor noted. As the resident was moving around on the bed, feces was observed smeared on the resident's bed sheets. The wheelchair next to the bed was observed was a soiled pull up sitting on top of a towel on the seat. On 10/25/21 at 11:04 A.M. observation and interview with STNA #372 confirmed the above findings. No additional information was provided to determine when the resident had last been provided personal care on this date prior to the surveyors observation. Review of the facility policy and procedure titled, Resident Care, dated June 2018 revealed residents would be given nursing care and supervision based upon their individual needs. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure all residents who required staff assistance with activities of daily living (ADL) care received timely and appropriate care and services to maintain proper hygiene and grooming. This affected five residents (#11, #13, #18, #65 and #85) of nine residents reviewed for ADL care. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the plan of care, dated 09/24/20 revealed staff would assist as needed with daily hygiene and assist with showering resident as per facility policy weekly. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident exhibited cognitive impairment, required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff member for toilet use, dressing and personal hygiene. On 10/26/21 at 10:20 A.M. and 3:13 P.M. Resident #11 was observed to have dried food on his clothes. In addition, the resident had a significant amount of facial hair; he appeared unshaven. Additional observations on 10/27/21 at 8:00 A.M. and 12:20 P.M. revealed the resident remained unshaven with a dried substance on his shirt. On 10/28/21 at 10:29 A.M. the resident remained unshaven. On 11/01/21 at 8:35 A.M. Resident #11 was observed up in his wheelchair with clothes that were stained. The resident was wearing sweat pants and a sweat shirt with dried food substances on them, holes in his sweatshirt and the resident remained unshaven at that time. At 11:27 A.M. Resident #11 was observed lying on his bed with his clothes stained (stains on his sweat pants and sweat shirt with dried food substance and holes in the sweat shirt). On 11/01/21 at 11:27 A.M. interview with Licensed Practical Nurse (LPN) #497 verified Resident #11 was unshaven and his clothes were in poor condition. The LPN did not provide any information that the resident refused care. 2. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, major depression and encephalopathy. Review of the plan of care, dated 11/09/20 revealed staff would assist as needed with daily hygiene and would assist with showering resident as per facility policy weekly. Review of the quarterly MDS 3.0 assessment, dated 10/04/21 revealed the resident was cognitively impaired, he required supervision with one staff member physical assist for transfers and toilet use and extensive assistance from one staff member for dressing and personal hygiene. There were no behaviors identified. On 10/26/21 at 9:14 AM and 3:15 P.M. observation of Resident #13 revealed the resident's hair appeared greasy, uncombed and he had long hairs on his neck. Additional observations on 10/27/21 at 8:10 A.M. and 11:30 A.M. revealed the resident's hair was uncombed with long hairs remaining on his neck. On 10/28/21 at 9:00 A.M., 10:39 A.M. and 3:20 P.M. Resident #13 was observed wearing a hospital gown. The resident's hair remained uncombed and long hairs remained on his neck. On 11/01/21 at 8:55 A.M. and 11:27 A.M. Resident #13 was observed in bed unshaven with long hairs on his neck wearing a hospital gown. At 1:46 P.M. Resident #13 was up in the dining/lounge area and observed to be wearing a shirt with stains on it, his hair was uncombed, the resident was unshaven and he had long hairs on his neck. On 11/01/21 at 1:55 P.M. interview with LPN #497 verified the above condition of the resident. The LPN did not provide any information that the resident refused care. 3. Review of Resident #18's medical record revealed the was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, diabetes and anemia. Review of plan of care, dated 06/29/21 revealed the resident needed (staff) assistance for ADL care due to cognitive and communication deficits. Review of the MDS 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired. Resident #18 was assessed to require extensive assistance of two or more staff members for bed mobility, transfers, dressing and toilet use. On 10/25/21 at 12:25 P.M. Resident #18 was observed unkept wearing clothing that was stained and with dried food. On 10/26/21 8:05 A.M. and 3:16 P.M. Resident #18 was observed wearing the same clothes that had been on 10/25/21 with stains and dried food. On 10/26/21 at 3:18 P.M. interview with State Tested Nursing Assistant (STNA) #331 verified the condition of the resident as noted above. The STNA did not provide any information that the resident refused care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide appropriate urinary catheter care to prevent the risk of urinary tract infections for residents. This affected four residents (#61, #383, #87 and #11) of five residents reviewed for urinary catheters and/or urinary tract infections. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 03/03/21 with diagnoses including encounter for orthopedic aftercare following surgical amputation, muscle weakness, paraplegia, neuromuscular dysfunction of bladder, urinary tract infection, adult failure to thrive, diabetes, dementia, major depressive disorder and personal history of cerebral infarction. Review of the plan of care, dated 05/03/21 revealed Resident #61 had potential for complications related to suprapubic catheter. Interventions for Resident #61 included to assist with catheter care as needed, educate resident on signs and symptoms of urinary tract infection (UTI), observe for signs and symptoms of UTI and report to physician. On 10/25/21 at 3:30 P.M. Resident #61 was observed to be sleeping in bed, with the bed in low position. Resident #61's catheter bag and tubing were observed to be hanging on the side of the bed and both the bottom of the catheter bag and a section of the tubing were observed to be resting directly on the floor. On 10/25/21 at 4:00 P.M. interview with State Tested Nursing Assistant (STNA) #507 confirmed Resident #61's catheter bag and tubing were resting directly on the floor. Review of the facility policy titled Foley Catheter Care, revised 04/2016 revealed the caregiver should not to allow the catheter bag to touch the floor. 2. Review of the medical record for Resident #383 revealed an admission date of 08/31/21 with diagnoses including neuromuscular dysfunction of bladder, paraplegia, polyneuropathy and chronic pain. Review of the plan of care, dated 08/31/21 revealed Resident #383 had the potential for complications related to use of an indwelling (Foley) catheter. Interventions included to assist with catheter care as needed and educate resident to report signs and symptoms of UTI. On 10/25/21 at 3:43 P.M. Resident #383 was observed resting in bed, with the bed in low position. Resident #383's catheter bag and tubing were observed to be hanging on the side of the bed and both the bottom of the catheter bag and a section of the tubing were observed to be resting directly on the floor. On 10/25/21 at 4:00 P.M. interview with State Tested Nursing Assistant (STNA) #507 confirmed Resident #383's catheter bag and tubing were resting directly on the floor. Review of the facility policy titled Foley Catheter Care, revised 04/2016 revealed the caregiver should not to allow the catheter bag to touch the floor. 3. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of eight. The resident required extensive assistance of one staff for bed mobility, transfers and dependent on one staff for toilet use. The resident was identified as being always incontinent of both bowel and bladder. Review of the admission assessment with baseline care plan, dated 10/19/21 revealed the resident was readmitted to the facility from an acute care hospital and was admitted with an indwelling urinary catheter. Review of the resident's bowel and bladder evaluation, dated 10/19/21 revealed the resident was incontinent of bowel and bladder. The assessment failed to identify the resident had an indwelling urinary catheter. Review of the plan of care dated 10/19/21 revealed the resident had potential for complications related to indwelling urinary catheter use. Interventions included to assist with Foley catheter care as needed, educate resident to report signs/symptoms of urinary tract infection (UTI), encourage proper nutrition and adequate fluid intake, evaluate need for catheter and supporting diagnoses and observe for signs/symptoms of UTI. Review of the resident's monthly physician's orders for October 2021 revealed an order, dated 10/19/21 for Foley catheter care every shift, change catheter collection bag as needed, change Foley catheter when blocked or unable to flow freely as needed, secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction, Foley catheter size 16 FR with 30 milliliter (ml) balloon and Foley catheter to remain covered for privacy and 10/28/21 Foley catheter for comfort care. On 10/25/21 at 1:14 P.M. observation of Resident #87's indwelling urinary catheter collection bag revealed it did not have a privacy bag and was placed under the bed directly on the floor. On 10/26/21 at 10:59 A.M. observation of Resident #87's indwelling urinary catheter collection bag revealed it was not covered and dark yellow urine was visible from the hallway. On 10/26/21 at 11:01 A.M. interview with Licensed Practical Nurse (LPN) #482 verified the resident's indwelling urinary catheter collection bag was not covered and dark yellow urine was visible from the hallway. On 10/28/21 at 11:37 A.M. observation of the resident revealed she was lying in a supine position in bed wearing a hospital gown with a disposable brief visible from the hallway. The resident's indwelling catheter collection bag was observed hanging on the bed frame above the resident's bladder. At the time of the observation, interview with LPN #406 verified the resident's indwelling urinary catheter collection bag was positioned above the resident's bladder. Review of the facility policy titled Foley Catheter Care Procedure, dated 04/2016 revealed to keep the catheter bag below the level of the resident's bladder to keep the urine from returning to the bladder and do not allow the catheter bag to touch the floor. 4. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the annual MDS 3.0 assessment, dated 10/04/21 revealed the resident was cognitively impaired, he required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff member for toilet use, dressing and personal hygiene. On 11/01/21 at 8:55 A.M. STNA #385 was observed to take Resident #11 to the shower room. The STNA applied gloves, had the resident stand up and removed the resident's incontinent (Depends) brief. The resident was observed to have had a bowel movement. The resident refused to sit on the toilet. STNA #385 proceeded to wash the resident's buttocks and rectal area and then placed a new Depends on the resident without first washing his penis or scrotum. On 11/01/21 at 9:00 A.M. interview with STNA #385 verified the resident had been incontinent of bowel and she did not thoroughly clean around the resident's penis/scrotum area to prevent the resident from developing a urinary tract infection. Review of the policy and procedure titled Perineal Care, revised in 2018 revealed for a male resident perineal care included starting starting with the urethra and working outward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility self-reported incidents (SRIs), review of facility investigations and interview the facility failed to develop and implement comprehensive and individualized behavior management programs for residents with dementia to prevent resident to resident altercations and to ensure each resident maintained their highest practicable physical, mental, and psychosocial well-being. This affected five residents (#10, #19, #113, #126 and #127) with the potential to affect all 21 residents residing on D hall/East Building and two residents (#13 and #111) with the potential to affect all 19 residents residing on A hall/East Building. The facility census was 134. Findings include: 1. Review of the medical record revealed Resident #113 admitted to the facility on [DATE] with diagnoses including aphasia, metabolic encephalopathy, Alzheimer's disease, major depressive disorder, essential hypertension, type two diabetes mellitus, dysphagia, obsessive-compulsive disorder, anxiety disorder. Review of the plan of care, dated 10/01/20 revealed Resident #113 had a behavior problem related to diagnoses of dementia, confusion, poor awareness of others personal space, history of biting another resident, resistance to care, combative with caregivers including hitting and pinching during care and tendency to take food from other meal trays. Interventions included administering medications as ordered, anticipating and meeting needs as able, documenting behavior, informing doctor or nurse practitioner of worsening behavior, intervening as needed to protect the rights and safety of others, praise all appropriate behaviors, remind resident that behavior is unacceptable and redirect. Additional review of the plan of care, dated 05/05/21 revealed the resident was at risk for wandering and elopement and was currently on a secured unit. Interventions included developing an activity program to divert attention and meet individual needs, discuss with resident and family the risks of wandering, redirect if resident was wandering in potentially unsafe area or situation, and observing and reporting to doctor risk factors for potential elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/20/21 revealed Resident #113 was rarely or never understood. The resident experienced physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others one to three days during look back period. She rejected care four to six days during look back period and experienced wandering four to six days. Review of the physician's orders revealed an order dated 07/08/21 to redirect Resident #113 when seen entering other's rooms. Review of the medical record for Resident #19 revealed an admission date of 08/03/17 with diagnoses including other schizoaffective disorder, type two diabetes mellitus, anxiety disorder, major depressive disorder, hypertension, unspecified dementia with behavioral disturbance, and aphasia. Review of the quarterly MDS 3.0 assessment, dated 10/06/21 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) of seven indicating severe cognitive impairment. Review of a facility self-reported incident, dated 07/08/21 revealed there was an allegation of physical abuse between two residents, Resident #19 and Resident #113. According to the summary of the incident Resident #113 stated Resident #11 struck her. The nurse completed a head to toe assessment with no negative outcomes. The residents were separated, and the doctor and responsible parties were notified. The incident was determined to be unsubstantiated by the Administrator. The actions the facility took included separating the residents and Resident #19 was moved to a different room or area per the request of the responsible party. Review of the change in condition evaluation dated 07/08/21, revealed there had been a resident-to-resident interaction involving Resident #113. The resident's skin and pain were assessed with no concerns and neurological checks were initiated. Review of the incident report dated 07/08/21 for Resident #19 revealed Resident #113 had wandered into her room and Resident #19 yelled at her to get out. Resident #19 pinned Resident #113 against the wall. A State Tested Nursing Aide (STNA) separated the two residents, in the meantime, Resident #19 struck Resident #113 in the face. Resident #19 denied the incident, she was assessed with no negative outcomes and placed on 15-minute checks. The predisposing factor was listed as another resident entering Resident #19's room. Review of the incident report, dated 07/08/21 for Resident #113 repeated the narrative in the incident report for Resident #19. The intervention that was implemented was to redirect Resident #113 when seen wandering into other rooms. The predisposing factors for the resident were confusion and wandering. The skin and pain assessments revealed no concerns and neurological checks were initiated. Review of the witness statement, dated 07/08/21 revealed Nurse Aide #301 was on the D hall by herself. Resident #19's door was open and Resident #113 entered the room. Nurse Aide #301 revealed she was in the doorway when Resident #19 yelled at Resident #113 to get out and jumped up to pin her against the door. The aide separated the two, Resident #19 stood there and as she was trying to talk her down, she punched Resident #113 in the face. Resident #19 grabbed the aide by the left arm roughly. The aide was able to free herself and get Resident #113 out of the room. Review of the witness statement dated 07/08/21, revealed Nurse Aide #541 was on a different hall when the incident occurred. She stated when she returned to the D Hall, Nurse Aide #301 reported she had to break up a fight between Resident #19 and Resident #113. Review of the witness statement dated 07/08/21, revealed LPN #497 was on the A Hall passing dinner trays when Nurse Aide #301 came to get her (related to the incident). On 10/25/21 at 3:05 P.M. interview with STNA #444 revealed staff needed to keep eyes on Resident #113 all day, every day, to prevent incidents with other residents. She reported Resident #113 was constantly wandering around the unit and in resident rooms. She reported residents got aggravated with Resident #113 because she wandered, entered other people's space and was grabby. STNA #444 revealed ideally there would be two STNAs on the unit, one STNA in the dining room at all times to monitor the room and the hallway and another STNA to address residents in their rooms. On 10/26/21 at 3:14 P.M. interview with LPN #327 revealed it was difficult to manage the D Hall with one staff member. She revealed this was because one person could not help the residents as needed and watch everyone. On 10/27/21 at 10:05 A.M. interview with STNA #456 revealed it was difficult to manage the D Hall with one staff member on the unit. She stated, there's nothing I can do to prevent wandering when I am by myself'. STNA #456 revealed if she was with another resident, she was unable to prevent Resident #113 from wandering into resident rooms. On 10/27/21 from 2:45 P.M. to 3:30 P.M. interview with the Administrator, Director of Nursing, and the Regional Director of Clinical Services #407 revealed they were aware of Resident #113's wandering. They reported it was difficult to redirect Resident #113 at times. In reference to the 07/08/21 incident the DON and Administrator confirmed the best practice when dealing with a resident to resident interaction would have been to get Resident #113 out of the room as soon as possible. The DON and Administrator were unsure why the STNA stayed to talk Resident #19 down but said Resident #19 was a larger woman and could have gotten around the STNA to get to Resident #113. The Administrator confirmed there was only one staff member on the unit at the time of the incident. The Administrator revealed ideally there would be 1.5 to 2.0 staff members on both units. The Administrator revealed the facility unsubstantiated an incident of resident to resident abuse because Resident #19 did not have cognitive intent. The DON revealed with Resident #11's dementia her mental status fluctuated. Additionally, the Administrator confirmed the 07/08/21 self-reported incident did not reflect the incident was witnessed. However, based on record review and the investigation completed, there was no evidence the facility had implemented comprehensive and individualized behavior management programs for Resident #113 or Resident #19 to prevent the resident to resident altercation and no evidence the facility had provided adequate supervision to the residents residing on the D hall to prevent this incident from occurring. 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, epilepsy, liver disease, dementia, obsessive compulsive disorder, schizophrenia and dysphagia. Review of the quarterly MDS 3.0 assessment, dated 10/05/21 revealed Resident #10 had severely impaired cognition. The resident had physical and verbal behaviors directed towards others one to three days during look back period. Review of a self-reported incident (SRI), dated 08/26/21 revealed an allegation of physical abuse was reported to the State agency involving Resident #10. The brief description of the allegation revealed resident entered another resident room. Resident residing in room became upset and made physical contact with visiting resident. The perpetrator was listed as being another resident, but no name was provided. The involved resident's section revealed Resident #10 was confused and unable to provide meaningful information but had slight redness to her cheek. The summary of the incident revealed staff reported the resident entered a resident's room and as staff were entering to intervene, the resident who resided in the room became upset and made contact with her open hand to the resident's cheeks. Slight redness was noted initially but faded quickly and no residual skin alterations were noted. Staff immediately separated the residents and placed the wandering resident on increased supervision to ensure she did not re-enter room. An allegation of physical abuse was determined to be unsubstantiated. The facility determined the event did not meet criteria for abuse as neither resident was able to express intent and reacted due to their diagnoses. The resident's skin was unremarkable and neither resident recalled the event. Following the incident, staff were educated on behaviors and redirecting residents who wander. Review of an interdisciplinary progress note for Resident #113, dated 08/26/21 revealed the resident had an altercation with another resident and was slapped by that resident. The intervention was to separate the residents and apply ice to the resident's face. Review of the nurse's progress note for Resident #113, dated 08/26/21 revealed the nurse was called to the unit by an STNA, the resident had been slapped hard on the left side of the face. The area was slightly puffy and red, and ice was applied. The two residents were separated, Resident #113 was noted to be ambulating in the hall and the other resident was in her room Review of the incident report for Resident #10, dated 08/26/21 at 7:13 A.M. revealed the resident was observed by the STNA slapping another resident in the face, the resident denied the allegation. The predisposing factors to the incident were noise, clutter, ambulating without assistance, and Resident #10 had other residents she did not like. Review of the incident report for Resident #113, dated 08/26/21 at 6:30 A.M. revealed an STNA observed the resident being physically abused by another resident. The resident was slapped by another resident on the left facial cheek with a red mark noted. The residents were immediately separated, and ice was placed on the resident's left cheek. The resident had a pain rated a two based on facial expression and body language. The predisposing factors to the incident were active exit seeker and wanderer. On 10/27/21 from 2:45 P.M. to 3:30 P.M. interview with the Administrator and the Director of Nursing confirmed the SRI reported to the state did not reflect Resident #113's part in the incident, it was additionally confirmed the SRI did not match what occurred according to the incident reports and made it appear as though Resident #10 was the victim of physical abuse. In addition, based on record review and the investigation completed, there was no evidence the facility had implemented comprehensive and individualized behavior management programs for Resident #113 or Resident #10 to prevent the resident to resident altercation and no evidence the facility had provided adequate supervision to the residents residing on the D hall to prevent this incident from occurring. 3. On 10/25/21 from 12:55 P.M. to 1:37 P.M. and 10/26/21 from 3:20 P.M. to 4:55 P.M. observation revealed Resident #113 wandering up and down the hallway and in the dining room. On 10/26/21 at 3:24 P.M. she entered another resident's room. On 10/25/21 at 1:37 P.M. observation revealed STNA #456 was passing lunch trays, behind her Resident #127 was standing in the doorway of a room (not her own) asking for salt. Resident #113 was walking past the room Resident #127 was standing in and Resident #127 rushed over and pushed her, yelling get out of here. Resident #113 stepped back and began walking down the hallway again. At 1:39 P.M. Resident #113 walked by Resident #127 again, Resident #127 pushed her with two hands against her chest. STNA #456 separated the two residents and redirected Resident #113 down the hallway. STNA #456 directed Resident #127 back to the room she had been in, spoke to her and shut the door. She then informed STNA #444 she was going to get the nurse and asked her to watch Resident #113. At 1:42 P.M. LPN #497 arrived to the unit to assess Resident #113. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE] with diagnoses including alcohol abuse, anxiety disorder, major depressive disorder, gastro-esophageal reflux disease, encephalopathy, dysphagia and cognitive communication deficit. Review of the quarterly MDS 3.0 assessment for Resident #127, dated 09/28/21 revealed the resident had severely impaired cognition. The resident experienced wandering and refusal of care one to three days during look back period. Review of the in-progress self-reported incident, dated 10/25/21 revealed there was an allegation of physical abuse between two residents (Resident #113 and #127). Both residents were listed as having dementia and it was documented the incident had no ill effect on them. Review of the physician's orders for Resident #113 revealed an order, dated 10/25/21 to involve in activities as tolerated. Review of a staff statement, dated 10/25/21 by STNA #456 revealed she was passing trays on the hall when Resident #127 came to her door asking for salt, Resident #113 walked up to Resident #127's door and was pushed. She reported she took Resident #113 down to the dining room to separate them and then reported the incident to the nurse. Review of the staff statement, dated 10/25/21 by STNA #444 revealed around 1:40 P.M. she heard somebody scream in the hallway while she was in a room with a resident. She stopped everything and saw Resident #113 running away from Resident #127. She believed the residents may have had an argument that made Resident #127 push Resident #113. Review of the staff statement, dated 10/25/21 by LPN #497 revealed she was on the A Hall when she was notified of Resident #127 pushing Resident #113. She went to the D Hall and both residents were already away from each other. On 10/25/21 at 2:12 P.M. interview with STNA #444 revealed she did not witness the incident between Resident #113 and #127. She reported she was aware Resident #127 was trying to find help and she heard her say go away. She stated by the time she arrived in the hallway Resident #113 was walking away. On 10/25/21 at 2:16 P.M. interview with STNA #456 revealed the information provided was consistent with her written statement. On 10/27/21 at 9:52 A.M. interview with Activities #329 and Activities #452 revealed Resident #113 did not participate in a lot of activities. They reported Resident #113 would get aggravated when they tried to get her to sit for activities. They revealed she wandered and observed group activities, otherwise they would do activities with her while she wandered, including snacks, reading and music. Activities #329 and #452 reported they had not found an activity that prevented the resident from wandering. They reported her wandering did include entering rooms and she was stated she was difficult to redirect. Activities #452 reported the most effective method was to dance with her and direct her away from rooms. On 10/27/21 from 2:45 P.M. to 3:30 P.M. interview with the Administrator, Director of Nursing and Regional Director of Clinical Services #407 confirmed the intervention for the 10/25/21 incident was to include the resident in activities. The Administrator and DON additionally confirmed this had been a part of Resident #113's care plan to prevent wandering prior to the incident. They were aware Resident #113's activities usually included the activities staff following her while she wandered and reported it was difficult to distract her. The Administrator stated a stop sign had been put on the room Resident #127 had been in that day. He stated this intervention did not last long as the resident continuously pulled the sign down. 4. On 10/25/21 at 1:55 P.M. observation of the dining room revealed the Administrator and STNA #444 were present in the area. At the time of the observation, Resident #113 grabbed Resident #126's coffee. Resident #126 yelled at Resident #113 and grabbed the resident's arm. STNA #444 redirected Resident #113 down the hallway. At 1:57 P.M. Resident #113 came back and reached for another resident's belongings. Resident #126 grabbed Resident #113's hand and told her to get out of her face. At 1:59 P.M. STNA #444 escorted Resident #113 to her room while the Administrator pulled up a chair at the table with Resident #126. Review of the medical record revealed Resident #126 admitted to the facility on [DATE] with diagnoses including heart disease, encephalopathy, altered mental status, hypertension, unspecified dementia without behavioral disturbance, delusional disorders and cognitive communication deficit. Review of the quarterly MDS 3.0 assessment Resident #126, dated 09/27/21 revealed the resident had a moderate cognitive impairment. No behavior concerns were documented. Review of the facility SRI's dated 10/25/21, 10/26/21 and 10/27/21 revealed no evidence this incident had been reported to the State agency as an incident of potential abuse. Review of a witness statement by STNA #444, dated 10/25/21 revealed at lunch time in the dining room Resident #126 was about to touch Resident #113 because she grabbed her cup of coffee, but she had prevented that. She reported she asked Resident #126 to return to her seat and redirected Resident #113 down the hallway. On 10/25/21 at 2:57 P.M. interview with Licensed Practical Nurse (LPN) #327 revealed she was unaware of any negative interactions between Resident #126 and Resident #113. On 10/25/21 at 3:05 P.M. interview with STNA #444 confirmed she observed the interaction between Resident #126 and Resident #113 on 10/25/21 resulting in Resident #126 grabbing Resident #113. She additionally stated nursing should be informed immediately of instances where residents put their hands on each other. On 10/27/21 from 2:45 P.M. to 3:30 P.M. interview with the Administrator, Director of Nursing and Regional Director of Clinical Services #407 confirmed the incident involving Resident #113 and Resident #126 had not been reported to the State on 10/25/21, as they did not believe it was a reportable incident. The Administrator confirmed he was in the dining room at the time of the incident, that Resident #113 was wandering around the dining room table, and that he sat at the table with Resident #126, but he denied observing a physical interaction. The DON stated she was told Resident #126 placed her hand on Resident #113's arm but she did not view this as harmful. It was confirmed STNA #444's witness statement said the contact did not happen, which was contrary to what was observed and what the DON stated she was told. The DON related this discrepancy to language barriers as the STNA was from a different country. RDCS #407 revealed the incident was not reported to the State agency because residents on the dementia unit touch each other all the time and the intent mattered. RDCS #407 then said she did not feel any interactions with demented resident's should be reported to the State as they did not have the intent to harm. Interview revealed the plan was to continue to attempt to redirect and involve Resident #113 in activities to prevent further resident-to-resident interactions. However, there was no evidence of any type of new interventions being implemented to address the resident's psychosocial needs related to her diagnosis of dementia. 5. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, major depression and encephalopathy. Resident #13 resided on the facility A hall, a memory care unit. Review of Resident #13's quarterly MDS 3.0 assessment dated [DATE] revealed the resident was cognitively impaired, he required supervision from staff for transfers and toilet use and extensive assistance from one staff member for dressing and personal hygiene. There were no behaviors identified on the MDS assessment. Review of Resident #13's plan of care, dated 10/09/21 revealed the resident was at high risk for wandering into other's space. Interventions included to redirect when resident goes into other residents' personal space. Review of a progress notes, dated 10/13/21 revealed Resident #111 pushed Resident #13 out of his room. Resident #13 fell to ground and hit his head. An STNA saw the resident fall to the ground and immediately notified the charge nurse. Resident #13 was assessed to have a laceration to the right eye area, was unbalanced and complained of pain to the left knee. The physician was notified and new orders were obtained to send the resident to the emergency room for an evaluation. Resident #13 was diagnosed with a fractured patella (knee), was sent back to facility with an immobilizer and an order for a follow up appointment with orthopedic doctor. Resident #111 was placed on 15 minute checks. The note revealed both residents' were located on the memory care unit. Review of a facility self-reported incident, dated 10/09/21 revealed Resident #111 (who had a Brief Interview for Mental Status (BIMS) score of six (cognitive impairment) was in his room when Resident #13 wandered into the room. Resident #111 got upset and yelled Get out of room and pushed Resident #13 to the ground. Staff immediately went to Resident #111's room and separated both residents. Resident #111 was placed on 15 minute checks and staff were educated when Resident #111 was in his room to try and keep his door closed. The SRI documented no injuries were noted. However, Resident #13 sustained a fractured knee and laceration to his right eye. The SRI revealed to try to redirect Resident #13 when seen entering other residents' rooms. Review of the incident revealed there was no evidence the facility had implemented comprehensive and individualized behavior management programs for Resident #13 or Resident #111 to prevent the resident to resident altercation and no evidence the facility had provided adequate supervision to the residents residing on the A hall to prevent this incident from occurring. On 11/01/21 at 10:39 A.M. the DON verified the above resident to resident altercation had occurred. No additional information was provided to show evidence of the implementation of comprehensive and individualized behavior management programs to address the total care needs for residents with dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy and procedure review and interview the facility failed to ensure medications were stored and labeled properly and were disposed of following expiration. This affected four residents (#61, #115, #128 and #59) of 21 residents who resided on the F Hall. Findings include: On [DATE] at 1:15 P.M. observation of the F Hall medication cart revealed several medications were observed to be without open or expiration dates. Several insulin pens, including Novolog insulin pens for Residents #61 and #115, were observed sitting loosely in the top drawer of the medication cart and were not stored in a bag or box. Novolog insulin pens were observed to be labeled for Residents #61 and #115 with no expiration dates written on the pens. Further observation revealed a Novolog insulin pen labeled for Resident #59 was penned with an expiration date of 09/28. A Humalog insulin pen was observed to be labeled for Resident #128 (who expired in the facility on [DATE]), with no expiration date. Additionally, a used, unlabeled, undated Humalog insulin pen was observed to be in the top drawer of the medication cart. On [DATE] interview with Agency Registered Nurse (RN) #560 at the time of the observation verified the absence of expiration dates on the insulin pens for Resident #61, #115 and #128, as well as the expired insulin for Resident #59 and the presence of an unlabeled, undated, open insulin pen in the top drawer of the medication cart. Review of the facility policy titled Insulin Administration, revised 09/2014 revealed the expiration dated should be checked prior to administration, if using an opened multi-dose vial and if opening a new vial, record the expiration date and time on the vial (follow manufactures recommendations for expiration after opening). Review of the Humalog KwikPen manufacturer's instructions, revised 04/2020 revealed the insulin should not be used longer than 28 days after opening. Review of the Novolog FlexPen manufacturer's instructions, revised 02/2015 revealed Novolog FlexPens may be kept at room temperature for up to 28 days.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. From 10/25/21 at 8:00 A.M. to 10/27/21 at 10:32 A.M. observation of the D Hall in the East building revealed the following environmental concerns: To the left of the entrance to the unit the wallpaper was peeing from the wall up to the hand railing. The entryway for Rooms 39, 40, 41, 42, 45, 46, 49 and 50 had a build up of dirt one to two inches on either side of the transition strip. In the dining room there was a build up of dirt and multiple spills and splatters along the bottom of the cabinets. In the back left corner there was a stained area approximately 1.5 feet by 2.5 feet, this area had a variety of unidentifiable stains that were layered. Next to this area was a rust brown splatter down the edge of the baseboard and onto the floor. To the left of the refrigerator extending to the cabinets was a light brown stain topped with black splatters and to the left of the couch were light brown stains under the end table with multiple brown smears. Under the television was a large brown stain extending from the baseboard. In the area in front of the nurse's station approximately five feet by six feet and to the side of the nurse's station approximately one foot by four feet were multiple unidentifiable brown and red splatters and gray stains. In room [ROOM NUMBER] in the corner of the room next to the window, the baseboard was hanging off the wall exposing the white wall underneath. In the bathroom the baseboard on either side of the toilet was coming off the wall, exposing the white wall and brown underneath. Towards the entrance of the restroom there was a large light brown stain next to the baseboard, it appeared to come from the baseboard. In the right corner behind the toilet there was a white substance that was suspected to be toilet paper spread across the wall. In room [ROOM NUMBER] the baseboard under the window and to the left was hanging off the wall exposing the white wall and brown underneath. In room [ROOM NUMBER] the paint was chipped in multiple locations on either side of the window, additionally the paint was chipped and there was an indent in the wall next to the bedside table. Under the window to the right the baseboard was missing for about two and a half feet exposing the wall. Underneath the second bedside table were splatters of an unidentifiable brown substances extending along the side of the stand. To the left of the door was an area of the wall that had been spackled and not painted. During a tour on 10/27/21 from 10:15 AM to 10:32 AM with Maintenance #346 and Housekeeper #447 the above observations were confirmed. Housekeeper #447 reported the refrigerator in the dining room had been moved and that was likely the cause of the 1.5 foot by 2.5 foot stain. However, he revealed the floor should have been stripped and waxed when this happened. Housekeeper #447 revealed the resident who resided in room [ROOM NUMBER] had behaviors including causing messes in the bathroom. He stated facility staff were to notify housekeeping when this occurred, and confirmed he was unaware of this incident. There were 21 residents who resided on the D hall. Based on observation and interview the facility failed to maintain a safe, functional and sanitary environment for all residents. This affected Resident #383 who resided on the F hall and had the potential to affect all 21 residents who resided on the D hall/East Building and all 19 residents who resided on the A hall/East Building. The facility census was 134. Findings include: 1. On 11/02/21 at 1:30 P.M. Resident #383 was observed to be resting in bed A of her room. At the time of the observation, the privacy curtain in the room was observed bunched in the middle corner of the L shaped track for bed A, and partially blocking the view of Resident #383 from the door. When attempting to pull the privacy curtain to the side, to gain entrance to the room and observe and interview Resident #383, the curtain was observed to feel lose and flimsy, and spring up and down several inches. Further observation revealed the metal, L shaped track that was connected to the ceiling and holding up the privacy curtain, was partially detached from the ceiling and hanging down approximately four to six inches at the location of the inside corner. On 11/02/21 at 1:37 P.M. interview with Agency Registered Nurse (RN) #560 confirmed the privacy curtain was coming detached from the ceiling. RN #560 revealed she would need to call maintenance to fix it. 3. On 10/27/21 from 10:15 A.M. to 10:32 A.M. an environmental tour of the A hall/East Building with Maintenance Man #346 revealed the following environmental concerns which were verified with MM #346 at the time of the observations: Room A11 had dark stained tiles around the commode and chipped paint on the door to the room and the walls. Room A8 had holes in the drywall in the bathroom, chips in the paint in the room and the wood finish was peeling off the night stand. Room A12 had holes in the drywall and the baseboard was coming off the wall in the bathroom. Room A7's door and door jams had chipped paint, the wall in the room had chipped paint. The call string in the bathroom had a dried brown substance on half of the string. Room A2 had the paint chipped on the walls, the toilet had bowel movement on it, the wall near the baseboard was bubbled and peeling. The blinds were broken on the window. The bedside stand had the top drawer missing. Room A9's baseboard was loose from the wall. Room A4 had paint chipped on the walls and dark stains on the tile around the commode. Room A10's baseboard was missing in the bathroom. There were 19 residents who resided on the A hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During the onsite recertification, extended and complaint survey concerns were identified related to the facility not developing and implementing comprehensive and individualized behavior management programs for residents (including Resident #113) with dementia to prevent resident to resident altercations and to ensure each resident maintained their highest practicable physical, mental and psychosocial well-being. See findings at F744. Resident #113 resided on the D hall which had a total census of 21 residents. Review of a facility self-reported incident, dated [DATE] revealed there was an allegation of physical abuse between two residents, Resident #19 and Resident #113. According to the summary of the incident Resident #113 stated Resident #11 struck her. The nurse completed a head to toe assessment with no negative outcomes. The residents were separated, and the doctor and responsible parties were notified. Review of the witness statement, dated [DATE] revealed Nurse Aide #301 was on the D hall by herself. Resident #19's door was open and Resident #113 entered the room. Nurse Aide #301 revealed she was in the doorway when Resident #19 yelled at Resident #113 to get out and jumped up to pin her against the door. The aide separated the two, Resident #19 stood there and as she was trying to talk her down, she punched Resident #113 in the face. Resident #19 grabbed the aide by the left arm roughly. The aide was able to free herself and get Resident #113 out of the room. Review of the witness statement dated [DATE], revealed Nurse Aide #541 was on a different hall when the incident occurred. She stated when she returned to the D Hall, Nurse Aide #301 reported she had to break up a fight between Resident #19 and Resident #113. Review of the witness statement dated [DATE], revealed LPN #497 was on the A Hall passing dinner trays when Nurse Aide #301 came to get her (related to the incident). On [DATE] at 3:05 P.M. interview with STNA #444 revealed staff needed to keep eyes on Resident #113 all day, every day, to prevent incidents with other residents. She reported Resident #113 was constantly wandering around the unit and in resident rooms. She reported residents got aggravated with Resident #113 because she wandered, entered other people's space and was grabby. STNA #444 revealed ideally there would be two STNAs on the unit, one STNA in the dining room at all times to monitor the room and the hallway and another STNA to address residents in their rooms. On [DATE] at 3:14 P.M. interview with LPN #327 revealed it was difficult to manage the D Hall with one staff member. She revealed this was because one person could not help the residents as needed and watch everyone. On [DATE] at 10:05 A.M. interview with STNA #456 revealed it was difficult to manage the D Hall with one staff member on the unit. She stated, there's nothing I can do to prevent wandering when I am by myself'. STNA #456 revealed if she was with another resident, she was unable to prevent Resident #113 from wandering into resident rooms. On [DATE] from 2:45 P.M. to 3:30 P.M. interview with the Administrator, Director of Nursing, and the Regional Director of Clinical Services #407 revealed they were aware of Resident #113's wandering. The Administrator confirmed there was only one staff member on the unit at the time of the incident. The Administrator revealed ideally there would be 1.5 to 2.0 staff members on both units. Review of the facility staffing schedule for [DATE] confirmed there was only one staff member on the D hall/East building at the time of the incident. On [DATE] at 1:33 P.M. interview with STNA #537 revealed she was the only STNA scheduled on this date on her assigned unit, the E hall/West Building. There were 20 residents on the hall including residents who required two or more staff for assistance with care and/or transferring. STNA #537 revealed she was unable to deliver all care the residents' required being the only scheduled STNA on the unit. The STNA revealed many days when there was only one STNA assigned to care for the residents on this hall. On [DATE] at 11:02 A.M. interview with Resident #98 and Resident #105 revealed both residents attended Resident Council meetings regularly and Resident #98 was the Resident Council President. During the interview, Resident #98 and Resident #105 voiced concerns there was not enough staff to answer call lights and provide the care and assistance resident's needed. Resident #98 and Resident #105 revealed they sometimes waited an hour or more for call lights to be answered and sometimes the staff don't answer the call light at all. Review of the facility policy titled Call Lights, revised 10/2018 revealed staff would attempt to respond to call lights timely and resolve the issue. Based on record review and interview the facility failed to maintain sufficient levels of nursing staff to meet the total care needs of all residents in a timely manner. This affected eight residents (#128, #123, #33, #103, #113, #19, #98 and #105) and had the potential to affect all 134 residents residing in the facility. Findings include: 1. Review of the closed medical record for Resident #128 revealed an admission date of [DATE] with diagnoses including COVID-19, heart disease, congestive heart failure, chronic kidney disease stage three, and atrial fibrillation. Record review revealed the resident was a Full Code related to advance directives. The resident expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 12 indicating the resident had moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for bed mobility and toilet use, extensive assistance from two staff for transfers, supervision with one staff assistance for locomotion and limited assistance from one staff for personal hygiene. Review of Resident #128's care plan, dated [DATE] revealed the resident/family chose CPR would be attempted during cardiac arrest with interventions to inform new caregivers of code status, nursing staff to provide chest compressions when the resident was in cardiac arrest and call ambulance for transport to the hospital, and notify family of changes in condition. Review of Resident #128's medical record revealed the resident was not receiving Hospice services and/or palliative care during his stay at the facility. The plan of care revealed the resident's goal was to return home. Review of Resident #128's care plan, dated [DATE] revealed the resident was tested and confirmed positive for COVID 19 with interventions to administer medications per physician orders, administer oxygen per physician orders, be alert for changes in activities of daily living assistance required, be alert for new or worsening symptoms including increased difficulty breathing, back or abdominal pain, increased lethargy and weakness, altered mental status and notify physician if this occurs, and follow Centers for Disease Control (CDC) and facility policies for isolation precautions related to COVID 19. Review of the physician's orders revealed an order, dated [DATE] for the resident to be placed on droplet precautions for 10 days due to COVID-19. The resident also had an order for a Full Code status. Review of the nurse's notes revealed on [DATE] at 5:49 P.M. Resident #128 was aware of his rapid positive COVID-19 test result and moved to the facility COVID unit. A nurse's note, dated [DATE] at 4:23 A.M. revealed the resident continued to refuse all care this shift. Certified Nurse Practitioner (CNP) #547 was notified at 2:48 A.M. and gave a new order to send the resident to the emergency room for further evaluation. Paramedics (EMT) were contacted for transport. The nurse's notes revealed the resident was unresponsive upon EMT arrival at 3:10 A.M. and CPR was started, the resident was pronounced dead at 3:46 A.M. and CNP #547 was notified. A note, dated [DATE] at 8:45 A.M. revealed the resident was discharged . On [DATE] at 11:21 A.M. interview with EMT/Paramedic #545 revealed they received a call around 3:00 A.M. that a resident was refusing his medications and care and needed an evaluation at the hospital. He stated they (himself and EMT #546) arrived at the facility a few minutes later but had not been notified the resident they were going to pick up was COVID positive, so they went to the front entrance door. Two staff were sitting behind the counter staring at them and didn't get up and answer the door. EMT/Paramedic #546 started aggressively pounding on the door until someone answered who directed them to another door stating they were going to an isolation door. When they arrived at the second door, they felt they woke the staff up and that staff stated the resident was on another isolation wing and sent them to a third door on the other side of the building. They loaded up the cot they had, and a staff member apologized for the confusion. They headed to the third door and changed their respirators to be prepared for a covid positive resident. When they finally got into the third door about eight to twelve feet into the hall, they heard a staff member saying CPR in progress. He stated the ball game had changed at this point because they were told this was a simple transport to the hospital. When EMT staff arrived at the resident's room, there were no staff in the room, the resident was slumped over in his wheelchair with dried bodily fluids on his shirt and in his nares and CPR was not in progress. EMT #545 revealed even if CPR had been initiated, it wouldn't have been effective (as the resident was in a wheelchair). Paramedic #546 moved the resident to the ground and initiated manual CPR while Paramedic #545 went back out to the ambulance to retrieve a Lucas Device (portable device that delivers consistent chest compression). When he got back into the facility Paramedic #546 was still doing CPR with no staff assisting him. He stated he also had the [NAME] Device in his arms and the resident's wheelchair was still in front of the resident's door, no one helped move the wheelchair so he had to set the [NAME] Device down to move the wheelchair himself, then pick the [NAME] Device back up and apply it to the resident. On [DATE] at 3:55 P.M. and again on [DATE] at 1:14 P.M. interview with Agency LPN #542 revealed she was working in the facility on [DATE] and assigned to care for Resident #128. The LPN revealed when she got onto the unit Resident #128 was refusing medications, meals and care and he did the same during her night shift. She stated around 10:30 P.M. the CNP was called for new orders and she stated the resident was just having a behavior, it was his normal and staff could just monitor him. LPN #542 revealed around 2:00 A.M. or something CNP #547 told staff to send the resident out for an evaluation. LPN #542 revealed she printed everything for EMS and called the paramedics. LPN #542 revealed she saw the resident around five minutes before EMS arrived and he was fine, then she went to answer another resident's call light and when she came out to let EMS in, she noticed the resident was unresponsive in his chair. LPN #542 revealed she and the paramedics got the resident out of the wheelchair and started CPR. They did CPR for about 30 minutes until they pronounced the resident deceased . At the time of the incident, LPN #542 revealed she was the only staff member working on the COVID unit. There were no STNAs or other staff with her on the unit, it was just herself, but she didn't think she needed any STNAs to help as she did okay on her own. Agency LPN #542 revealed paramedic staff covered Resident #128 with a sheet, but the resident didn't have any funeral home listed so she asked a supervisor. Agency LPN #542 revealed about an hour later she was provided information on which funeral service to use so she set up the transport. Agency LPN #542 revealed there were no STNA staff working with her on the unit, she was working by herself and just left the resident on the floor covered with the sheet awaiting the funeral home to arrive. Agency LPN #542 verified the resident had urine and feces on him at the time he passed away and verified she had not provided any type of personal or post-mortem care to the resident. Agency LPN #542 revealed she left the facility at the end of her shift around 7:00 A.M., at which time the funeral home had not arrived. Agency LPN #542 indicated she was not sure what time the funeral home arrived that morning. During the interview, Agency LPN #542 verified she did not complete post-mortem care for Resident #128, the agency LPN revealed if you have help you can do the care, but she didn't have any help. Agency LPN #542 revealed she was not sure what the facility policy was on post mortem care so she wasn't sure if it was unacceptable the care wasn't provided. On [DATE] at 2:21 P.M. interview with the DON revealed the expectation following a resident's death would be for post-mortem care to be completed once everything had calmed down. The DON revealed it should not be multiple hours after a after the resident's death. On [DATE] at 1:01 P.M. interview with a staff member who wished to remain anonymous (Staff #544) revealed she worked the day shift on [DATE] and the resident was lethargic, had refused all care and was spitting at staff. Staff #544 revealed she notified the certified nurse practitioner (CNP) and the CNP revealed this was typical behavior of the resident, to refuse care and to notify the CNP if it continued. Staff #544 revealed the resident would let her check his oxygen saturation which was about 96% on room air but stated the resident wouldn't allow her to take any other vital signs. Staff #544 revealed on [DATE] when she arrived to work, around 7:00 A.M.-7:15 A.M. she found Resident #128 deceased on the floor. Staff #544 revealed she had to provide personal care to the resident. Staff #544 revealed no staff had provided post-mortem care to Resident #128 immediately after he passed away. Staff #544 revealed funeral transport arrived to the facility at approximately 8:00 A.M. and she did offer to assist moving the resident off the floor but they declined. Staff #544 revealed she had not notified anyone related to the condition of the resident because the resident had been deceased for hours and she assumed someone had known and would have already notified administrative staff. On [DATE] at 2:43 P.M. interview with Contracted Funeral Home Transport (CFHT) #543 revealed when he arrived at the facility around 8:00 A.M. Resident #128 was laying on the floor, in soiled clothes (stated urine and feces), his skin had not been taken care of, his mouth and eyes were wide open and his arms were at his side. CFHT #543 revealed he did not recall what the resident's shirt looked like, but stated he had to wipe dried mucus off the resident's face and nose. CFHT #543 revealed he had to pull the defibrillator paddles off of him, remove the IV from his arm and stated the resident was still in the clothes EMS staff cut off of him. CFHT #543 revealed when he rolled the resident, blisters on his legs were popping, his skin was noted with skin slippage. CFHT #543 revealed the resident's body was definitely starting to decompose. Review of the facility policy and procedure titled, Medical Emergency Response, dated [DATE] revealed in the event of a medical emergency any staff member, visitor or resident may initiate a medical emergency response. Staff would immediately notify the nurse in charge of the unit and they would announce a code blue and the general location. Staff in the vicinity would respond to the area immediately. The (resident's) code status would be verified by the nurse, staff would obtain a crash cart and 911 would be called. Once CPR was initiated, responders would continue until a physician provided the order to stop, the resident recovered with heart beat and breaths or emergency response team arrived and took over and transported the resident to a higher level of care. Review of the facility policy and procedure titled, Post-Mortem Care, dated [DATE] revealed residents who expire in the building receive the care appropriate for transporting to a receiving facility. The policy revealed post-mortem care was provided for a resident after their death had been pronounced and appropriate persons and agencies had been notified. The policy indicated the resident should be treated with dignity and respect; nurses would remove intravenous lines (IVs), tubes, catheters and replace soiled dressings; the residents' body should be washed carefully and the clothes should be changed if soiled. 2. On [DATE] at 10:31 A.M. interview with Resident #123 revealed concerns there were not enough nursing staff working in the facility. The resident did not share any specific concerns or dates/times of a lack of staff but rather indicated it was a general concern with the facility. On [DATE] at 12:49 A.M. interview with Resident #33 revealed concerns there were not enough nursing staff working in the facility. The resident did not share any specific concerns or dates/times of a lack of staff but rather indicated it was a general concern with the facility. On [DATE] 11:45 A.M. interview with Resident #103 revealed concerns there were not enough nursing staff working in the facility. The resident did not share any specific concerns or dates/times of a lack of staff but rather indicated it was a general concern with the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure it was administered in a manner to ensure all residents received the care and services necessary to attain or maintain their highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 134 residents residing in the facility. Findings include: During the annual recertification, extended and complaint survey completed from [DATE] through [DATE] the following concerns were identified through observation, record review, facility policy and procedure review and interview: a. The facility failed to ensure all residents (including Resident #11, #13, #65 and #85) who required staff assistance with activities of daily living (ADL) care received timely and appropriate care and services to maintain proper hygiene and grooming. See findings at F677. b. The facility failed to initiate timely and adequate Cardio-pulmonary Resuscitation (CPR) for Resident #128 who was a full-code and required CPR after being found unresponsive and without vital signs. This resulted in Immediate Jeopardy on [DATE] at approximately 3:21 A.M. when Resident #128 was observed unresponsive. The facility failed to ensure EMS had timely access to the facility and failed to provide CPR timely for the resident. On [DATE] at 3:21 A.M., EMS arrived on-site and identified facility staff were not providing CPR to a resident whom staff had identified as unresponsive and coding. EMS staff immediately initiated CPR for the resident, however CPR efforts were not successful and the resident expired. The lack of immediate and adequate CPR and delay in staff allowing EMS into the facility resulted in life threatening harm and death for Resident #128. See findings at F678. c. The facility failed to provide adequate supervision and/or assistive devices to prevent falls and/or resident injury for Resident #12, Resident #33, Resident #35 and Resident #93. Actual Harm occurred on [DATE] when Resident #35, who required extensive assistance from two (plus) staff for bed mobility sustained a fall out of bed resulting in a fractured nose when State Tested Nursing Assistant (STNA) #407 was providing bed mobility without a second staff member assisting. Actual Harm occurred on [DATE] when Resident #33, who was dependent on two staff for transfers sustained an injury/hematoma with increased excruciating pain and subsequent two week hospitalization with surgical intervention during a staff assisted mechanical (Hoyer) lift transfer. See findings at F689. d. The facility failed to maintain sufficient levels of nursing staff to meet the total care needs of all residents in a timely manner. This affected six residents (#128, #123, #33, #103, #113, #98 and #105) and had the potential to affect all 134 residents residing in the facility. See findings at F725. e. The facility failed to develop and implement comprehensive and individualized behavior management programs for residents with dementia to prevent resident to resident altercations and to ensure each resident maintained their highest practicable physical, mental and psychosocial well-being. This affected five residents (#10, #19, #113, #126 and #127) and had the potential to affect all 21 residents residing on the D hall/East Building. See findings at F744. f. The facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy when the facility failed to implement adequate infection control measures increasing the resident outbreak status of five residents (#22, #47, #61, #128 and #383) testing positive for COVID-19 on [DATE] to seven residents (#44, #52, #59, #64, #115, #384 and #482) testing positive for COVID-19 on [DATE]. Furthermore, Resident #128 who was COVID-19 positive expired on [DATE] in the facility. See findings at F880. In addition, concerns were also identified related to documentation, medication storage, oxygen therapy, dental services, vision services, resident assessments, care planning, skin management, unnecessary medication use, nutritional services, pharmacy services, physical environment, dignity and hemodialysis services. On [DATE] at 11:40 A.M. interview with RDCS #406 revealed she knew this survey identified multiple issues and the facility was considering it a reset to start over. On [DATE] at 8:30 A.M. interview with the Administrator and Regional Director of Clinical Services (RDCS) #406 revealed if a problem was identified it could be addressed by the facility quality assurance process. The Administrator and RDCS #406 revealed overall this survey highlighted certain circumstances and they had been so focused on reducing the number of complaint surveys there didn't seem to be any issues. Review of the facility demographic administrator information revealed the effective date for the current Administrator was [DATE]. Review of the facility survey history revealed complaint surveys were conducted at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The surveys completed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] resulted in certification deficiencies. The survey conducted on [DATE] resulted in concerns related to Treatment/Services for Dementia (F744) and Infection Prevention & Control (F880). Review of the facility assessment, revised 2021 revealed the assessment did not address the system failures identified during the survey.