**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, policy review and review of the Center of Disease Control recommendations, the facility failed to ensure appropriate infection control procedures were followed while incontinence care was provided. This affected one (Resident #2) of one residents observed for incontinence care. Facility census was 68. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure with hypoxia, dependence of respirator, and type 2 diabetes. The Minimum Data Set, dated [DATE] revealed Resident #2 was moderately impaired and was always incontinent of bowel and bladder. An observation on 04/21/25 at 10:00 A.M. of incontinence care by Certified Nurse Assistant (CNA) #206 for Resident #2, who was in enhanced barrier precautions (EBP), revealed CNA #206 put a gown and gloves on to provide care. Resident #2 had a small soft bowel movement. CNA #206 used wipes to remove the feces. CNA #206 did not remove gloves or perform any hand hygiene before placing a clean incontinence brief on Resident #2 and pulling the sheet up to cover Resident #2. CNA #206 verified she did not remove the gloves she was wearing when cleaning feces. CNA #206 stated she was not aware she had to change gloves when wearing the personal protective equipment (PPE) for EBP. The Centers for Disease Control (CDC) website https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html dated 02/27/24 revealed recommendations for hand hygiene for healthcare workers included hand hygiene should be performed before moving from working on a soiled body site to a clean body site on the same patient and after contact with body fluids or contaminated surfaces. The facility policy for Hand Hygiene/Handwashing revised on 02/28/25 revealed the use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. This deficiency represents non-compliance investigated under Complaint Number OH00164491.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy the facility failed to notify the physician of a change in Resident #71's skin condition. This affected one resident (#71) of two residents reviewed for pressure ulcers. The facility census was 70. Findings include: Review of Resident #71's medical record revealed an admission date of 01/20/25 with a discharge date of 02/24/25, diagnoses included acute respiratory failure, discitis, osteomyelitis of vertebra, encephalopathy, dysphagia, and ileus. Review of Resident #71's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He had three stage two pressure ulcers upon admission. Review of Resident #71's skin observation dated 01/30/25 revealed the resident had shearing to the right and left gluteal fold. Review of Resident #71's progress notes from 01/30/25 to 02/07/25 revealed no evidence the physician was notified of the residents' change in skin condition. Review of Resident #71's skin observation dated 02/08/25 revealed the resident had developed shearing to his coccyx. Review of Resident #71's progress notes from 02/08/25 to 02/10/25 revealed no evidence the physician was notified of the resident's change in skin condition. Review of the policy 'Resident Change in Condition Policy' dated 06/27/24, revealed the licensed nurse would recognize and intervene in the event of a change in condition. The physician will be notified as soon as the nurse has identified the change in condition and the resident is stable. A significant change of condition was a decline or improvement in the residents status that will not normally resolve itself without intervention by staff or implementing standard disease- related clinical intervention, impacts more than one area of the resident's health status, and/or requires interdisciplinary review or revision to the care plan.

Based on interviews and medical record reviews the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected three (#69, #174 and #175) of four reviewed for discharge. The total facility census was 70. Findings Include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, her diagnoses included cirrhosis of liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24 with diagnoses including cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24. Diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of the facility's list of discharged residents' names reported to the Ombudsman for the months of 09/2024,10/2024, 12/2024, 01/2025 and 02/2025 revealed Residents #69 and #175 were not reported as being discharged from the facility. Interview and observation on 03/19/25 at 3:07 P.M. with the Director of Nursing (DON) confirmed Residents #69, #174 and #175 date of discharge was not reported to the Ombudsman. The facility denied having a notification to Ombudsman policy for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #53. This affected one resident of six closed records reviewed. The facility census was 70. Findings include: Review of Resident #53's medical record revealed an admission date of 05/21/24 and a discharge date of 12/23/24 with diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia. Review of Resident #53's discharge MDS assessment dated [DATE] revealed it was finalized but not submitted. Review of section 'Z Assessment Administration' revealed all sections of the assessment had been completed on 03/12/25. Review of Resident #53's progress note dated 12/27/25 revealed they had returned from a leave of absence that began on 12/23/25 and reported they were not returning to the facility. Interview on 03/19/25 at 2:05 P.M. with the Director of Nursing (DON) verified the MDS assessment got missed and had not been completed until 03/12/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review the facility failed to obtain a discharge physician order when residents were being discharged from the facility. This affected three (#69, #174, and #175) of four residents reviewed for discharge. The census was 70. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, diagnoses included cirrhosis of the liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. Review of Resident #69's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits. Review of Resident #69's progress note dated 12/20/24 revealed the resident moved out of the facility when the family came in around 2:15 P.M. to take her home. Discharge summary and a copy of the medication list were provided to the resident. Review of Resident #69's physician orders from 12/01/24 through 12/20/24 revealed there was no discharge order included in the medical record. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24, diagnoses included cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. Review of Resident #174's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive deficits. Review of Resident #174's progress note dated 10/01/24 revealed she was alert and oriented and was discharging home on [DATE]. The nurse went over the medications with the resident and their power of attorney. Review of Resident #174's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24, diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of Resident #175's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #175's progress note dated 09/21/24 revealed the resident was discharged at 2:20 P.M. after reviewing the current medication list and discharge paperwork with the resident and her mother. Review of Resident #175's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. Interview with the Social Service Designee #42 and Minimum Data Set Coordinator #19 on 3/19/25 at 2:30 P.M. confirmed there was no discharge order obtained when Residents #69 , #174 and #175 were discharged home. Interview on 03/19/25 at 3:07 P.M. interview with the DON confirmed there were no physician orders to discharge residents #69, #174, and #175. Review of the Facility's, Discharge Planning Policy, dated 09/24/2020 revealed a physician order is needed when a resident is discharged and or transferred from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #4's nails were maintained in a clean manner and at a good length. This affected one resident (#4) of three residents reviewed for activities of daily living (ADL). The facility census was 70. Findings include: Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, and unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. She was dependent for personal hygiene. Review of Resident #4's plan of care dated 03/11/25 revealed she had a self care deficit related to ADL limitation, restlessness and agitation, and her diagnoses. Interventions included monitoring toenails and fingernails with ADL care daily for need of trimming or additional services, and assistance of one staff for personal hygiene. Observation on 03/17/25 at 9:24 A.M. and on 03/20/25 at 11:59 A.M. of Resident #4 revealed the resident had long curved nails that appeared dirty underneath. Interview on 03/20/25 at 11:59 A.M. with Certified Nursing Assistant (CNA) #21 verified the observation. CNA # 21 reported she would ask hospice to cut them when they came in to do her bed bath later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure physician orders were present for therapy services prior to delivering services to one (#42) of one reviewed for hospice services, and the facility failed to follow practitioner recommendation for vascular surgery consult for one (#35) of one reviewed for non pressure skin condition. The census was 70. Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date of 06/29/21, diagnoses included Alzheimer's Disease, dementia, anxiety, bi-polar disorder and a history of falling. Resident #42 admitted to hospice services on 10/31/23 and was a Do Not Resuscitate Comfort Care (DNR-CC). Observation on 03/18/25 at 11:30 A.M. revealed Resident #42 was in bed, and Certified Occupational Therapist Aide (COTA) #102 was present and revealed she had just finished working with Resident #42 to improve her sitting position in her wheelchair. Resident #42 appeared to be very restless with involuntary head and hand control, COTA #42 explained the sessions are about forty minutes long and she has seen little improvement. Review of the Hospice Interdisciplinary Team (IDT) Comprehensive Assessment and Plan of Care Update Report from 01/17/25 to 03/17/25 revealed Resident #42's health had declined in the last two weeks cognitively and physically. Morphine (opioid) for pain had increased from two times a day to three times a day, involuntary head and hand movement continues. Resident #42 sleeps 20 to 24 hours a day and requires total care for activities of daily living, bed baths are provided due to poor trunk control. The plan did not include orders for any type of rehabilitation services. Review of the Occupational Therapy notes from 03/04/25 to 03/18/25 revealed Resident #42 received a total of eight therapy sessions. Review of the Hospice Physician Order Report from 01/17/25 to 03/19/25 revealed there was no order for physical or occupational therapy to evaluate or treat. Review of Resident #42's physician notes from 01/01/25 to 03/19/25 revealed there was no physician order for occupational therapy to treat Resident #42 for increased trunk control to utilize a wheel chair while out of bed. Review of the Resident #42 plan of care dated 12/23/24 did not include occupational or physical therapy services as being included in the care of Resident #42. Review of Resident #42 nurses progress notes from 2/2/25 to 3/10/25 revealed no indication the medical director and or the hospice physician were notified to obtain an order for Resident's #42 to receive occupational therapy. Interview with the Director of Nursing (DON) on 03/19/25 at 8:47 A.M. confirmed she was unaware that Occupational Therapist/Aide had been seeing the resident for chair positioning. Interview with the Director of Nursing and the Rehab Director #107 on 03/19/25 at 1:30 P.M. confirmed Resident #42 had been evaluated and treated by the occupational therapist with no physician order from hospice or her primary care physician. The DON verified the hospice agency Registered Nurse or physician should have been notified to obtain therapy orders for Resident #42. Review of the facility Hospice Care Policy , dated 05/24/23 revealed the hospice assumes responsibility for determining the appropriate course for hospice care, including the determination to change the level of care services provided. 2. Review of Resident #35's medical record revealed an admission date of 11/21/24 with diagnoses including depression, dysphagia, peripheral vascular disease (PVD), type two diabetes mellitus, hemiplegia, chronic diastolic heart failure, gastric ulcer, and atherosclerosis of native arteries of bilateral legs. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had moderately impaired cognition. Review of Resident #35's physician note dated 12/12/24 revealed a recommendation to follow up with vascular surgery related to Peripheral Vascular Disease (PVD). Review of Resident #35's Certified Nurse Practitioner (CNP) notes dated 12/18/24, 12/26/24, 01/22/25, 02/04/25, 02/11/25, and 02/19/25 revealed a recommendation to follow up with vascular surgery related to PVD. Review of Resident #35's physician note dated 03/13/25 revealed a recommendation to follow up with vascular surgery related to PVD. Observation on 03/17/25 at 9:08 A.M. of Resident #35 revealed both of his feet were a dark purple color. Interview on 03/17/25 at 9:08 A.M. with Resident #35 revealed the hospital had wanted him to see a vascular doctor but that had not happened yet. Interview on 03/18/25 at 2:10 P.M., 2:14 P.M. and 5:05 P.M. with the Director of Nursing (DON) verified the physician and CNP notes had indicated follow up with vascular surgery but that had not occurred. She reported his hospital notes indicated he was not appropriate for vascular surgery and she would follow up with the CNP to ensure they were aware. She verified they had been documenting this for months and it had gone unaddressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor Resident #4 and Resident #20's use of a splint. This affected two residents (#4 and #20) of two residents reviewed for limited range of motion. The facility census was 70. Findings include: 1. Observation on 03/17/25 at 12:01 P.M. revealed a splint in Resident #4's room. Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #4's occupational therapy discharge evaluation dated 02/28/25 revealed a discharge recommendation to tolerate a left elbow splint for six hour intervals. Review of Resident #4's medical record from 02/28/25 to 03/16/25 revealed no indication resident #4 was using a splint. Review of Resident #4's physician order dated 03/17/25 revealed an order to wear a left elbow brace for four to six hours a day as tolerated. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified there was no tracking or monitoring for Resident #4's splint in the medical record. 2. Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 10/30/24 revealed the resident was to wear left resting hand splint six hours as tolerated at bedtime with hygiene and skin check prior to donning. Review of Resident #20's medical record from 10/30/24 to 03/18/25 revealed no indication that the left resting hand splint was being applied. Observation on 03/18/25 at 8:25 A.M. revealed Resident #20's left hand was contracted into a tight fist. Interview on 03/18/25 at 8:25 A.M. with Resident #20 revealed she had a splint for her left hand she was supposed to wear daily but staff did not always provide it. Interview on 03/18/25 at 9:47 A.M. with the DON she verified they had not been tracking or monitoring when Resident #20 was using her splint. She reported the resident was noncompliant, but verified there was no evidence of this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place and falls were documented for one (#11) of two residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #11's medical record revealed an admission date of 03/04/22, diagnoses included dementia, major depressive disorder, epilepsy, other chronic pain, paroxysmal atrial fibrillation, fracture of one rib on left side (12/03/24), and glaucoma. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #11's plan of care dated 02/14/25 revealed she was at risk for falls related to her diagnoses, history of falls, lack of coordination, and impaired mobility. Interventions included but were not limited to removing regular socks from her room and providing non-skid socks, maintaining the call light in reach, and nonskid socks. Review of Resident #11's medical record revealed no documentation related to a fall which occurred on 03/16/25. Review of the post huddle form dated 03/16/25 revealed Resident #11 had been found sitting in the door way of her bedroom with her walker back beside her recliner. Observation on 03/17/25 at 9:20 A.M. and 11:05 A.M. revealed Resident #11 was wearing regular socks, not non-skid socks. Observation on 03/19/25 at 8:45 A.M. and 9:40 A.M. revealed Resident #11 lying in bed. Her call light was out of reach, it was laced through her bedside table drawer and hanging out the far side of the drawer. Interview on 03/19/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #96 verified Resident #11's call light was out of reach. Resident #11 would have to sit up on the side of the bed to get to the call light. LPN #96 reported the resident had a fall on 03/16/25 Interview on 03/19/25 at 10:25 A.M. with the Director of Nursing (DON) verified the fall on 03/16/25 had not been documented in the progress notes. A post fall huddle form had been completed that was not part of the medical record. Review of the policy titled Fall Prevention and Management Policy dated 12/09/19 and last revised on 08/06/24 reveaeld: Residents will be assessed for fall risk[s] on admission, quarterly, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. Individualized interventions will be implemented based on this assessment and care planned accordingly.

Based on interview, medical record review, and facility policy review the facility failed to ensure an indwelling foley catheter was inserted correctly and monitored after insertion. This had the potential to affect one (#24) of two reviewed for catheter care. The census was 70. Findings include: Review of the medical record for Resident #24 revealed an admission date of 08/08/24 with sever cognitive deficits. Diagnoses included hypertensive chronic kidney disease, depression, overactive bladder, neuromuscular dysfunction of bladder and anxiety. Review of Resident #24 nurses progress notes revealed on 10/22/24 at 6:41 P.M. the nurse changed her catheter with 22 french (FR) 10 cc balloon, because the resident was found playing in her stool, pulling her catheter, and having spasms. The nurse followed the sterile technique protocol. When the procedure was completed Resident #24 was resting in her bed. Review of Resident #24 progress notes on 10/23/24 at 10:11 A.M. the nurse was notified by the Certified Nursing Assistant (CNA) that the resident did not have any urine output overnight. Resident #24 was examined, and it was determined her catheter was inserted in the incorrect area. A new 22 FR 10 cc balloon catheter was inserted with urine coming present after insertion. Review of Resident #24's documentation of urine out put from 10/22/24 at 6:41 P.M. to 10/23/24 at 10:11 A.M. revealed no documentation indicating she had any urine output for sixteen hours. An interview on 03/18/25 at 11:30 A.M. with CNA #93 confirmed they are to monitor residents' urine output when they have an indwelling catheter inserted, if they have any problems, they are to report them to the nurse taking care of the resident. Interview on 03/19/24 at 3:00 P.M. with the Director of Nursing (DON) it was confirmed standard nursing practice was to record resident urine out put at least every eight hours. DON verified Resident #24's catheter was not monitored or changed in the sixteen hours when the catheter was inserted incorrectly into Resident #24 on 10/22/24. Review of the Facility's ,Urinary Catheterization and Removal Procedure, (Female) dated 04/24/07 and last revised on 11/06/24 revealed: If a catheter is mistakenly placed in the vagina repeat the entire procedure with another sterile catheter. Pinch catheter when flow of urine ceases (do not remove more than 1000 ml at once) hold catheter in place. The catheter is to remain in place to measure the total amount of urine.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to maintain availability of ordered pain management medications for one resident (Resident #33) out of two residents reviewed for pain management. The facility census was 70. Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cellulitis of right lower limb, dysphagia, tracheostomy, acute pancreatitis, acute myocardial infarction, depression, squamous cell carcinoma of skin, anxiety disorder, obstructive sleep apnea, hypertension, atrial fibrillation, and chronic congestive heart failure. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact with mild depression. Resident #33 received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications with indications noted. Review of physician's orders revealed Resident #33 had an order for a Fentanyl patch (opioid) 100 micrograms (mcg) per hour to be changed every 72 hours. Patch placement to be monitored every shift. Resident #33 also had an order for Oxycodone (opioid) 5 mg every four hours as needed for pain. Interview on 03/17/25 at 9:54 A.M. with Resident #33 revealed the resident had some level of pain all the time. Resident #33 stated he has a Fentanyl patch that is changed every three days. Resident #33 stated he recently went 10 - 12 days without the patch because there was a problem getting the prescription refilled. Review of the March 2025 medication administration record (MAR) revealed Resident #33 was without a Fentanyl patch from 03/09/25 until 03/14/25. Progress note dated 03/06/25 at 12:58 P.M. Registered Nurse (RN) #47 documented this nurse called the pharmacy for a refill on resident's Fentanyl 100 mcg/hr patch. Per the pharmacy, we need a new prescription to fill this medication. Physician was documented as being called and a new prescription was requested to be sent to the pharmacy so the medication could be refilled. Progress note dated 03/14/25 at 10:22 A.M. RN #30 documented Fentanyl patch was delivered the pervious shift, this nurse placed patch on this morning on left upper extremity. Interview on 03/19/25 at 7:37 A.M. with RN #47 confirmed when the last Fentanyl patch in stock was placed on 03/06/25, RN #47 placed a call to the pharmacy to reorder the medication for Resident #33. The pharmacy informed RN #47 there were no more refills on the prescription and a new prescription was required to refill the medication. RN #47 then placed a request on the physician's medication refill voice mail requesting a new prescription be sent to the pharmacy for Resident #33. Interview on 03/19/25 at 12:20 P.M. with Director of Nursing (DON) confirmed there was no Fentanyl patch placed on Resident #33 as the facility did not obtain a current order from the physician from 03/09/25 until the morning of 03/14/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pre and post dialysis assessments were completed for Resident #20. This affected one resident (#20) of one resident reviewed for dialysis. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's plan of care dated 02/21/25 revealed the resident required dialysis three times a week and the facility provided transportation. Her chair time and location for dialysis were provided. Interventions included noon meal provided by facility prior to dialysis, assessing for fluid excess, assuring medications are administered before and after dialysis as ordered, diet as ordered, monitor intake and output, monitor laboratory work, monitor weight, notify physician of weight changes or fluid volume excess, and report changes in neurological status. Review of Resident #20's physician orders revealed an order dated 01/16/25 indicating she was to go to dialysis on Monday, Wednesday, and Friday's. Review of Resident #20's pre and post dialysis assessments from 02/03/25 to 03/14/25 revealed on 02/03/25 the pre assessment was not fully completed, on 02/05/25 the facility did not complete a pre-assessment, on 02/07/25 and 02/10/25 the pre assessment was not fully completed, on 02/12/25 neither pre or post assessment was completed, on 02/17/25 the pre assessment was not fully completed and dialysis did not complete the post assessment, on 02/19/25 and 02/24/25 the pre assessment was not fully completed, on 02/26/25 the pre assessment was not fully completed and dialysis did not complete a post assessment, on 02/28/25 the pre assessment was not fully completed, on 03/05/25 neither the pre or post assessment was completed, on 03/07/25 and 03/10/25 the pre assessment was not fully completed, on 03/12/25 neither the pre or post assessment was completed, on 03/14/25 the pre assessment was not fully completed and the post assessment was not completed by dialysis. Interview on 03/19/25 at 9:22 A.M. with the Director of Nursing (DON) verified pre and post dialysis assessments were not being completed with every dialysis treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #20's medication was held as ordered by the physician This affected one resident (#20) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 01/03/25 revealed an order for Enulose (Lactulose) (osmotic laxative) 30 milliliters (ml) three times a day. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) for heart rate below 60 beats per minute. Review of Resident #20's physician order dated 03/06/25 revealed an order to hold the morning dose of Lactulose and metoprolol on dialysis days. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Enulose was not held prior to dialysis on 03/10/25, 03/14/25, or 03/17/25. Metoprolol was not held prior to dialysis on 03/10/25 and 03/14/25. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her medication was not held according to the physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow medication parameters for one (#20) of five reviewed for unnecessary medication. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) or heart rate below 60 beats per minute. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Metoprolol was not held for a systolic blood pressure below 110 mmHg on 03/10/25 when her blood pressure was 106 over 67 mmHg. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her Metoprolol was not held according to the orders/parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review a facility investigation, review of hospital documentation and facility policy review the facility failed to use a mechanical lift sling pad correctly resulting in a fall from a mechanical lift. This affected one resident (Resident #73) of two residents reviewed for accidents. The facility census was 71. Findings Include: A review of Resident #73's medical record revealed admission date 10/02/24 with diagnoses including but not limited to respiratory failure with ventilator dependency, tracheostomy, dysphagia, chronic obstructive pulmonary disease (COPD), and high blood pressure. A review of Resident #73's admission fall risk assessment revealed Resident #73 was at risk for falls related to impaired mobility. A review of Resident #73's admission [NAME] Data Set (MDS) dated [DATE] revealed Resident #73 had moderate cognitive impairment and was dependent on staff for all care and Activities of Daily Living (ADL) tasks including transfers using a mechanical lift. A review of Resident #73's baseline care plan dated 10/02/24 revealed Resident #73 required a mechanical lift, and two staff assistance for all transfers. A review of Resident #73's physician orders dated 10/01/24 to 10/10/24 revealed an order dated 10/02/24 for blood thinning medication Eliquis 5 milligram (mg) given by mouth twice daily for deep vein thrombosis (DVT). Further review revealed an order dated 10/02/24 for the use of a mechanical lift for transfers. A review of Resident #73's progress notes revealed: On 10/10/24 at 7:00 P.M. authored by Licensed Practical Nurse (LPN) #234 revealed at approximately 6:40 P.M. LPN #234, Certified Nursing Assistant (CNA) #276 and Respiratory Therapist (RT) #505 were assisting Resident #73 transfer from wheelchair to the bed using a mechanical lift (hoyer). Resident #73 had been elevated out of the wheelchair, CNA #276 moved the wheelchair from under Resident #73 and RT #505 was maintaining the ventilator tubing, prior to the hoyer lift being unlocked and moved towards the bed, Resident #73 rolled to the right side of the lift sling and continued rolling out of the top right side of the lift sling, landing on her right shoulder and right side of her face. Resident #73 fell approximately 4.5 feet to the floor from the elevated lift sling. LPN #234 completed a head-to-toe assessment of Resident #73, noting an abrasion on the top of the right shoulder. LPN #234 notified the physician and received a new order to send Resident #73 to the hospital for further evaluation. Resident #73's family member was present during the fall and accompanied Resident #73 to the hospital. On 10/11/24 at 1:17 A.M., authored by Registered Nurse (RN) #404, revealed hospital nurse stated Resident #73 had no acute injury and advised Resident #73 would be returning to the facility once transportation was available. On 10/11/24 at 12:28 P.M., authored by the Director of Nursing (DON), revealed Resident #73 was dependent for transfers and utilized a hoyer lift. Resident #73 had sustained a fall from the hoyer lift during a transfer on 10/10/24 at 6:40 P.M. Resident #73 was sent to the hospital for further evaluation and was admitted back to the facility on [DATE] at 4:30 A.M. with no acute injury results on the X-ray and computed tomography (CT) from the fall on 10/10/24. A review of Resident #73's hospital documents dated 10/10/24 to 10/11/24 revealed a CT of Resident #73's head revealed no acute intracranial abnormality, only small right posterior parietal scalp swelling. Further review revealed portable chest radiograph (Xray) results revealed Resident #73's stable tracheostomy and a stable small left pleural effusion There were no acute abnormalities noted. A review of the fall investigation dated 10/10/24 completed by the DON revealed during Resident #73's transfer from the wheelchair to the bed using a mechanical lift (hoyer) Resident #73 appeared to have shifted in the sling causing her to slide out of the top right side of the sling. Upon investigation by the DON on 10/11/24, the sling which had been used during the transfer was examined and found to be a cross-strap sling which would require the leg straps to be crossed between the resident's legs. This type of sling was not appropriate for use with Resident #73. Resident #73 required a full body lift sling. An interview on 12/10/24 at 10:38 A.M. with the DON confirmed Resident #73 had fallen from the hoyer lift sling during a transfer on 10/10/24 at 6:40 P.M. Resident #73 did not sustain any acute injury from the fall, only an abrasion to the top of right shoulder. The DON stated during the investigation following Resident #73's fall it was determined the root cause of the fall from the hoyer lift sling was due to improper use of a cross- strap lift sling. The DON stated on 10/11/24 she had examined the sling which had been used during Resident #73's transfer, once the sling had been laid out on the floor, the DON realized the sling was actually a cross-strap lift sling which required lower straps to be crossed between the resident's legs and then hooked to the lift bar. The DON determined the lower straps of the cross-strap lift sling must not have been crossed during the transfer. Resident #73 required the use of a full body lift sling. The DON further stated an audit was completed for any cross-strap lift slings in circulation. The DON then removed all cross-strap slings that were in circulation, this was completed on 10/11/24. The DON and the Unit Managers conducted clinical staff education and competencies for dependent residents utilizing a mechanical lift (hoyer) for transfers. The education was initiated on 10/10/24 and completed on 10/11/24. An interview on 12/10/24 at 1:11 P.M. with CNA #276 revealed Resident #73 had been up in the wheelchair for the day on 10/10/24 and Resident #73 had requested to go back to bed. LPN #234 and RT #505 were also assisting CNA #276 in the transfer. CNA #276 stated once Resident #73 had been elevated out of the wheelchair, CNA #276 moved the wheelchair from under Resident #73 and turned back to the hoyer lift when Resident #73 began sliding out of the top right side of the lift sling, landing on right shoulder and right side of her face. CNA #276 stated the four lift sling straps had been secured to the lift bar prior to the transfer. An interview on 12/10/24 at 1:42 P.M. with LPN #234 revealed she was assisting CNA #276 with Resident #73's transfer and RT #505 was also in the room helping maintain Resident #73's ventilator tubing during the transfer. LPN #234 stated the lift sling straps had been hooked securely to the lift bar prior to the transfer of Resident #73. The brakes were locked on the hoyer lift and the wheelchair. CNA #276 had moved the wheelchair from underneath Resident #73, Resident #73 appeared to shift or move in the sling causing her to slide out of the top right side of the sling onto the floor striking her right shoulder and the right side of her face. LPN #234 notified other staff members of the need for assistance, notified the physician and called Emergency Medical Services (EMS). LPN #234 performed a head-to-toe assessment of Resident #73 and noted an abrasion to the top of her right shoulder. Resident #73 was able to communicate absence of pain and was able to move all extremities. Resident #73's family member was present during the transfer. Attempts to reach RT #505 were made during the survey however, unsuccessful. An observation on 12/10/24 at 2:10 P.M. revealed there were no cross-strap lift slings in the clean linen closet or in the laundry facilities. Review of the facility's policy titled, Mechanical Lift Policy dated 01/07/22 revealed, A mechanical lift may be used for transferring residents that cannot be safely transferred by themselves or with staff assistance. Slings will be inspected for any damage with each use. If the sling has any evidence of damage or fraying of the straps, the sling will be removed from circulation and disposed of. The deficiency was corrected on 10/11/24 when the facility implemented the following corrective actions: • On 10/10/24 a head to toe assessment was completed by LPN #234 for Resident #73 with an abrasion noted to the top of her right shoulder. The physician was notified and Resident #73 was sent to the hospital for further evaluation. The resident returned and did not have any injuries aside from the abrasion that did not require additional treatment. • On 10/10/24 Resident #73's care plan was reviewed with no corrections required. • On 10/10/24 all like residents (24 residents) requiring the use of a mechanical lift for transfers medical records were reviewed for accuracy, there were no corrections required. • On 10/10/24 clinical staff education and competencies conducted by the DON and Unit Managers were initiated for proper use of mechanical lifts during transfers. The staff educated included 35 CNAs, 8 RNs, and 13 LPNs. The education and competencies were completed on 10/11/24. • On 10/10/24 the DON audited all lift slings in the facility and removed all cross-strap slings from circulation. • On 10/10/24 an ad hoc (immediate, unscheduled) Quality Assurance Performance Improvement (QAPI) meeting was conducted with the following in attendance: the Administrator, the DON, the Assistant DON and the Medical Director. The subject of the meeting covered a resident fall from the hoyer lift due to improper use of a lift sling. • On 10/10/24 the DON initiated audits of all lift slings which were conducted weekly for four weeks and then monthly for two months with the audits being completed on 12/02/24. • As of 12/10/24 there have been no further falls occurring from transfers with the use of a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number OH00159887.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility did not ensure Resident #105 participated in and received a copy of her baseline care plan within 48 hours of admission. This affected one resident (Resident #105) of two residents reviewed for baseline care plans. The facility census was 59. Findings Include: Review of Resident #105's medical record revealed the resident admitted on [DATE] with diagnoses including diabetes, atrial fibrillation, hypertension and displaced intertrochanteric fracture of left femur. The resident discharged on 10/11/23. Resident #105 was listed as her own guarantor, and no other responsible parties were listed. Further review of the medical record revealed there was no baseline care plan, nor comprehensive plan of care in lieu of the baseline care plan, signed by Resident #105 to serve as evidence Resident #105 agreed to initial care goals and services and treatments that would be provided by the facility and personnel acting on behalf of the facility. There was one document regarding resident centered care all about me information and revealed the form was dated 10/09/23 at 9:40 A.M. The form documented Resident #105's preferred name, care preferences including showering and bathing preference and time of day preferred, wake and bedtime preferences, and therapy service time preference. The form was signed by the activity director and there was no resident signature. Interview with Resident #105 on 10/10/23 at 1:10 P.M. revealed she did not know if a care plan meeting had been held on her behalf, and she had not received a copy of any care plan. Interview with Social Service Director (SSD) #500 on 10/11/23 at 4:15 P.M. confirmed an initial care plan meeting with Resident #105 to discuss care goals, services and treatments was not completed within 48 hours of admission having just had the initial care plan meeting on 10/09/23. SSD #500 stated the initial resident care path was completed five to seven days after admission and then a resident care conference occurred in the first month at the facility. Review of the Policy titled Interim/Baseline Care Planning Policy, dated 11/28/16 with a revision date of 08/11/20, revealed within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will be used until the comprehensive assessment and care plan is developed by the interdisciplinary team. The procedure to implement will include involving the interdisciplinary team and the resident and/or residents family and/or resident's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure physician orders were obtained to provide treatment to an area of skin impairment for Resident #40. The affected one (#40) resident of seven residents reviewed for wounds. The facility census was 59. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis and chronic venous hypertension with ulcer and inflammation to lower left leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no hallucinations, required supervision for activities of daily living, was occasionally incontinent of bladder and always continent of bowel. The resident was coded as being at risk for pressure ulcers but as not having any pressure ulcers. Review of a progress note dated 10/09/23 at 1:25 P.M. revealed Resident #40 had dry skin caught in her sock and a skin tear occurred when the podiatrist removed the sock for a nail assessment. The wound was cleansed, and dressing applied. Review of Resident #40's treatment administration record and physician orders revealed there was no treatment ordered or documented wound care for the Resident's skin tear which occurred on 10/09/23. Interview with Resident #40 on 10/10/23 at 11:05 A.M. revealed the resident had an area to her left ankle the facility was treating. Observation of wound care on 10/11/23 at 11:14 A.M. performed by Registered Nurse (RN) #143 revealed the wound was wrapped with Kerlix (gauze), had an ABD pad (absorbent dressing) over the Xeroform (wound cover) which was placed on the wound. The wound dressing removed was not dated with the day the dressing was applied. The wound was observed to be cleansed with normal saline, and redressed with Xeroform, an ABD pad and wrapped with Kerlix. The dressing was dated 10/11/23, and initialed by the nurse. Interview with RN #143 on 10/11/23 at 11:16 A.M. confirmed she was the RN who provided wound care to the residents. RN #143 verified she had been employed at the facility about two months. RN #143 stated Resident #40 had very dry skin and often refused to have her lotion applied. Interview with RN #143 on 10/11/23 at 11:47 A.M. confirmed she was the nurse who initiated the wound care for resident #40 after the skin tear occurred on 10/09/23. RN #143 verified the wound treatment was not ordered, and she was just putting the wound care orders in place stating after she had dressed the wound on 10/09/23 all craziness broke out and she had just gotten to put the orders in the computer. RN #143 revealed she was having the nurse practitioner see the resident's wound on 10/13/23 when rounds are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident # 305's medical record revealed Resident #305 was admitted to the facility on [DATE] with the diagnoses including congestive heart failure, cardiomyopathy, high blood pressure, diabetes mellitus type two, weakness, and alcohol dependency. Review of Resident #305's admission assessments revealed Resident #305 had impaired cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including dressing, personal hygiene, bed mobility, and transfers. Review of Resident #305 physician orders revealed an order dated 10/01/23 for the application of Prevalon boots (pressure relieving devices) to bilateral lower legs and feet to be worn at all times and may be removed for bathing and hygiene. Review of Resident #305's baseline care plan dated 10/05/23 revealed Resident #305 had potential for skin breakdown with the goal of Resident #305's skin to remain intact with the implementation of interventions including the use of pressure relieving devices as indicated. Observations on 10/10/23 at 12:06 P.M. revealed Resident #305 sitting in a wheelchair, there were no pressure relieving devices in place to bilateral lower legs and feet. Further observation on 10/10/23 at 2:47 P.M. revealed a set of green colored pressure relieving devices laying on the top of the clothes armoire located in Resident #305's room. Observations on 10/11/23 at 6:38 A.M. and at 1:00 P.M. and again on 10/12/23 at 8:15 A.M. revealed Resident #305 did not have the pressure relieving devices in place to bilateral lower legs and feet. The green colored pressure relieving devices remained on the top of the clothes armoire in Resident #305's room. Interview on 10/12/23 at 8:15 A.M. with the Director of Nursing (DON) confirmed Resident #305 was laying in bed without the pressure relieving devices in place to bilateral lower legs and feet. Further confirmation by the DON revealed the pressure relieving devices were laying on top of the clothes armoire in Resident #305's room. Review of the facility's policy titled, :Skin and Wound Care Best Practices revised date 06/10/22 revealed, Provide pressure redistribution/relief devices according to interdisciplinary assessment and recommendation. 3. Review of the medical record for Resident #10 revealed an admission date of 07/08/23 with readmission on [DATE]. Diagnoses included chronic kidney disease, bipolar disorder, depression, vascular disease, muscle weakness and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact with a BIMS of 13 and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of care plan dated 07/10/23 revealed Resident #10 was at risk of skin impairments with interventions including administer medications and treatments as ordered, assess and document the status of the area (healing or declining), monitor document and report to physician any changes in wounds, turn and reposition as indicated. Resident had potential for skin breakdown related to decreased mobility with interventions to turn and reposition, use pressure reducing devices as indicated and complete skin assessments. Review of Physician order dated 07/08/23 revealed order to elevate heels off bed as tolerated for preventative care. Physician order dated 08/08/23 for Prevlon boots on while in bed for wound care prevention. Review of orders dated 07/08/23 revealed order to turn and reposition as tolerated and while in bed. Review of progress notes revealed no noted documentation of residents refusal to wear the prevalon boots or offload heels. Observation on 10/10/23 at 9:40 A.M., 11:10 A.M., 2:05 P.M., 4:20 P.M. revealed observations of Resident #10 laying in bed flat on his back with no off loading support and prevlon boots sitting in the chair next to Resident's bed. Interview and observation dated 10/11/23 at 11:59 A.M. with Resident #10 revealed he was laying in bed with his heels pressed upon the bed matress. Resident #10 had prevlon boots sitting on the chair next to his bed. Resident 10 said he had boots to wear on his legs/feet and confirmed they were sitting on his chair and he was not wearing boot while in bed. Interview and observation on 10/12/23 at 9:03 A.M. with Registered Nurse (RN) #149 confirmed Resident #10 had his feet placed with heels pressed against the matress. RN #149 confirmed Resident #10 should be wearing Prevlon boots for off loading support. RN #149 confirmed orders were in place for off loading, repositioning and to wear the prevlon boots while in bed. Observation on 10/12/23 at 11:00 A.M. revealed resident was in the same position flat on his back with heels pressed into matress and prevlon boots were sitting on dresser in the same spot as two hours prior. Review of facility policy titled Skin and Wound care Best Practices, dated 06/10/22 revealed facility shall provide evidence based prevenative based skin care and treatment to prevent skin complications. This deficiency represents noncompliance investigated under complaint OH00146954. Based on observation, interview, record review, and review of facility policies, the facility failed to ensure pressure reducing interventions were in place for Resident #9, #10, and #305. This affected three residents (#9, #10, and #305) of seven residents reviewed for skin impairment or pressure ulcers. The facility census was 59. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 12/01/10 with diagnoses including major depressive disorder, type two diabetes mellitus, sleep disorder, dissociative and conversion disorders, Alzheimer's disease, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was rarely or never understood. Review of the plan of care dated 12/02/20 revealed Resident #9 was at risk for impaired skin integrity related to incontinence, fragile skin, impaired mobility, impaired cognition, and diagnoses. Interventions biweekly skin checks, barrier cream after incontinence, cushion to wheelchair, encourage fluids, encourage and assist to elevate heels off mattress, pillows for positioning, pressure reducing mattress, treatments as ordered, and turning and repositioning as tolerated. Review of the physician order dated 10/01/21 revealed Resident #9 was to lay down between meals to take pressure off of her coccyx. Review of the meal times revealed breakfast was at 7:30 A.M., lunch was at 11:30 A.M., and dinner was at 5:00 P.M. Observation on 10/10/23 at 10:22 A.M. and on 10/11/23 at 8:37 A.M., 9:31 A.M., 9:57 A.M., 11:24 A.M., 12:30 P.M., and 1:33 P.M. revealed Resident #9 was in her wheelchair in the common area or in her room sitting in her wheelchair. Interview on 10/11/23 at 2:35 P.M. with Registered Nurse (RN) #117 revealed Resident #9 had been recently put to bed. RN #117 verfied she had been otherwise up in her chair and revealed being unaware of any time schedule for Resident #9 to be in bed. Interview on 10/11/23 at 4:41 P.M. with the Director of Nursing (DON) verified Resident #9 had a physician order to lay down after meals to reduce pressure. Interview and observation on 10/12/23 at 10:01 A.M. with State Tested Nursing Aide (STNA) #154 verified Resident #9 was up in her chair instead of being put back to bed after breakfast. Review of the policy Skin and Wound Care Pest Practices revised 06/10/22, revealed pressure reduction and redistribution should be provided for those at risk. They should be provided according to interdisciplinary assessment and recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of Resident #29's medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including brain cancer, lung cancer, depression, alcohol dependence and nicotine dependence. Review of Resident #29's physician orders revealed the order dated 05/15/23 as Resident #29 being an independent smoker. Review of Resident #29's quarterly [NAME] Data Set (MDS) dated [DATE] revealed Resident #29 had intact cognition and required supervision by staff for activities of daily living (ADL) tasks. Review of Resident #29's care plan dated 04/06/22 revealed Resident #29 was an independent smoker with the goal for Resident #29 to maintain a safe smoking environment with the implementation of interventions including staff to complete smoking assessments to ensure continued safety while smoking. Review of Resident #29 admission assessments revealed there were no smoking assessments or smoking evaluations completed upon admission to the facility on [DATE]. Further review of Resident #29's assessments revealed a quarterly smoking assessment completed on 05/15/23. Observation on 10/11/23 at 1:30 P.M. revealed Resident #29 independently smoking with other residents. Interview on 10/12/23 at 9:09 A.M. with Licensed Practical Nurse (LPN) #118 revealed the initial smoking evaluation and assessment should be completed upon admission to the facility and then quarterly smoking assessments should be completed each quarter to coincide with the scheduled quarterly MDS. LPN #118 confirmed Resident #29 did not have an admission smoking evaluation or assessment completed and the only quarterly smoking assessment was completed on 05/15/23. Review of the facility's policy titled, Resident Smoking Policy revised date 10/20/22 revealed, During the admission process, nursing will ask resident if they smoke or if they have the intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. This deficiency represents noncompliance investigated under complaint OH00146954. Based on observation, interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place for Resident #1 and #38 and failed to ensure Resident #29 had smoking assessment upon admission and quarterly This affected three residents (#1, #38, and #29) of six residents reviewed for accidents/hazards. The facility census was 59. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 09/02/16 with diagnoses including schizophrenia, dysphagia, dementia, depression, anxiety, type two diabetes mellitus, heart failure, and cerebral palsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She'd had one fall since the previous assessment. Review of the plan of care dated 10/01/16 revealed Resident #1 was at risk for falls characterized by history of falls, injury, and or multiple risk factors related to impaired balance, non-ambulatory, receives diuretic, antianxiety, antidepressant, and antipsychotic medications, and diagnoses. Interventions included assisting with mobility, keeping the bed in the lowest position, applying dycem to grab bar in bathroom, nonskid strips to exit side of bed, in front of commode, and in the room's doorway, and wheelchair at bedside when resident was in bed. Review of the physician order dated 09/22/18 revealed Resident #1 was to have nonskid strips in front of her toilet. Observation on 10/10/23 at 12:05 P.M., 10/11/23 at 11:00 A.M., and 10/12/23 at 8:00 A.M. revealed there were no nonskid strips in Resident #1's room or bathroom. Interview on 10/11/23 at 10:36 A.M. with State Tested Nursing Aide (STNA) #154 verified there were no nonskid strips in the resident's room. 2. Review of the medical record for Resident #38 revealed an admission date of 06/29/21 with diagnoses including bipolar disorder, anxiety disorder, Alzheimer's disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 05/05/23 revealed Resident #38 was at risk for falls. On 10/18/22 she had a fall without injury and on 05/04/23 she had an unwitnessed fall without injury. Interventions included keeping the bed in the lowest position, maintaining needed items within reach, nonskid strips to the doorway and exit side of bed, offering to lay down between meals, and tilt and space wheelchair for mobility. Observation on 10/10/23 at 12:30 P.M.,10/11/23 at 11:00 A.M., and 10/12/23 at 8:00 A.M. revealed there were no nonskid strips in Resident #38's room. Interview on 10/11/23 at 10:36 A.M. with State Tested Nursing Aide (STNA) #154 verified there were no nonskid strips in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #305's medical record revealed Resident #305 was admitted to the facility on [DATE] with the diagnoses including congestive heart failure, cardiomyopathy, high blood pressure, diabetes mellitus type two, and alcohol dependency. Review of Resident #305's admission assessments revealed Resident #305 had impaired cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including dressing and transfers. Review of Resident #305 physician orders revealed an order dated 10/05/23 for the completion of daily weights related to the diagnosis of congestive heart failure. Review of Resident #305's weight record revealed entries for completed weights on 09/28/23 at 223 pounds (lbs.), 10/01/23 at 234 lbs., 10/6/23 at 235.1 lbs., and 10/8/23 at 236.2 lbs. indicating from 09/28/23 to 10/08/23 Resident #305's weight had increased significantly by 13.2 lbs. or 5.58 percent in 10 days. Review of Resident #305's baseline care plan dated 10/05/23 revealed Resident #305's weight is to be monitored due to potential weight fluctuations related to fluid retention caused by congestive heart failure. Review of Resident #305's Point of Care (POC) task documentation revealed weight entries for 09/28/23 to 10/11/23 with only one entry dated 10/09/23 at 2:22 A.M. marked not applicable to obtain Resident #305's weight. Interview on 10/12/23 at 8:14 A.M. with the Director of Nursing (DON) confirmed Resident #305 was not being monitored for fluid retention related to congestive heart failure by the lack of daily weights being obtained per the physician's order. Review of the facility's policy titled, Weight Policy revised date of 02/01/20 stated obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight. Based on record review, review of facility policy and interviews, the facility failed to ensure weights were completed as ordered and the physician was notified of weight changes for Resident #22 and Resident #305. This affected two residents (#22 and #305) out of five residents reviewed for nutrition. The facility census was 59. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 08/25/23 with diagnoses including chronic pulmonary edema, anxiety disorder, acute and chronic respiratory failure, cognitive communication deficit, and acute on chronic diastolic heart failure. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the physician order dated 08/26/23 to 08/29/23 revealed Resident #22 was to be weighed every day shift at the same time each morning. The heart failure center and primary care physician were to be notified of weight gain or loss of more than two pounds overnight or five pounds in one week. Review of the physician order dated 08/30/23 revealed Resident #22 was to be weighed daily at 6:00 A.M., she was to be weighed at the same time each morning. The heart failure center and primary care physician were to be notified of weight gain or loss of more than two pounds overnight or five pounds in one week. Review of Resident #22's weights revealed she experienced a two pound (lbs.) or more weight change from 09/03/23 (216.0 lbs.) to 09/04/23 (214.0 lbs.), from 09/05/23 (213.4 lbs) to 09/06/23 (215.4 lbs.), from 09/10/23 (217.0 lbs.) to 09/11/23 (214.4 lbs.), from 09/16/23 (216.8 lbs.) to 09/17/23 (224.0 lbs.), from 09/22/23 (222.8 lbs.) to 09/23/23 (218.2 lbs.), from 10/02/23 (219.0 lbs.) to 10/03/23 (215.0 lbs.), from 10/08/23 (214.6 lbs.) to 10/09/23 (218.8 lbs.), and from 10/09/23 (218.8 lbs.) to 10/10/23 (214.8 lbs.). Review of Resident #22's weights revealed she experienced a five-pound weight change in a week from 08/27/23 (223.2 lbs.) to 09/04/23 (214.0 lbs.), from 09/10/23 (217.0 lbs.) to 09/17/23 (224.0 lbs.), and from 09/17/23 (224.0 lbs.) to 09/24/23 (217.0 lbs.). Review of the progress notes from 08/27/23 to 10/10/23 revealed no evidence the physician or heart failure center was notified of weight changes. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing (DON) verified there was no evidence the physician was notified of weight changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure pain was addressed timely and appropriately for Resident #258. This affected one (Resident #258) of four residents reviewed for pain. Facility census was 59. Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, and osteoporosis. Review the admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Review of the care plan dated 10/09/23 revealed Resident #258 had potential for pain with interventions to administer pharmacological interventions as ordered and assess residents pain for verbal and non verbal indicators. Review of physician orders dated 10/09/23 revealed an order for oxycodone-acetaminophen (pain medication containing narcotics) oral tablet 10-325 mg to be given every six hours as needed. Review of EBOX (a secured, electronic prescription containment and dispensing system) contents list revealed oxycodone-acetaminophen 10-325 mg was available in the facility upon order from a physician. Review of the Medication Administration Record (MAR) dated 10/2023 revealed Resident #258 received one dose of oxycodone-acetaminophen medication late afternoon on 10/10/23 and one dose in the morning 10/11/23. Review of progress notes dated 10/09/23 to 10/11/23 revealed no mention of pain assessments after the initial admission. Interview on 10/10/23 at 1:45 P.M. with Resident #258 revealed she was not provided with pain medication upon request in a timely manner. She revealed she requested pain medication and had to wait about two hours before staff brought in pain meds. She revealed she told the State Tested Nursing Aide (STNA) #111 that she was in pain and the STNA informed the nurse. After a while she told the STNA she never received pain medication as requested and the STNA got the Director of Nursing (DON) involved. Resident #258 revealed the DON came and spoke with her and that was the only reason she was given the pain medication around the two hour mark after asking for it. Resident #258 revealed she had admitted the previous day and not received any pain medications since before she left the hospital to come to the facility. Interview on 10/10/23 at 1:51 P.M. with STNA #111 revealed Resident #258 had informed her she was in pain and asked for a pain medication. STNA #111 revealed she informed the bedside nurse right away. STNA #111 revealed resident reported to her she was still waiting on her pain medication so STNA reported the delay in pain treatment to the DON who went and spoke with Resident #258 and was able to get her pain medication. Interview on 10/11/23 at 4:45 P.M. with DON confirmed resident had complained about not getting the pain medication timely and revealed she was asked by staff to speak with her after she had requested a pain medication that was not provided timely. The DON revealed after looking into her medications, DON found resident was changed from getting pain medication every four hours at the hospital to every six hours at the facility and the DON believed Resident #258 did not understand the change in timing. The DON revealed she had no explanation as to why Resident #258 was only given one pain medication dose on 10/10/23 and one on 10/11/23. The DON confirmed Resident #258 should have been able to receive pain medication every six hours as ordered and verified the lack of pain assessments. Review of policy titled Physician/Provider Orders dated 12/14/21 revealed the charge nurse shall review all physician orders upon admission. The facility did not have a policy related to following Physician orders or providing medications as ordered. Review of policy titled Pain Management Protocol, dated 10/24/22, revealed facility shall ensure residents are assessed for pain. Residents pain shall be addressed by pharmalogical and nonpharmalogical interventions.

Based on record review, observation, interview and review of facility policy, the facility did not ensure an assessment for the appropriateness of use of bed rails versus alternatives was completed for Resident #259. This affected one resident (#259) of four residents reviewed for accidents/hazards. The facility census was 59. Findings include: Review of the medical record for Resident #259 revealed an admission date of 10/09/23. Diagnoses included fracture of humerus, diabetes, anxiety, fatigue, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment revealed the MDS had not yet been completed due to new admission. Review of physician orders revealed no evidence of order for bed rails of any kind. Review of assessments revealed no evidence of a bed rail or safety assessment being completed prior to Resident #259 being given bed rails. Review of the care plan revealed no evidence of bed rails being included in the care plan. Interview and observation on 10/10/23 at 11:54 A.M. with Resident #259 revealed she had bilateral bed rails on her bed, resident was lying in bed with a right arm fracture with her arm in a sling. The resident revealed she was not sure why the bed had bed rails on it and revealed she did not have much strength and did not use them to get adjusted in bed. Observation on 10/11/23 at 11:57 A.M. of Resident #259 revealed her bed had bilateral bed rails. Interview and observation on 10/11/23 at 12:20 P.M. with Registered Nurse (RN) #136 confirmed Resident #259 had bilateral bed rails and revealed she did not know why. RN #136 confirmed Resident #259 did not have physician order for bed rails and did not have any assessments for bed rails or safety with bed rails. RN #136 confirmed resident had a broken arm in a sling and revealed a bedrail on that side of the bed would not be appropriate as it could not be used to pull herself up. RN #136 also confirmed the admission checklist in Resident #259's paper chart included a check off for bed rails including assessment and physician order and revealed this section was left blank. Interview on 10/11/23 at 12:45 P.M. with the Administrator and Director of Nursing (DON) at 12:55 P.M. revealed the admission checklist was an internal document and although it was a part of the paper medical record, the facility would not provide a copy for the survey and survey team to review and removed it from the chart. Interview on 10/11/23 at 12:55 P.M. with the DON acknowledged a resident should be assessed for the need and safety of bed rails and they should be ordered by a physician prior to use and should also be part of the care plan. DON reviewed the care plan and confirmed it did not have bed rails included. Review of the policy titled, Bed Rail Policy, dated 04/25/23. revealed facility would use bed rails only in limited circumstances to treat a medical condition and enhance functional abilities. The facility would attempt to use appropriate alternatives prior to use of bed rails. If a bed rail would be used, first the facility would assess for potential risks, assess for risk verse benefit and review with resident and or representative, obtain consent prior to installation, ensure proper dimensions based on residents' size and weight, and install them based on the manufacturer's guidelines. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146954.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor blood pressure according to medication parameters and failed to ensure parameters were in place for pain medication for Resident #35. This affected one resident (#35) of six residents reviewed for medications. The facility census was 59. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 09/10/21 with diagnoses including depression, anxiety, Parkinson's disease, hypertension, and chronic atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the plan of care dated 08/24/22 revealed Resident #35 was at risk for altered cardiac status, atrial fibrillation, and hypertension. Interventions included providing medications as ordered, monitoring for signs of decreased cardiac output, notifying the physician as needed with any changes, and vital signs as ordered. Review of the physician order dated 10/11/22 revealed Resident #35 had an order for Norvasc Tablet 10 milligrams (mg) one tablet by mouth one time a day. The medication was to be held for systolic blood pressure below 110 milligrams per deciliter (mg/dl). Review of the Medication Administration Record (MAR) for September 2023 and 10/01/23 through 10/10/23 revealed Norvasc was administered daily, however, there was no daily monitoring of blood pressure. Review of the blood pressure documentation revealed for September 2023 and 10/01/23 through 10/10/23 Resident #35's blood pressure was assessed on 09/08/23, 09/15/23, 10/03/23, and 10/10/23. Interview on 10/12/23 at 9:10 A.M. with the Director of Nursing (DON) verified blood pressure was not being documented daily and should have been according to the orders to determine whether or not the Norvasc should be given or put on hold. 2. Review of the medical record for Resident #35 revealed an admission date of 09/10/21 with diagnoses including depression, anxiety, Parkinson's disease, hypertension, and chronic atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the plan of care revised 06/20/23 revealed Resident #35 had pain related to pre-admission fall, history of falls, Parkinson's disease, decreased mobility, and disease process. Interventions included administering medications as ordered, assessing and recording pain per routine, and non-pharmacological pain interventions as allowed. Review of the physician order dated 10/01/22 revealed an order for Tylenol 325 mg two tablets by mouth every six hours as needed for pain. There were no parameters for administration. Review of the MAR for September 2023 revealed Tylenol was not administered. Review of the MAR for October 2023 revealed Tylenol was not administered. Review of the physician order dated 03/21/23 revealed Resident #35 was to receive morphine Sulfate 20 milligrams (mg) per milliliter (ml) 0.25 ml by mouth every three hours as needed for pain or shortness of breath. There were no parameters for administration. Review of the MAR for September 2023 revealed morphine was given on 09/03/23 for a pain of seven, on 09/08/23 for a pain of eight, on 09/11/23 for a pain of five, on 09/17/23 for a pain of ten, on 09/23/23 for a pain of ten, on 09/25/23 for a pain of ten, and on 09/27/23 for a pain of six. Review of the MAR for October 2023 revealed it was given on 10/02/23 twice for a pain of three and pain of six, on 10/07/23 for a pain of six, and on 10/10/23 for a pain five. Interview on 10/12/23 at 9:10 A.M. with the Director of Nursing (DON) verified there were no parameters for the 'as needed' pain medication. She reported the resident was alert and oriented and would often request which medication she wanted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure Resident #258 was administered medications in accordance with physician orders and therefore free of significant medication errors. This affected one resident (#258) of six residents reviewed for medication administration. The facility census was 59. Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, surgical wound infection, and osteoporosis. Review of the nursing admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Resident #258 had an elevated,. above normal blood pressure of 147/90. Review of the Hospital Discharge summary dated [DATE] revealed instructions to take these meds which included Carvedilol (cardiac medication used to treat high blood pressure and heart conditions) 12.5 milligrams (mg) by mouth twice daily, Cephalexin ( an antibiotic used to treat infection) 500 mg capsule by mouth three times daily and Venlafaxine (antidepressant) 75 mg by mouth daily in evenings. Review of the care plan dated 10/09/23 revealed Resident #258 was on antibiotic therapy with interventions to administer full course of antibiotic as prescribed. Review of physician orders revealed orders dated 10/10/23 for Carvedilol oral tablet 12.5 mg to be given twice daily, an order dated 10/09/23 and again 10/10/23 for Cephalexin 500 mg oral tablet to be given three times daily, and an order dated 10/10/23 for Venlafaxine HCl Oral tablet 75 mg to be given once daily. Review of EBOX ( an electronic prescription containment and dispensing system ) contents list included Carvedilol 12.5 mg and Cephalexin 500 mg indicating these prescription were available upon Resident #258 admitting to the facility. Review of the Medication Administration Record (MAR) dated 10/2023 revealed Carvedilol oral tablet 12.5 mg was not given on 10/09/23 evening dose, Cephalexin 500 mg oral tablet was not received on 10/10/23 morning dose and Venlafaxine HCl Oral tablet 75 mg was not received on 10/09/23 evening dose. Review of progress notes dated 10/09/23 to 10/11/23 revealed no mention of resident missing doses or delays from pharmacy and staff informing the physician of these concerns or delays. Interview on 10/10/23 at 1:45 P.M. with Resident #258 revealed she was not provided her antibiotic medication, her blood pressure medication or her antidepressant medication as her doctor prescribed. Interview on 10/11/23 at 2:53 P.M. with Licensed Practical Nurse (LPN) #156 revealed she worked night shift 10/09/23 and revealed she had two admissions and was told by the previous nurse everything was done for Resident #258 except the aides needed to complete the inventory sheet of belongings. She revealed Resident #258's medications had been submitted to pharmacy and they did not arrive until about 3:00-4:00 A.M. the next morning on 10/10/23. LPN #156 revealed she did not provide any medications to Resident #258 and revealed it was her first day working at this facility and was not familiar with their EBox procedures. LPN #156 confirmed Resident #258 missed several medications after admitting to the facility on [DATE]. Interview on 10/11/23 at 3:17 P.M. with LPN #133 revealed she was working day shift on 10/09/23 and revealed she was not assigned to Resident #258, but helped the assigned nurse with imputing orders and medications into the computer and sending scripts to pharmacy. She revealed she was unaware of what medications Resident #258 received after admission to the facility. Interview on 10/11/23 at 3:26 P.M. with LPN #165 revealed she worked day shift on 10/09/23 and was assigned to Resident #258 and revealed she could not remember if she provided any medications to Resident #258. LPN #165 revealed another nurse assisted in putting orders in the chart and sent to pharmacy. Interview on 10/11/23 at 4:45 P.M. with the Director of Nursing (DON) confirmed Resident #258 missed doses of medication and revealed she was not aware of any details. The DON revealed she was not aware several of the missed medications were in the Ebox and said Resident #258 decided to leave the facility after just under two days of admission. Review of policy titled Physician/Provider Orders, dated 12/14/21, revealed the charge nurse shall review all physician orders upon admission. The facility did not have a policy related to following Physician orders or providing medications as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility did not keep an accurate record of skin impairment and wound status in the medical record for Resident #10. This affected one (Resident #10) of seven residents reviewed for skin impairments. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/08/23 with readmission on [DATE]. Diagnoses included chronic kidney disease, bipolar disorder, depression, vascular disease, muscle weakness and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the care plan dated 07/10/23 revealed Resident #10 was at risk of skin impairments with interventions including administer medications and treatments as ordered, assess and document the status of the area (healing or declining), monitor document and report to physician any changes in wounds, turn and reposition as indicated. Resident had potential for skin breakdown related to decreased mobility with interventions to turn and reposition, use pressure reducing devices as indicated and complete skin assessments. Review of wound assessments dated 08/01/23, 08/08/23, 08/16/23 and 08/22/23 revealed Resident #10 had a right great toe wound noted to be an abrasion. These assessments lacked consistency regarding date of onset of the right great toe wound. The wound assessment dated [DATE] indicated wound onset was 08/01/23. The wound assessment dated [DATE] indicated the wound was identified as new on 07/08/23 and the wound assessment dated [DATE] indicated the wound was identified as new on 08/16/23. The wound assessment dated [DATE] indicated the wound was identified as new on 07/08/23. Review of a physician order dated 08/17/23 revealed an order to monitor scabs to toes every shift until healed, monitor scabs to bilateral knees every shift, and for the right great toe, cleanse with normal saline, pat dry and cover with a clean dry dressing daily and as needed. Review of weekly skin assessments dated 10/02/23 revealed Resident #10 had skin issues including right great toe and small, scabbed areas on the right shin. Review of weekly skin assessments dated 10/09/23 revealed Resident #10 had no current skin issues. Review of the Treatment Administration Record (TAR) dated 09/2023 and 10/2023 revealed the physician ordered treatment and dressing to the right great toe was being marked off as completed daily. Interview on 10/11/23 at 11:59 A.M. with Resident #10 revealed he had wounds on his legs, shins and feet areas. Interview and observation on 10/12/23 at 9:03 A.M. with Registered Nurse (RN) #149 confirmed Resident #10 had scabbed areas to shins/legs. RN #149 revealed Resident #10 did not have any wounds on his feet. Observation of Resident #10's legs and feet revealed he had over 10 scabbed areas on his bilateral shins and no sores visible on his feet or toes. RN #149 reviewed Resident #10's physician orders and revealed the treatment dressing change to the right toe as indicted on the TAR was actually not being done as marked on the TAR because it was not needed and should have been discontinued once it had healed. RN #149 verified it was incorrect documentation that did not reflect Resident #10's current skin status. Interview on 10/12/23 at 10:40 A.M. with RN #149 revealed the wound and skin assessments did not accurately reflect the dates a wound was first found, status of wounds and skin impairments. RN #149 confirmed it was not documented when the wound on Resident #10's right toe was healed. RN #149 verified the skin assessments in the medical record did not show all details of treatments and stages of wound care through healing of the wounds. RN #149 verified the facility should have documentation of when each wound had healed and verified the weekly skin assessment dated [DATE] was not accurate, as Resident #10 had scabs on his shins at that time. Review of facility policy titled Skin and Wound care Best Practices, dated 06/10/22, revealed facility shall complete weekly skin assessments and shall be reviewed by the interdisciplinary team.

Based on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for COVID-19 immunization. This affected three residents (#17, #6, and #16) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Moderna Bivalent Booster on 09/22/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing verified she could not locate evidence of education for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood disorder, chronic obstructive pulmonary disease, and psychosis. Review of the immunization report for Resident #6 revealed they received the Pfizer bivalent booster on 09/22/22. Review of the medical record revealed no evidence Resident #6 or their responsible party received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. 3. Review of the medical record for Resident #16 revealed an admission date of 09/25/19 with diagnoses including hypertension, anxiety disorder, bipolar disorder, and unspecified psychosis. Review of the immunization report for Resident #16 revealed they received the Pfizer Bivalent Booster on 09/22/22. Review of the medical record revealed no evidence Resident #16 or their responsible party received education or signed consent for the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. Review of the policy Resident Vaccination Policy dated 05/18/22 revealed when a vaccination order revealed the staff were to review the Center for Disease Control (CDC) vaccine information statement or Emergency Use Authorization with any resident or resident representative before obtaining consent. Education was to be provided before administration. Consent, refusals, and medical ineligibility was to be documented in the immunization portal in the electronic health record.

Based on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for influenza and pneumococcal immunizations. This affected four residents (#17, #6, #106, and #16) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing (DON) verified she could not locate education and a signed consent form for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood disorder, chronic obstructive pulmonary disease, and psychosis. Review of the immunization report for Resident #6 revealed they received the influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #6 or their responsible party received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate education and a signed consent form for the immunization. 3. Review of the medical record for Resident #106 revealed an admission date of 09/06/23 with diagnoses including chronic pulmonary embolism, hypertension, metabolic acidosis, and hyperlipidemia. Review of the immunization report for Resident #106 revealed the refused the pneumococcal vaccine on 09/07/23. Review of the medical record revealed no evidence Resident #106 received education related to the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. 4. Review of the medical record for Resident #16 revealed an admission date of 09/25/19 with diagnoses including hypertension, anxiety disorder, bipolar disorder, and unspecified psychosis. Review of the immunization report for Resident #16 revealed they refused the pneumococcal vaccine on 05/15/23 and consented to the influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #16 or their responsible party received education related to the pneumococcal vaccine or received education and signed consent for the influenza vaccine. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate education or a signed consent form for the immunization. Review of the policy Resident Vaccination Policy dated 05/18/22 revealed when a vaccination was ordered, the staff were to review the Center for Disease Control (CDC) vaccine information statement or Emergency Use Authorization with any resident or resident representative before obtaining consent. Education was to be provided before administration. Consent, refusals, and medical ineligibility was to be documented in the immunization portal in the electronic health record.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview the facility failed to have eight consecutive hours daily of Registered Nurse (RN) coverage in the facility. This had the potential to affect the 59 residents who resided at the facility. Findings include: Review of the payroll based journal information revealed the facility failed to have eight consecutive hours of Registered Nurse (RN) coverage in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. Interview with Assistant Administrator (AA) #131 on 10/10/23 at 4:40 P.M. confirmed there was no RN in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. AA #131 stated the Director of Nursing (DON) during that time stated she was available and on call on those days. AA #131 stated the DON did not realize having a RN available and on call did not meet the requirement. AA #131 stated the facility had prioritized the hire of RN's even for Licensed Practical Nurse (LPN) positions and the facility utilized RN agency staff and this had not continued to be a problem. The deficient practice was corrected on 02/28/23 when the facility implemented the following corrective actions: • Education was provided on 02/28/23 to the DON and the Assistant Director of Nursing by the Administrator/designee regarding of the staffing requirement and the need for the RN to be present in the facility and if the RN scheduled called off the DON or another RN designated by the DON would be required to come to the facility. • Monitoring of the nursing schedule completed by the Assistant Administrator was completed weekly for four weeks then monthly times two months. Review of the the monitoring revealed the weekly monitoring was performed in March 2023 and the monthly monitoring was performed in April 2023 and May of 2023. There was no current non-compliance identified at the time of the annual survey completed on 10/12/23. Review of the staffing tool completed for 09/24/23 through 09/30/23, the daily staffing posting for 09/23/23 through 09/29/23 and the daily staffing for 10/10/23 through 10/12/23 confirmed there was an RN in the facility for eight consecutive hours daily.

Based on record review, review of the staffing tool and resident and staff interviews, the facility administration failed to ensure there was sufficient direct care staff at all times in the facility to meet the minimum staffing requirement of two point five (2.5) hours of direct care per resident per day. This had the potential to affect all 59 residents living in the facility. Findings include: Review of the staffing tool completed for 09/24/23 through 09/30/23 revealed on 09/24/23 the facility only provided two point two seven (2.27) hours of direct care per resident per day. Interview with Resident #106 on 10/10/23 at 10:14 A.M. revealed staff are all nice, but when the facility was short staffed it takes a long time to answer the call light. The resident stated she needed assistance to complete her daily care needs and one time staff attempted to weigh her at 12:00 A.M. and she refused to be weighed at that time and was weighed the next day. Interview with Resident #107 on 10/10/23 at 10:25 A.M. revealed the facility was short in nurse aides which affected the call light response time. Resident #107 stated call lights usually take 20-25 minutes to be answered by the staff. Interview with Resident #45 on 10/10/23 at 3:33 P.M. revealed he thought the facility needed more staff. He stated he does not always get put to bed at 8:30 P.M. as he desires. Interview with Assistant Administrator (AA) # 131 included record review of the staffing tool completed 09/24/23 through 09/30/23. AA #131 confirmed the facility did not meet the two point five (2.5) hours of direct care per resident per day on 09/24/23. AA #131 stated the facility had agency staff scheduled on that day and they did not show up to work. This deficiency represents noncompliance investigated under complaint OH00146954.

Based on medical record review, review of a facility discharge notice, and staff interview, the facility failed to ensure a 30-day discharge notice was sent to the Ombudsman office as required with proof of the notification maintained. This affected one resident (#52) of one sampled resident reviewed who was provided a discharge notice for non-payment. The facility census was 50. Findings include: Review of Resident #52's medical record revealed a copy of a 30-day discharge notification, dated 12/30/22. The notice identified Resident #52 was being discharged to her apartment by 01/30/23 for lack of payment to the facility. The notice was provided to Resident #52 on 12/30/22; however, there was no evidence the Ombudsman office received the notification. Interview with the Administrator on 03/02/23 at 9:30 A.M. revealed the facility mailed the notification, however did not email the notification or have evidence the notification was sent to the Ombudsman. The Administrator revealed the facility was not aware of the need to email discharge notifications. Interview with the facility Ombudsman on 03/02/23 at 9:38 A.M. revealed all 30-day discharge notifications should be emailed immediately to ohioombudsman@age.ohio.gov. The Ombudsman indicated this was the central location for all discharges to be submitted by facilities. The Ombudsman denied receiving notification of the 30-day discharge notice issued to Resident #52. This deficiency represents non-compliance investigated under Complaint Number OH00140241.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and Skin and Wound Care Best Practices Policy and Procedure, the facility failed to monitor and document appearance, measurements, exudate, and presence of surgical wound for Resident #55. This affected one (Resident #55) out of three reviewed for wounds. The facility also failed to ensure Residents #36 and #55 received medications as ordered. This affected two (Residents #36 and #55) out of three residents reviewed for medication administration. Facility census was 54. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] and discharged on 11/25/22. Diagnoses included chronic respiratory failure, pressure ulcer of left heel, dehydration, paroxysmal atrial fibrillation, hypertension, acute kidney failure, and infection/inflammatory reaction due to internal right hip prosthesis. History and physical dated 10/10/22 revealed Resident #55 was at the hospital from [DATE] to 10/07/22. Resident #55 had a large fluid collection around the right trochanter which was concerning for a right hip abscess with prosthetic infection. Resident #55 went through prosthesis removal and antibiotic spaced placement on 09/25/22. A nurse note dated 10/17/22 at 7:05 P.M. revealed Resident #55 had 21 staples to the right hip. A nurse note dated 10/18/22 at 1:09 A.M. revealed Resident #55 had removed the dressing from the right hip and has been picking at staples. The dressing was reapplied four times. A nursing note at 2:03 P.M. revealed Resident #55 had staples to right hip surgical site. The incision was intact, and the edges were well approximated. Drainage of red blood was noted. A nurse note dated 10/21/22 at 9:31 A.M. revealed Resident #55 had a moderate amount of bleeding from the surgical incision to the right hip. The area was cleansed, and a new dressing was applied. A nurse note dated 10/21/22 at 10:24 A.M. revealed the orthopedic surgeon sent Resident #55 to the hospital. The nurse called the orthopedic surgeons office and was informed that the surgeon had removed the staples to the residents right hip and there had been a lot of drainage from the site. A nurse note dated 10/27/22 at 2:24 P.M. revealed Resident #55 returned to the facility. The resident had a dressing covering the surgical incision to the right hip. A nurse note dated 10/29/22 at 6:20 P.M. revealed Resident #55 kept removing dressing to right hip. The resident picked at the incision site. The dressing had been reapplied four times. Review of the Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 11/03/22, revealed Resident #55 had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. A nurse note dated 11/08/22 at 12:24 A.M. revealed Resident #55 tore the dressing off the right hip and was picking at the incision. There were two open areas with active bleeding. The incision was cleaned, and a new dressing was applied. A nurse note dated 11/16/22 at 3:43 P.M. revealed there was a small amount of drainage from Resident #55's right hip. The resident frequently removed the dressing and touched the incision to the right hip. Interview on 01/31/23 at 11:17 A.M. wound Certified Nurse Practitioner revealed she did not assess or provide care for the surgical wound to Resident #55's left hip. Interview on 02/01/23 at 7:39 A.M. Director of Nursing (DON) verified the surgical incision to Resident #55's right hip was not monitored upon admission or weekly. DON verified Resident #55 returned to the facility on [DATE] after surgery to the right hip. There was no documentation of the appearance of the wound or how many staples there were to the wound. Documentation of the staples to the right hip was not mentioned until a nurses note dated 10/17/22. The DON verified Resident #55 had an infection to the surgical site and was frequently picking at the site. Review of the facility Skin and Wound Care Best Practices Policy and Procedure revised 06/10/22 revealed the purpose was to provide evidence based preventive skin care and wound treatment to prevent unavoidable skin complications. On admission the nurse will conduct a full body assessment. A second full body assessment will be scheduled within the first 24 hours of admission. The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistants shower sheet skin reviews. Any resident leaving the facility for an appointment, leave of absence, dialysis, etc., will have a departure/return assessment before the resident leaves the facility and upon return to the facility. The licensed nurse will complete the assessment in the health record. 2. Review of the medical record revealed Resident #55 was admitted on [DATE] and discharged on 11/25/22. Diagnoses included chronic respiratory failure, pressure ulcer of left heel, dehydration, paroxysmal atrial fibrillation, hypertension, acute kidney failure, and infection/inflammatory reaction due to internal right hip prosthesis. History and physical dated 10/10/22 revealed Resident #55 was at the hospital from [DATE] to 10/07/22. Resident #55 had a large fluid collection around the right trochanter which was concerning for a right hip abscess with prosthetic infection. Resident #55 went through prosthesis removal and antibiotic spaced placement on 09/25/22. The wound was positive for pseudomonas and the resident would receive intravenous (IV) cefepime (antibiotic) through 11/06/22. Review of physician order dated 10/27/22 revealed Resident #55 was ordered cefepime two gram/100 milliliter infused over four hours twice a day. Review of the medication administration record (MAR) revealed Resident #55 missed multiple doses of cefepime due to no IV access. Review of the medical record and MAR revealed Resident #55 had IV access but was not administered cefepime on 11/01/22 at 6:00 A.M. and on 11/04/22 at 8:00 P.M. Interview on 02/01/23 at 7:39 A.M. the DON verified Resident #55 had IV access but did not receive cefepime on 11/01/22 at 6:00 A.M. and on 11/04/22 at 8:00 P.M. 3. Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses that included but not limited to anxiety, depression, hypertension, osteoarthritis, type II diabetes, fracture of right clavicle, and cerebral infarction. Review of the 5-day Medicare MDS 3.0 assessment, dated 12/27/22, revealed Resident #36 had intact cognition. A nurse note dated 12/21/22 at 12:38 P.M. revealed the doctor had visited and ordered a nicotine patch (to control nicotine withdrawal symptoms) for Resident #36 per the residents request. Review of the MAR revealed Resident #36 did not receive a nicotine patch from 01/03/23 to 01/07/23 and on 01/16/23 due to medication not being available. Further review of the MAR revealed on 01/16/23 at 6:00 A.M. Resident #36 did not receive Aspirin (helps prevent blood clots) 81 milligrams (mg), Lasix (diuretic) 40 mg, Losartan Potassium (to treat hypertension) 25 mg, Metoprolol Tartrate (to treat hypertension) 12.5 mg, Tylenol (pain reliever) 650 mg, and Alprazolam (antianxiety) one mg. Interview on 02/01/23 at 1:54 P.M. DON verified Resident #36 did not receive a nicotine patch from 01/03/23 to 01/07/23 and on 01/16/23. The DON also verified Resident #36 did not receive medications that were scheduled on 01/16/23 at 6:00 A.M. This deficiency represents non-compliance investigated under Master Complaint Number OH00129331 and Complaint Number OH00139112.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of Skin and Wound Care Best Practices, and review of Pressure Injury Prevention and Treatment Policy the facility failed to assess, adequately monitor, and correctly document the pressure ulcers for Residents #45 and #55. This affected two (Residents #45 and #55) out of three residents reviewed for pressure ulcers. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] and discharged on 11/25/22. Diagnoses included chronic respiratory failure, pressure ulcer of left heel, dehydration, paroxysmal atrial fibrillation, hypertension, acute kidney failure, and infection/inflammatory reaction due to internal right hip prosthesis. The history and physical dated 10/10/22 revealed Resident #55 was at the hospital from [DATE] to 10/07/22. Resident #55 had a large fluid collection around the right trochanter which was concerning for a right hip abscess with prosthetic infection. Resident #55 went through prosthesis removal and antibiotic spaced placement on 09/25/22. Review of the medical record revealed no evidence of wound documentation when Resident #55 returned to the facility on [DATE]. The wound certified nurse practitioner (CNP) note dated 10/14/22 revealed Resident #55 had a Stage III (full thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it) pressure ulcer to left heel that measured one centimeter (cm) long, 1.2 cm wide, and 0.1 cm deep. There was a moderate amount of serosanguineous (consists of blood and serum) drainage, and the wound bed had 100-percent slough/eschar (dead tissue). The wound CNP note dated 10/14/22 revealed Resident #55 had a Stage III pressure ulcer to midline sacrum that measured two cm long, 2.2 cm wide, and 0.8 cm deep. The wound bed was red with 10-percent slough/eschar. There was 1.0 cm of undermining at 3 o'clock and 9 o'clock. There was a moderate amount of serous drainage. The wound CNP note dated 10/14/22 revealed Resident #55 had a suspected deep tissue injury (DTI) to the right heel that measured one cm long, and 1.5 cm wide. A dark purple area was noted. The wound CNP note dated 10/14/22 revealed Resident #55 had an unstageable (full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) DTI to right buttock upon admission that measured 3.0 cm long and 6.5 cm wide. There was no drainage, and the wound bed was pink in color. There was also an area that was dark purple in color. Review of the Weekly Wound assessment dated [DATE] completed by the Assistant Director of Nursing (ADON) revealed Resident #55 had tunneling/undermining of 1.0 cm at 9 o'clock to the sacrum wound. The assessment did not reveal the undermining at 3 o'clock as described by the CNP wound nurse. A nurse note dated 10/27/22 at 2:24 P.M. revealed Resident #55 returned to the facility. The resident had a dressing covering the surgical incision to the right hip and on buttocks. The nurse was unable to see the wound to the buttocks upon admission due to dressings being in place. The wound CNP note dated 10/28/22 revealed Resident #55 had a Stage III pressure ulcer to the left heel that measured 0.5 cm long, 0.7 cm wide, and 0.1 deep. There was a moderate amount of serosanguineous drainage. The wound bed had 100-percent slough/eschar. The wound CNP note dated 10/28/22 revealed Resident #55 had a Stage III pressure ulcer to midline sacrum that measured 2.3 cm long, 1.8 cm wide, and 0.8 cm deep. There was 1.0 cm of undermining at 3 o'clock and 9 o'clock. The wound bed had 90-percent slough/eschar. The wound CNP note dated 10/28/22 revealed Resident #55 had a suspected DTI to right heel that measured 1.0 cm long, 0.8 cm wide, and 0.1 cm deep. The wound bed had 100-percent slough/eschar. No drainage or odor was noted. The wound CNP note dated 10/28/22 revealed Resident #55 had an unstageable DTI to right buttock that measured 6.0 cm long, 4.0 cm wide, and 0.1 cm deep. No drainage or odor was present. The Weekly Wound assessment dated [DATE] completed by the ADON revealed Resident #55 had a Stage III pressure ulcer to sacrum. The ADON did not identify undermining that was identified by the wound CNP. Review of the Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 11/03/22, revealed Resident #55 had impaired cognition. The resident required extensive assistance of two for bed mobility and transfers. The wound CNP note dated 11/04/22 revealed Resident #55 had a Stage III pressure ulcer to midline sacrum that measured 3.0 cm long, 2.0 cm wide, and 1.0 cm deep. There was 1.0 cm of undermining at 3 o'clock and 9 o'clock. The wound CNP note dated 11/04/22 revealed Resident #55 a suspected DTI to right heel. The wound measured 1.4 cm long, 1.2 cm wide, and 0.1 cm deep. The wound had 100-percent intact eschar. The Weekly Wound assessment dated [DATE] completed by the ADON revealed Resident #55's right heel had a suspected DTI that measured 5.0 cm long, 4.5 cm wide, and 0.1 cm deep. The ADON also assessed Resident #55's sacrum but failed to identify the undermining. The wound CNP note dated 11/11/22 revealed Resident #55 had a Stage III pressure ulcer to midline sacrum that measured 2.3 cm long, 2.0 cm wide, and 1.0 cm deep. There was 1.0 cm of undermining at 3 o'clock and 9 o' clock. The wound CNP note dated 11/11/22 revealed Resident #55 had a Stage III pressure ulcer to right buttock that measured 6.0 cm long, 4.5 cm wide, and 0.1 cm deep. No drainage or odor was noted. The Weekly Wound assessment dated [DATE] completed by the ADON revealed Resident #55 had a Stage III pressure ulcer to sacrum. The ADON failed to identify any tunneling/undermining. An additional Weekly Wound Assessment revealed Resident #55 had a Stage III pressure ulcer to the left buttock that measure 6.0 cm long, 4.5 cm wide, and 0.1 cm deep. The CNP wound nurse that identified the Stage III pressure ulcer was to Resident #55's right buttock. The wound CNP note dated 11/18/22 revealed Resident #55 had a Stage III pressure ulcer to sacrum that measured 2.5 cm long, 2.5 cm wide, and 1.2 cm deep. There was undermining of 1.0 cm at 12 o'clock and 2.0 cm at 9 o'clock. No odor was noted. The wound CNP note dated 11/18/22 revealed Resident #55 had a Stage III pressure ulcer to left (should have been right) buttock that measured 7.0 cm long, 4.4 cm wide, and 0.2 cm deep. There was a moderate amount of serosanguineous drainage with 100-percent slough/eschar. The wound CNP note dated 11/18/22 revealed Resident #55 had an unstageable pressure ulcer to right (should have been left) buttock that measured 1.5 cm long, 1.0 cm wide, and 0.1 cm deep. The area was new and in-house acquired. There was a small amount of serosanguineous drainage. The Weekly Wound assessment dated [DATE] by the ADON revealed Resident #55 had a Stage III pressure ulcer to sacrum. The ADON noted there was a strong odor. The ADON also identified tunneling/undermining of 2.8 cm at 9 o'clock, 1.2 cm at 12 o'clock, and 0.6 cm at 3 o'clock. There was no documentation of the wound CNP being notified of the increased undermining or odor to the resident's sacrum. An additional Weekly Wound Assessment revealed Resident #55 had a Stage III pressure ulcer to right buttock (should have been left buttock) that was identified on 11/18/22. The ADON had no documentation of the pressure ulcer to the right buttocks that had been present on admission. The wound CNP note dated 11/25/22 revealed Resident #55 had a Stage III pressure ulcer to sacrum that measured 15.0 cm long, 6.5 cm wide, and 1.5 cm deep. There was undermining of 1.0 cm at 12 o'clock and 2.0 cm at 9 o'clock. There was a moderate amount of serosanguineous drainage with mild odor. The wound condition was marked as worsening. The CNP wrote that there was skin failure versus Kennedy ulcer due to decreased intake and overall decline despite interventions. This area had coalesced with the left and right buttock which was now measured as one area. A CNP wound nurse note dated 11/25/22 revealed Resident #55 had a Stage III pressure ulcer to right buttock that was in-house acquired. (Should have been the right buttock) The area measured 1.5 cm long, 1.0 cm wide, and 0.1 cm deep. There was a moderate amount of serosanguineous drainage. The wound bed had 80-percent slough/eschar and 20-percent epithelial. The wound condition was marked as coalesced due to unavoidable skin failure due to decreased intake and overall decline. A handwritten note revealed the left buttock was measured with the right buttock. A Weekly Wound assessment dated [DATE] by the ADON revealed Resident #55 had a Stage III pressure ulcer to right buttock (should have been the left buttock) that was identified on 11/18/22. The ADON had no documentation of the pressure ulcer to the right buttock that was present on admission. Interview on 01/31/23 at 11:17 A.M. wound CNP verified she had confused the residents right and left buttock documentation on 11/18/22 and 11/25/22. CNP stated on 11/25/22 the left buttock and right buttock and sacrum had all become one area. The CNP also verified the facility assessed the residents that were admitted /readmitted and called her if they had any questions or concerns. Interview on 01/31/23 at 3:30 P.M. ADON verified that she did not document the undermining to the sacrum on 10/14/22, 10/28/22, 11/04/22, and 11/11/22. The ADON verified on 11/04/22 she had incorrectly documented the size of the DTI to Resident #55's right heel as 5.0 cm long. 4.5 cm wide, and 0.1 cm deep compared to the documentation by the wound CNP of 1.4 cm long, 1.2 cm wide, and 0.1 cm deep. The ADON stated she had no idea where she got those measurements. The ADON verified she did not notify the wound CNP on 11/18/22 when additional undermining to the sacrum wound was found and an odor was noted. The ADON also verified she had confused the right and left buttock and provided incorrect documentation on 11/11/22, 11/18/22, and 11/25/22. Interview on 02/01/23 at 7:39 A.M. the Director of Nursing (DON) verified an admission/readmission skin assessment was not completed when Resident #55 returned to the facility on [DATE]. A skin assessment was not completed until 10/14/22 when the wound CNP visited. An admission/readmission skin assessment was not completed when Resident #55 returned to the facility on [DATE]. A skin assessment was not completed until 10/28/22 when the wound CNP visited. The DON verified the in-house acquired Stage III pressure ulcer to left buttock was not discovered until 11/18/22 when it was found by the wound CNP. Review of the facility Pressure Injury Prevention and Treatment Policy, revised on 09/18/20, revealed residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection. New pressure injuries will not develop unless the individuals clinical condition demonstrates that they are unavoidable. Monitoring will be done at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer/pressure injury will be documented. Review of the facility Skin and Wound Care Best Practices, revised 06/10/22, revealed the purpose was to provide evidence based preventive skin care and wound treatment to prevent unavoidable skin complications. On admission the nurse will conduct a full body assessment. A second full body assessment will be scheduled within the first 24 hours of admission. The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistants shower sheet skin reviews. Any resident leaving the facility for an appointment, leave of absence, dialysis, etc., will have a departure/return assessment before the resident leaves the facility and upon return to the facility. The licensed nurse will complete the assessment in the health record. 2. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses including acute kidney failure, abscess of left lower leg and buttock, and fistula of intestine. The admission/readmission evaluation dated 01/06/23 revealed Resident #45 was readmitted to the facility on [DATE] at 6:00 P.M. Resident #45 had skin impairment that included cutaneous abscess of right lower limb, cutaneous abscess of left lower limb, and cutaneous abscess of buttock. The resident stated they had pain at the coccyx that was throbbing. Pressure was listed as an aggravating factor. The attached nurse note revealed no documentation of impaired skin. A skilled nursing note dated 01/07/23 revealed Resident #45 had skin impairment observed and to refer to Complete Wound Assessment. The attached nurse note revealed no documentation of impaired skin. A Weekly Wound assessment dated [DATE] revealed Resident #45 had a pressure ulcer (no stage listed) to left lower extremity that measured 0.5 cm long, 0.4 cm wide, and 0.2 cm deep. The wound was listed as being present upon admission on [DATE]. The Weekly Wound assessment dated [DATE] revealed Resident #45 had a Stage III pressure ulcer to left lateral leg that measured 0.5 cm long, 0.5 cm wide, and 0.1 cm deep. Interview on 02/01/23 at 7:39 A.M. the DON verified an admission/readmission skin assessment was not completed when Resident #45 was readmitted on [DATE]. A Weekly Wound assessment dated [DATE] revealed Resident #45 had a pressure ulcer to the left lower extremity but was not staged. The Weekly Wound assessment dated [DATE] revealed Resident #45's pressure ulcer was a Stage III. Review of the facility Pressure Injury Prevention and Treatment Policy, revised on 09/18/20, revealed residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection. New pressure injuries will not develop unless the individuals clinical condition demonstrates that they are unavoidable. Monitoring will be done at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer/pressure injury will be documented. Review of the facility Skin and Wound Care Best Practices, revised 06/10/22, revealed the purpose was to provide evidence based preventive skin care and wound treatment to prevent unavoidable skin complications. On admission the nurse will conduct a full body assessment. A second full body assessment will be scheduled within the first 24 hours of admission. The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistants shower sheet skin reviews. Any resident leaving the facility for an appointment, leave of absence, dialysis, etc., will have a departure/return assessment before the resident leaves the facility and upon return to the facility. The licensed nurse will complete the assessment in the health record. This deficiency represents non-compliance investigated under Master Complaint Number OH00139331.

Based on record review, staff interview and facility policy and procedure review the facility failed to develop a care plan for Resident #37 related to the use of adaptive equipment. This affected one resident (Resident #37) of 14 residents reviewed for care plans. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/30/17 with diagnoses including muscle spasm, contracture, multiple sclerosis and abnormal posture. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed the resident was cognitively impaired, required extensive assistance from one person for bed mobility, dressing and eating and total assistance from staff for transfers, toileting, personal hygiene and bathing. Review of the physician's orders for August 2021 revealed Resident #37 had an order for an air mattress, pillow between the knees at all times, an order that her heels should never lay directly on the mattress, turn side to side every two hours, short heel booties only, bilateral spacer wedge to be on four hours per shift as resident tolerates, and occupational therapy recommended a dynamic elbow splint to be applied to the right arm for four to five hours a day or as tolerated by the resident. Review of the resident's current plan of care revealed the plan did not address any adaptive equipment for the resident. On 08/18/21 at 2:30 P.M. interview with the Director of Nursing (DON) revealed adaptive equipment should be care planned and revealed Resident #37's adaptive equipment should be care planned under the skin integrity plan of care. Review of the care plan with the DON at the time of the interview verified Resident #37 was not care planned for her adaptive equipment. Review of the facility policy titled Comprehensive Care Planning, dated 07/19/19 revealed the facility must develop a comprehensive person centered care plan for every resident. Care plans must include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessments. Additionally, the comprehensive care plan was to be reviewed and updated at least every 90 days by the interdisciplinary team. Care plans were also updated by the MDS Coordinator prior to care conferences by addressing previously unresolved problems, and by noting all new problems, approaches and target dates as they were identified through medical record review, resident contact and staff input.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure adaptive equipment, including an elbow splint, blue bilateral spacer wedges and pillow between the resident's knees were provided to maintain the resident's functional mobility and failed to ensure staff only documented the delivery of care when it was actually provided. This affected one resident (#37) of three residents reviewed for adaptive equipment. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/30/17 with diagnoses including muscle spasm, contracture, multiple sclerosis and abnormal posture. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed the resident was cognitively impaired, required extensive assistance from one person for bed mobility, dressing and eating and total assistance from staff for transfers, toileting, personal hygiene and bathing. Review of the physician's orders for August 2021 revealed Resident #37 had orders for an air mattress, pillow between the knees at all times, an order her heels should never lay directly on mattress, turn side to side every two hours, short heel booties only, bilateral spacer wedge to be on four hours per shift as resident tolerated, and occupational therapy recommended dynamic elbow splint to be applied to the right arm for four to five hours a day or as tolerated by the resident. On 08/16/21 at 10:55 A.M. Resident #37 was observed in bed in bed with boots on both feet and a pillow under her knees. The resident's right hand was laying on her chest and appeared to be contracted. On 08/17/21 at 11:30 A.M. Resident #37 was observed with Licensed Practical Nurse (LPN) #302. At the time of the observation, the resident did not have a blue bilateral spacer wedge, elbow splint or pillow between her legs. Interview with LPN #302 at the time of the observation verified the findings. On 08/18/21 at 9:25 A.M. Resident #37 was observed with Registered Nurse (RN) #301. At the time of the observation, the resident did not have a blue bilateral spacer wedge or elbow split adaptive equipment in place. Interview with RN #301 at the time of the observation verified the findings. In addition, review of the Treatment Administration Record (TAR) for August 2021 revealed LPN #302 and RN #301 had both documented the resident's blue bilateral spacer wedge and elbow splint and pillow were provided as ordered. During the interview with LPN #302 on 08/17/21 at 11:30 A.M. LPN #302 verified she documented on the Treatment Administration Record (TAR) the adaptive equipment was in place when it was not. During the interview with RN #01 on 08/18/21 at 9:25 A.M. the RN verified she had documented on the TAR the adaptive equipment was in place when it was not. Review of the facility policy titled Issuing Adaptive Equipment revealed adaptive equipment to meet resident needs shall be determined by the therapist and be issued upon a physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #28 was instructed to rinse his mouth with water following the administration of Flovent inhalation medication to decrease the resident's risk of developing oropharyngeal candidiasis. This affected one resident (#28) of ten residents observed for medication administration. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the bronchus and ling, dementia, chronic pain, major depressive disorder, hypertension and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/21 revealed Resident #28 had moderately impaired cognition. Review of the August 2021 physician's order revealed Resident #28 had an order (dated 04/02/21) for one puff/inhalation of Flovent Diskus 100 micrograms (mcg) twice daily for COPD. The order indicated to rinse the mouth out with water after use and to not swallow the water. On 08/18/21 at 8:05 A.M. Licensed Practical Nurse (LPN) #303 was observed to administer medication to Resident #28. LPN #303 administered one inhalation of 100 mcg Flovent Diskus and then left the room. LPN #303 verified at this time of the observation she did not have the resident rinse his mouth out after receiving the Flovent even though the orders included to have him rinse his mouth out with water and spit it (the water) out after use. On 08/18/21 at 3:40 P.M. interview with Resident #28 revealed staff had never had him rinse his mouth out after using the inhaler medication. The resident revealed sometimes he had a sore throat. Review of the Flovent Diskus manufacturer's instructions revealed in the administration information section: After inhalation the patient should rinse their mouth out with water without swallowing to help reduce the risk of oropharyngeal candidiasis. On 08/18/21 at 3:39 P.M. interview with the administrator revealed the facility did not have a medication administration policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to adequately monitor areas of skin impairment/breakdown for Resident #30 and failed to ensure Resident #20 had physician ordered heel suspension boots in place for prevention of skin break down. This affected two residents (#20 and #30) of four residents reviewed for skin conditions. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 06/25/21 with diagnoses including chronic heart failure, borderline personality disorder, anxiety, depression, chronic respiratory failure and attention deficit hyperactivity disorder. Review of the annual Minimum Date Set (MDS) 3.0 assessment, dated 07/02/21 revealed Resident #30 had intact cognition. The resident required extensive assistance of two persons for bed mobility, toilet use and personal hygiene and was totally dependent on two persons for transfers. The assessment indicated the resident was at risk for developing pressure ulcers and injuries. Interventions included pressure reducing devices for chairs, pressure reducing devices for bed, and applications of ointments or medications to areas other than the feet. Review of the plan of care, dated 08/13/21 revealed Resident #30 had the potential for impaired skin integrity related to impaired mobility, incontinence, noncompliance with care performance, diagnoses, her preference of staying in bed and laying on her back and her refusal to have incontinence care performed more than once during a 12 hour shift. Interventions included a bariatric bed with an air mattress, encouraging her to turn and reposition as indicated, keeping her skin clean and dry, and completing skin assessments according to protocol. Review of the physician's order for June 2021, July 2021, and August 2021 revealed an order for weekly skin checks on Wednesday nights beginning 06/30/21 and ending 07/15/21 and an order for weekly skin checks on Friday Nights beginning 07/16/21. Review of the Treatment Administration Record for June 2021 (beginning 06/25/21), July 2021, and August 2021 revealed the Wednesday night skin check was not completed on 07/14/21, but the Friday night skin check was completed on 07/16/21, all other weekly skin checks were marked as completed. Review of the Daily Skilled Nursing Notes dated 06/25/21, 06/26/21, 06/28/21, 06/30/21, 07/03/21, 07/04/21 07/05/21 07/06/21, 07/07/21, 07/08/21, 07/10/21, 07/11/21, 07/12/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/18/21, 07/25/21, 07/29/21, 07/31/21, and 08/02/21 all revealed Resident #30's skin was intact and her flesh tone was normal for her ethnicity. However, the note on 07/02/21 indicated there was a skin impairment present. Additional review of the Daily Skilled Nursing Notes revealed two notes on 06/27/21 and 07/02/21, for both days, one note indicated Resident #30's skin was intact with normal flesh tone and one indicated there was a skin impairment. Review of the Weekly Skin Evaluation forms, dated 06/25/21 to 08/16/21 revealed completed assessments on 06/25/21, 07/08/21 and 07/15/21. Review of the 06/25/21 evaluation revealed there were skin issues, contrary to the Daily Skilled Nursing Notes. The evaluation indicated the resident had red buttocks with excoriation and small open areas under her right buttocks. The assessment addressed bruises to her right and left hand and indicated there was a concern with her groin, but this was not described. Review of the medical record revealed no additional information related to the small open areas or unidentified area on her groin. Review of the 07/08/21 skin evaluation revealed no skin concerns. Review of the 07/15/21 skin evaluation revealed the resident's buttocks was red and excoriated. There were no Weekly Skin Evaluation's completed after 07/25/21. Review of the wound nurse's documentation, dated 08/03/21 revealed Resident #30 had an in-house acquired moisture friction wound to her left posterior thigh, no dimensions were provided, and it was documented this was a scattered area. It was indicated this wound had moderate blood exudate. The wound nurse noted the resident had a history of wounds that come and go and was noncompliant with turns and repositioning. Treatment was to cleanse and apply alginate and an abdominal pad daily and as needed. The nurse indicated the facility should continue to apply zinc barrier cream twice a day and as needed to the bilateral gluteus and right posterior thigh. Review of the wound nurse's documentation dated 08/10/21 revealed the moisture friction area remained and was measured at 0.6 centimeters (cm) by 0.4 cm by 0.1 cm. The wound nurse indicated the wound was healing and the treatment could be discontinued, however, the facility should continue to apply zinc barrier cream twice a day and as needed to the bilateral gluteus and bilateral posterior thighs. The wound nurse's documentation dated 08/17/21 revealed the area was healed. Review of the Weekly Wound assessment dated , 08/04/21, revealed the information provided in the wound nurse's documentation from 08/03/21 was repeated. Review of the Weekly Wound assessment dated , 08/11/21, revealed the wound nurse's documentation from 08/10/21 was repeated. Review of the shower sheets completed by the nursing aides revealed on 07/01/21 Resident #30's skin was intact no redness, rashes, bruises, or swelling were indicated, contrary to the Daily Skilled Nursing note on that day that indicated a skin impairment. Review of the shower sheet dated 07/15/21 revealed the resident's skin was intact and no redness, rashes, bruises, or swelling were indicated, contrary to the Weekly Skin Evaluation completed on that day which identified excoriation to the resident's buttocks. On 07/21/21 the shower sheet indicated the resident had redness to her buttocks and had just same open areas on her bottom. Review of the medical record revealed no further documentation related to the mentioned open areas. On 08/08/21 and 08/12/21 the shower sheets indicated the resident's skin was intact, however, the wound nurse's notes indicate the resident had a skin impairment at that time. On 08/16/21 at 11:46 A.M. interview with Resident #30 revealed her skin was currently broken down but not bleeding. She stated the wound nurse had been following her for the first time in a long time. She stated the wound nurse had previously quit following her because she told her her skin was not going to change. On 08/18/21 at 10:18 A.M. interview with Licensed Practical Nurse (LPN) #303 revealed when nurses sign off on weekly skin checks they should be completing a document in the assessments. LPN #303 additionally stated Resident #30 currently had excoriation on the back of her thighs. She stated the wound nurse followed the resident because her skin occasionally breaks open. LPN #303 revealed the STNA staff were to notify the nurses when her skin was open. On 08/18/21 at 2:45 P.M. and 5:06 P.M. and on 08/19/21 at 8:51 A.M. interview with the Director of Nursing revealed she considered the daily skilled nursing notes as a replacement for the weekly skin checks as they addressed skin areas. She stated repeatedly the resident's skin concerns were an ongoing problem and referred to the daily skilled nursing notes (last one completed 08/02/21), the weekly skin checks, and the shower sheets as a way to monitor the resident's skin. The Director of Nursing did not have any information related to the opened areas documented on 06/25/21 or 07/21/21, and confirmed the contradicting documentation on 06/27/21, 07/01/21, 07/02/21, 08/08/21 and 08/12/21. On 08/19/21 at 10:45 A.M. interview with Regional Director of Clinical Services #333 revealed the shower sheets were used as a tool to notify nurses of changes. The nurses then would assess the area and notify the wound nurse and physician. The regional director revealed the wound nurse and physician were responsible for weekly skin grids and should be notified of open areas. On 08/19/21 at 11:03 A.M. interview with Wound Nurse #319 revealed Resident #30 had on and off open areas which she believed were related to the resident's noncompliance. The wound nurse revealed facility staff notified her of open areas, but moisture breakdown they often manage themselves. Wound Nurse #319 revealed prior to the 08/03/21 skin area, May 2021 was the last time she was notified of an open area for Resident #30. On 08/18/21 at 10:55 A.M. interview with State Tested Nursing Aide (STNA) #308 revealed the STNA staff document residents skin status on the shower sheet every time. She stated they might document no new areas when a resident had skin problems, however, they would check with the nurse to discuss any skin issues identified. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of abnormal gait and mobility, muscle weakness, hypertension, chronic pain syndrome, generalized anxiety disorder, osteoarthritis, major depressive disorder, adult failure to thrive, chronic kidney disease, dementia, diverticulosis, history of falling and heart failure. Review of the plan of care, dated 11/03/16 revealed Resident #20 had potential/actual impairment to skin integrity related to pressure ulcers. The goal was for the resident to have no complications related to a pressure ulcer of the left heel. Interventions included an air mattress to the bed, assess/document location and report abnormalities to physicians, encourage good nutrition, and hydration, follow facility protocols for treatment of injury, keep skin clean and dry, use lotion on dry skin as needed, laboratory tests as ordered and treatments as ordered. Review of the quarterly MDS 3.0 assessment, dated 06/11/21 revealed Resident #20 had severely impaired cognition and required extensive assistance from staff for personal hygiene. Review of the August 2021 physician's orders revealed Resident #20 had an order, (dated 07/23/19) for heel suspension boots on at all times while in bed. The order indicated the boots may be removed for hygiene. On 08/16/21 at 1:14 P.M., 2:16 P.M. and 3:09 P.M. Resident #20 was observed without the physician's ordered heel suspension boots on while in bed. On 08/16/21 at 3:13 P.M. interview with Licensed Practical Nurse (LPN) #304 verified Resident #20 did not have her ordered heel suspension boots on as ordered. LPN #304 revealed staff had given the resident a bath and probably did not put them back on when they laid the resident back down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to check for proper gastrostomy tube placement for Resident #293 prior to administering medications to prevent complications. This affected one resident (#293) of ten residents observed for medication administration. Findings include: Review of the medical record revealed Resident #293 was admitted to the facility on [DATE] with diagnoses of catatonic disorder psychotic disorder with delusions, catatonic schizophrenia, depression and anxiety. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #293 had severely impaired cognition, required total assistance for all activities of daily living and had enteral tube for feeding. On 08/17/21 at 11:37 A.M. Licensed Practical Nurse (LPN) #304 was observed to administer medications to Resident #293 via gastrostomy tube. Prior to administering medications, LPN #304 did not check for placement of the gastrostomy tube and did not check for any residual prior to administering the medications to prevent potential complications. On 08/17/21 at 2:30 P.M. interview with LPN #304 verified she had not checked the residual for Resident #293 prior to administering her medications and she indicated it was not the facility policy to check for placement but it was the policy to check the residual prior to administering medications. Review of the facility policy titled Enteral Feeding Tube policy, dated 06/07/21 revealed ongoing verification of placement was done at each subsequent access of the tube for installation of fluids, nutrition or medications. Verification of placement would be conducted using the following methods: Evaluation of the clinical presentation of the patient/ resident, respiratory status, complaints of nausea or vomiting, feelings of fullness or excessive belching or unusual abdominal distention. Observation of the volume and character of the gastric aspirate and external length of feeding tube compared to initial measurements.

**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 implement an effective and individualized pain management program for Resident #243, including the administration of pain medication as ordered by the physician. This affected one resident (#243) of 10 residents reviewed for procuring ordered medications. Findings include: Review of the medical record for Resident #243 revealed an admission date of 07/23/21 with diagnoses including liver and anal cancer, colostomy, hypertension, diabetes mellitus and pain. Review of physician's orders, dated 07/23/21 revealed an order for the narcotic analgesic, Oxycodone 10 milligrams (mg) every six hours as needed (prn) for pain. Review of the plan of care, dated 07/23/21 revealed Resident #243 had pain. Interventions included to administer pharmacological interventions as indicated per physician and monitor the effectiveness, assess for verbal and nonverbal signs and symptoms related to pain: grimacing, guarding, moaning, crying, increase anxiety and implement non-pharmacological interventions to ease pain. Review of the nursing progress notes, for 08/2021 revealed the resident was sent to the hospital for treatment of her cancer on 08/07/21 and returned to the facility on [DATE]. The resident was admitted to Hospice on 08/11/21. A physician's order, dated 08/11/21 revealed a new order for Oxycodone concentrate 100 mg per five milliliters, give 0.75 milliliters by mouth every four hours as needed for pain or for shortness of breath. The order had no end date. On 08/15/21 a new order was noted for Oxycodone concentrate 100 mg per five ml, give 0.75 ml every four hours scheduled (routinely) with no end date. Review of the Medication Administration Record (MAR) for July 2021 and August 2021 revealed the resident received Oxycodone 10 mg at least once every day from 07/24/21 through 07/31/21 for pain levels ranging from five to nine out of 10 (on a pain scale of 1 to 10). Further review revealed the resident received Oxycodone 10 mg every six hours from 08/02/21 through 08/06/21 for documented pain levels of seven and eight and the medication was effective. Further review of the MAR revealed no evidence the resident was administered any Oxycodone from 08/11/21 through 08/14/21. On 08/15/21 at 8:00 P.M. the resident was administered Oxycodone concentrate 0.75 ml for a pain level of four and the result was documented as effective. Review of the medical record revealed daily pain assessments were not ordered by the physician. The medical record did not contain evidence of any daily pain assessments being completed related to the order or administration of the Oxycodone or resident's diagnoses. On 08/16/21 at 2:18 P.M. interview with Family Member # 405 revealed the facility was unable to obtain the resident's pain medication for a few days following the resident's readmission from the hospital. Family member reported there was an issue with the pharmacy or hospice or something. Family Member #405 revealed she was not aware of the resident having complaints of pain during this time but indicated the resident had also been unable to make her needs known. On 08/18/21 at 9:32 A.M. interview with Registered Nurse (RN) #301 revealed she was caring for Resident #243 last week on 08/11/21 when resident was re-admitted to the facility with new orders. The nurse revealed there was a problem obtaining the pain medication that day and she had to call the pharmacy several times. The nurse confirmed the medication was not obtained or administered on 08/11/21 and revealed she passed the information on in report to the night shift nurse. RN #301 provided a copy of the authorization to pull the Oxycodone from the pharmacy dated 08/14/21 and revealed the medication was pulled on 08/15/21. The nurse confirmed the medication was not administered to the resident as part of her pain management as ordered from 08/11/21 through 08/15/21 at 8:00 P.M. On 08/18/21 at 3:48 P.M. interview with the Director of Nursing (DON) confirmed Resident #243 was not administered any Oxycodone from 08/11/21 through 08/15/21 at 8:00 P.M. and that the medication was not available to the resident until 08/15/21. The DON further revealed the medication was ordered as needed from 08/11/21 through 08/15/21 and did not believe the resident was having pain (although the medication had been administered as needed on a daily basis prior to this) and on 08/15/21 a new order was obtained for the medication to be given routinely/scheduled and not just prn. The DON also confirmed the lack of evidence of any pain assessments being completed for the resident from 08/11/21 through 08/15/21 and indicated a pain assessment should typically be performed when a resident was ordered as needed pain medication. On 08/18/21 at 3:39 P.M. interview with the Administrator revealed the facility did not have a policy on medication administration. Facility policies related to pain, pain assessments and procuring medications were requested from the DON and Regional DON during the annual survey. These policies were not provided for review.

2. Review of the medical record for Resident #30 revealed an admission date of 06/25/21 with diagnoses including chronic heart failure, borderline personality disorder, anxiety, depression, chronic respiratory failure and attention deficit hyperactivity disorder. Review of the annual MDS 3.0 assessment, dated 07/02/21 revealed Resident #30 had intact cognition. The Patient Health Questionnaire (PHQ-9) revealed the resident had mild depression. Review of the plan of care, dated 08/13/21 revealed Resident #30 was on anti-anxiety therapy. Interventions included administering anti-anxiety medication as ordered, implement non-pharmacological interventions specific for resident, monitor and report side effects of antidepressant therapy including lack of energy, confusion, and drowsiness and report side effects to the physician. Review of the physician's orders for Resident #30 for June (beginning 06/25/21), July and August 2021 revealed the resident was receiving Duloxetine HCl capsule Delayed Release Particles 90 mg once daily. Review of the Medication Administration Record (MAR) for June (beginning 06/25/21), July and August 2021 revealed Resident #30 received the medication as ordered. Review of the Behavior Flow Record for June 2021 (beginning 06/25/21) revealed for the medication Duloxetine the facility was monitoring the resident for sadness twice a day. The resident indicated no sadness with no interventions provided, except for the evening of 06/28/21 and 06/29/21 but which did not have any additional documentation for. Review of the Behavior Flow Record for July 2021 revealed for the medication Duloxetine the facility was monitoring the resident for sadness twice a day. The resident indicated no sadness and no interventions were provided, except for the morning of 07/10/21 and 07/23/21 and the evening of 07/02/21, 07/03/21, 07/04/21, 07/06/21, 07/08/21, 07/15/21, 07/21/21, 07/22/21, 07/26/21, 07/27/21 and 07/28/21 which did not have any additional documentation. Review of the Behavior Flow Record for August 2021 revealed for the medication Duloxetine the facility was monitoring the resident for sadness twice a day. The resident indicated no sadness and no interventions were provided, except for the morning of 08/05/21 and 08/13/21 and the evening of 08/02/21, 08/03/21, 08/04/21, 08/05/21, 08/06/21, 08/09/21, 08/10/21, 08/11/21, and 08/14/21 for which there was no additional documentation. Review of the Daily Skilled Nursing notes dated 06/25/21, 06/26/21, 06/27/21, 06/28/21, 06/30/21, 07/01/21, 07/02/21, 07/03/21, 07/04/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/10/21, 07/11/21, 07/12/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/18/21, 07/25/21, 07/29/21, 07/31/21 and 08/02/21 revealed the resident's mood was assessed and no feelings of anxiety were documented. Review of the progress notes, dated 06/25/21 to 08/16/21 revealed no direct references to signs of anxiety, although on 08/16/21 the resident reported she was not mentally prepared to be up in her wheelchair. On 08/19/21 at 11:26 A.M. and on 08/19/21 at 3:05 P.M. and 4:18 P.M. interview with the DON revealed side effects of anxiety medications and symptoms of anxiety were monitored through a team effort. She reported activities, therapy and additional staff, paid attention to mood and it was discussed as needed. The DON revealed therapy would notify the staff of any red flags with the resident. The DON verified there was no formal documentation for monitoring for anxiety or side effects of medication, but anxiety may be mentioned in the progress notes as needed. The DON confirmed the behavior flow sheet addressed sadness related to the Duloxetine and not anxiety. The DON confirmed the documentation was incomplete to provide evidence of adequate monitoring of the resident's anxiety, to ensure the resident was not exhibiting side effects of the medication and to ensure the medication was being administered at the most appropriate dose. The DON confirmed the resident's care plan indicated the resident should be monitored for side effects of anxiety. Review of the policy titled Behavior Management Program, dated 08/17/17 revealed the behavior monitoring grid was to be reviewed for completion, trends, total number of behaviors and non-pharmacological interventions. Based on observation, record review, facility policy and procedure review and interview the facility failed to monitor behaviors and/or for side effects of medication for Resident #30 and Resident #40, who were prescribed psychotropic medication. The affected two residents (#30 and #40) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #40 revealed an original admission date of 09/04/19 and a readmission date on 04/30/21 with diagnoses including chronic pain syndrome, other symbolic dysfunctions, unspecified tremor, vertigo of central origin, other idiopathic peripheral autonomic neuropathy, recurrent major depressive disorder, fibromyalgia and chronic obstructive pulmonary disease with acute exacerbation. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/02/21 revealed the resident had intact cognition. The resident required extensive assistance from one staff with activities of daily living (ADLs), except eating. The Patient Health Questionnaire (PHQ-9) revealed no signs of depression. There were no indications of any behaviors noted. The resident received daily anti-depressant medications. Review of the plan of care, revised 08/05/21 revealed Resident #40 was at risk for depression related to a diagnosis of major depressive disorder. Interventions included to allow the resident to vent thoughts and feelings, assist resident to identify strengths, positive coping skills, anger management techniques and reinforce these. Resident #40 was on antidepressant therapy. Interventions included to administer antidepressant medication as prescribed by the physician, monitor for suicidal ideations, constipation, urinary retention, dry eyes, and dry mouth, and monitor the resident's PHQ-9 assessment. The resident had a behavior problem related to attention seeking behaviors and making false accusations toward staff. Interventions included to monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of the physician's orders for Resident #40 revealed the resident had an order for Amitriptyline Hydrochloride (HCl) tablet 75 milligrams (mg) with instructions to administer one tablet by mouth at bedtime for depression with an order date of 04/30/21. Review of the Medication Administration Record (MAR) for Resident #40 for the months of May, June, July, and August 2021 revealed the depression medication was administered daily as ordered. Review of the Treatment Administration Record (TAR) for Resident #40 for the months of May, June, July, and August 2021 revealed there was no monitoring for side effects of the medication or the resident's behaviors. Review of the Behavior and Intervention Flow Records for Resident #40 revealed there was not any behavior monitoring completed for the months of May, June, July, or August 2021. Review of tasks for Resident #40 revealed there was not a task to monitor behaviors entered for the resident. Review of the Daily Skilled Nursing notes revealed no notes had been completed since 2019. Resident #40's mood was noted to be pleasant and cooperative at that time. Review of the progress notes dated from May 2021 to current revealed a note on 06/04/21 at 12:30 P.M. indicating a summary of mental status showed the resident was oriented times three, always understood others, sometimes followed directions, was sometimes cooperative with care, and was sometimes motivated to participate with impulsive or unsafe behavior noted. There were no additional progress notes that addressed Resident #40's mood or behaviors. On 08/19/21 at 10:03 A.M. interview with the Director of Nursing (DON) revealed the side effects of antidepressant medications and behaviors were monitored through a team effort. The DON revealed the resident was monitored by all staff involved with her plan of care, including activities, therapy as ordered, nurses and STNA staff who would assess the resident daily and would inform the appropriate staff person(s) if the resident displayed any abnormal behaviors or experienced any possible side effects from the medication. The DON confirmed there was not any formal documentation for monitoring side effects or behaviors to justify the use of the antidepressant medication or to ensure the medication was being administered at the dose most effective. The DON confirmed the resident's care plan revealed the resident she should be monitored for side effects and behavior episodes.

Based on observation, staff interview and facility policy review the facility failed to ensure Resident #20's room was maintained in a clean and sanitary manner. This affected one resident (#20) of 41 residents whose rooms were observed. Findings include: On 08/16/21 at 1:14 P.M., 2:16 P.M. and 3:09 P.M., on 08/17/21 at 8:48 A.M., 11:30 A.M. and 2:30 P.M. and on 08/18/21 at 7:25 A.M. and 9:32 A.M. observations of Resident #20's room revealed several black dirt spots the size of golf balls on Resident #20's floor and a white substance spilled all over the fall mat on the floor. Resident #20 was observed sleeping during the observations made and was identified to be not interviewable. On 08/18/21 at 9:37 A.M. interview with Housekeeping Aide #350 revealed resident rooms were to be cleaned everyday. Housekeeping Aide (HA) #350 revealed she was responsible to swept, mop, spray and wipe down all hard surface areas in the resident rooms. HA #350 also indicated housekeeping staff were responsible to clean the fall mats for residents also. At the time of the interview, HA #350 verified the floor and fall mat were dirty in Resident #20's room. Review of the facility policy titled Environmental Services: Housekeeping, dated 04/01/20 revealed occupied residents rooms would be cleaned daily to maintain a sanitary environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain comfortable sound levels throughout the facility when Resident #17 frequently played his music too loud and Resident #293 could frequently be heard yelling out. This affected eight residents (#293, #17, #2, #26, #28, #30, #37 and #342) and had the potential to affect 11 additional residents (#41, #294, #194, #33, #3, #242, #343, #35, #34, #7 and #15) who resided on the B and D units of the facility. The facility census was 41. Findings include: 1. Review of the medical record for Resident #293 revealed the resident was admitted to the facility on [DATE] with diagnoses including catatonic disorder due to known physiological condition, psychotic disorder with delusions due to physiological condition, catatonic schizophrenia, unspecified psychosis not due to a substance or known physiological condition, depression and anxiety. Review of the plan of care, dated 08/06/21 revealed the resident had a psychiatric disorder. Interventions included encouraging the resident to express feelings and help to come up with alternative ways to handle feelings of anger and frustration, maintain a calm, non-threatening manner while working with the resident, providing reassurance and comfort measures and refer to psychiatric services per physician orders. Review of the progress notes, dated 08/05/21 revealed the resident had been awake most of the night yelling out. The progress notes dated 08/08/21 revealed the resident had been yelling out throughout the day. Additional progress noted dated 08/07/21 at 5:52 P.M., 08/13/21 at 8:23 A.M. and 2:19 P.M., and 08/16/21 at 1:59 P.M., revealed the resident was yelling out. Review of the task documentation titled, Monitor-behavior symptoms revealed the resident had a behavior of yelling or screaming on 08/05/21 at 1:14 A.M., 08/06/21 at 6:57 A.M., 08/07/21, at 4:39 A.M., 08/08/21 at 1:11 A.M., 08/09/21 at 5:59 A.M., 08/10/21 at 6:50 P.M., 08/11/21 at 5:47 A.M., 08/12/21 at 12:41 P.M., 08/13/21 at 3:55 A.M., 08/15/21 at 1:54 A.M., 08/16/21 at 3:10 A.M. and 9:44 A.M., 08/17/21 at 2:46 A.M. and 9:43 A.M., and on 08/18/21 at 2:10 A.M. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/11/21 revealed Resident #293 had severely impaired cognition. On 08/16/21 from 11:32 A.M. to 11:44 A.M. Resident #293 was heard yelling out. Interview with Resident #30 at the time of the observation revealed concerns that Resident #293 yelled out all day and all night. On 08/16/21 at 2:00 P.M. Resident #293 was yelling out and could be heard throughout the B hallway. Further observation at 3:18 P.M. revealed Resident #293 was making eh noises that could be heard from the end of the hallway, she briefly began screaming no and then resumed making eh noises that could be heard throughout the hallway. On 08/16/21 at 2:00 P.M. interview with Resident #28 revealed he was frequently disturbed by Resident #293's constant yelling. On 08/19/21 at 10:40 A.M. and 11:15 A.M. interview with Resident #26 revealed he was frequently disturbed by Resident #293's screaming. Resident #26 reported he was able to sleep the previous night for the first time since Resident #293 had been admitted . Resident #26 revealed he had gotten two hours of sleep the night prior and most other nights. Resident #26 reported the other residents in the hall (with the exception of a deaf woman) were bothered by Resident #293 and having difficulty sleeping as well. Resident #26 revealed he had reported this to the Director of Nursing (DON) the week prior and again the day before. The resident felt Resident #293 should have been placed in a different room. Review of the plan of care for Resident #26 dated 09/23/13 revealed the resident was at risk for an alteration in sleep pattern related to insomnia. Interventions included promoting a quiet environment at night. On 08/18/21 at 10:11 A.M. interview with Licensed Practical Nurse (LPN) #303 revealed Resident #293 yelled out most of the time. She stated residents had frequently made complaints about Resident #293's yelling. LPN #303 revealed she had notified administration about the resident's yelling and the resident concerns. On 08/18/21 at 12:14 P.M. interview with Life Enrichment Director #307 revealed Resident #293 was constantly screaming. On 08/18/21 at 2:45 P.M. and on 08/19/21 at 11:26 A.M. interview with the DON revealed she was aware of the Resident #293's behavior of yelling and indicated she could hear it from her office. The Director of Nursing revealed a resident had reported concerns related to the yelling on 08/18/21 but she denied having any residents complain prior to this. The DON revealed they were addressing the resident, but were unable to identify any intervention(s) they were putting in place for residents who may be affected by Resident #293's yelling. On 08/18/21 at 3:25 P.M. interview with the Administrator revealed she was aware of Resident #293's behavior of yelling out. She stated she had heard rumors of resident's concerns but nobody had come to her. She stated a room change could be arranged for residents with concerns. 2. On 08/16/21 at 11:12 A.M. observation revealed loud music was heard from the D-hallway. Upon walking down the D-hallway, the music being played was identified to be coming from Resident #17's room. The door was open and the resident was observed in the room, listening to the music. However at the time of the observation, Resident #17 refused to answer any questions or discuss the music. Additional observations made intermittently throughout 08/16/21, 08/17/21, 08/18/21 and 08/19/21 at various times and from various areas of the facility, including the dining room, on the D-hallway, near the therapy room, and from the A-hallway nursing station revealed Resident #17's music could be heard throughout the various locations during the day and evening. On 08/16/21 at 11:15 A.M. interview with Licensed Practical Nurse (LPN) #302 confirmed Resident #17 played music loudly throughout the day and night. LPN #302 revealed this was a normal behavior of the resident when he gets angry and he refused to turn down the music when asked. On 08/16/21 at 10:51 A.M. interview with Resident #2 revealed the man in the room next to her blares music when he gets angry. The resident reported this was frustrating because she liked to sleep in in the mornings and he would sometimes start the loud music at 4:00 A.M. Resident #2 revealed all of the staff including the Administrator were aware of the concern but there was no resolution. On 08/18/21 at 1:17 P.M. interview with Resident #342 revealed concerns Resident #17's music was too loud and bothered her when he played it that loud. Resident #342 revealed the administrator was aware of the concern. On 08/18/21 at 1:19 P.M. interview with Resident #37 revealed Resident's #17's music was too loud and bothered her at times. Resident #37 revealed the administrator was aware of the concern. On 08/18/21 at 9:45 A.M. interview with the Administrator and Social Service Director #306 revealed they were aware Resident #17 played his music too loud all hours of the day and often refused to turn his music down when asked. The Social Service Director revealed they had asked Resident #17 to wear headphones and he refused. The Administrator shared they had discussed with other residents going to Resident #17 directly and that was also ineffective. The Administrator revealed Resident #17 refused to move rooms at this time. The facility failed to produce a policy on comfortable and homelike environment.