Based on record review and interview, the facility failed to complete a comprehensive assessment for Resident #275 within 14 days after admission. This finding affected one resident (#275) of ten residents reviewed for comprehensive assessments. The facility census was 11. Findings include: Review of the medical record for Resident #275 revealed an admission date of 05/16/23. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries, celiac disease, Parkinson's disease, and chronic heart failure. Review of Resident #276's Minimum Data Set (MDS) 3.0 assessments revealed an admission assessment was initiated with an assessment reference date (ARD) of 05/19/23 but was not completed as required. Interview with Registered Nurse (RN) #796 on 05/31/23 at 12:50 P.M. confirmed the admission MDS assessment for Resident #275 was opened on 05/19/23 but sections C, D, E, and Q were still in progress, and the assessment was not completed on time. Interview with Licensed Social Worker (LSW) #802 on 05/31/23 at 1:10 P.M. confirmed she assessed sections C, D, E and Q. LSW #802 confirmed sections C, D, E and Q were not completed on time for Resident #275's admission MDS assessment with an ARD of 05/19/23.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for Resident #7 to include anticoagulant use. This affected one resident (#7) of five residents who were reviewed for care plans with high-risk medications. The facility census was 11. Findings include: Review of the medical record for Resident #7 revealed an admission date of 05/10/23. Diagnoses included acute on chronic systolic congestive heart failure, atrial fibrillation, essential primary hypertension, and ischemic cardiomyopathy. Review of the admission Minimum Data Set (MDS) assessment, dated 05/17/23, revealed Resident #7 had intact cognition. Resident #7 received an anticoagulant seven of the seven days prior to the assessment reference date. Review of Resident #7's physician orders effective May 2023 revealed Eliquis 5 milligrams (mg) twice daily for blood thinner (anticoagulant). Review of Resident #7's comprehensive care plan dated 05/24/23 revealed a focus of activities of daily living, risk for falls, alteration in nutrition status, risk for pain, and risk for skin impairment/breakdown. There was no focus or interventions for anticoagulant use. Interview on 05/31/23 at 3:07 P.M. with Registered Nurse (RN) #796 verified Resident #7's comprehensive care plan dated 05/24/23 did not contain a focus for anticoagulant use. Interview on 06/01/23 at 11:14 A.M. with Administrator indicated the facility had no policy regarding care plans and only used standard requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the fall care plan for Resident #76 was updated in a timely and complete manner. This affected one resident (#76) of ten resident care plans reviewed. The facility census was 11. Finding include: Resident #76 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, gastrostomy status, and abnormal findings on diagnostic imaging of central nervous system. Review of the admission Minimum Data Set (MDS) assessment, dated 05/15/23, revealed Resident #76 had severely impaired cognition. The resident could sometimes make self understood and sometimes understood others. Resident #76 was totally dependent on two people for transfers. The resident was totally dependent on one person for locomotion and eating. The resident required the extensive assistance of two people for bed mobility, dressing, toilet use, and personal hygiene. The Morse Fall scale reviews completed on 05/10/23, 05/16/23, 05/18/23, 05/21/23, 05/22/23, 05/27/23, and 05/28/23 each revealed Resident #76 to be a high fall risk. Review of the plan of care dated 05/10/23 revealed the resident was at risk for falls. Interventions added on 05/10/23 included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs a prompt response to all requests for assistance, bed against wall per family's request, bed bolsters in place to bed, and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Interventions added on 05/27/23 were for the bed to be kept in the lowest position and mats to floor on both sides of the bed. Interventions added on 05/28/23 were to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Review of the care plan dated 05/28/23 revealed Resident #76 had an actual fall with no injury, related to poor communication/comprehension on 05/28/23. Interventions included: continue interventions on the at-risk plan, determine and address causative factors of the fall, and neuro-checks to be done per facility protocol. There were no interventions added to the care plan after Resident #76's falls on 05/15/23, 05/16/23, 05/17/23, and 05/21/23 even though there were interventions in the nurse's notes and Interdisciplinary Team (IDT) notes. Resident #76's fall from 05/08/23 was reviewed by the IDT on 05/31/23. The resident's fall from 05/16/23 had a fall report done on 05/16/23 but the post fall assessment was not completed until 05/30/23. The IDT review on 05/18/23 for Resident #76's fall on 05/17/23 recommended hourly rounds, but that was added to the care plan. The post fall note completed on 05/24/23 for Resident #76's fall on 05/21/23 had an intervention to place things that were grabbable, such as the resident's tube feed pole, on his left side. That was not added to the fall care plan. The IDT review done on 05/31/23 of Resident #76's fall on 05/27/23 recommended offer to toilet before bed and P.M., but that was not added to the fall care plan. Interview on 06/01/23 at 10:45 A.M. Registered Nurse (RN) #796 verified Resident #76's care plan updates were not timely and all recommended interventions were not included in the care plan.

Based on observation and interview the facility failed to ensure all medications were stored appropriately in medication carts. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation of the medication carts completed on 05/30/23 at 9:15 A.M. revealed there were a total of 23 loose medications observed. There were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. The facility had a total of two medication carts. Interview on 05/30/23 at 9:30 A.M. with Registered Nurse (RN) #801 revealed she confirmed there were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart.

Based on observation and interview, the facility failed to maintain the overhead hood vents, fire suppression nozzles, and backsplash behind the stove in a clean, sanitary, and safe manner. This had the potential to affect ten of the eleven residents residing in the facility. Resident #76 did not receive food from the facility kitchen. The facility census was 11. Findings include: A tour of the kitchen on 05/30/23 from 9:15 A.M. through 9:44 A.M. with Dietary Manager #821 revealed the overhead vents and the fire suppression nozzles were greasy and had accumulated dust. The backsplash behind the stovetop was greasy. Dietary Manager #821 verified the condition of the hood, nozzles, and back splash at the time of the observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure oxygen tubing was dated per acceptable standards of nursing practice for Residents #119 and #123, and the facility did not ensure oxygen administration orders were in place for Resident #123. This affected two Residents (#119 and #123) of two residents reviewed for respiratory care. The facility reported two residents on oxygen therapy. The facility census was 19. Findings include: 1. Record review revealed Resident #119 was admitted on [DATE] with diagnoses of sepsis, urinary tract infection, chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of physician's orders dated 04/23/21 revealed continuous oxygen via nasal cannula at two liters per minute (LPM), and check oxygen saturation and respiratory rate every shift. Observation on 04/26/21 at 1:27 P.M. revealed Resident #119 sitting up in a wheelchair with oxygen nasal cannula in place, oxygen setting at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 7:50 A.M. revealed Resident #119 was in bed with oxygen nasal cannula in place, oxygen setting at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 11:18 A.M. with Registered Nurse (RN) #250 of Resident #119 confirmed the oxygen nasal cannula was in place, oxygen was set at two LPM, and the oxygen tubing was not dated. 2. Record review revealed Resident #123 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, dementia with behavioral disturbance, hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease, and combined systolic congestive heart failure. Review of the admission five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #123 had impaired cognition, required extensive one staff assistance for bed mobility and toileting, required extensive two staff assistance for transfers, was dependent on one staff assistance for bathing, was always incontinent of urine and bowel, and received oxygen. Review of physician's orders for Resident #123 for April 2021 revealed no oxygen administration orders. Review of Resident #123's Medication Administration Record (MAR) for April 2021 revealed no documentation of administration of oxygen. Observation on 04/26/21 at 1:29 P.M. revealed Resident #123 in bed with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 7:54 A.M. revealed Resident #123 was sitting up in a chair with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 11:24 A.M. with RN #250 of Resident #123 confirmed the oxygen nasal cannula was in place, oxygen was set at two LPM, and the oxygen tubing was not dated. RN #250 indicated oxygen tubing required dating for weekly replacement. Interview on 04/29/21 at 12:36 P.M. with RN #251 confirmed there were no physician orders for oxygen administration, and verified the nurses should document administering oxygen in the MAR. Review of the facility policy titled Respiratory Therapy and Care of Equipment, revised September 2017, revealed oxygen tubing and the delivery device (nasal cannula or mask) will be changed routinely once a week, equipment will be dated when changed by both the nursing staff and the oxygen company. Review of the facility education of policy titled Oxygen Administration Process, dated 04/27/21 to 04/28/21, revealed oxygen tubing will be labeled with the patients name and date, and verify that there is a physician's order.

Based on observation, interview, record review and policy review, the facility failed to appropriately store medications in two of two medication carts, and in one of one medication room refrigerator. This had the potential to affect all 19 residents residing in the facility. Findings include: Observation on 04/27/21 at 11:08 A.M. with Registered Nurse (RN) #250 during medication administration from the medication cart labeled cherry revealed a vial of Lispro U-100 insulin stored in the top drawer of the medication cart. The Lispro insulin vial was opened, not dated, not labeled, and was not in a labeled storage box or container. Interview with RN #250 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:26 A.M. with RN #251 of medication storage room revealed three Aplisol 5 tuberculin units per 0.1 milliliter vials (used to diagnose tuberculosis) stored in the refrigerator. Each of the three Aplisol vials were opened and undated. Interview with RN #251 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:44 A.M. with RN #252 of medication cart storage revealed an injectable pen of Ozempic (anti-diabetic medication) 2.5 milligrams per 1.5 milliliter stored in the top drawer of the medication cart labeled maple. The Ozempic injectable pen was observed to be previously used, was not dated, was not labeled, and was not in a labeled storage box or container. Review of the facility policy titled Storage of Medication/Nutritional Supplements, reviewed February 2021, revealed medications/nutritional supplements shall be stored in the packaging, containers or other dispensing systems in which they are received, and medication containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Review of the facility policy titled Insulin Storage, reviewed March 2021, revealed opened insulin will be dated the day it is opened. Review of the facility policy titled Medication Administration, dated 09/14/20, revealed prepare medications according to orders and standard of practice/ensuring to check package open dates/expiration dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to ensure transmission based precautions were initiated upon admission for Resident #70, the facility failed to ensure staff and visitors followed appropriate transmission based precautions guidelines for Resident #70, and the facility failed to ensure soiled laundry was handled appropriately for Resident #119. This affected two Residents (#70 and #119) of three residents reviewed for infection control, and had the potential to affect all 19 residents residing in the facility. Findings include: 1. Record review revealed Resident #70 was admitted on [DATE] from the hospital with diagnoses including sicca syndrome (Sjogren syndrome) (an autoimmune disease), orthostatic hypotension, essential primary hypertension, and repeated falls. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required limited one staff assistance for bed mobility and toileting, limited two staff assistance for transfers, and was always continent of urine and bowel. The assessment did not indicate isolation or quarantine. Review of Resident #70's medical record revealed no documented immunization information for COVID-19. Review of the physician's orders dated 04/16/21 revealed quarantine 14 days, transmission based respiratory droplet and contact precautions every shift until 04/27/21. Review of the progress notes dated 04/16/21 revealed transmission based precautions (TBP) were in place. There was no documentation of TBP prior to 04/16/21. Interview on 04/29/21 at 1:36 P.M. with RN #251 confirmed TBP were not ordered until 04/16/21, three days after Resident #70's admission from the hospital on [DATE], and there was no documentation TBP were initiated prior to 04/16/21. Registered Nurse (RN) #251 indicated TBP were required for COVID-19 because the resident had a hospital stay and there was no documentation of COVID-19 vaccination. Observation on 04/27/21 at 8:44 A.M. with RN #252 during medication administration revealed on the door of Resident #70's room two posted signs, Droplet Precautions and Contact Precautions. Review of the facility TBP sign, Contact Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room. Further review of Contact Precautions sign indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Review of the facility TBP sign, Droplet Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention 2. Observation on 04/27/21 at 8:46 A.M. with RN #252 during medication administration revealed RN #252, who was wearing an N95 (respirator) mask and face shield, donned a gown and gloves, and enter Resident #70's room. Observed standing next to Resident #70's bed was a visitor wearing no personal protective equipment (PPE). RN #252 requested the visitor put on a surgical mask, which the visitor complied, and did not request the visitor wear any additional PPE including a face shield or goggles, gloves or a gown. The visitor then left Resident #70's room indicating a need to obtain a cup for the resident. Upon exiting the room, the visitor did not perform handwashing and walked to the common dining area, obtained a Styrofoam cup and re-entered Resident #70's room still wearing a surgical mask. Upon entry, the visitor did not perform handwashing and did not put on any additional PPE including a face shield or goggles, gloves or a gown. RN #252 then exited Resident #70's room after removing the gown, gloves and performing handwashing. RN #252 did not change the N95 mask which was unprotected by a surgical mask, and did not disinfect the face shield or change the face shield. Interview with RN #252 at the time of the observation confirmed the above findings and indicated an understanding that visitors only had to wear surgical masks including residents on TBP. Interview on 04/27/21 at 9:57 A.M. with Unit Clerk #300 verified visitors were pre-scheduled and educated with guidelines for wearing a surgical mask with visits. Unit Clerk #300 indicated no one visited when on TBP unless approved by management. Review of the visit schedule titled Rehab Pavilion, dated 04/27/21, revealed a visitor scheduled for Resident #70 at 10:30 A.M. Resident #70 was not identified on the list with a requirement for TBP. Interview on 04/27/21 at 11:36 A.M. with RN #251 confirmed visitors for residents in TBP were educated to wear a gown, face shield and an N95, and to perform handwashing before and after leaving the resident's room. RN #251 indicated activity staff monitored visitors and helped ensure guidelines were followed. Interview on 04/27/21 at 12:50 P.M. with Activities #302 verified visits were pre-scheduled and the information was provided to nursing staff. Activities #302 confirmed visitors for residents in TBP were to wear a mask and gown, and Unit Clerk #300 would use the schedule to know which residents were on TBP to educate visitors as they arrived or nursing staff would do the same as needed. Interview on 04/27/21 at 1:20 P.M. with Housekeeping #303 confirmed with residents in TBP, the N95 mask had to be covered with a surgical mask upon entry or the N95 mask changed upon exit of the room, and the face shield or goggles disinfected upon exit of the room. Interview on 04/27/21 at 2:12 P.M. with RN #251 verified when exiting resident rooms with TBP, the face shield or goggles had to be disinfected or changed. Interview on 04/27/21 at 2:23 P.M. with Infection Preventionist (IP) #304 confirmed residents admitted and not vaccinated for COVID-19 are placed on TBP for 14 days. IP #304 verified visitors for residents on TBP were required to wear a surgical mask, face shield, and gown, and use handwashing prior to entering and when exiting the room. Interview on 04/28/21 at 9:23 A.M. with Unit Clerk #300 verified the visitation schedule dated 04/27/21 did not have residents identified with TBP including Resident #70, and confirmed when Resident #70's visitor arrived on 04/27/21, the visitor was not educated on TBP as required. Review of the facility policy titled COVID-19: PPE Use During Pandemic, dated 02/10/20, all staff will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC (Centers for Disease Control) disinfection guidelines. Review of the facility policy titled COVID-19: Visitation and Communal Activities, dated 01/25/21, revealed residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. 3. Record review revealed Resident #119 was admitted on [DATE] with diagnoses including sepsis, urinary tract infection, chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of care plan dated 04/24/21 revealed the resident had a self-care performance deficit with activities of daily living. Interventions included to provide one staff assistance with bed mobility, toileting, transfers, dressing and bathing, and encourage the resident to participate to the fullest extent possible. Observation on 04/27/21 at 11:07 A.M. with RN #250 during medication administration revealed soiled linen on Resident #119's bathroom floor adjacent to the sink, soiled towels on Resident #119's bathroom shower floor, and soiled clothing on Resident #119's bathroom floor adjacent to the bathroom door. Interview with RN #250 at the time of the observation confirmed the above findings and indicated soiled laundry should be bagged and placed in the soiled laundry area and not left on a resident's floor. Review of the facility education of policy titled Soiled Linen, dated 04/27/21 to 04/28/21, revealed make sure the soiled linen is properly handled from the point of collection to the laundry, and treat all soiled linen as potentially infectious. 4. Resident #9 was admitted on [DATE] with diagnoses including hypertensive heart disease, cognitive communication deficit, osteoporosis, diabetes and a history of falling. Review of physician orders revealed and order dated 04/15/21 for quarantine for 14 days, Transition Based, Respiratory Droplet and Contact Precautions. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/15/21 revealed a care area for at risk of respiratory illness, COVID-19 with an intervention of Institute isolation precautions as individually appropriate. Observation of and interview with State Tested Nurse Aide (STNA) #205 on 04/28/21 9:01 A.M. revealed the STNA exited Resident #9's room wearing a face shield and face mask but no gown. The door to the room had isolation signs prominently displayed and personal protection equipment (PPE) including surgical masks, gowns and gloves hanging on the door. The STNA verified she should have donned a gown and wiped her face shield. Interviews on 04/27/21 at 2:12 P.M. with RN #251 verified staff need to wipe or change their face shield when exiting isolation rooms. Review of the COVID-19: PPE Use During Pandemic policy dated 02/10/20 revealed : all staff will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC. 5. Resident #126 was admitted on [DATE] with diagnoses including acute neoplastic leukemia not having achieved remission and Alzheimer's disease. Review of physician orders revealed an order of 04/23/21 for quarantine for 14 days, transmission based respiratory droplet and contact precautions every shift until 05/06/21. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/21/21 revealed care areas included impaired immunity related to leukemia with recent chemotherapy with a risk for contracting infections due to impaired immune status and an intervention to keep the environment clean and people with infection away. The care plan revealed a second care area was for risk of COVID-19 with an intervention to institute isolation precautions as individually appropriate. Interview on 04/27/21 at 11:36 A.M. with RN #251 revealed visitors for residents on isolation are educated to wear a gown and face shield and an N95 and to wash hands before and after leaving the room. Activities staff monitor the visitors and the visits are pre-scheduled and monitored by them, and they go over the guidelines with them. Observation on 04/27/21 at 4:15 P.M. revealed Resident #126's daughter was visiting in his room, wearing a surgical mask and no face shield or goggles and no personal protective gown. The door to the room had isolation signs prominently displayed and PPE including surgical masks, gowns and gloves hanging on the door. She was momentarily joined by Resident #126's son who was wearing a surgical mask. Interview on 04/27/21 at 4:18 P.M. with Resident #126's daughter and son revealed no staff had informed them they needed to wear a face shield and gown when visiting their father. The son reported he was not screened by anyone when he entered the building and proceeded back to his father's room with no instructions on PPE. Interview on 04/29/21 with RN #251 revealed she could find no documentation that transmission based precautions were ordered for Resident #126 upon his admission on [DATE], only the order of 04/23/21. Review of the schedule for visitors for 04/27/21 did not contain any visits for Resident #126. Review of the undated facility transmission-based precautions sign, Droplet Precautions revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of the Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated was the source of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of resident records, observation and review of facility reported incidents (FRI) for allegations of abuse and the facility's investigations, the facility failed to report or to timely report allegations of abuse. This affected Resident #10 for an allegation of abuse that was never reported to the Ohio Department of Health (ODH) and Residents #87 and #93 for allegations that were not reported timely to ODH. The facility census was 29. Findings include: 1. During an interview on 03/25/19 at 3:04 P.M., Resident #87 indicated an attendant here called her a liar. The resident asked the attendant if that was what she said, and the person stated she did. Resident #87 described the attendant as a tall female, middle aged with reddish hair. She was unable to provide any additional details. On 03/25/19 at 3:25 P.M., an interview with Registered Nurse (RN) #54 revealed Resident #87 had never complained of how staff treat her. During the interview, the surveyor shared the resident's concern. On 03/25/19 at 5:00 P.M., an interview with the Director of Nursing (DON) and RN #100/Nurse Manager revealed they met with Resident #87 who repeated that staff called her a liar. She described the staff as a tall female, middle aged. She was unable to provide any other details. RN #100 indicated she spoke with the resident's son who thought the resident may have been confused. During an interview on 03/26/19 at 2:20 P.M., the Administrator indicated he was aware of Resident #87's concern. He spoke with RN #100, and she did not feel it was abuse. The Administrator agreed the facility did not report the allegation of abuse to the ODH. On 03/26/19 at 2:28 P.M., an interview with RN #100/Nurse Manager revealed her conversation with Resident #87's son indicated the son was not sure if the incident really occurred. Review of a FRI for Resident #87's allegation of verbal abuse revealed the facility reported it to ODH on 03/26/19 at 3:23 P.M. During an interview on 03/26/19 at 7:09 P.M., the Administrator indicated the facility went ahead and filed and completed a FRI today for the allegation. 2. Review of a FRI reported to ODH on 10/19/18 at 12:19 P.M. revealed Resident #93 alleged to a nurse on 10/16/18 at approximately 1:00 A.M. that a State Tested Nursing Assistant (STNA) hit her in the head with a remote control. The resident was sent to the hospital later on 10/16/18. On 10/18/18 while at the hospital, Resident #93 reported an allegation that a nurse at the nursing home was so mad she picked up the resident's walker and threw it at her and she fell. Hospital staff reported the allegation to the facility on [DATE]. Review of Resident #93's record revealed a progress note dated 10/16/18 at 2:42 A.M. The note documented by RN #55 indicated at approximately 1:00 A.M., Resident #93 reported an STNA hit her in the head with the chair remote. RN #55 interviewed the STNA's. STNA #57 indicated she witnessed Agency STNA #95 hand the remote to the resident. Approximately an hour later, Resident #93 screamed, You f .g bitch, don't you ever take my wheelchair again. It's my wheelchair. There was no evidence the 10/16/18 allegation of abuse was reported to ODH until 10/19/18 at 12:19 P.M. following a second allegation of abuse reported to the facility by the hospital staff. During an interview on 03/28/19 at 2:32 P.M., the DON and RN #100/Nurse Manager agreed the abuse allegation was reported following the allegation voiced by hospital staff on 10/18/18. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including displaced lateral mass fracture of first cervical vertebra and fracture of the second lumbar vertebra, major recurrent depressive disorder, repeated falls, difficulty walking, dementia and delirium. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/28/19, indicated he had moderate cognitive impairment in daily decision making ability, displayed no behaviors and required the extensive assistance for transfers and toileting. Review of the progress note dated 03/04/19 at 6:43 P.M. the nurse noted a physical therapy assistant and a speech therapist found Resident #10 on the floor. His private aide was at his side. He was yelling to get the damn lady away from him. He angrily reported the aide knocked him over. Interview with Resident #10 on 03/25/19 at 12:42 P.M. indicated he had to wear the neck collar because he was beat up and hit in the head. He denied his injury was from a fall. There was no evidence the resident had an injury because of an altercation. He denied any abuse toward him by anyone. Resident #10 was observed on 03/25/19 at 2:27 P.M., 03/26/19 at 11:08 A.M., 12:08 P.M. and 3:27 P.M. and on 03/27/19 at 10:35 and 11:09 A.M. to have a private sitter in close proximity. He utilized a wheelchair and wore a cervical neck collar. Interview with the Administrator on 03/27/19 at 3:58 P.M. revealed the allegation of abuse was not reported to him and not reported as required. Interview with RN #100 and the DON on 03/27/19 at 4:03 P.M. verified the allegation of abuse was not reported nor investigated. They indicated the nurse on duty was from an agency and should have reported the allegation the facility's abuse policy and procedures should have been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of facility reported incidents (FRI) for allegations of abuse, and review of the facility's investigations, the facility failed to thoroughly investigate allegations of abuse. This affected three (Residents #3, #87, and #93) of three residents during review of three facility reported incidents. The facility census was 29. Findings include: 1. Review of an FRI dated 10/16/18 revealed Resident #3 reported to Social Worker #41 that a six foot two inch tall, heavy set, African-American female was verbally and mentally abusive towards him. He described the perpetrator as an aide. The aide was going to bully him into doing things and provoke him to do things. Resident #3 was unable to state any specifics, including date, time, name. Review of the facility's investigation included no resident interviews or statements. The investigation summary indicated Resident #3 was interviewed. 2. Review of an FRI dated 10/19/18 revealed Resident #93 alleged an agency aide, State Tested Nurse Aide (STNA) #95 hit her in the head with a remote at approximately 1:00 A.M. on 10/16/18. The resident was sent to the hospital on [DATE]. On 10/18/18 while hospitalized , Resident #93 alleged a nurse at the nursing home picked up her walker and threw it at her. She then fell. Hospital staff reported the allegation to the facility on [DATE]. Review of the facility's investigation of the FRI revealed no resident interviews or statements. 3. Review of an FRI dated 03/26/19 revealed Resident #87 reported to the state surveyor that a tall, middle aged, female staff called her a liar. The FRI investigation was completed on 03/26/19 at 4:47 P.M. Review of the facility's investigation of the FRI revealed an interview with Resident #87 and no additional resident interviews or statements. During an interview on 03/28/19 at 3:19 P.M., the Director of Nursing (DON) and Registered Nurse (RN) #100/Nurse Manager agreed they did not interview or get statements from other residents during the investigations of abuse for Resident #3, #87, and #93.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medication administration records reflected the amount of insulin administered. This affected one (Resident #3) of one resident with a sliding scale insulin order of five residents reviewed for unnecessary medications. The facility had three residents with sliding scale insulin orders. The facility census was 29. Findings include: Review of the record revealed Resident #3 was admitted on [DATE] with diagnoses including diabetes and Parkinson's disease. The resident had a physician's order, dated 12/04/18, for accuchecks (blood sugar monitoring) before meals and at bedtime with Lispro insulin coverage per sliding scale order. Humalog insulin coverage was for blood sugar 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, greater than 400 notify the physician. Lispro is a fast acting insulin which begins working in about 15 minutes. Review of Resident #3's electronic medication administration records (eMAR's) for January, February, and March 2019 revealed the nurses documented the blood sugar before meals and at bedtime and initialed the medication to indicate they administered the Lispro insulin. There was no indication how much insulin the nurse administered each time. Resident #3's blood sugars varied between 41 and 405. During an interview on 03/27/19 at 4:27 P.M., Registered Nurse (RN) #40 (Director of Minimum Data Set) reviewed Resident #3's eMAR for March 2019. She indicated the eMAR had the sliding scale insulin order and documentation of the blood sugars but did not indicate how much insulin was administered. RN #40 wanted to ask one of the nurses who administers medications. In an interview on 03/27/19 at 4:32 P.M., RN #54 agreed the eMAR did not reflect how much Lispro insulin was administered for the sliding scale insulin order. During an interview on 03/28/19 at 8:08 A.M., RN #40 reviewed Resident #3's eMAR's for January and February 2019. She agreed the eMAR's did not indicate how much sliding scale insulin coverage the nurses administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of resident records, review of three facility reported incidents for allegations of abuse and the facility's investigations, and review of the facility's abuse policy, the facility failed to implement their policy for abuse. This affected Resident #10 for an allegation of abuse that was never identified or reported, Residents #87 and #93 for allegations of abuse that were not reported timely to the Ohio Department of Health, and Residents #3, #87, and #93 for allegations of abuse that were not thoroughly investigated. This had the potential to affect all 29 residents. Findings include: 1. During an interview on 03/25/19 at 3:04 P.M., Resident #87 indicated an attendant here called her a liar. The resident asked the attendant if that was what she said, and the person stated she did. Resident #87 described the attendant as a tall female, middle aged with reddish hair. She was unable to provide any additional details. On 03/25/19 at 3:25 P.M., the allegation was reported to Registered Nurse (RN) #54. On 03/25/19 at 5:00 P.M., an interview with the Director of Nursing (DON) and Registered Nurse (RN) #100/Nurse Manager revealed they met with Resident #87 who repeated that staff called her a liar. She described the staff as a tall female, middle aged. She was unable to provide any other details. RN #100 indicated she spoke with the resident's son who thought the resident may have been confused. During an interview on 03/26/19 at 2:20 P.M., the administrator indicated he was aware of Resident #87's concern. He spoke with RN #100, and she did not feel it was abuse. The administrator agreed the facility did not report the allegation of abuse to the Ohio department of health (ODH). On 03/26/19 at 7:09 P.M., an interview with the administrator revealed the facility went ahead and filed and completed a FRI today for the allegation. Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed December 2017) indicated all written or verbal allegations asserting that resident abuse, neglect, or misappropriation occurred will be reported immediately (or as soon as possible). The DON and/or nursing administration will submit an immediate report to ODH. 2. Review of an FRI reported to ODH on 10/19/18 at 12:19 P.M. revealed Resident #93 alleged to a nurse on 10/16/18 at approximately 1:00 A.M. that a state tested nursing assistant (STNA) hit her in the head with a remote control. The resident was sent to the hospital later on 10/16/18. On 10/18/18 while at the hospital, Resident #93 reported an allegation that a nurse at the nursing home was so mad she picked up the resident's walker and threw it at her and she fell. Hospital staff reported the allegation to the facility on [DATE]. Review of Resident #93's record revealed a progress note dated 10/16/18 at 2:42 A.M. The note documented by RN #55 indicated at approximately 1:00 A.M., Resident #93 reported an STNA hit her in the head with the chair remote. Review of the facility's investigation completed 10/23/19 and the FRI revealed no evidence the 10/16/18 allegation of abuse was reported to ODH until 10/19/18 at 12:19 P.M. following a second allegation of abuse reported to the facility by the hospital staff. During an interview on 03/28/19 at 2:32 P.M., the DON and RN #100/Nurse Manager agreed the abuse allegation was reported following the allegation voiced by hospital staff. Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed December 2017) indicated all written or verbal allegations asserting that resident abuse, neglect, or misappropriation occurred will be reported immediately (or as soon as possible). The DON and/or nursing administration will submit an immediate report to ODH. 3. Review of an FRI dated 10/16/18 revealed Resident #3 reported to Social Worker #41 that a six foot two inch tall, heavy set, African-American female was verbally and mentally abusive towards him. He described the perpetrator as an aide. The aide was going to bully him into doing things and provoke him to do things. Resident #3 was unable to state any specifics, including date, time, name. Review of the facility's investigation completed 10/19/18 included no resident interviews or statements. The investigation summary indicated Resident #3 was interviewed. Review of an FRI dated 10/19/18 revealed Resident #93 alleged an agency aide (STNA #95) hit her in the head with a remote at approximately 1:00 A.M. on 10/16/18. The resident was sent to the hospital on [DATE]. On 10/18/18 while hospitalized , Resident #93 alleged a nurse at the nursing home picked up her walker and threw it at her. She then fell. Hospital staff reported the allegation to the facility on [DATE]. Review of the facility's investigation completed 10/23/18 revealed no resident interviews or statements. Review of an FRI dated 03/26/19 revealed Resident #87 reported to the state surveyor that a tall, middle aged, female staff called her a liar. The facility's investigation completed on 03/26/19 included an interview with Resident #87 and no additional resident interviews or statements. During an interview on 03/28/19 at 3:19 P.M., the DON and RN#100/Nurse Manager agreed they did not interview or get statements from other residents during the investigations of abuse for Resident #3, #87, and #93. Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed December 2017) indicated the supervisor in charge at the time of the allegation will begin the immediate investigation. Investigations may include 1-to-1 interviews, pictures, statement from staff/visitors, review of medical record, inspection of environment, physical exam, or hospital exam. The DON and/or nursing administration will submit an immediate report to ODH and will ensure and/or conduct a thorough investigation. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including displaced lateral mass fracture of first cervical vertebra and fracture if the second lumbar vertebra, major recurrent depressive disorder, repeated falls, difficulty walking, dementia and delirium. Review of the comprehensive assessment (MDS 3.0) dated 02/28/19 indicated he had moderate cognitive impairment in daily decision making ability, displayed no behaviors and required the extensive assistance for transfers and toileting. Review of the progress note dated 03/04/19 at 6:43 P.M. the nurse noted a physical therapy assistant and a speech therapist found Resident #10 on the floor. His private aide was at his side. He was yelling to get the damn lady away from him. He angrily reported the aide knocked him over. Interview with Resident #10 on 03/25/19 at 12:42 P.M. indicated he had to wear the neck collar because he was beat up and hit in the head. He denied his injury was from a fall. There was no evidence the resident had an injury because of an altercation. He denied any abuse toward him by anyone. Resident #10 was observed on 03/25/19 at 2:27 P.M., 03/26/19 at 11:08 A.M., 12:08 P.M. and 3:27 P.M. and on 03/27/19 at 10:35 and 11:09 A.M. to have a private sitter in close proximity. He utilized a wheelchair and wore a cervical neck collar. Interview with the administrator on 03/27/19 at 3:58 P.M. revealed the allegation of abuse was not reported to him. Interview with Registered Nurse (RN) #100 and the director of nursing on 03/27/19 at 4:03 P.M. verified the allegation of abuse was not reported nor investigated. They indicated the nurse on duty was from an agency and should have reported the allegation the facility's abuse policy and procedures should have been implemented. Review of the abuse policy revised December 2017 indicated reportable events include but are not limited to when a specific written or verbal allegation asserting that resident abuse, neglect, or misappropriation of resident property occurred. Abuse may be verbal, physical, mental or sexual. Witnessed or suspected incidents of abuse or neglect are reported to the Abuse Coordinator and immediate supervisor. The supervisor in charge at the time of the allegation will begin the immediate investigation. An immediate investigation will begin and may include 1:1 interviews, pictures, statements of staff/visitors, review of medical chart, inspection of resident environment, physician exam or hospital examination, and reporting of results to the proper authorities. The Director of Nursing and/or nursing administration will submit immediate reports to ODH, ensure and/or conduct a thorough investigation, and report the findings of the investigation within 5 working days to ODH. Any staff or person suspected of abuse/neglect will be suspended and/or removed from the building pending the result of the investigation. The resident will be assured that they will be free from retribution of any kind; the incident kept confidential and will be monitored closely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to maintain acceptable parameters of nutritional status by obtaining ordered daily weights and obtaining re-weights for the dietitian to have accurate data to properly evaluate three residents (Resident's #17, #23, and #25) of four residents reviewed for nutrition and who had sustained weight loss. The facility census was 29. Findings include: 1. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including pneumonia, moderate chronic kidney disease, major depressive disorder recurrent, cirrhosis of liver, diabetes with complications, cognitive communication deficit, dysphagia, hyperlipidemia, hypercalcemia, acute and chronic respiratory failure, congestive heart failure, paroxysmal atrial fibrillation, cerebral infarction, and gastrointestinal hemorrhage. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/23/19, indicated she had moderate cognitive impairment. She was 63 inches tall and weighed 143 pounds. The MDS 3.0, dated 03/11/19, indicated she now had severe cognitive impairment and weighed 130 pounds. The assessment indicated she had no or unknown weight loss. The nutrition plan of care initiated on 02/27/19 indicated to obtain daily weights, monitor oral intake for accuracy, pudding supplement daily between meals, and another nutritional supplement daily. Review of the physician order, dated 02/26/19, indicated to obtain weight daily. Review of the weight record revealed she weighed 129 pound on 02/26/19. No weights were obtained until 03/01/19, when she also weighed 129 pounds. She was weighed on 18 of 28 days in March 2019. Interview with Registered Dietitian (RD) #91 on 03/27/19 at 12:40 P.M. reported there was no indication Resident #17 refused to be weighed and verified the daily weights were not obtained as ordered to afford an accurate assessment of her nutritional needs. 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included displaced fracture of greater trochanter of left femur subsequent encounter for closed fracture with delayed healing, cognitive communication deficit, malignant neoplasm of the pancreas, antineoplastic chemotherapy, chondrocalcinosis, hyperlipidemia, gout, hypothyroidism, moderate chronic kidney disease, localized edema, acute embolism and thrombosis of deep veins of right lower extremity. Review of the MDS 3.0, dated 02/13/19, indicated she was 63 inches tall and weighed 138 pounds. Review of the MDS 3.0, dated 03/08/19, indicated she weighed 119 pounds and she was not on a prescribed weight loss program. Review of the physician order, dated 02/22/19, indicated to obtain daily weights and on 03/08/19 to obtain weights weekly on Tuesdays and Fridays. Review of the weight record revealed although she was ordered daily weights on 02/22/19 the first weight was not obtained until 02/26/19 when she weighed 135 pounds. The next weight was not obtained until 03/08/19 when she weighed 119 pounds. A difference of 11. 85%. Interview with RD #91 on 03/17/19 at 12:52 P.M. indicated the resident had a 15.8% weight loss since admission, verified weights were not obtained daily as ordered to afford an accurate assessment. RD #91 said a re-weight should be obtained with any three to four pound difference. 3. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses included traumatic subdural hemorrhage, repeated falls, anemia, atrial flutter, paroxysmal atrial fibrillation, encephalopathy, cognitive communication deficit, nausea with vomiting, moderate chronic kidney disease, atherosclerotic heart disease, hypertension, hyperlipidemia, localized edema, major depressive disorder, cardiac pacemaker and gastro-esophageal reflux disease. Review of the MDS 3.0, dated 03/11/19, indicated he had moderate cognitive impairment. He was 72 inches tall and weighed 156 pounds with no or unknown weight loss. Review of the nutrition care plan initiated 02/27/19 indicated he refused nutritional supplements upon admission but the interventions indicated to provide eight ounces of ensure clear twice daily with meals. Review of the aide documentation revealed in the last 30 days his average intake was 50% and he was not provided any snacks. Review of the physician's order, dated 02/26/19, to obtain weight daily. Review of the dietary note, dated 11/19/18, indicated he was to be weighed daily. There was only one weight for December 2018, 19 weights for January 2019, nine weights for February 2019 and 22 weights for March 2019. He also had weights recorded with differences above three to four pounds as evidence by the following: 02/28/19 he weighed 166 pounds, 03/01/19 he weighed 158 pounds, 03/02/19 he weighed 160 pounds, 03/03/19 he weighed 157 pounds, 03/23/19 he weighed 154 pounds, 03/24/19 he weighed 168 pounds and on 03/25/19 he weighed 150 pounds. There was no documented evidence re-weights were obtained. Interview with RD #91 on 03/17/19 at 12:52 P.M. verified weights were not obtained daily as ordered to afford an accurate assessment. RD #91 said a re-weight should be obtained with any three to four pound difference. Interview with State Tested Nurse Aide (STNA) #58 on 03/27/19 at 02:56 P.M. said daily weights were obtained by the night shift. She pointed to a posted list in the nurses station titled daily weights indicating to please do all daily weights at 6:00 A.M. All weekly weights were done on day shift. Another posting of shower schedules revealed weights were obtained for the odd numbered rooms on Mondays and the even numbered rooms on Tuesdays, the form was dated 11/28/18. Interview with RN #54 on 03/27/19 at 03:10 P.M. said the aides do the weights she inputs it into the computer. She said she notifies the Director of Nursing, Physician and Dietary Manager of weight changes. Interview with RN #100 and the Director of Nursing on 03/27/19 at 4:10 P.M. reported the physician wanted daily weights taken at 6:00 A.M. for residents with congestive heart failure like they do at the hospital. Review of the Weight Monitoring policy and procedure, revised December 2017, revealed the charge nurse would notify the dietitian/diet technician and primary physician of significant weight variances. Weight gains or losses of three pounds would prompt a re-weigh of the resident. The dietitian/diet technician will review information, assess and document follow up in the medical record within three to five business days of notification. Weights were kept in the medical record. When recording the weight in the medical record the nurse will review whether a significant weight variation prompted a re-weigh. If a significant gain or loss, the resident would be placed on weekly weight schedule unless contraindicated and would be evaluated as needed. Significant changes were as follows: 5% in one month, 7.5% in three months and 10% in six months.

Based on observation, interview and policy review, the facility failed to ensure the kitchen environment and service hallways were maintained in sanitary condition. This affected all 29 residents in the facility. Findings include: The initial tour of the facility on 03/25/19 began at 8:50 A.M. Three stainless steel hoods (interior sides, roof and lip), over the cooking appliances were observed covered with grease and lint, hair and dust stuck in the grease. The Ansul system nozzles were heavily covered in dust. The edge of the hood appeared to have grease drips hanging on the edge directly over the cooking appliances. Interview with the Director of Dining Services #90 on 03/25/19 at 9:00 A.M. verified the condition of the hood and said the hood and Ansul system were cleaned every couple of months. She said it was professionally cleaned in November 2018. The perimeter of the kitchen floor was heavily soiled with dust, dirt and debris. The gray grout in between the tiles were black in color. Interview with the Director of Dining Services #90 on 03/25/19 at 9:10 A.M. verified the condition of the floor said it was the responsibility of the closing cook to make sure the floors were cleaned and mopped daily. The food was served from a servery. The food was sent to the unit prior to each meal down a long service hallway. The floors of the service hallway were heavily soiled with dirt, dried and loose debris. The gray grout was black in color. Interview with the Director of Dining Services #90 verified the condition of the service hallway floors and said it was the responsibility of the dish washer to sweep and wash the service hallway floor. A subsequent visit to the kitchen on 03/25/19 at 11:15 A.M. revealed the hoods in the same condition. Foods were being cooked on the appliances below. Interview with the Director of Dining Services #90 on 03/25/19 at 11:15 A.M. confirmed the liquid drips on the edge of the hood were oily when she rubbed them with her fingers. Review of the service invoice, dated 03/2018, indicated the kitchen exhaust systems serving four hoods cleaning included underside of hoods, filter holders, filter plenums, interior of ductwork and two fans located on roof. This also included the cleaning of 32 baffle filters, four hoods and eight filters in each hood. Review of the cleaning procedures for the vent hood, dated 2013, indicated daily to clean the drip pans and weekly clean the exterior surfaces. The weekly cleaning indicated to remove filters and clean using procedure outlined for this purpose. Spray all inside and outside surfaces with heavy duty oven cleaner. On heavily soiled areas or where grease was baked on, loosen with brush until the grease and soil were broken down and could be removed. Clean out the drain trough around the lower inside edge of the hood, as well as the channels which hold the filters. Flush soil and solution with clean, hot water. Allow inside surfaces to air dry and wipe outside surfaces dry. Polish the exterior surfaces with stainless steel polish. Review of the master cleaning schedule #24503 indicated the exhaust hood and filters were cleaned weekly on Thursdays, the floors were to be cleaned daily, gray rolling garbage cans every Monday, white garbage cans every Friday, line garbage cans every Saturday.